Cardiovascular Management in Pregnancy
Chronic Hypertension in Pregnancy
Ellen W. Seely, MD; Jeffrey Ecker, MD
C hronic hypertension in pregnancy is defined by the
American College of Obstetrics and Gynecology (ACOG)
as blood pressure 140 mmHg systolic and/or 90 mmHg dia-
stolic before pregnancy or, in recognition that many women
seek medical care only once pregnant, before 20 weeks of ges-
tation, use of antihypertensive medications before pregnancy,
or persistence of hypertension for >12 weeks after delivery.1
Chronic hypertension needs to be distinguished from new-onset
hypertensive complications of pregnancy such as preeclampsia
(elevated blood pressure and proteinuria often accompanied by
evidence of maternal organ injury and fetal compromise from
placental dysfunction)2 and gestational hypertension (elevated
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blood pressure alone after 20 weeks of gestation and most
commonly in the mid to late third trimester without evidence
or history of hypertension before pregnancy; Table1).
Epidemiology
Chronic hypertension is estimated to be present in 3% to 5%
of pregnancies1,3,4 and is increasingly more commonly encoun-
tered. Factors contributing to the increase in prevalence include
2 major risk factors for hypertension, obesity and older age,
which are of increasing prevalence in pregnancy. These shifts
in risk and childbearing have resulted in an increased number
of women who will require counseling on the risks of chronic
hypertension in pregnancy and management of their antihy-
pertensive medications both in anticipation of and during preg-
nancy.5 Because many pregnancies are unplanned,6 all women
with chronic hypertension should receive regular counseling so
that they can anticipate any issues that may arise if they become
pregnant and optimize their health and care to temper risk.
Because blacks have a higher prevalence of chronic hyperten-
sion7 and onset occurs at younger ages,8 it is more common to
encounter chronic hypertension in blacks during pregnancy.
Despite its increasing prevalence, the majority of women
with chronic hypertension do well in pregnancy, but as we
discuss below, some women develop complications such as
superimposed preeclampsia, fetal growth restriction, placen-
tal abruption,4,9,10 and preterm birth, and women with chronic
hypertension have an increased likelihood of cesarean delivery.
Physiological Changes in Blood
Pressure During Pregnancy
Women who are normotensive entering pregnancy typically
experience a decrease in blood pressure toward the end of the
From the Endocrinology, Diabetes, and Hypertension Division, Brigham and Womens Hospital, Harvard Medical School, Boston, MA (E.W.S.); and
Maternal Fetal Medicine Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA (J.E.).
Series Editor is Sharon Reimold, MD.
Correspondence to Ellen W. Seely, MD, Director of Clinical Research, Endocrinology, Diabetes, and Hypertension Division, Brigham and Womens
Hospital, 221 Longwood Ave, Boston, MA 02115. E-mail eseely@partners.org
(Circulation. 2014;129:1254-1261.)
2014 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org
1254
first trimester. This decrease is thought to be secondary to the
marked vasodilation that occurs despite the increase in plasma
volume that comes with pregnancy. Blood pressure usually falls
by 5 to 10 mmHg and remains at this lower level throughout
pregnancy until the third trimester, when it rises to return to
prepregnancy values. For the majority of women with chronic
hypertension, blood pressure changes also follow this same pat-
tern. As a result, some hypertensive women become normoten-
sive during pregnancy, and others who remain hypertensive can
have their antihypertensive medications tapered. These physi-
ological changes may confuse the diagnosis of chronic hyper-
tension when a woman presents for prenatal care for the first
time in the second trimester once the physiological decrease has
occurred and is now normotensive. In such cases, the increase
to prepregnancy values in the third trimester may suggest gesta-
tional hypertension. It may not be until elevated blood pressures
persist beyond 12 weeks postpartum that, in retrospect, the cor-
rect diagnosis of chronic hypertension is recognized.
Pregnancy Complications in Women
With Chronic Hypertension
Although many women with chronic hypertension do well in
pregnancy, they are at increased risk for several pregnancy
complications, including superimposed preeclampsia, fetal
growth restriction, placental abruption, preterm birth, and
cesarean section (Table2). As part of family planning before
conception, they should be counseled about these risks and
the anticipated need for surveillance and management of any
incident complications during pregnancy.
