4/12/2015

Management of hypertension in pregnant and postpartum women

OfficialreprintfromUpToDate
www.uptodate.com2015UpToDate

Managementofhypertensioninpregnantandpostpartumwomen
Author
PhyllisAugust,MD,MPH

SectionEditors
CharlesJLockwood,MD,
MHCM
GeorgeLBakris,MD

DeputyEditor
VanessaABarss,MD,
FACOG

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Nov2015.|Thistopiclastupdated:Nov23,2015.
INTRODUCTIONTherearefourmajorhypertensivedisordersthatoccurinpregnantwomen:
PreeclampsiaeclampsiaPreeclampsiareferstothesyndromeofnewonsetofhypertensionandeither
proteinuriaorendorgandysfunction(table1)mostoftenafter20weeksofgestationinapreviously
normotensivewoman[1].Eclampsiaisdiagnosedwhenseizureshaveoccurred.
Chronic(preexisting)hypertensionChronichypertensionisdefinedassystolicpressure140mmHg
and/ordiastolicpressure90mmHgthatantedatespregnancy,ispresentbeforethe20thweekof
pregnancy,orpersistslongerthan12weekspostpartum.
PreeclampsiaeclampsiasuperimposeduponchronichypertensionPreeclampsiaeclampsia
superimposeduponchronichypertensionisdiagnosedwhenawomanwithchronichypertensiondevelops
worseninghypertensionwithnewonsetproteinuriaorotherfeaturesofpreeclampsia(eg,elevatedliver
enzymes,lowplateletcount).
GestationalhypertensionGestationalhypertensionreferstoelevatedbloodpressurefirstdetected
after20weeksofgestationintheabsenceofproteinuriaorotherdiagnosticfeaturesofpreeclampsia.
Overtime,somepatientswithgestationalhypertensionwilldevelopproteinuriaorendorgandysfunction
characteristicofpreeclampsia(table1)andbeconsideredpreeclamptic,whileotherswillbediagnosed
withpreexistinghypertensionbecauseofpersistentbloodpressureelevationpostpartum.
Thistopicwilldiscussthetreatmentofhypertensionrelatedtothesedisordersinpregnantandpostpartum
women.Otheraspectsofthesedisordersarereviewedinseparatetopics,including,butnotlimitedto:

(See"Preeclampsia:Clinicalfeaturesanddiagnosis".)
(See"Preeclampsia:Managementandprognosis".)
(See"Eclampsia".)
(See"Gestationalhypertension".)

GENERALAPPROACHThedecisiontotreathypertensionduringpregnancyshouldconsidertherisksand
benefitsforbothmotherandfetus.Thelevelofbloodpressureisthemostimportantfactor:Treatmentof
severehypertension(systolicBP160mmHgand/ordiastolicBP110mmHg)isalwaysrecommended
becauseitisbelievedtoreducetheriskofmaternalstroke.
Thedecisiontouseantihypertensivetherapyinwomenwithmild(systolic140to150mmHg,diastolic90to
100mmHg)tomoderate(systolic150to159mmHg,diastolic100to109mmHg)hypertensionandno
comorbiditiesislessclear.Untilrecently,maternalorfetalbenefitsfromtreatmentofmildtomoderate
hypertensionovertherelativelyshortdurationofafulltermpregnancyhadnotbeendemonstratedandthereis
someobservationalevidencethat,insomewomen,aggressiveloweringofbloodpressure,oreventhe
medicationsthemselves,caninhibitfetalgrowthandexposethefetustopotentiallyharmfulphysiological
effectsofthesedrugs.
Thefollowingdatahavebeeninterpretedasdemonstratingpotentialfetalharmofaggressiveloweringofblood
pressureduringpregnancy:
Ina2002metaregressionanalysisthatspecificallyevaluatedtheeffectofloweringmaternalblood
pressureonfetalweight,fetalgrowthappearedtobesignificantlyimpairedbythereductioninmean
http://www.uptodate.com/contents/managementofhypertensioninpregnantandpostpartumwomen?topicKey=OBGYN%2F6815&elapsedTim

1/21

4/12/2015

Management of hypertension in pregnant and postpartum women

arterialpressureinducedbyantihypertensivetherapy:A10mmHgfallinmeanarterialpressurewas
associatedwitha176gramdecreaseinbirthweight[2].Thiseffectwasunrelatedtothetypeof
hypertensionorchoiceofmedication.
However,concernsoverpotentialfetalharmfromantihypertensivetherapymayhavebeenexaggerated.
Emergingdatasuggestthattreatmentmaybeassociatedwithmaternalbenefits,withoutexcessrisktothe
fetus:
Ina2014metaanalysisthatevaluatedmaternalandfetaloutcomesin49randomizedtrialsoftreatment
versusnotreatmentofpregnantwomenwithmildtomoderatehypertension,treatmentdidnotresultin
eitherfetalbenefitorharm[3].Mildtomoderatehypertensionwasdefinedasbloodpressuresof140to
169/90to109mmHgrelatedtoanydiagnosticcategoryofpregnancyhypertension.Antihypertensive
therapysignificantlydecreasedtheincidenceofseverehypertensionby40to60percentandtheneedfor
additionalantihypertensivedrugsby40to70percentbutdidnotincreasethefrequencyofdeliveryofa
smallforgestationalageinfant.Italsodidnotsignificantlyreduceperinatalmortalityorfrequencyof
prematurity,preeclampsia,orabruptioplacentae.
Ina2015trialthatrandomlyassignedpregnantwomenwithgestationalorchronichypertensionto
diastolicbloodpressuretreatmenttargetsof85or100mmHg,therewerenodifferencesinmaternal,
fetal,orneonataloutcomesforthetwobloodpressuretargets,althoughfewerwomeninthelower
diastolicbloodpressuretargetgroupdevelopedseverehypertension[4].Themeandifferenceinblood
pressurebetweengroupswas4.6mmHgfordiastolicbloodpressureand5.8mmHgforsystolicblood
pressure.Importantly,therewerenoadversefetaleffectsinthoserandomizedtothelowertargetblood
pressure.
Aprudentapproachshouldalsoconsiderthepatientscomorbiditiesandsymptoms(eg,headaches,visual
disturbances)whendecidingwhethertotreatmildtomoderatehypertension.
AntihypertensivetherapyAllantihypertensivedrugscrosstheplacenta.Therearenodatafromlargewell
designedrandomizedtrialsonwhichtobaseastrongrecommendationforuseofonedrugoveranother.Data
regardingbothcomparativeefficacyinimprovingpregnancyoutcomeandfetalsafetyareinadequateforalmost
allantihypertensivedrugs.Addingtotheconfusioninthisareaaredatasuggestingthatwomenwithchronic
hypertension,eithertreatedoruntreated,areatincreasedriskofcongenitalmalformations,particularlycardiac
malformations,comparedwithnormotensivewomen.Ina2015systematicreviewofthisissueincluding16
studiesandfivemillionsubjects,theriskforcongenitalheartdisease(CHD)inoffspringoftreatedwomen
increasedby100percent(relativerisk[RR]2.095%CI1.52.7)andby40percentinuntreatedwomen(RR
1.495%CI1.21.7)[5].ThemagnitudeofeffectwasgenerallysimilaracrosssubtypesofCHDandacross
therangeofantihypertensiontherapieshowever,thedatawereinsufficienttoexcludemodestdifferences.
Theseresultsshouldbeinterpretedwithcaution,asneitheradoseresponserelationshipbetweenmaternal
hypertensionmedicationandCHDsnorsomepotentiallyimportantcharacteristicsofthepopulation(eg,
severityofhypertension)couldbeascertained.
OptionsThefollowingdrugsareeffectiveantihypertensiveagentswithanacceptablesafetyprofilein
pregnancy.Thechoiceofdrugdependsontheacuityandseverityofhypertensionandwhetherornot
parenteralororaltherapyisusedthesefactorsarediscussedbelow.(See'Managementofcommon
hypertensivedisordersduringpregnancy'below.)
MethyldopaMethyldopahasbeenwidelyusedinpregnantwomenanditslongtermsafetyforthe
fetushasbeendemonstrated[6,7],butitisonlyamildantihypertensiveagentandhasaslowonsetofaction
(threetosixhours).Manywomenwillnotachievebloodpressuregoalsonthisoralagentorarebotheredbyits
sedativeeffectathighdoses.
BetablockersIna2013systematicreviewof13populationbasedcasecontrolorcohortstudies
examiningtheriskofcongenitalmalformationsassociatedwithfirsttrimesteroralbetablockerexposure
comparedwithnoexposure,therewasnooverallincreaseinmajorcongenitalmalformations(OR0.90,95%CI
0.911.10)[8].Associationswithsomeorganspecificmalformationswereobserved:cardiovasculardefects
(OR2.0195%CI1.183.424studies),cleftlip/palate(OR3.1195%CI1.795.432studies),andneuraltube
defects(OR3.5695%CI1.1910.672studies).Furtherresearchisrequiredgiventhelimitationsofthese
http://www.uptodate.com/contents/managementofhypertensioninpregnantandpostpartumwomen?topicKey=OBGYN%2F6815&elapsedTim

