Hypertension is a primary contributor to cardiovascular disease (CVD), which is a major cause of death in women. Traditionally defined as an average blood pressure of at least 140/90 mm Hg or use of antihypertensive medication, hypertension affects about 30% of US adults aged 18 or older.1 While the 140/90 mm Hg cutoff is used in the 2004 Joint National Commission (JNC) report on hypertension, more recently, the American College of Cardiology and the American Heart Association (ACC/AHA) recommended lowering the defining blood pressure for hypertension to 130/80 mm Hg.2,3 According to the new ACC/AHA guidelines, stage I hypertension is diagnosed by a systolic blood pressure of 130 to 139 mm Hg or diastolic blood pressure of 80 to 89 mm Hg. A blood pressure of ≥ 140 mm Hg systolic or 90 mm Hg diastolic defines stage II hypertension. Blood pressure should be taken by trained personnel who ensure that the patient has been at rest and seated in a chair with feet on the floor and has an empty bladder. A properly sized cuff encircles 75% to 100% of the patient’s arm. The diagnosis can be made by averaging at least two readings on at least two separate occasions using readings from ambulatory blood pressure monitoring, home self-monitoring, and/or a follow-up visit.3 The American College of Obstetricians and Gynecologists (ACOG) acknowledges the new, lower diagnostic threshold for hypertension in its bulletin on chronic hypertension in pregnancy and recommends that patients diagnosed with hypertension using these values be managed in pregnancy using the guidelines for chronic hypertension. However, because ACOG adheres to the JNC cutoff in its definition of gestational hypertension, and given that the data currently available utilize the 140/90 threshold, we will also utilize the 140/90 cutoff in this article.4
Among women, prevalence of hypertension rises from 10% in the 20- to 44-year-old age range to 78% by age 75.3 Significant disparities exist in medical treatment of hypertension. Approximately half of all adults (53.5%) and 52.1% of women have uncontrolled hypertension.5 Hypertension is more common among black adults (38.6% prevalence) and is less likely to be treated in this population. Women aged 18 to 39 are less likely than older women to have controlled hypertension, potentially predisposing women in this age group to pregnancy complications related to their hypertension. In addition, people who are Mexican-American, lack a usual medical care site, receive medical care less than twice per year, or lack health insurance are less likely to receive medical treatment for hypertension than other people with hypertension.1 Moreover, groups already at disproportionate risk of adverse pregnancy outcomes, such as black women and women lacking health insurance, are more likely to experience complications of hypertension. Given that many reproductive-aged women choose to receive their primary healthcare through their ob/gyn, there is an opportunity to diagnose, counsel on, and treat hypertension during the health maintenance exam. We have opportunities to engage in innovative patient-centered management of hypertension before, during, and after pregnancy to reduce disparities.6
- Centers for Disease Control and Prevention (CDC). Vital Signs: Prevalence, Treatment, and Control of Hypertension – United States. 1999-2002 and 2005-2008. MMWR Morb Mortal Wkly Rep. 2011;60(4):103-108.
- National Institutes of Health, National Heart, Lung and Blood Institute, National High Blood Pressure Education Program. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. https://www.nhlbi.nih.gov/files/docs/guidelines/jnc7full.pdf. Accessed August 31, 2019.
- Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71(6):1269-1324.
- ACOG Practice Bulletin No. 203: Chronic Hypertension in Pregnancy. Obstet Gynecol. 2019;133(1):e26-e50.
- Centers for Disease Control and Prevention (CDC). Vital signs: awareness and treatment of uncontrolled hypertension among adults--United States, 2003-2010. MMWR Morb Mortal Wkly Rep. 2012;61:703-709.
- D’Alton ME, Friedman AM, Bernstein PS, et al. Putting the “M” back in maternal-fetal medicine: A 5-year report card on a collaborative effort to address maternal morbidity and mortality in the United States. Am J Obstet Gynecol. 2019 Oct;221(4):311-317.
- Aliskiren. In: Micromedex. Greenwood Village (CO): Truven Health Analytics; publication year . Available from: www.micromedexsolutions.com. Subscription required to view.
- Brahmbhatt Y, Gupta M, Hamrahian S. Hypertension in Premenopausal and Postmenopausal Women. Curr Hypertens Rep. 2019;21(10):74.
- U.S. Preventive Services Task Force. Final Recommendation Statement: Low-Dose Aspirin Use for the Prevention of Morbidity and Mortality From Preeclampsia: Preventive Medication. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/low-dose-aspirin-use-for-the-prevention-of-morbidity-and-mortality-from-preeclampsia-preventive-medication. Accessed September 9, 2019.
- Ramakrishnan A, Lee LJ, Mitchell LE, Agopian AJ. Maternal Hypertension During Pregnancy and the Risk of Congenital Heart Defects in Offspring: A Systematic Review and Meta-analysis. Pediatr Cardiol. 2015;36(7):1442-1451.
- Centers for Disease Control and Prevention. Contraceptive guidance for health care providers.https://www.cdc.gov/reproductivehealth/contraception/contraception_guidance.htm. Accessed September 20, 2019.
- Curtis KM, Mohllajee AP, Martins SL, Peterson HB. Combined oral contraceptive use among women with hypertension: a systematic review. Contraception. 2006;73(2):179-188.
- Cardoso F, Polonia J, Santos A, Silva-Carvalho J, Ferreira-de-Almeida J. Low-dose oral contraceptives and 24-hour ambulatory blood pressure. Int J Gynecol Obstet. 1997;59(3):237–243.
- Centers for Disease Control and Prevention. Reproductive Health: Classifications for Combined Hormonal Contraceptives. https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/appendixD.html#mec_cardio. Accessed September 5, 2019.
- Dilshad H, Yousuf RI, Shoaib MH, Jamil S, Khatoon H. Cardiovascular disease risk associated with the long-term use of depot medroxyprogesterone acetate. Am J Med Sci. 2016;352(5):487-492.
- Dehlendorf C, Krajewski C, Borrero S. Contraceptive counseling: Best practices to ensure quality communication and enable effective contraceptive use. Clin Obstet Gynecol. 2014;57(4):659-673.