Preeclampsia
The most prevalent complication in pregnancy in women
with chronic hypertension is the development of preeclamp-
sia. In the general population, the risk of preeclampsia is 3%
to 5%, yet among women with chronic hypertension, 17% to
25% develop superimposed preeclampsia.4,911 In a study of
763 women with chronic hypertension that reported a 25%
rate of superimposed preeclampsia, rates were higher12 in
women with >4-year duration of hypertension and with dia-
stolic blood pressures of 100 to 110 mmHg compared with
<100 mmHg. In a more recent study of 822 women with chronic
hypertension enrolled in a trial of antioxidants for the preven-
tion of preeclampsia, the risk of superimposed preeclampsia
was 22%. Of note, 44% of this 22% developed superimposed
DOI: 10.1161/CIRCULATIONAHA.113.003904
 Seely and Ecker Chronic Hypertension in Pregnancy 1255

Table 1. Classification of Hypertension in Pregnancy1
Classification
Preeclampsia
Gestational hypertension
Chronic hypertension
Chronic hypertension with
superimposed preeclampsia
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Criteria Met
After 20 wk of gestation, SBP
140mmHg or DBP 90 mmHg in a
previously normotensive woman
Proteinuria (excretion of 0.3 g protein
in a 24-h urine collection) or with other
systemic manifestations
Elevated BP (SBP 140 mmHg or DBP
90 mmHg) after 20 wk of gestation in
a previously normotensive woman
SBP 140 mmHg and/or DBP 90
mmHg before pregnancy or before
20wk of gestation
New onset of proteinuria in the setting
of hypertension before 20 wk of
gestation
An increase in proteinuria (if present
earlier)
both predict and diagnose preeclampsia. Chief among the can-
didate tests studied are angiogenic markers, including soluble
fms-like tyrosine kinase 1 (sFlt-1) and placental growth fac-
tor. A post hoc analysis of blood collected as part of a study
examining the utility of calcium supplementation to prevent
recurrent preeclampsia demonstrated higher levels of sFlt-1
and reduced levels of placental growth factor in those women
who developed preeclampsia compared with those who did
not. sFlt-1, for example, was reported to be elevated as early
as the second trimester in women who went on to develop
preeclampsia.17 From these and other supportive results,18,19
sFlt-1 was proposed as a potential predictive marker for the
development of preeclampsia. However, in a prospective study
that excluded women with chronic hypertension, sFlt-1 mea-
sured in the first trimester had a poor positive predictive value
(<10%) for the development of preeclampsia.20 On the basis of
current data, these markers are not recommended for clinical
use at this time.1 It is possible that future work and analyses
may show that, although these markers do not appear to be

An increase in blood pressure

Onset of HELLP syndrome useful in a general population, they may function more effec-
BP indicates blood pressure; DBP, diastolic blood pressure; HELLP, hemolysis, tively as predictors of preeclampsia among a group whose risk
elevated liver enzymes, low platelets; and SBP, systolic blood pressure. for primary or recurrent preeclampsia is chronic hypertension.

preeclampsia before 34 weeks of gestation, a rate that stands
in contrast to patterns seen in women without chronic hyper-
tension, who more commonly develop preeclampsia closer to
term.13 Preeclampsia is more commonly observed in blacks
than whites, but whether this is due to the greater prevalence
of underlying chronic hypertension in blacks or to a greater
underlying propensity for preeclampsia is controversial.14,15
Preeclampsia is a major contributor to preterm birth and cesar-
ean delivery in women with chronic hypertension because of
its association with induced early delivery, placental abruption,
and fetal growth abnormalities.10,13 Accordingly, women with
chronic hypertension with superimposed preeclampsia have
worse birth outcomes than women with chronic hypertension
without superimposed preeclampsia.12,16
It can be challenging to diagnose preeclampsia in women
with chronic hypertension because their blood pressures are
already elevated and proteinuria may be present before preg-
nancy. In this population, superimposed preeclampsia should
be considered if blood pressure increases in pregnancy and
especially if there is new-onset proteinuria or worsening of
prepregnancy proteinuria. Laboratory abnormalities (throm-
bocytopenia, elevated liver function tests, and increasing
serum creatinine) will also often distinguish preeclampsia
from worsening of underlying hypertension.