2/21

4/12/2015

Management of hypertension in pregnant and postpartum women

data,includinginabilitytoanalyzedatabytypeofbetablocker,variabilityintimingofexposurewithinthefirst
trimester,differencesinindicationsforbetablockertherapy,andrecall,recording,publication,andsurvivor
biases.
Labetalolhasbothalphaandbetaadrenergicblockingactivity,andmaypreserveuteroplacentalbloodflowto
agreaterextentthantraditionalbetablockers.Ithasamorerapidonsetofactionthanmethyldopa(withintwo
hoursversusthreetosixhours).Randomizedtrialscomparinglabetaloltonicardipineormethyldopahave
shownthatlabetaloliseffectiveandgenerallysafeinpregnancy,althoughdataarelimited[9,10].Labetalolhas
beenassociatedwithmaternalhepatotoxicity,whichalthoughrare,isimportanttorecognizeasitmaybe
confusedwiththeelevatedliverenzymesoftheHELLP(Hemolysis,ElevatedLiverenzymes,andLow
Plateletcount)syndrome.Mostcasesarereversible,butfatalitieshavebeenreported[11].Aretrospective
populationbasedcohortstudyobservedslightlymoreadverseoutcomes(respiratorydistresssyndrome,
sepsis,seizure)amonginfantsexposedinuterotolabetalolthanthoseexposedtomethyldopa,butonlywhen
maternaltreatmentwasforchronichypertensionratherthananacutepregnancyrelatedhypertensivedisorder
[12].Thesefindingsmayberelatedtothedurationoftherapyinchronichypertensionanddifferencesin
baselinecharacteristicsofthemothersineachtreatmentgroup(eg,severityofhypertension,controlof
hypertension),variablesnotaccountedforintheanalysis.Labetalolmaybeadministeredorallyorparenterally.
Althoughlesswellstudiedinpregnantwomen,pindololandthelongactingformofmetoprololareacceptable
alternativeagents[13].
Thesafetyofbetaadrenergicblockersissomewhatcontroversialduetoreportsofprematurelabor,fetal
growthrestriction,andneonatalapnea,bradycardia,andhypoglycemia[7,12,14].Furthermore,myometrial
relaxationofthegraviduterusisabeta2receptormediatedprocess,andnonselectivebetaadrenergicblockers
(suchaspropranolol)maycounteracttheeffectofbeta2stimulation.Betaadrenergicblockersthatlackalpha
blockingproperties(eg,atenolol)havebeenassociatedwithlowerplacentalandfetalweightatdeliverywhen
usedearlyinpregnancy,andaregenerallyavoidedifaneffectivedrugwithabettersafetyprofileisavailable
[15].
CalciumchannelblockersCalciumchannelblockersappeartobesafeforuseinpregnancy
[16,17].Longactingnifedipine(30to90mgoncedailyassustainedreleasetablet,increaseat7to14day
intervals,maximumdose120mg/day)hasbeenusedwithoutmajorproblems[18].Althoughamlodipineis
widelyusedinnonpregnantindividualswithhypertension,therearesparsedataofitsuseinpregnancy[19].
Nondihydropyridinecalciumantagonistssuchasverapamilanddiltiazemhavebeenused,aswell,although
mostreportsintheliteratureareofsmallnumbersofwomen.
Wecautionagainsttheuseofimmediatereleaseoralnifedipine,althoughanAmericanCollegeofObstetricians
andGynecologistscommitteeopinionendorseditsuseasanoptionforemergenttreatmentofacute,severe
hypertensioninpregnancyorpostpartum(otheroptionsweresustainedreleasenifedipine,labetalol,and
hydralazine)[20].Inmostcasesuseofimmediatereleasenifedipinewillbesafeandwelltoleratedhowever,
thereisasmallriskofanacute,precipitousfallinbloodpressure,whichmayresultinareductionin
uteroplacentalperfusionandheadache.
Ina2014metaanalysisofsixtrialsoftreatmentofseverepregnancyassociatedhypertension,lessthan2
percentofwomentreatedwithnifedipinedevelopedhypotensionandshortactingnifidipine,parenteral
hydralazine,andlabetalolwereassociatedwithsimilarratesofadversematernalandfetaloutcomes[21].
HydralazineIntravenoushydralazinehasbeenusedextensivelyinthesettingofpreeclampsiafor
theacutetreatmentofseverehypertension.Althoughametaanalysisdemonstratedaslightlyincreasedrateof
adverseeventswithhydralazinecomparedtolabetalol,theevidencewasnotsufficienttomakeadefinitive
recommendationforonedrugovertheother[22].Hydralazinehasbeenwidelyusedformanyyearsinthe
settingofacutehypertensioninpregnancyandisanacceptableantihypertensivedruginthissetting[20,23].
However,thehypotensiveresponsetohydralazineislesspredictablethanthatseenwithotherparenteral
agents.Hydralazinecanalsobetakenorallyhowever,itcausesreflextachycardiaandfluidretention,which
limititsusefulnessinpregnancy.
ThiazidediureticsTheroleofthiazidediureticshasbeenasourceofcontroversy,althoughsome
guidelinessuggestthattheseagentscanbecontinuedinwomenwithchronichypertensionwhoweretaking
http://www.uptodate.com/contents/managementofhypertensioninpregnantandpostpartumwomen?topicKey=OBGYN%2F6815&elapsedTim

3/21

4/12/2015

Management of hypertension in pregnant and postpartum women

thempriortopregnancy[24].Significantvolumedepletionisnotlikelyinthissetting,sinceallofthefluidloss
occurswithinthefirsttwoweeksofuse,assumingthatdrugdoseanddietarysodiumintakearerelatively
constant.Diureticsarenotgenerallyusedinwomenwithpreeclampsiaunlesspulmonaryedemahas
developed.
ClonidineClonidinehasasimilarmechanismofactionasmethyldopaandcanbeaneffectivedrug
fortreatmentofmildhypertensioninpregnancy[2527].However,ithasbothersomesideeffectsandthe
possibilityofreboundhypertensionifitisstoppedsuddenly,sootheragentsarepreferred.Theauthorhas
prescribeditforrarepatientsinwhommethyldopa,nifedipine,andlabetalolcouldnotbeused.Because
clonidineisavailableasatransdermalpatch,itisparticularlyusefulforpatientswhocannottakeanoral
antihypertensivedrug.
Drugstoavoidinpregnancy
ACEinhibitors,ARBs,directrenininhibitorsAngiotensinconvertingenzyme(ACE)inhibitors,
angiotensinIIreceptorblockers(ARBs)anddirectrenininhibitorsarecontraindicatedatallstagesofpregnancy
becausetheyareassociatedwithsignificantfetalrenalabnormalitieswhenmaternalexposurehasbeeninthe
latterhalfofpregnancy,andfirsttrimesterexposurehasbeenassociatedwithfetalcardiacabnormalities.
Therefore,itisbesttoavoidinitiatingthesedrugsduringpregnancyandtodiscontinuetheseagentsinwomen
planningpregnancyandswitchtoanotheragent[28].(See"Angiotensinconvertingenzymeinhibitorsand
receptorblockersinpregnancy".)
NitroprussideLimitedclinicalexperience(22pregnancies[29])andthepossibilityoffetal
cyanidepoisoninghaverestrictedtheuseofnitroprussideinpregnancy.Nitroprusside(0.5to10mcg/kg/min)is
theagentoflastresortforurgentcontrolofrefractoryseverehypertensionitsuseshouldbelimitedtoashort
periodoftimeinanemergencysituation[20,29,30].
OptionsforbreastfeedingmothersBreastfeedingdoesnotincreasebloodpressureinnursingmothers.
Betaadrenergicblockersandcalciumchannelblockersenterbreastmilkhowever,mostappeartobesafe
duringlactation[31]andareconsidered"compatible"withbreastfeedingbyexperts(seeindividualdrugsinthe
drugdatabase).Itisprudenttoconsultwiththeinfantspediatricianbeforeinitiatingmaternalantihypertensive
drugs.
Withineachclassofantihypertensiveagents,physiciansshouldselectthemedicationwiththelowesttransfer
intohumanmilk.
Betablockersandalpha/betablockersPropranolol,metoprolol,andlabetalolhavethelowesttransfer
intomilk,withrelativeinfantdosesoflessthan2percent.Nonehasbeenassociatedwithadverse
eventsininfants.
Incontrast,atenololandacebutololarerelativelyextensivelyexcretedintobreastmilkandbetablockade
innursinginfantshasbeenreported[3234]therefore,otheragentsarepreferableforwomenwhoare
nursinganinfantlessthan3monthsofageorapreterminfant,orwhoaretakingahighmaternaldose.
Becausethereislittletonopublishedexperiencewithcarvedilolorbisoprololduringbreastfeeding,other
agentsmaybepreferred,especiallywhilenursinganewbornorpreterminfant.
CalciumchannelblockersDiltiazem,nifedipine,nicardipine,andverapamilareassociatedwitha
relativeinfantdoseoflessthan2percent.TheAmericanAcademyofPediatrics(AAP)listsallthreeas
compatiblewithbreastfeeding.
Angiotensinconvertingenzyme(ACE)inhibitorsThesedrugsaretransferredintomilkatverylow
levels.CaptoprilandenalaprilhavebeenreviewedbytheAAPandarecompatibleforuseinlactation.
However,newbornsmaybemoresusceptibletothehemodynamiceffectsofthesedrugs,suchas
hypotension,andsequelaesuchasoliguriaandseizures.Therefore,wesuggestthatthehemodynamic
statusoftheinfantbetakenintoaccountwhendecidingwhetherwomentakingthesedrugsshould
breastfeed.
ThereisnoinformationonuseofangiotensinIIreceptorblockersduringbreastfeeding.
http://www.uptodate.com/contents/managementofhypertensioninpregnantandpostpartumwomen?topicKey=OBGYN%2F6815&elapsedTim

