Hypertension medication and pregnancy
Lifestyle modifications such as weight loss (for overweight or obese patients), a heart-healthy diet, sodium reduction, increased physical activity, and limitation of alcohol consumption3 are recommended for first-line management of hypertension. The first-line pharmacologic classes of antihypertensives are thiazide diuretics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers, and calcium channel blockers.3 However, among women seeking pregnancy or who are currently pregnant, the preferred antihypertensive medications are methyldopa, nifedipine, and/or labetalol per the ACC/AHA.3 In clinical practice, methyldopa is less frequently used; per ACOG, it is less effective in the control of chronic hypertension and more likely to have side effects (drowsiness, headache, orthostatic hypotension).4 Women with hypertension should not be treated with ACE inhibitors, angiotensin receptor blockers, or direct renin inhibitors in pregnancy because of the risk of fetal renal damage.3 Exposure to these medications in the second and third trimesters is most concerning because of the risk of impaired fetal kidney function leading to oligohydramnios, which may in turn impair lung development. Data are less clear regarding exposure risk in the first trimester; however, most studies show a slight increased risk in congenital malformations with medications affecting the renin-angiotenin-aldosterone system.7
Hypertension is a risk factor for CVD, which itself is the top cause of death in the United States.8 Cardiovascular disorders are a top cause of maternal mortality in the United States and hypertensive disorders of pregnancy are specifically responsible for 9.4% of maternal deaths. Patients with a history of preeclampsia have quadruple the risk of developing chronic hypertension.8
Impact on pregnancy
Although most people with hypertension have no associated complications in pregnancy, hypertension is associated with increased risk for adverse health events as a result of pregnancy. In particular, chronic hypertension is associated with increased risk of gestational diabetes, postpartum hemorrhage, planned cesarean section, and preeclampsia.4 Given the increased risk of preeclampsia, women with chronic hypertension should initiate low-dose aspirin daily prior to 16 weeks’ gestation for preeclampsia prophylaxis per ACOG and the US Preventive Services Task Force.4,9 Chronic hypertension also carries fetal risks; growth restriction, stillbirth, and preterm birth are more common in pregnancies exposed to chronic hypertension.4 Both treated and untreated hypertension are associated with an increase in fetal congenital heart defects (RR 2, 95% CI [1.5-2.7] and RR 1.4, [1.2-1.7] respectively).10
- 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.