Because preeclampsia is managed differently from worsen-
ing chronic hypertension, it is important to distinguish these
2 entities. There is a continuing search for improved tests to
Table 2. Complications of Chronic Hypertension in Pregnancy
Superimposed preeclampsia
Fetal growth restriction
Placental abruption
Preterm birth
Caesarian section
Fetal Growth Restriction
American, Canadian, and New Zealand population data dem-
onstrate a 10% to 20% prevalence of fetal growth restriction,
defined as absolute or estimated weight less than the 10th per-
centile for gestational agebased population norms, in preg-
nancies in women with chronic hypertension.4,9,10 A similar
association remained even after adjustment for age, body mass
index, smoking, parity, and diabetes mellitus in an analysis of the
Danish National Birth Cohort. In that analysis, definite chronic
hypertension was associated with a 5.5- and 1.5-fold risk for
preterm and term small-for-gestational-age birth, respectively
(95% confidence intervals [CIs], 3.29.4 and 1.02.2).21 A more
recent analysis using growth curves customized for fetal sex
and maternal height, weight, parity, and ethnicity suggests that
the risk may be higher, 41% and 21% among women with and
without superimposed preeclampsia, respectively.13
Placental Abruption
Because fetal growth abnormalities are often thought of as
manifestations of placental dysfunction,22 it is interesting to
note that placental abruptionpremature separation of the
placenta from the underlying myometrium resulting in pain,
bleeding, and, potentially, clinical significant interruption of
fetal gas and nutrient exchangeis more common in women
with chronic hypertension. National Center for Health Statistics
data from 1995 to 2002 demonstrated that women with chronic
hypertension had a frequency of placental abruption of 1.56%
compared with 0.58% in nonhypertensive women (adjusted
relative risk, 2.4; 95% CI, 2.32.5).23 In the Sibai etal12 study of
women with chronic hypertension mentioned above, the over-
all rate of abruption was 1.5%, with higher rates in those with
superimposed preeclampsia (3%) than those without (1%). A
more recent analysis of a large Swedish birth registry found
rates of abruption of 1.1% versus 0.4% when women with and
without chronic hypertension, respectively, were compared.24
 1256CirculationMarch 18, 2014
Preterm Birth and Cesarean Delivery
The individual pregnancy complications discussed above con-
tribute to an increased risk for preterm delivery among women
with chronic hypertension because, faced with such problems,
early delivery may be judged as unavoidable, necessary, or
better than continued expectant management. Rates of pre-
term delivery range from 12% to 34% among all women with
chronic hypertension4 but as high as 62% to 70% in women
with severe hypertension, defined as 2 blood pressure read-
ings 170/110 mmHg measured at least 24 hours apart.10,25
These rates contrast with a preterm delivery rate of 10%
to 12% for the US population as a whole. An Israeli study
noted odds ratios for preterm delivery of 1.89 and 3.23 for
treated and untreated chronic hypertension, respectively, with
22.9% of those in the group who received a prescription for
antihypertensives (treated group) delivering at <37 weeks of
gestation compared with just 8% of the control group with
no diagnosis of chronic hypertension.26 Such early deliveries
are often the result of the decisions patients make with their
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obstetric providers when worsening maternal or fetal health
argues for induction at an early gestational age. Prematurity
certainly contributes to the recognized increased risk of peri-
natal mortality among pregnancies in women with chronic
hypertension. Zetterstrm and colleagues24 conducted an
analysis of >800000 Swedish birth records, including those
in 4749 women with chronic hypertension, and reported an
odds ratio of 2.71 (95% CI, 1.963.73) for intrauterine demise
(stillbirth) and an odds ratio of 2.89 (95% CI, 1.954.83) for
neonatal death among the group with chronic hypertension.