4/21

4/12/2015

Management of hypertension in pregnant and postpartum women

DiureticsTheoretically,diureticsmayreducemilkvolume,buttheAAPconsiderstheirusecompatible
withbreastfeeding.
ActivityWedonotadvisebedrestformostpregnantwomenwithhypertension,particularlythosewith
stablechronichypertension.Restrictedactivityisdisruptiveformostwomenandcanbeassociatedwith
deconditioning,boneloss,andanincreasedriskofthromboembolicevents[35,36].Reducedactivity(including
bedrest)forwomenwithpreeclampsiamayimproveuteroplacentalbloodflowandpreventexacerbationof
hypertension,particularlyifbloodpressureisnotadequatelycontrolledhowever,thereisnoevidencethatit
significantlyimprovesmajormaternalorfetaloutcomes.Recommendationsforlevelofactivityshouldbe
individualizedforexample,awomanwithstablechronichypertensionearlyinpregnancyisunlikelytobenefit
frombedrest,whileawomanwithnewlydiagnosedpreeclampsiainthethirdtrimestershouldbeadvisedto
limitactivityifsheisbeingmanagedasanoutpatient.TheAmericanCollegeofObstetriciansand
Gynecologists(ACOG)counselwomenwithwellcontrolledchronichypertensionwhoareusedtoexercising
thattheycancontinuemoderateexerciseduringpregnancyintheabsenceofpregnancycomplications[1].
Therearenolargerandomizedtrialsthathaveevaluatedthebenefitsandrisksofbedrestinthemanagement
ofpregnantwomenwithhypertensionofanyetiology.A2005Cochranereviewofbedrestduringpregnancyfor
managementofhypertensionincludedonlyfourtrialswithatotalof449women[37].Twotrials(145women)
comparedstrictbedrestwithsomerestinhospitalforwomenwithproteinurichypertensionanddidnotfindany
differencesinoutcomebetweenthegroups.Theothertwotrials(304women)comparedsomebedrestin
hospitalwithroutineactivityathomeforwomenwithnonproteinurichypertensionandreportedsomebedrest
wasassociatedwithareducedriskofseverehypertension(1trial,218womenRR0.58,95%CI0.380.89)
andaborderlinereductioninriskofpretermbirth(1trial,218womenRR0.53,95%CI0.290.99).
DietAnormaldietwithoutsignificantsaltrestrictionisgenerallyadvised,assaltrestrictionmayinducelow
intravascularvolume[38].
MANAGEMENTOFCOMMONHYPERTENSIVEDISORDERSDURINGPREGNANCY
PreeclampsiaThedefinitivetreatmentofpreeclampsiaisdelivery,whichisalwaysbeneficialforthe
mother.Aslongasthegravidaremainsundelivered,sheisatincreasedriskofcomplicationssuchas
seizures,placentalabruption,thrombocytopenia,cerebralhemorrhage,pulmonaryedema,liverhemorrhage,
andacutekidneyinjury.Theriskofthesecomplicationssubsidesinthehoursafterdeliverysince
preeclampsiaresolvesafterdeliveryandlongtermsequelaearerare.However,deliverymaynotbebeneficial
forthefetusifitisbornpreterm.Althoughthefetusisatincreasedriskofintrauterinegrowthrestrictionand
stillbirthinthepreeclampticenvironment,conservativemanagement,includingantihypertensivetherapy,may
bepursuedinselectedcasestogainfetalmaturity.
Theclinicalfeatures,evaluation,andoverallmanagementofpreeclampsiaarereviewedseparately.(See
"Preeclampsia:Clinicalfeaturesanddiagnosis"and"Preeclampsia:Managementandprognosis".)
IndicationsforantihypertensivetherapyWedonotprescribeantihypertensivetherapyformild
hypertension,whichwedefineasbloodpressuresconsistentlylessthan150/100mmHg.Thebenefitof
antihypertensivetherapyinpregnantwomenwithmildhypertensionisareductioninriskofdevelopingsevere
hypertension[3],whichmaynotbesufficienttowarrantexposingthefetustothepotentialadverseeffects
fromthesedrugs[2](see'Generalapproach'above).Loweringbloodpressuredoesnotaffectthecourseof
preeclampsiabecausetheprimarypathogeneticprocessisanabnormalityoftheplacentalvasculaturethat
resultsinplacentalunderperfusion,which,inturn,leadstoreleaseoffactorsthatcausewidespreadmaternal
endothelialdysfunctionwithmultiorgandysfunction.(See"Preeclampsia:Pathogenesis".)
Severehypertensionshouldbetreatedtopreventmaternalvascularcomplications(eg,stroke,heartfailure).
Thereisnoconsensusastotheoptimalbloodpressurethresholdforinitiatingtherapy.Weinitiate
antihypertensivetherapyinadultwomenatsystolicpressures150mmHgordiastolicbloodpressures95to
100mmHg.Wemayinitiatetreatmentearlierinwomenwithsignsofcardiacdecompensationorcerebral
symptoms(eg,severeheadache,visualdisturbances,chestdiscomfort,shortnessofbreath,confusion)andin
youngerwomenwhosebaselinebloodpressureswerelow(lessthan90/75mmHg),butweacknowledgethat
thisrecommendationisnotstronglyevidencebased.Thereissomeevidencethatthepathophysiologyofthe
neurologicmanifestationsofeclampsiaissimilartothatoftheposteriorreversibleleukoencephalopathy
http://www.uptodate.com/contents/managementofhypertensioninpregnantandpostpartumwomen?topicKey=OBGYN%2F6815&elapsedTim

5/21

4/12/2015

Management of hypertension in pregnant and postpartum women

syndrome(PRES)[39].Ifthisisthecase,thenwomenwithpreeclampsiamaybemoresusceptibletothe
neurologicfeaturesofseverediseaseatlowerbloodpressures(eg,150mmHgsystolic).
Otherphysiciansbeginantihypertensivetreatmentwhensystolicpressureis160mmHgordiastolicpressure
is105to110mmHg[1,40].However,inananalysisof24womenwithstrokerelatedtopreeclampsia,4
percenthadsystolicbloodpressures>155mmHgand<160mmHg[40],whichsupportsourlowerthresholdfor
initiatingtherapy.Severesystolichypertensionappearstobemorepredictiveofadversecerebraleventsthan
severediastolichypertension.
Highqualityclinicaltrialsareneededtoclarifytheparametersforantihypertensiveuseinwomenwith
preeclampsia.Atpresent,thereisalackofhighqualityevidencetosupportpracticerecommendations
becausetheavailabletrialsarelimitedbyseveralfactors,includingdifferencesinbloodpressuremeasurement
techniques,diagnosticcriteria,etiologyofhypertension,andtargetbloodpressure.
ChoiceofdruganddoseTherearetwosettingsinwhichantihypertensivetherapyisusedin
preeclampsia:
Acutemanagementofseverehypertension,whichmayrequireparenteraltherapy,and
Longertermbloodpressurecontrolduringexpectantmanagementofseverepreeclampsia.(See
"Expectantmanagementofpreeclampsiawithseverefeatures".)
AcutetherapyWesuggestlabetalolorhydralazineasfirstlineagentsforacutetherapyofsevere
hypertension.A2013Cochranereviewofdrugsfortreatmentofveryhighbloodpressureinpregnancy
concludedthatthechoiceofantihypertensiveshoulddependontheclinician'sexperienceandfamiliaritywitha
particulardrug,withconsiderationofitsadverseeffectsandpatientpreferences,butnimodipine,diazoxide,and
ketanserinwereprobablybestavoided[41].A2014systematicreviewsuggestedthatoralnifedipineisan
acceptablealternativetoparenterallabetalolorhydralazineforseverehypertension[21].
LabetalolWerecommendintravenouslabetalolforfirstlinetherapybecauseitiseffective,hasarapid
onsetofaction,andagoodsafetyprofile.
Beginwith20mgintravenouslyover2minutesfollowedat10minuteintervalsbydosesof20to80mg
uptoamaximumtotalcumulativedoseof300mg.Asanexample,give20mg,then40mg,then80mg,
then80mg,then80mg.Aconstantinfusionof1to2mg/mincanbeusedinsteadofintermittenttherapy.
Thefallinbloodpressurebeginswithin5to10minutesandlastsfrom3to6hours.Continuouscardiac
monitoringisnotnecessaryroutinely,butshouldbeusedinpatientswithrelevantcomorbidities(eg,
coronaryarterydisease).
HydralazineBeginwith5mgintravenouslyover1to2minutesifthebloodpressuregoalisnot
achievedwithin20minutes,givea5to10mgbolusdependingupontheinitialresponse.Themaximum
bolusdoseis20mg.Ifatotaldoseof30mgdoesnotachieveoptimalbloodpressurecontrol,another
agentshouldbeused.Thefallinbloodpressurebeginswithin10to30minutesandlastsfrom2to4
hours.
CalciumchannelblockersSustainedreleasenifedipine(30mg)andimmediatereleasenicardipineare
otheroptions.Nicardipinecanbegivenintravenously.Experiencewiththesedrugsinpregnancyismore
limitedthanforlabetalolandhydralazinehowever,publishedexperienceshowedthattargetblood
pressurewasreachedwithin23minutesin70percentofpregnantpatientswithseverehypertensionand
91percentreachedtargetbloodpressurewithin130minutes,withnoseverematernalorfetalsideeffects
[42].Amorecompletereviewofdrugdosesandpotentialsideeffectsisdiscussedseparately.(See
"Drugsusedforthetreatmentofhypertensiveemergencies".)
Asdiscussedabove,wecautionagainsttheuseofimmediatereleaseoralnifedipine,althoughan
AmericanCollegeofObstetriciansandGynecologistscommitteeopinionendorseditsuseasanoption
foremergenttreatmentofacute,severehypertensioninpregnancyorpostpartum(otheroptionswere
sustainedreleasenifedipine,labetalol,andhydralazine)[20].Inmostcasesuseofimmediaterelease
nifedipinewillbesafeandwelltoleratedhowever,thereisariskofanacute,precipitousfallinblood
pressure,whichmayresultinareductioninuteroplacentalperfusionandheadache.
http://www.uptodate.com/contents/managementofhypertensioninpregnantandpostpartumwomen?topicKey=OBGYN%2F6815&elapsedTim

6/21

4/12/2015

Management of hypertension in pregnant and postpartum women

Ifused,acommondosefornifedipineis10mgorallyadministeredat20minuteintervalsuntilthetarget
bloodpressureisachieved.Inonetrialthatincluded30pregnantwomenwithsustainedsevere
hypertension(mean165/108mmHg),amedianoftwodoseswasrequiredforcontrolofbloodpressure
[43].
NitroglycerinNitroglycerin(glyceryltrinitrate)isagoodoptionfortreatmentofhypertensionassociated
withpulmonaryedema[38].Itisgivenasanintravenousinfusionof5mcg/minandgraduallyincreased
every3to5minutestoamaximumdoseof100mcg/min.
Rarely,bloodpressureisnotcontrolledwiththedrugregimensdescribedabove.Consultationwitha
hypertensionspecialist(availableathttp://www.ashus.org/PhysicianDirectory.aspx)isadvised.Optionsfor
secondlinetherapyincludelabetalolornicardipinebyinfusionpump[20].Nitroprussideisadministeredasa
lastresort.(See'Nitroprusside'above.)
LongtermoraltherapyOccasionally,preeclampticwomenwithseverehypertensionremotefrom
termarestabilizedandnotdeliveredimmediately.Oralantihypertensivetherapyisoftenindicatedforthese
patients(see"Expectantmanagementofpreeclampsiawithseverefeatures").Optionsfororalantihypertensive
therapyarethesameasforwomenwithpreexistinghypertension.(See'Choiceofdrug'below.)
TargetbloodpressureOurtargetbloodpressuresare130to150mmHgsystolicand80to100mmHg
diastolic.Therapiditywithwhichbloodpressureshouldbebroughttosafelevelsiscontroversial.Cerebralor
myocardialischemiaorinfarctioncanbeinducedbyaggressiveantihypertensivetherapyifthebloodpressure
fallsbelowtherangeatwhichtissueperfusioncanbemaintainedbyautoregulation.Therefore,reducingmean
arterialpressurebynomorethan25percentover2hoursandachievingatargetof130to150mmHgsystolic
and80to100mmHgdiastolicseemsreasonable[44].Weacknowledgethelackofclinicaltrialdatatosupport
theserecommendations,andtheneedtoindividualizetherapybaseduponmaternalandfetalfactors.(See
"Managementofsevereasymptomatichypertension(hypertensiveurgencies)inadults".)
GestationalhypertensionTheindicationsforandchoiceofantihypertensivetherapyinwomenwith
gestationalhypertensionarethesameasforwomenwithpreeclampsia.Theclinicalfeatures,evaluation,and
overallmanagementofthesepatientsarediscussedseparately.(See"Gestationalhypertension".)
Chronic(preexisting)hypertensionHypertensionwithorwithoutantihypertensivedrugtreatmentis
associatedwithadversepregnancyoutcome(eg,poorfetalgrowth,stillbirth,iatrogenicpretermbirth)and
accountsforasubstantialfractionofmaternalmorbidity(eg,pulmonaryedema,stroke,superimposed
preeclampsia,cesareandelivery)comparedwithnormotensivepregnancies[45].A2014systematicreviewof
studiesofpregnancyoutcomeinwomenwithchronichypertension,includingthosewithsuperimposed
preeclampsia,reportedthefollowingincidencesandriskratiosofcomplicationscomparedwiththegeneral
obstetricalpopulationoftheUnitedStates[46]:
Cesareandelivery42.4percent(95%CI35.050.1)RR1.3(95%CI1.11.5)
Pretermdelivery<37weeks33.0percent(95%CI23.744.0)RR2.7(95%CI1.93.6)
Superimposedpreeclampsia29.2percent(95%CI21.638.2)RR7.7(95%CI5.710.1)
Birthweight<2500grams22.2percent(95%CI15.430.9)RR2.7(95%CI1.93.8)
Neonatalintensivecare19.3percent(95%CI13.427.0)RR3.2(95%CI2.24.4)
Perinataldeath4.6percent(95%CI3.07.1)RR4.2(95%CI2.76.5)
Mostpregnancyoutcomestudieshavenotdistinguishedbetweenwomenwithchronichypertensionalone
versusthosewithchronichypertensionandsuperimposedpreeclampsia[47],orbetweenwomenwith
controlledversusuncontrolledhypertension.Theriskofadversepregnancyoutcomeincreaseswiththe
severityofhypertensionandpresenceofendorgandamage[48].Theabsoluterangesofriskforadverse
pregnancyoutcomesreportedinobservationalstudiesofwomenwithmildpreexistinghypertensionare[13]:
Superimposedpreeclampsia10to25percent(versus3to5percentinthegeneralobstetrical
population)
http://www.uptodate.com/contents/managementofhypertensioninpregnantandpostpartumwomen?topicKey=OBGYN%2F6815&elapsedTim