Importantly, this risk appears to be independent of but may be
augmented by the development of superimposed preeclamp-
sia, abruption, or fetal growth restriction. Finally, as expected
for pregnancies in which there is concern for maternal or fetal
well-being and higher rates of preterm induction of labor and
delivery, women with chronic hypertension are more likely to
undergo cesarean delivery than their normotensive peers. An
Israeli study of >100000 deliveries reported an odds ratio of
2.7 (95% CI, 2.43.0) for caesarian section even after adjust-
ment for superimposed preeclampsia.27
Management of the Woman With
Chronic Hypertension
Prepregnancy Care
Prenatal care of women with chronic hypertension should
begin before pregnancy to provide counseling about the preg-
nancy risks discussed above and to optimize antihypertensive
regimens before conception. The majority of women who
enter pregnancy with chronic hypertension have hypertension
of unknown origin. Evaluation for secondary causes of hyper-
tension should follow recommendations of the Seventh Report
of the Joint National Commission8 and, when indicated,
should occur before pregnancy because such evaluation may
involve radiation exposure or require surgical intervention.
Women with chronic hypertension should also be evaluated
as indicated according to Seventh Report of the Joint National
Commission for end-organ damage before pregnancy because
end-organ damage may affect pregnancy outcomes or help
stratify the risk of developing specific obstetric complications.
A 24-hour urine collection for protein determination before
pregnancy may assist in the diagnosis of superimposed pre-
eclampsia and provides prognostic information because
women with prepregnancy proteinuria have an increased risk
for fetal growth restriction.12 Finally, as discussed below, anti-
hypertensive agents may need to be changed to another class
before conception.
Lifestyle Modification
Lifestyle modifications such as sodium restriction,8 weight
reduction,28 and implementation of the Dietary Attempts to
Stop Hypertension (DASH) diet29 have been demonstrated to
improve blood pressure control in many nonpregnant individ-
uals. Given the need for volume expansion in pregnancy, strict
sodium restriction in hypertensive women planning pregnancy
is of concern, and new dietary sodium restriction is not recom-
mended by the Canadian guidelines.30 However, both weight
reduction and the DASH diet are reasonable to recommend for
such women. ACOG recommends weight reduction in over-
weight/obese women with hypertension before pregnancy.31
Whether such recommendations implemented before preg-
nancy, however prudent, result in improved pregnancy out-
comes among hypertensive women is unknown, however, and
needs to be studied.
Management During Pregnancy
Blood Pressure Goals in Pregnancy
Studies suggest that the primary benefit of antihyperten-
sive treatment of hypertension pregnancy is the reduction
of maternal morbidity by limiting episodes of severe hyper-
tension.32 Antihypertensive treatment has not been shown to
reduce superimposed preeclampsia, placental abruption, or
growth restriction or to improve neonatal outcome.32 There
is concern that overly aggressive antihypertensive treatment
may decrease fetoplacental perfusion and increase the risk for
fetal growth restriction. A large meta-analysis, for example,
suggests that treatment of hypertension in pregnancy may
be associated with increased fetal growth restriction.33 As a
result, blood pressure goals are higher during pregnancy than
they are outside of pregnancy, and medication dosages may
need to be adjusted downward, particularly in the second tri-
mester when pregnancy-associated nadirs of blood pressure
are typically encountered. The exact goal ranges for blood
pressures during pregnancy in women with chronic hyper-
tension are not established because, at this point, there are
no randomized studies to support one goal over another. As
a result, blood pressure goals for pregnancy for women with
chronic hypertension are often not specified in guidelines or
differ among guidelines. ACOG recommends that blood pres-
sures in women with uncomplicated hypertension be main-
tained between 120/80 and 160/105 mmHg.1 The Society of
Obstetricians and Gynaecologists of Canada clinical practice
guidelines target systolic blood pressure of 130 to 155 mmHg
and diastolic blood pressure of 80 to 105 mmHg in women
without comorbid conditions and systolic blood pressure of
130 to 139 mmHg and diastolic pressure of 80 to 89 mmHg in
women with comorbid conditions (such as type 1 diabetes mel-
litus).30 Some experts recommend stopping antihypertensives
 Seely and Ecker Chronic Hypertension in Pregnancy 1257

during pregnancy, as long as pressures fall below these thresh-
olds. For women with chronic hypertension who enter preg-
nancy not on antihypertensive treatment, ACOG recommends
initiating antihypertensive treatment when blood pressures
are consistently >160 mmHg systolic and/or >105 mmHg
diastolic.1 The Society of Obstetric Medicine of Australia
and New Zealand guidelines indicate a definitive recom-
mendation for antihypertensive treatment when blood pres-
sure is 160 mmHg systolic or 100 mmHg diastolic and
that treatment of blood pressure between 140 and 159 mmHg
systolic or 90 and 99 mmHg diastolic is common practice
with good outcomes.22 Thus, there is variability in goal range
for blood pressure in pregnancy. When blood pressures fall
below these ranges, there is a recommendation to taper the
antihypertensive and eventually to stop the antihypertensive
if blood pressure remains within the goal range. There are no
evidence-based regimens for tapering antihypertensive medi-
cations in pregnancy. Thus, the tapering regimen needs to take
into consideration factors related to the particular medication
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Table 3. FDA Classification of Drugs in Pregnancy34
Category A: controlled studies in pregnant women have demonstrated no risk
of fetal abnormalities.