7/21

4/12/2015

Management of hypertension in pregnant and postpartum women

Abruptioplacentae0.7to1.5percent(versus1percentinthegeneralobstetricalpopulation)
Fetalgrowthrestriction8to16percent(versus10percentinthegeneralobstetricalpopulation)
Theseriskswereevenhigherinwomenwithseverepreexistinghypertensioninthefirsttrimester,andwere
highestforthosewithbothseverehypertensionandsuperimposedpreeclampsia:
Superimposedpreeclampsia50percent
Abruptioplacenta5to10percent
Pretermbirth62to70percent
Fetalgrowthrestriction31to40percent
Superimposedpreeclampsia,abruptioplacentae,andfetalgrowthrestrictionarecommonreasonsforiatrogenic
pretermdelivery.Twelveto34percentofwomenwithmildpreexistenthypertensiondeliverpreterm,oftenfor
theseindicationsandoftenrequiringcesareanbirth[13].
Despitetheserisks,thetreatmentofpreexistinghypertensionduringpregnancyiscontroversial.Beneficial
effectsoftreatmentappeartobelimitedtopreventionofmaternalmorbidityanddependupontheseverityof
thedisease.(See'Indicationsfortreatment'below.)
MaternalevaluationTheinitialevaluationofthehypertensivepatientisdescribedseparately.(See
"Initialevaluationofthehypertensiveadult".)
Althoughuncommon,nonobesewomenunderage30yearswithaconfirmednegativefamilyhistoryof
hypertensionmayhavesecondaryhypertension,socausesofsecondaryhypertensionshouldbeconsideredin
thosewithsuggestiveclinicalfeaturessuchassevereorresistanthypertension,acuteonsetofhypertension,
metabolicabnormalitiesassociatedwitheitherrenovascularhypertension(highplasmareninactivity)orprimary
aldosteronism(lowplasmareninactivity,lowserumpotassium),orprovenonsetofhypertensionbefore
puberty.(See"Evaluationofsecondaryhypertension".)
Baselinelaboratoryteststhathavebeenrecommendedforpregnantwomenwithhypertensioninclude[13]:

Urinalysis
Urineculture
Creatinine
Glucose
Electrolytes
Quantitativeanalysisofurineprotein

Thesetestswilleffectivelyscreenforthepresenceofrenaldisease,andwillalsoidentifyimportant
comorbidities,suchasdiabetesmellitus.Womenwithproteinuriaonaurinedipstickorurinalysisshouldhave
aquantitativetestfor24hoururineproteinexcretion.Anelectrocardiogramshouldbeobtainedinwomenwith
longstandinghypertension.Measurementofserumuricacidandliverenzymesisalsoreasonableinorderto
establishbaselinelevels,sincethesetestsareoftenusedintheevaluationofpreeclampsia.Sincebothhypo
andhyperthyroidismmaybeassociatedwithhypertension,itisreasonabletoassessthyroidfunction,
althoughvaluesshouldbeinterpretedwithcautionsincealterationsinthyroidstimulatinghormone(TSH)and
thyroidhormonelevelsarenotunusual,especiallyinearlypregnancy.
Theeffectsofpregnancyonmaternalrenaldiseaseandtheeffectofrenaldiseaseontheoutcomeof
pregnancyarediscussedindetailseparately.(See"Renalandurinarytractphysiologyinnormalpregnancy"
and"Pregnancyinwomenwithunderlyingrenaldisease".)
IndicationsfortreatmentInallpatients,amajorgoaloftreatmentofhypertensionistominimizethe
riskofcardiovascularorcerebrovascularevents.Untreatedmildhypertensionoverthecourseofapregnancy
isunlikelytoaffectthisrisk.Ontheotherhand,untreatedseverehypertension,evenovertheshortterm,may
beassociatedwithadverseoutcomes.
MildtomoderatechronichypertensioninpregnancyMildtomoderatechronichypertensionin
http://www.uptodate.com/contents/managementofhypertensioninpregnantandpostpartumwomen?topicKey=OBGYN%2F6815&elapsedTim

8/21

4/12/2015

Management of hypertension in pregnant and postpartum women

pregnancyisdefinedassystolicBP140to159mmHgordiastolic90to109mmHg.Thislevelofblood
pressurecorrespondsmostcloselytostage1primary(formerlyessential)hypertension(stage1definedas
systolic140to159mmHgordiastolic90to99mmHg).Theindicationsforinitiatingantihypertensivedrugsin
patientswithmildtomoderatehypertensioninpregnancywithoutevidenceoftargetorgandamagewhohave
notpreviouslybeentreatedorwhohavediscontinuedtherapyarenotclear.Neitherthepatientnorthefetus
appearstobeatriskfrommildlyelevatedbloodpressureduringpregnancy(systolic<150mmHg,diastolic
<100mmHg).Itisnotclearwhetherwomenwithmoderatelyelevatedbloodpressurelevels(systolicBP150
to160mmHgordiastolic100to109mmHg)havesimilarbenignoutcomes.Controlledtrials,whichhave
usuallyincludedwomenwithbothmildandmoderatehypertension,havenotdemonstratedthatloweringthe
bloodpressurewithantihypertensivemedicationsreducestheriskofpreeclampsiaorabruption,orimproves
fetalormaternaloutcome,althoughthesestudieshaveprobablynothadsufficientpowertomakedefinitive
conclusions[3].Itisclearfromsystematicreviewsthattherapydecreasestheincidenceofsevere
hypertension[3].Eightto13womenwouldneedtobetreatedwithanantihypertensivedrugtopreventone
episodeofseverehypertension.
Womenwithchronichypertensionwhoarenormotensiveormildlyhypertensiveonmedicationmaycontinue
theirtherapyorhavetheirantihypertensiveagentstaperedand/orstoppedduringpregnancy,withclose
monitoringofthematernalbloodpressureresponse[13,49].Thereisnoconsensusonthebestapproach.
Basedontheavailabledata,weavoidtreatmentofpregnantwomenwithmildhypertensionandnoevidenceof
targetorgandamage,especiallyinthefirsttrimester,sincebloodpressurenormallydecreasesaspregnancy
progressesintothesecondtrimester.Inwomenalreadyonantihypertensivetherapywhohaveearlypregnancy
bloodpressureslessthan120/80mmHg,wewouldconsidertapering/discontinuingantihypertensivedrugsand
closelymonitoringthebloodpressureresponse[49].Ourindicationsforinitiatingorreinstituting
antihypertensivetherapyarepersistentdiastolicpressuresof95to99mmHg,systolicpressures150mmHg,
orsignsofhypertensivetargetorgandamage.Thesethresholds,althoughnotinthesevererange,allow
nonemergentinterventionwithoraldrugswhilehypertensionisonlymoderatelyelevated.
Recommendationsfromvariousnationalorganizationsareprovidedbelow.(See'Recommendationsof
selectednationalandinternationalsocieties'below.)
ComplicatedandsecondaryhypertensionSubgroupsofwomenwithmildtomoderate
hypertensionappeartobeatgreaterriskofmaternalorfetalcomplicationsandmaybenefitfrom
antihypertensivetherapy.Wesuggesttreatmentofthesewomentoattainbloodpressuresof120to140/80to
90mmHgtheserecommendationsarenotbasedondatafromrandomizedtrials.Thesesubgroupsinclude
womenwith[13]:

Secondaryhypertension.
Targetorgandamage(eg,leftventricularhypertrophy,microalbuminuria,retinopathy).
Dyslipidemia.
Maternalageover40yearsold.
Historyofstroke.
Previousperinatalloss.
Diabetes.TheAmericanDiabetesAssociationsuggestsabloodpressuretargetof110to129/65to79
mmHginpregnantwomenwithdiabetesandchronichypertension[50].(See"Treatmentofhypertension
inpatientswithdiabetesmellitus".)

SeverehypertensionSeverehypertensioninpregnancy(bloodpressure160/110mmHg)shouldbe
treatedtoprotectthemotherfromseriouscomplications,suchasstroke,heartfailure,orrenalfailure.(See
"Moderatetoseverehypertensiveretinopathyandhypertensiveencephalopathyinadults".)
ChoiceofdrugOurpreferenceistostarttreatmentwitheithermethyldopaorlabetalol.Alongacting
calciumchannelblocker(eg,nifedipine)canbeaddedaseithersecondorthirdlinetreatment(table2).
BloodpressuregoalAreasonablegoalinwomenwithouttargetorgandamageissystolicpressure
between140and150mmHganddiastolicpressurebetween90and100mmHg[13,44].Inatrialthatrandomly
assignedpregnantwomenwithgestationalorchronichypertensiontodiastolicbloodpressuretreatmenttargets
http://www.uptodate.com/contents/managementofhypertensioninpregnantandpostpartumwomen?topicKey=OBGYN%2F6815&elapsedTim

9/21

4/12/2015

Management of hypertension in pregnant and postpartum women

of85or100mmHg,therewerenodifferencesinmaternal,fetal,orneonataloutcomesforthetwoblood
pressuretargets,althoughfewerwomeninthelowerdiastolicbloodpressuretargetgroupdevelopedsevere
hypertension[4].Themeandifferenceinbloodpressurebetweengroupswas4.6mmHgfordiastolicblood
pressureand5.8mmHgforsystolicbloodpressure.Importantly,therewerenoadversefetaleffectsinthose
randomizedtothelowertargetbloodpressure.Wehavenotchangedourbloodpressuretargetsbasedonthis
trialbecausemoreseverehypertensioninthe100mmHgtargetgroupwasnotassociatedwithanincreasein
transientischemicattackorstrokeandthistrialwasnotpoweredtoexcludeaclinicallyimportantincreasein
fetalgrowthrestrictioninthe85mmHgtargetgroup.(See'Generalapproach'above.)
Inwomenwithtargetorgandamage,itmaybedesirabletokeepthebloodpressurebelow140/90mmHg[13].
Currentlyunresolvediswhetherloweringbloodpressuretothe"normal"range(ie,120/80mmHg)wouldconfer
eithermaternalorfetalbenefits.
OthermanagementissuesAntepartumassessmentisdirectedtowardearlydiagnosisofpreeclampsia
andfetalgrowthrestriction.Thisisbestaccomplishedbyfrequentprenatalvisitsformonitoringmaternalblood
pressure,proteinuria,andfundalgrowthandbyperiodicsonographicestimationoffetalsize[13].
FetalevaluationThereisnoconsensusontheroleofantepartumfetalassessmentinmanagement
ofpregnanciescomplicatedbymildmaternalhypertension[44].Abaselineultrasoundexaminationat16to20
weeksofgestationisrecommendedtoconfirmgestationalage.Asecondultrasoundinthethirdtrimesteris
suggestedtoscreenforfetalgrowthrestriction[1].Thisavoidsuncertaintyaboutadiagnosisoffetalgrowth
delayversusincorrectestimationofthetimeofconceptionifalatepregnancysonogramshowsasmallfetus
[13].
Intheabsenceofsuperimposedpreeclampsiaorfetalgrowthrestriction,theneedfor,andfrequencyof,
antepartumfetalassessmentiscontroversial.Closefetalsurveillanceiswarrantedwhenthereisahigh
potentialforuteroplacentalvasculopathy,aswithsuperimposedpreeclampsiaorintrauterinegrowthrestriction.
Inthesecases,serialassessmentoffetalgrowthisindicated,withtwiceweeklynonstresstestingor
biophysicalprofileexamination,andDopplervelocimetryoftheumbilicalartery,inthelatterweeksof
pregnancy[1].(See"Fetalgrowthrestriction:Diagnosis"and"Dopplerultrasoundoftheumbilicalarteryfor
fetalsurveillance"and"Fetalgrowthrestriction:Evaluationandmanagement",sectionon'Pregnancy
management'.)
DeliveryTherearenorandomizedtrialsevaluatingtheoptimumtimefordeliveryinwomenwithpre
existinghypertension.AnexpertconsensuspanelandtheAmericanCollegeofObstetriciansand
Gynecologists(ACOG)suggestedthefollowingapproachforwomenwithchronichypertension:38to396/7ths
weeksofgestationforwomennotrequiringmedication,37to396/7thsweeksforwomenwithhypertension
controlledwithmedication,and36to376/7thsweeksforwomenwithseverehypertensiondifficulttocontrol
[51,52].Thisrecommendationwasbased,inpart,fromindirectevidencefromtheHypertensionand
PreeclampsiaInterventionTrialAtTerm(HYPITAT)trialinwhichwomenwithgestationalhypertensionormild
preeclampsiahadbettermaternaloutcomesandequivalentneonataloutcomeswithinductionat37weeks
comparedwithexpectantmanagement[53].TheACOGTaskForceonHypertensioninPregnancy
recommendsavoidingdeliverybefore380/7thsweeksinwomenwithuncomplicatedchronichypertensionin
whombloodpressureremainscontrolled[1].
Forwomenwithsuperimposedpreeclampsiaorotherpregnancycomplications(eg,fetalgrowthrestriction,
previousstillbirth,abruptioninthecurrentorpastpregnancy),thetimingofdeliveryshouldbedecidedona
casebycasebasisbasedonthetypeandseverityofthesecomplications.(See"Preeclampsia:Management
andprognosis"and"Placentalabruption:Management"and"Fetaldemiseandstillbirth:Incidence,etiology,
andprevention"and"Fetalgrowthrestriction:Evaluationandmanagement",sectionon'Timingdelivery'.)
PostpartumanalgesiaThedecisiontousenonsteroidalantiinflammatoryagentsforperipartum
analgesiashouldbeindividualized,asthesedrugsareknowntocauseelevationsinbloodpressureinnon
pregnantindividualswithhypertension.Ifbloodpressureiselevatedinthepostpartumperiod,werecommend
avoidingthesedrugs.
RECOMMENDATIONSOFSELECTEDNATIONALANDINTERNATIONALSOCIETIES
http://www.uptodate.com/contents/managementofhypertensioninpregnantandpostpartumwomen?topicKey=OBGYN%2F6815&elapsedTi

10/21

4/12/2015

Management of hypertension in pregnant and postpartum women

TheSocietyofObstetriciansandGynaecologistsofCanada(SOGC)guidelinerecommendsanti
hypertensivetreatmentfornewonsetsystolicbloodpressure>160mmHgordiastolicbloodpressure
>110mmHg,withgoalbloodpressure<160/110mmHg[30].Forwomenwithchronicnonsevere
hypertension(140159/90109mmHg)withoutcomorbidconditions,antihypertensivedrugtherapyshould
beusedtokeepsystolicbloodpressureat130to155mmHganddiastolicbloodpressureat80to105
mmHg.Forwomenwithchronicnonseverehypertensionwithcomorbidconditions,antihypertensivedrug
therapyshouldbeusedtokeepsystolicbloodpressure<140mmHganddiastolicbloodpressure<90
mmHg.
TheNationalInstituteforHealthandClinicalExcellence(NICE)recommendsthatforpregnantwomen
withuncomplicatedchronichypertensionthegoalistokeepbloodpressurelowerthan150/100mmHg
[54].Inwomenwithgestationalhypertensionorpreeclampsia,treatmentisinitiatedatbloodpressures
150/100mmHgwiththegoalofsystolicbloodpressures<150mmHganddiastolicbloodpressuresof
80to100mmHg.Theyalsorecommenduseoflowdoseaspirin(75mg/day)from12weeksofgestation
toreducetheriskofpreeclampsia.(See"Preeclampsia:Prevention",sectionon'Approachtotherapy'.)
TheAmericanCollegeofObstetriciansandGynecologists(ACOG)TaskForceonHypertensionin
Pregnancyrecommendstreatmentofpersistentchronichypertensionwhensystolicpressureis160
mmHgordiastolicpressureis105mmHgandsuggestsavoidingantihypertensivetherapyinwomen
withbloodpressuresbelowthislevelandnoevidenceofendorgandamage[1].Theysuggestlabetalol,
nifedipine,ormethyldopaasfirstlinetherapy.Theyalsosuggestavoidingangiotensinconvertingenzyme
inhibitors,angiotensinreceptorblockers,renininhibitors,andmineralocorticoidreceptorantagonists.The
goalofmanagementismaintenanceofbloodpressuresbetween120/80and160/105mmHg.
TheACOGCommitteeOpiniononemergenttherapyofacuteonsetseverehypertensioninpregnancy
andpostpartumrecommendstreatmentofacuteonset,severesystolic(160mmHg)hypertension,
severediastolic(110mmHg)hypertension,orbothtoachieveabloodpressureof140to150/90to100
mmHg[20].Theysuggestlabetalol,hydralazine,ororalnifedipineasfirstlinetherapyandprovideexplicit
treatmentguidelinesforloweringbloodpressure.Theyrecommendusingtheshortactingpreparationof
oralnifedipine,whichinourexperienceisassociatedwithmoresymptomatichypotensionandheadache
comparedwiththeextendedreleasepreparationwhichhasalsobeensuccessfullyusedinthissetting.
TheTaskForceontheManagementofCardiovascularDiseasesduringPregnancyoftheEuropean
SocietyofCardiology(ESC)recommendsthefollowing[38]:
Nonpharmacologicalmanagementforpregnantwomenwithsystolicbloodpressureof140to150
mmHgordiastolicbloodpressureof90to99mmHg
Inwomenwithgestationalhypertensionorpreexistinghypertensionsuperimposedbygestational
hypertensionorwithhypertensionandsubclinicalorgandamageorsymptomsatanytimeduring
pregnancy,initiationofdrugtreatmentisrecommendedatbloodpressureof140/90mmHg.Inany
othercircumstances,initiationofdrugtreatmentisrecommendedifsystolicbloodpressureis150
mmHgordiastolicbloodpressureis95mmHg.
Systolicbloodpressure170mmHgordiastolicbloodpressure110mmHginapregnantwomanis
anemergency,andhospitalizationisindicated.
TheAmericanHeartAssociation(AHA)/AmericanStrokeAssociation(ASA)madethefollowing
recommendations[55]:
Womenwithprimaryorsecondaryhypertensionorpreviouspregnancyrelatedhypertensionshould
takelowdoseaspirinduringpregnancytoreducetheriskofdevelopingpreeclampsia.Calcium
supplementationmaybeusefultodecreasebloodpressureandpreventpreeclampsiainwomen
withlowdietarycalciumintake.(See"Preeclampsia:Prevention".)
Severehypertensioninpregnancyshouldbetreatedwithmedicationssuchasmethyldopa,
labetalol,andnifedipine.Treatmentofmoderatehypertensionshouldbeconsideredtodecreasethe
riskofdevelopingseverehypertensiontheriskofstrokemayalsobedecreased.Highblood
http://www.uptodate.com/contents/managementofhypertensioninpregnantandpostpartumwomen?topicKey=OBGYN%2F6815&elapsedTi