Category B: reproduction studies in animal indicate no fetal risk, but there
are no adequate and well-controlled studies in pregnant women; or animal
reproduction studies have shown an adverse effect of the drug but not in well-
controlled studies in pregnant women.
Category C: animal reproduction studies have shown an adverse effect of the
fetus but no adequate human or animal studies; or animal reproduction studies
have not been conducted and it is not known whether the drug can cause fetal
harm when administered to a pregnant woman.
Category D: evidence of human fetal risk, but benefits outweigh risks. Women
taking this drug during pregnancy should be informed of potential fetal risk.
Category X: evidence of human fetal risk. Drug is contraindicated in women
who are pregnant or who may become pregnant. If this drug is used during
pregnancy or if the patient becomes pregnant while taking this drug, the
patient should be apprised of the potential hazard to a fetus.
FDA indicates Food and Drug Administration.

used, dose, and timing in pregnancy (ie, keeping in mind the
physiological decrease in blood pressure at the end of the first
trimester.) We recommend tapering antihypertensives when
blood pressures consistently fall below 130/80 mmHg, a
threshold consistent with Canadian guidelines.30
As indicated above, prospective studies randomizing women
to different levels of blood pressure and pregnancy outcomes
are lacking. The Control of Hypertension in Pregnancy Study
(CHIPS; NCT01192412) is ongoing and randomizing women
to less tight (target diastolic blood pressure, 100 mmHg)
or tight (target diastolic blood pressure, 85 mmHg) control
and will determine maternal, fetal, and neonatal outcomes of
the different goals. Results from CHIPS are not available at
this time; study completion is anticipated in 2014.
Antihypertensive Medications
The Food and Drug Administration provides classification
of medications in pregnancy34 based on the level of the data
available to support safety (Table3). Because of a lack of ran-
domized, controlled studies, no antihypertensive are catego-
rized as class A: controlled human studies have demonstrated
no fetal risk. Instead, commonly used antihypertensives in
pregnancy are classified as class B (-methyldopa) or class C
(labetalol, -blockers, calcium channel blocker, and thiazide
diuretics). Angiotensin-converting enzyme inhibitors (ACEIs)
are considered class C in the first trimester and class D in the
second and third trimesters. In contrast to nonpregnant indi-
viduals with hypertension for whom good data exist, there are
no randomized trials to guide how race and other comorbidi-
ties should influence the choice of antihypertensive therapy
during pregnancy.
Commonly used antihypertensive agents in pregnancy and
their class are depicted in Table4. Of note, there is a lack
of randomized, placebo-controlled trials of antihypertensives
in pregnancy looking at the important maternal and fetal/neo-
natal outcomes. As a result, many of the data on antihyper-
tensive use in pregnancy are from reviews and meta-analyses
of small, retrospective studies. The majority of studies com-
pare 1 antihypertensive with no treatment, so comparative
efficacy and safety data to guide choices between alternative
antihypertensives are generally absent. Even among those stud-
ies that compare agents head to head, allocation was generally
not blinded, raising concerns for possible biases in and con-
founding of the data. -Methyldopa is considered a first-line35 or
cofirst-line drug30 by many guideline groups on the basis
of the large amount of safety data resulting from its use in
pregnancy since the 1960s. A follow-up study of offspring
of pregnancies exposed to -methyldopa noted no adverse
developmental effects up to 7.5 years of age.36 However,
-methyldopa may not be well tolerated by women because
of the common side effect of somnolence.