11/21

4/12/2015

Management of hypertension in pregnant and postpartum women

pressurewasdefinedasmild(diastolic90to99mmHgorsystolic140to149mmHg),moderate
(diastolic100to109mmHgorsystolic150to159mmHg),orsevere(diastolic110mmHgor
systolic160mmHg).
POSTPARTUMHYPERTENSIONPostpartumhypertensionmaybeduetopersistenceofantepartumor
intrapartumhypertension,ormaybeofnewonset.Ithasbeenobservedinasmanyas20percentof
postpartumwomen[56]Preeclampsiarelatedhypertensionusuallyresolvesspontaneouslywithinafewweeks
(average169.5days)andisalmostalwaysgoneby12weekspostpartum[5759].However,somecases
maytakeaslongassixmonthstoresolve[57].Hypertensionthatpersistsbeyondthisperiodshouldbe
evaluatedandtreatedasinanynonpregnantwoman.(See"Hypertension:Whoshouldbetreated?".)
Bloodpressuremaybesignificantlyhigherintheimmediatepostpartumperiodthanantepartumorintrapartum.
Thismaybeduetoacombinationoffactors,includingadministrationofintravenousfluidstowomenwhohave
hadacesareandeliveryorneuraxialanesthesiaforlabor,lossofpregnancyassociatedvasodilationafter
delivery,mobilizationofextravascularfluidafterdelivery,andadministrationofnonsteroidalantiinflammatory
agentsforpostdeliveryanalgesia[56].Riskfactorsincludedahigherbodymassindexandhistoryofdiabetes
mellitus.
Newonsetpostpartumhypertensionmaybeduetoacombinationoffactors,includingadministrationofalarge
volumeofsalinesolutiontowomenwhohavehadacesareandeliveryorneuraxialanesthesiaforlabor,lossof
pregnancyassociatedvasodilationafterdelivery,mobilizationofextravascularfluidafterdelivery,
administrationofnonsteroidalantiinflammatoryagentsforpostdeliveryanalgesia,andsubclinicalpreeclampsia
[56,60].Ergotderivatives,whichareusedtotreatpostpartumhemorrhage,alsocausehypertension.Ifblood
pressuresareborderlinepriortodischarge,bloodpressuresshouldbefollowedcloselyafterdischargehome
bloodpressuremonitoringisuseful,ifpossible.Womenshouldbeadvisedtoseekmedicalattentionifthey
developsevereheadachesorifbloodpressureincreasestoseverelevels.
Womenwithnewonsetpostpartumhypertensionshouldbeevaluatedbyhistory(includingreviewof
postpartummedicationsandfluidbalance)andphysicalexamination.Thepresenceofneurologic,cardiac,or
gastrointestinalsymptomssuggestsadisorderotherthantransienthypertensionrelatedtofluidsand/or
medications[58].
NewonsetpostpartumhypertensionmaybeduetoonsetofpreeclampsiaorHELLPsyndromeafterdelivery
thesediagnosesaresupportedbylaboratoryevidenceofproteinuria,lowplatelets,and/orabnormalliver
enzymes.(See"Preeclampsia:Clinicalfeaturesanddiagnosis"and"Preeclampsia:Managementand
prognosis"and"HELLPsyndrome".)
Primaryaldosteronismisararecauseofpostpartumhypertension.Womenwiththisdisordermayhavelower
bloodpressureduringpregnancyduetothenatriureticeffectsofprogesterone,andmaypresentwithsignificant
postpartumhypertensionwithorwithouthypokalemia[61].(See"Pathophysiologyandclinicalfeaturesof
primaryaldosteronism".)
ManagementAntihypertensiveagentsshouldbeadministeredtowomenwithpersistentpostpartum
hypertension.Themajorityofpregnancyrelatedstrokesoccurinthefirst48hourspostpartum,with
hypertensionthestrongestriskfactor[62].Evidencetoguideoptimummanagementofpostpartum
hypertensionislimited[63].WerecommenddiscontinuingNSAIDsinwomenwhodeveloppostpartum
hypertension.Wealsorecommendinitiatingantihypertensivetherapyifbloodpressuresarepersistentlygreater
than140mmHgsystolicatthetimeofdischargefromthehospital.Oralmedicationssimilartothoseusedin
thenonpregnantpopulationcanbeprescribed,withmodificationsifthewomanisbreastfeeding(see'Options
forbreastfeedingmothers'above).Brieffurosemidetherapy(20mgorallyonceortwiceperdayforfivedays)
mayfacilitatereturntonormotensioninwomenwithsevere,butnotmild,preeclampsia,particularlythosewith
significantedema[64].Oneguidelinesuggestsavoidingmethyldopapostpartumbecauseoftheriskof
postnataldepression[38].Inwomenwithchronichypertension,antihypertensivedrugsshouldbecontinuedor
theprepregnancyregimenresumedafterdelivery,withdosageadjustmentstoreflectthedecreaseinvolumeof
distributionandglomerularfiltrationratethatoccursafterdelivery[55].Althoughrare,strokesassociatedwith
pregnancy(bothhemorrhagicandthrombotic)aremorelikelytooccurinthepostpartumperiod[62]thus
persistenthypertensionshouldnotbeignored.
http://www.uptodate.com/contents/managementofhypertensioninpregnantandpostpartumwomen?topicKey=OBGYN%2F6815&elapsedTi

12/21

4/12/2015

Management of hypertension in pregnant and postpartum women

Bloodpressureshouldbemonitoredclosely,ideallywithevaluationinthepatient'shomeafterdischarge,to
avoidhypotensionasthewoman'sbloodpressurereturnstohernormalbaselinelevel.Ifprepregnancyblood
pressurewasnormalandthepatientisnothypertensiveonmedication,itisreasonabletostopthe
antihypertensiveagentafterthreeweeksandmonitorbloodpressuretoassesswhetherfurthertreatmentis
indicated.
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,TheBasics
andBeyondtheBasics.TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6th
gradereadinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagiven
condition.Thesearticlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easytoread
materials.BeyondtheBasicspatienteducationpiecesarelonger,moresophisticated,andmoredetailed.
Thesearticlesarewrittenatthe10thto12thgradereadinglevelandarebestforpatientswhowantindepth
informationandarecomfortablewithsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthese
topicstoyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingon
patientinfoandthekeyword(s)ofinterest.)
Basicstopics(see"Patientinformation:Preeclampsia(TheBasics)"and"Patientinformation:Highblood
pressureandpregnancy(TheBasics)")
BeyondtheBasicstopics(see"Patientinformation:Preeclampsia(BeyondtheBasics)")
SUMMARYANDRECOMMENDATIONSWhenhypertensionisdiagnosedinapregnantwoman,themajor
issuesareestablishingadiagnosis,decidingthebloodpressureatwhichtreatmentshouldbeinitiatedandthe
targetbloodpressure,andavoidingdrugsthatmayadverselyaffectthefetus.
Incontrasttononpregnantindividualsinwhombloodpressureisstagedasnormal,prehypertension,orstage1
or2,bloodpressureinpregnantwomeniseithernormal(<140/90mmHg),mildtomoderatehypertension(140
to159/90to109mmHg),orseverehypertension(160/110mmHg).
Treatmentofseverehypertensionhasawellestablishedmaternalbenefitofreductioninstrokerisk,butthere
isnoprovenmaternalorfetalbenefitfromtreatmentofmildtomoderatehypertensionovertherelativelyshort
durationofafulltermpregnancy.Inaddition,loweringmaternalbloodpressureexcessivelymaybeassociated
withdecreasedplacentalperfusion,andexposureofthefetustopotentiallyharmfuleffectsofmedications.
(See'Generalapproach'above.)
Angiotensinconvertingenzymeinhibitors,angiotensinIIreceptorblockers,anddirectrenininhibitorsare
contraindicatedatallstagesofpregnancy.(See'ACEinhibitors,ARBs,directrenininhibitors'above.)
Preeclampsia
Wesuggestavoidingantihypertensivetherapyformildhypertensionassociatedwithpreeclampsia(Grade
2B).Therearenoprovenbenefitstomotherorfetus,otherthanreductioninriskofseverematernal
hypertension,andweareconcernedaboutpotentialadversefetaleffects(see'Generalapproach'above
and'Indicationsforantihypertensivetherapy'above).Moderatehypertensionistreatedonacasebycase
basis,suchasinwomenwithworrisomecerebrovascularsymptomsorevidenceoftargetorgandamage.
Werecommendtreatmentofseverehypertension(Grade1B).Thegoaloftreatmentistoprevent
maternalcerebrovascularcomplications.Weinitiateantihypertensivetherapyinadultwomenatsystolic
pressures150mmHganddiastolicbloodpressures100mmHg.Weinitiatetreatmentatalower
thresholdinyoungerwomenwhosebaselinebloodpressurewaslow,andinthosewithsymptomsthat
maybeattributabletoelevatedbloodpressure(eg,headache,visualdisturbances,chestdiscomfort).
Otherorganizations,suchastheAmericanCollegeofObstetriciansandGynecologists(ACOG),have
recommendedtreatmentofhypertensionwhensystolicbloodpressureis160mmHg.(See'Indications
forantihypertensivetherapy'above.)
Foracutebloodpressuretherapy,werecommendintravenouslabetalol(Grade2B)orhydralazine.(See
http://www.uptodate.com/contents/managementofhypertensioninpregnantandpostpartumwomen?topicKey=OBGYN%2F6815&elapsedTi

13/21

4/12/2015

Management of hypertension in pregnant and postpartum women

'Acutetherapy'above.)
Forpatientsreceivingantihypertensivedrugs,ourtargetbloodpressuregoalissystolicpressureof140to
150mmHganddiastolicpressureof90to100mmHg.(See'Targetbloodpressure'above.)
Chronic(preexisting)hypertension
Forpregnantwomenwithuncomplicatedmildprimaryhypertension:
Wesuggestnotinitiatingantihypertensivedrugtreatment(Grade2B)andtaperingandeventually
discontinuingantihypertensivedrugtreatmentinwomenalreadyontherapy(Grade2C),while
closelymonitoringthebloodpressureresponse.Therearenoprovenmaternalorfetalbenefitsfrom
therapyofmildhypertension,otherthanareductioninriskofdevelopingseverehypertension,and
thereissomeconcernaboutpotentialadverseeffectsoftreatmentonfetalgrowth.(See'General
approach'aboveand'Mildtomoderatechronichypertensioninpregnancy'above.)
Weinitiateorresumeantihypertensivetherapyinpregnantwomenwithpersistentsystolic
pressures150mmHg,diastolicpressures95to99mmHg,orinthosewithlowerpressuresand
signsofhypertensiveendorgandamage(Grade2C).Thesethresholdsallownonemergency
interventionwithoraldrugswhilehypertensionisonlymoderatelyelevated.Otherclinicianslimit
antihypertensivedrugtreatmenttopregnantwomenwithseverehypertension(bloodpressure
160/110mmHg),sincethereisconsensusthatinterventionatthislevelhasaprovenbenefitof
protectingthemotherfromseriouscomplications,suchasstroke,heartfailure,orrenalfailure.(See
'Mildtomoderatechronichypertensioninpregnancy'aboveand'Severehypertension'above.)
Wesuggestantihypertensivetherapywitheithermethyldopaorlabetalol(Grade2B).Alongacting
calciumchannelblocker(eg,nifedipine)canbeaddedifneeded.(See'Choiceofdrug'above.)
Ourtreatmenttargetissystolicpressure140to150mmHganddiastolicpressure90to100mmHg.
(See'Bloodpressuregoal'above.)
Forpregnantwomenwithcomplicatedorsecondaryhypertension(eg,targetorgandamage[left
ventricularhypertrophy,microalbuminuria,retinopathy],dyslipidemia,maternalageover40years,history
ofstroke,previousperinatalloss,diabetes),wesuggesttreatmentofhypertension,evenifmild.Our
treatmenttargetissystolicpressure120to140mmHganddiastolicpressure80to90mmHg.(See
'Complicatedandsecondaryhypertension'above.)
Postpartumhypertension
Bloodpressuremaybesignificantlyhigherintheimmediatepostpartumperiodthanantepartumor
intrapartum.Thismaybeduetopreeclampsia,intrapartumadministrationofintravenousfluids,lossof
pregnancyassociatedvasodilationafterdelivery,mobilizationofextracellularfluidafterdelivery,
administrationofnonsteroidalantiinflammatoryagentsforpostdeliveryanalgesia,oradministrationof
ergotderivativestotreatpostpartumhemorrhage.(See'Postpartumhypertension'above.)
Treatmentisindicatedforpersistenthypertensionandconsiderationshouldbegiventoinitiatingtherapy
wellbeforelevelsreachthesevererange,especiallysinceconcernsregardingplacentalperfusionareno
longerrelevant.Oralmedicationssimilartothoseusedinthenonpregnantpopulationcanbeprescribed,
withmodificationsifthewomanisbreastfeeding.(See'Management'aboveand'Optionsfor
breastfeedingmothers'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
REFERENCES
1. AmericanCollegeofObstetriciansandGynecologists,TaskForceonHypertensioninPregnancy.
Hypertensioninpregnancy.ReportoftheAmericanCollegeofObstetriciansandGynecologistsTask
ForceonHypertensioninPregnancy.ObstetGynecol2013122:1122.
2. vonDadelszenP,MageeLA.Fallinmeanarterialpressureandfetalgrowthrestrictioninpregnancy
http://www.uptodate.com/contents/managementofhypertensioninpregnantandpostpartumwomen?topicKey=OBGYN%2F6815&elapsedTi

14/21

4/12/2015

Management of hypertension in pregnant and postpartum women

hypertension:anupdatedmetaregressionanalysis.JObstetGynaecolCan200224:941.
3. AbalosE,DuleyL,SteynDW.Antihypertensivedrugtherapyformildtomoderatehypertensionduring
pregnancy.CochraneDatabaseSystRev20142:CD002252.
4. MageeLA,vonDadelszenP,ReyE,etal.Lesstightversustightcontrolofhypertensioninpregnancy.
NEnglJMed2015372:407.
5. RamakrishnanA,LeeLJ,MitchellLE,AgopianAJ.MaternalHypertensionDuringPregnancyandthe
RiskofCongenitalHeartDefectsinOffspring:ASystematicReviewandMetaanalysis.PediatrCardiol
201536:1442.
6. CockburnJ,MoarVA,OunstedM,RedmanCW.Finalreportofstudyonhypertensionduringpregnancy:
theeffectsofspecifictreatmentonthegrowthanddevelopmentofthechildren.Lancet19821:647.
7. XieRH,GuoY,KrewskiD,etal.Betablockersincreasetheriskofbeingbornsmallforgestationalage
orofbeinginstitutionalisedduringinfancy.BJOG2014121:1090.
8. YakoobMY,BatemanBT,HoE,etal.Theriskofcongenitalmalformationsassociatedwithexposureto
blockersearlyinpregnancy:ametaanalysis.Hypertension201362:375.
9. PeacockWF4th,HillemanDE,LevyPD,etal.Asystematicreviewofnicardipinevslabetalolforthe
managementofhypertensivecrises.AmJEmergMed201230:981.
10. MolviSN,MirS,RanaVS,etal.Roleofantihypertensivetherapyinmildtomoderatepregnancyinduced
hypertension:aprospectiverandomizedstudycomparinglabetalolwithalphamethyldopa.ArchGynecol
Obstet2012285:1553.
11. ClarkJA,ZimmermanHJ,TannerLA.Labetalolhepatotoxicity.AnnInternMed1990113:210.
12. XieRH,GuoY,KrewskiD,etal.Associationbetweenlabetaloluseforhypertensioninpregnancyand
adverseinfantoutcomes.EurJObstetGynecolReprodBiol2014175:124.
13. SibaiBM.Chronichypertensioninpregnancy.ObstetGynecol2002100:369.
14. HeidaKY,ZeemanGG,VanVeenTR,HulzebosCV.Neonatalsideeffectsofmaternallabetalol
treatmentinseverepreeclampsia.EarlyHumDev201288:503.
15. LydakisC,LipGY,BeeversM,BeeversDG.Atenololandfetalgrowthinpregnanciescomplicatedby
hypertension.AmJHypertens199912:541.
16. MageeLA,DuleyL.Oralbetablockersformildtomoderatehypertensionduringpregnancy.Cochrane
DatabaseSystRev2003:CD002863.
17. BatemanBT,HuybrechtsKF,MaedaA,etal.CalciumChannelBlockerExposureinLatePregnancyand
theRiskofNeonatalSeizures.ObstetGynecol2015126:271.
18. SmithP,AnthonyJ,JohansonR.Nifedipineinpregnancy.BJOG2000107:299.
19. AhnHK,NavaOcampoAA,HanJY,etal.Exposuretoamlodipineinthefirsttrimesterofpregnancyand
duringbreastfeeding.HypertensPregnancy200726:179.
20. CommitteeonObstetricPractice.CommitteeOpinionNo.623:Emergenttherapyforacuteonset,severe
hypertensionduringpregnancyandthepostpartumperiod.ObstetGynecol2015125:521.
21. FirozT,MageeLA,MacDonellK,etal.Oralantihypertensivetherapyforseverehypertensionin
pregnancyandpostpartum:asystematicreview.BJOG2014121:1210.
22. MageeLA,ChamC,WatermanEJ,etal.Hydralazinefortreatmentofseverehypertensioninpregnancy:
metaanalysis.BMJ2003327:955.
23. AmericanCollegeofObstetriciansandGynecologists.Diagnosisandmanagementofpreeclampsiaand
eclampsia.ACOGpracticebulletin#33.AmericanCollegeofObstetriciansandGynecologists,
Washington,DC2002.ObstetGynecol2002.
24. CollinsR,YusufS,PetoR.Overviewofrandomisedtrialsofdiureticsinpregnancy.BrMedJ(ClinRes
Ed)1985290:17.
25. PhippardAF,FischerWE,HorvathJS,etal.Earlybloodpressurecontrolimprovespregnancyoutcome
inprimigravidwomenwithmildhypertension.MedJAust1991154:378.
26. RothbergerS,CarrD,BratengD,etal.Pharmacodynamicsofclonidinetherapyinpregnancy:a
heterogeneousmaternalresponseimpactsfetalgrowth.AmJHypertens201023:1234.
27. HorvathJS,PhippardA,KordaA,etal.Clonidinehydrochlorideasafeandeffectiveantihypertensive
agentinpregnancy.ObstetGynecol198566:634.
28. CooperWO,HernandezDiazS,ArbogastPG,etal.Majorcongenitalmalformationsafterfirsttrimester
exposuretoACEinhibitors.NEnglJMed2006354:2443.
29. SassN,ItamotoCH,SilvaMP,etal.Doessodiumnitroprussidekillbabies?Asystematicreview.Sao
http://www.uptodate.com/contents/managementofhypertensioninpregnantandpostpartumwomen?topicKey=OBGYN%2F6815&elapsedTi