The combined - and -blocker labetalol is often recom-
mended as an alternative first-line1,30 or second-line agent35 for
the treatment of hypertension in pregnancy. Labetalol compared
with -methyldopa or no treatment was studied in a population
of 300 women with chronic hypertension. Both labetalol and
-methyldopa effectively lowered blood pressure. Exposure to
labetalol (n=86) or -methyldopa (n=88) compared with no
antihypertensive (n=90) was associated with no increased risk
of congenital malformations, but neither were there any differ-
ences in risk for superimposed preeclampsia, placental abrup-
tion, or preterm delivery compared with no antihypertensive
treatment.37 -Blockers are used less commonly in pregnancy
because of concerns about fetal growth restriction raised in
retrospective studies examining the outcomes of pregnancies
in which atenolol was used.38 Some organizations recommend
that atenolol be avoided in pregnancy.1
Data are sparse for the use of calcium channel blockers in
pregnancy to control blood pressure (as opposed to short-term
use for the treatment of preterm contractions/preterm labor),
and most data are available for long-acting nifedipine. In a
prospective study in which a mixed population of 283 women
with chronic hypertension or new-onset hypertension during
pregnancy (diastolic blood pressure, 90110 mmHg) were
randomized to long-acting nifedipine versus no medication at
12 to 34 weeks of pregnancy, there were no differences among
the pregnancy outcomes of preterm delivery, caesarian section,
or birth weight.39 A study of nifedipine use in the first tri-
mester does not suggest an increase in major birth defects.40
Although there has been theoretical concern that calcium
 1258CirculationMarch 18, 2014
Table 4. Antihypertensive Therapies Commonly Used in Pregnancy*
Agent Indication Dose Range
-Methyldopa Often used as first line 250 mg1.5 g orally twice a day
Labetalol Often used as first line 1001200 mg orally twice a day
Calcium channel Second line or Varies according to drug used
blockers alternative first line
(nifedipine)
-Blockers Second line Varies according to drug used
Thiazide diuretics Second line 12.550 mg orally once a day
FDA indicates Food and Drug Administration.
*Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are contraindicated in the second and third trimesters of pregnancy and are class D.
Safety in the first trimester is controversial; in this trimester, they are class C.
channel blockers could be synergistic with magnesium sulfate
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(used to prevent eclampsia in women with a diagnosis of pre-
eclampsia), leading to neuromuscular depression, this concern
was not borne out in a large retrospective study.41
The use of thiazide diuretics in the first trimester of preg-
nancy has not been associated with increased risk of major
birth defects.42 However, because volume expansion is char-
acteristic of healthy pregnancies, there has been long-standing
concern about potential diuretic-related volume depletion.
However, data do not support this concern,43 and continuing
the use of diuretics in women with chronic hypertension is
supported by some.1
Maternal exposure to ACEIs in the second and third tri-
mesters has clearly been associated with adverse pregnancy
outcomes, including impaired fetal renal function resulting in
oligohydramnios, growth abnormalities, skull hypoplasia, and
fetal death, as well as neonatal anuria and neonatal death.44,45
Similar fetal effects have been reported with exposure to angio-
tensin receptor blockers in the second half of pregnancy.4648
The use of ACEIs in early pregnancy was previously thought
to be safe, but a 2006 study raised the issue of a potential increase
in fetal cardiovascular and central nervous system anomalies
from such use and exposure. In that retrospective study, the risk
ratio for birth defects among 209 infants exposed to ACEIs in
the first trimester compared with those exposed to other anti-
hypertensives was 4.04 (95% CI, 1.897.30) for cardiovascular
defects and 5.45 (95% CI, 1.6917.64) for central nervous sys-
tem defects.5 Because this report was retrospective, differences
between groups other than treatment class, including maternal
body mass index, might explain the results. A subsequent study
did not confirm these findings but instead suggested that the
association of ACEIs with congenital malformation was con-
founded by the underlying diagnosis of hypertension and not
explained by class of antihypertensive.49 Because of the clear
contraindication of ACEIs/angiotensin receptor blockers in the
second and third trimesters, the difficulty in dating pregnan-
cies, and the large number of women who do not present for
prenatal care until the second trimester, many caregivers avoid
ACEIs and angiotensin receptor blockers in women planning
to conceive or in women of childbearing age altogether, given
that 50% of pregnancies are unplanned.