15/21

4/12/2015

Management of hypertension in pregnant and postpartum women

PauloMedJ2007125:108.
30. MageeLA,PelsA,HelewaM,etal.Diagnosis,evaluation,andmanagementofthehypertensive
disordersofpregnancy:executivesummary.JObstetGynaecolCan201436:416.
31. BeardmoreKS,MorrisJM,GalleryED.Excretionofantihypertensivemedicationintohumanbreastmilk:
asystematicreview.HypertensPregnancy200221:85.
32. BoutroyMJ,BianchettiG,DubrucC,etal.Tonursewhenreceivingacebutolol:isitdangerousforthe
neonate?EurJClinPharmacol198630:737.
33. SchimmelMS,EidelmanAI,WilschanskiMA,etal.Toxiceffectsofatenololconsumedduringbreast
feeding.JPediatr1989114:476.
34. DrugsandLactationDatabase(LactMed)http://toxnet.nlm.nih.gov/(AccessedonJuly02,2014).
35. MaloniJA.Lackofevidenceforprescriptionofantepartumbedrest.ExpertRevObstetGynecol2011
6:385.
36. AbdulSultanA,WestJ,TataLJ,etal.Riskoffirstvenousthromboembolisminpregnantwomenin
hospital:populationbasedcohortstudyfromEngland.BMJ2013347:f6099.
37. MeherS,AbalosE,CarroliG.Bedrestwithorwithouthospitalisationforhypertensionduringpregnancy.
CochraneDatabaseSystRev2005:CD003514.
38. EuropeanSocietyofGynecology(ESG),AssociationforEuropeanPaediatricCardiology(AEPC),
GermanSocietyforGenderMedicine(DGesGM),etal.ESCGuidelinesonthemanagementof
cardiovasculardiseasesduringpregnancy:theTaskForceontheManagementofCardiovascular
DiseasesduringPregnancyoftheEuropeanSocietyofCardiology(ESC).EurHeartJ201132:3147.
39. BrewerJ,OwensMY,WallaceK,etal.Posteriorreversibleencephalopathysyndromein46of47
patientswitheclampsia.AmJObstetGynecol2013208:468.e1.
40. MartinJNJr,ThigpenBD,MooreRC,etal.Strokeandseverepreeclampsiaandeclampsia:aparadigm
shiftfocusingonsystolicbloodpressure.ObstetGynecol2005105:246.
41. DuleyL,MeherS,JonesL.Drugsfortreatmentofveryhighbloodpressureduringpregnancy.Cochrane
DatabaseSystRev20137:CD001449.
42. NijBijvankSW,DuvekotJJ.Nicardipineforthetreatmentofseverehypertensioninpregnancy:areview
oftheliterature.ObstetGynecolSurv201065:341.
43. ShekharS,SharmaC,ThakurS,VermaS.Oralnifedipineorintravenouslabetalolforhypertensive
emergencyinpregnancy:arandomizedcontrolledtrial.ObstetGynecol2013122:1057.
44. VisintinC,MugglestoneMA,AlmerieMQ,etal.Managementofhypertensivedisordersduring
pregnancy:summaryofNICEguidance.BMJ2010341:c2207.
45. OrbachH,MatokI,GorodischerR,etal.Hypertensionandantihypertensivedrugsinpregnancyand
perinataloutcomes.AmJObstetGynecol2013208:301.e1.
46. BramhamK,ParnellB,NelsonPiercyC,etal.Chronichypertensionandpregnancyoutcomes:
systematicreviewandmetaanalysis.BMJ2014348:g2301.
47. BatemanBT,BansilP,HernandezDiazS,etal.Prevalence,trends,andoutcomesofchronic
hypertension:anationwidesampleofdeliveryadmissions.AmJObstetGynecol2012206:134.e1.
48. AnkumahNA,CantuJ,JaukV,etal.Riskofadversepregnancyoutcomesinwomenwithmildchronic
hypertensionbefore20weeksofgestation.ObstetGynecol2014123:966.
49. NakhaiPourHR,ReyE,BrardA.Discontinuationofantihypertensivedruguseduringthefirsttrimester
ofpregnancyandtheriskofpreeclampsiaandeclampsiaamongwomenwithchronichypertension.AmJ
ObstetGynecol2009201:180.e1.
50. AmericanDiabetesAssociation.(12)Managementofdiabetesinpregnancy.DiabetesCare201538
Suppl:S77.
51. SpongCY,MercerBM,D'altonM,etal.Timingofindicatedlatepretermandearlytermbirth.Obstet
Gynecol2011118:323.
52. AmericanCollegeofObstetriciansandGynecologists.ACOGcommitteeopinionno.560:Medically
indicatedlatepretermandearlytermdeliveries.ObstetGynecol2013121:908.
53. KoopmansCM,BijlengaD,GroenH,etal.Inductionoflabourversusexpectantmonitoringfor
gestationalhypertensionormildpreeclampsiaafter36weeks'gestation(HYPITAT):amulticentre,open
labelrandomisedcontrolledtrial.Lancet2009374:979.
54. NationalCollaboratingCentreforWomen'sandChildren'sHealth.Hypertensioninpregnancy.The
managementofhypertensivedisordersduringpregnancy.London(UK):NationalInstituteforHealthand
ClinicalExcellence(NICE)2010Aug.46p.(Clinicalguidelineno.107).
http://www.uptodate.com/contents/managementofhypertensioninpregnantandpostpartumwomen?topicKey=OBGYN%2F6815&elapsedTi

16/21

4/12/2015

Management of hypertension in pregnant and postpartum women

http://www.guideline.gov/content.aspx?id=24122.
55. BushnellC,McCulloughLD,AwadIA,etal.Guidelinesforthepreventionofstrokeinwomen:a
statementforhealthcareprofessionalsfromtheAmericanHeartAssociation/AmericanStroke
Association.Stroke201445:1545.
56. GoelA,MaskiMR,BajracharyaS,etal.EpidemiologyandMechanismsofDeNovoandPersistent
HypertensioninthePostpartumPeriod.Circulation2015.
57. PodymowT,AugustP.Postpartumcourseofgestationalhypertensionandpreeclampsia.Hypertens
Pregnancy201029:294.
58. SibaiBM.Etiologyandmanagementofpostpartumhypertensionpreeclampsia.AmJObstetGynecol
2012206:470.
59. MikamiY,MatsumotoT,KanoK,etal.Currentstatusofdrugtherapiesforosteoporosisandthesearch
forstemcellsadaptedforboneregenerativemedicine.AnatSciInt201489:1.
60. MakrisA,ThorntonC,HennessyA.Postpartumhypertensionandnonsteroidalanalgesia.AmJObstet
Gynecol2004190:577.
61. Podymow,T,Brucculeri,M,August,P.PrimaryHyperaldosteronisminPregnancy:aCaseSeries.
HypertensioninPregnancy200625:24.
62. KuklinaEV,TongX,BansilP,etal.Trendsinpregnancyhospitalizationsthatincludedastrokeinthe
UnitedStatesfrom1994to2007:reasonsforconcern?Stroke201142:2564.
63. MageeL,vonDadelszenP.Preventionandtreatmentofpostpartumhypertension.CochraneDatabase
SystRev20134:CD004351.
64. AscarelliMH,JohnsonV,McCrearyH,etal.Postpartumpreeclampsiamanagementwithfurosemide:a
randomizedclinicaltrial.ObstetGynecol2005105:29.
Topic6815Version67.0

http://www.uptodate.com/contents/managementofhypertensioninpregnantandpostpartumwomen?topicKey=OBGYN%2F6815&elapsedTi

17/21

4/12/2015

Management of hypertension in pregnant and postpartum women

GRAPHICS
Criteriaforthediagnosisofpreeclampsia
Systolicbloodpressure140mmHgordiastolicbloodpressure90mmHgontwooccasionsat
leastfourhoursapartafter20weeksofgestationinapreviouslynormotensivepatient
Ifsystolicbloodpressureis160mmHgordiastolicbloodpressureis110mmHg,
confirmationwithinminutesissufficient
and
Proteinuria0.3gramsina24hoururinespecimenorprotein(mg/dL)/creatinine(mg/dL)
ratio0.3
Dipstick1+ifaquantitativemeasurementisunavailable
Inpatientswithnewonsethypertensionwithoutproteinuria,thenewonsetofany
ofthefollowingisdiagnosticofpreeclampsia:
Plateletcount<100,000/microliter
Serumcreatinine>1.1mg/dLordoublingofserumcreatinineintheabsenceofotherrenal
disease
Livertransaminasesatleasttwicethenormalconcentrations
Pulmonaryedema
Cerebralorvisualsymptoms
Adaptedfrom:Hypertensioninpregnancy:ReportoftheAmericanCollegeofObstetriciansand
Gynecologists'TaskForceonHypertensioninPregnancy.ObstetGynecol2013122:1122.
Graphic79977Version9.0

http://www.uptodate.com/contents/managementofhypertensioninpregnantandpostpartumwomen?topicKey=OBGYN%2F6815&elapsedTi

18/21

4/12/2015

Management of hypertension in pregnant and postpartum women

Drugdosesfororaltreatmentofhypertensioninpregnancy

Drug
Methyldopa

Class
Centrallyacting
alphaagonist

Initialdose
250mgtwoto
threetimes
daily,increase

Usual
effective
doserange

Maximum
totaldaily
dose

250to1000mg
intwotothree
divideddoses

3000mg

2400mg

everytwodays
asneeded*
Labetalol

Nifedipine
extended
release

Combinedalpha

100mgtwo

200to800mg

andbetablocker

timesdaily,
increaseby100
mgtwicedaily
everytwoto
threedaysas
needed

intwodivided
doses

Calciumchannel
blocker

30to60mg
oncedailyasan
extendedrelease

30to90mg
oncedaily

120mg

200mg

tablet,increase
at7to14day
intervals
Hydralazine

Peripheral

Beginwith10

50to100mgin

NOTE:Dueto
reflex
tachycardia,
monotherapy

vasodilator

mgfourtimes
perday,increase
by10to25
mg/doseevery2
to5days

twotofour
divideddoses

withoral
hydralazineis
not
recommended
hydralazinemay
becombined
withmethyldopa
orlabetalolif
neededasadd
ontherapy

*Thefullhypotensiveeffectofaninitialdoseoradjustmentofmethylodopamaynotoccuruntilafter
2to3daysofcontinuoususe.
Useofimmediatereleasenifedipine(oralorsublingual)isnotrecommendedbecauseitmaycause
significantrapiddecreasesinbloodpressure.
Chronichydralazinedosesabove100mgdailyareassociatedwithanincreasedriskfordeveloping
lupuserythematosus,particularlyinwomenandslowacetylatorsascertainmentofacetylatorstatus
isrecommendedbeforeincreasingdoseabove100mgperdayinmanycountries.
Adaptedfrom:
1. SeelyEW,EckerJ.Chronichypertensioninpregnancy.NEnglJMed2011365:439.
2. MageeLA.Treatinghypertensioninwomenofchildbearingageandduringpregnancy.Drug
http://www.uptodate.com/contents/managementofhypertensioninpregnantandpostpartumwomen?topicKey=OBGYN%2F6815&elapsedTi

19/21

4/12/2015

Management of hypertension in pregnant and postpartum women

Saf200124:457.
Graphic55212Version7.0

http://www.uptodate.com/contents/managementofhypertensioninpregnantandpostpartumwomen?topicKey=OBGYN%2F6815&elapsedTi

20/21

4/12/2015

Management of hypertension in pregnant and postpartum women

Disclosures
Disclosures:PhyllisAugust,MD,MPHNothingtodisclose.CharlesJLockwood,MD,MHCM
Consultant/AdvisoryBoards:Celula[Aneuploidyscreening(PrenatalandcancerDNAscreeningtests
indevelopment)].GeorgeLBakris,MDGrant/Research/ClinicalTrialSupport:Bayer,Boeringher
Ingelheim,Relypsa,VascularDynamics,Medtronic[diabeticneuropathy,diabetes,hypertension
(empagliflozin,patriromer)].Consultant/AdvisoryBoards:AstraZeneca,ArborPharma,Bayer,
BoeringherIngelheim,Relypsa,VascularDynamics,Medtronic[diabeticneuropathy,diabetes,
hypertension(empagliflozin,patriromer)].VanessaABarss,MD,FACOGNothingtodisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,these
areaddressedbyvettingthroughamultilevelreviewprocess,andthroughrequirementsfor
referencestobeprovidedtosupportthecontent.Appropriatelyreferencedcontentisrequiredofall
authorsandmustconformtoUpToDatestandardsofevidence.
Conflictofinterestpolicy

http://www.uptodate.com/contents/managementofhypertensioninpregnantandpostpartumwomen?topicKey=OBGYN%2F6815&elapsedTi

21/21