FDA Potential Side
Classification Effects Comments
B Lethargy Data on offspring up to 7.5 y of age
demonstrating long-term safety
C Exacerbation of asthma Widely used in pregnancy
C Concern for synergy with
magnesium sulfate for
neuromuscular depression
C Exacerbation of asthma Some recommend avoiding atenolol
during pregnancy and lactation
C Volume depletion and
hypokalemia
Lifestyle Modification for Blood Pressure Control
During Pregnancy
Limiting weight gain is advisable in obese and overweight
women during pregnancy, according to the Institute of
Medicine.50 Whether limiting weight gain in chronic hyper-
tensive women will lead to improved pregnancy outcomes, in
particular lowered risk of superimposed preeclampsia, is not
known, with data showing no benefit to limiting weight gain
in nonhypertensive women.51 Whether implementing or con-
tinuing the DASH diet during pregnancy improves outcomes in
women with chronic hypertension is also unknown and should
be studied. Dietary sodium restriction during pregnancy has
raised concerns that it would limit the volume expansion char-
acteristic of normal pregnancy. Sodium restriction implemented
after the first 12 weeks of pregnancy does not appear to be harm-
ful in normotensive women,52,53 but there are no data to support
that sodium restriction limits the occurrence of preeclampsia.54
ACOG recommends against the use of very low salt diets
(<100 mEq/dy) to manage chronic hypertension in pregnancy.1
Acute Management of Severe Hypertension
in Pregnancy
Because of concern for maternal morbidity, including cerebro-
vascular accidents, when blood pressure rises to severely ele-
vated levels (160 mmHg systolic or 110 mmHg diastolic),
intravenous antihypertensive medications are often used to
promptly lower pressures below these thresholds. The major-
ity of experience with the use of intravenous antihypertensive
use in pregnancy is derived from their use in cases of severe
preeclampsia.55,56 Commonly used intravenous antihyperten-
sive agents in pregnancy include labetalol and hydralazine.
A Cochrane review did not demonstrate superiority of one of
these over the other or over other antihypertensive medications
in the acute management of severe hypertension in pregnancy.54
Prevention of Preeclampsia
For women with chronic hypertension, superimposed pre-
eclampsia is the major adverse pregnancy outcome; how-
ever, there currently are no effective preventive measures to
decrease this risk. Large, randomized, placebo-controlled
 Seely and Ecker Chronic Hypertension in Pregnancy 1259
studies have demonstrated that the use of calcium supple-
mentation,57
low-dose aspirin,58 or antioxidant supplemen-
tation with vitamin C and E59 does not decrease the risk for
preeclampsia.
Surveillance of Fetal Well-Being
More frequent prenatal visits are recommended for pregnant
women with chronic hypertension compared with healthy
women. Such visits are designed to evaluate women for
complications of chronic hypertension in pregnancy by fol-
lowing blood pressures, urine protein, fundal height, and
maternal symptoms. Because these pregnancies are more
likely to be complicated by growth abnormalities, ACOG
indicates that evaluation of fetal growth by ultrasound in
women with chronic hypertension is warranted.1 In prac-
tice, most undertake surveillance for fetal growth restric-
tion with ultrasounds beginning in the third trimester and
spaced at 2- to 4-week intervals, depending on maternal
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blood pressure, medications, complications, and findings on
prior scans. With the recognition of the association between
chronic hypertension and stillbirth, fetal testing is often rec-
ommended,60 although some restrict such testing to those
pregnancies with complications such as growth restric-
tion or preeclampsia.1 However, ACOG states that there is
no consensus on the most appropriate fetal surveillance
test(s) or the interval and timing of testing in women with
chronic hypertension.1 Although no single protocol is of
demonstrated superior utility, testing often includes daily
fetal kick counts, fetal heart rate testing60 (nonstress test-
ing), and ultrasound evaluation of amniotic fluid volume or
fetal movements and tone (biophysical profile). The particu-
lar tests chosen, the frequency of testing, and the time for
initiating surveillance are often based on individual patient
characteristics, including degree and duration of hyper-
tension, use of antihypertensives, evidence of underlying
maternal organ compromise related to hypertension, suspi-
cion for fetal growth restriction, and presence of pregnancy
complications such as preeclampsia.
Timing of Delivery in Women With
Chronic Hypertension
Because of the risks associated with chronic hypertension,
delivery is often planned near the estimated due date, although
the need for such intervention, if testing and growth are reas-
suring, is uncertain. A 2011 Eunice Kennedy Shriver National
Institute of Child Health and Human Development and the
Society for Maternal-Fetal Medicine workshop, Timing of
Indicated Late Preterm and Early Term Deliveries, indicated
that for chronic hypertension requiring no medications, deliv-
ery was recommended at 38 to 39 weeks of gestation.61 In con-
trast, for women with chronic hypertension on medications
and for women whose hypertension was difficult to control,
defined as requiring frequent medication adjustment, this
expert group recommended delivery at 37 to 39 and 36 to 37
weeks of gestation, respectively. For cases in which there was
superimposed preeclampsia, delivery was recommended at 37
weeks of gestation or earlier if markers of severe preeclampsia
were present.61
Breast-Feeding
Given the benefits of breast-feeding, women with chronic
hypertension, including those on antihypertensive medications,
should be encouraged to breast-feed. Although most antihy-
pertensives are measurable in breast milk, levels are generally
lower than in maternal plasma.62 From these data and obser-
vational data, the American Academy of Pediatrics has labeled
most antihypertensives, including ACEIs, as usually compatible
with breast-feeding.63 Higher breast milk levels and case reports
of lethargy and bradycardia in newborns breast-fed by mothers
on atenolol led the American Academy of Pediatrics to recom-
mend that atenolol be used with caution.63 In addition, on the
basis of the higher degree of excretion of atenolol into breast
milk, the Drugs and Lactation Database of the National Library
of Medicine64 indicates that agents other than atenolol may be
preferable for newborns, preterm infants, and babies of mothers
on high doses. The American Society of Hypertension recom-
mends against the use of diuretics during breast-feeding because
of the concern that they may decrease breast milk production.35
Summary
Although the majority of women with chronic hypertension
have healthy pregnancy outcomes, pregnancies among such
women have increased risk of superimposed preeclampsia, fetal
growth restriction, early delivery, and caesarian section. Women
should be counseled about these risks before pregnancy and fol-
lowed up for the potential development of these complications
during pregnancy. Blood pressure goals are higher in pregnant
compared with nonpregnant women because of the concern
of adversely affecting fetoplacental perfusion with too large a
decrease in maternal blood pressure. Therefore, during preg-
nancy, antihypertensive therapy can be tapered in many women.
Labetalol and -methyldopa are considered first-line therapies
for those women who require medications during pregnancy.
ACEIs and angiotensin receptor blockers are contraindicated
for use in the second and third trimesters of pregnancy because
of adverse effects of the fetus, and there is controversy over
whether ACEIs are safe in the first trimester. Randomized stud-
ies comparing various antihypertensives for the management of
chronic hypertension in pregnancy are limited, and as a result,
the ideal range for blood pressure to optimize the health of the
mother, fetus, and neonate remains unknown. It is important
that these studies be undertaken and funded.
Thus, pregnancy in women with chronic hypertension needs
to be carefully planned and managed. In our view, such care is
best undertaken by comanagement among obstetricians, inter-
nists, and other medical specialists. It is our experience that
such coordinated care will optimize pregnancy outcomes and
the health of women with chronic hypertension during their
reproductive years.
Disclosures
Dr Seely received support from Bayer Health Care for an
investigator-initiated study of postmenopausal women ending in
2012. Dr Ecker reports no conflicts.
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Key Words:hypertension pre-eclampsia pregnancy pregnancy
complications
 Chronic Hypertension in Pregnancy
Ellen W. Seely and Jeffrey Ecker

Circulation. 2014;129:1254-1261
doi: 10.1161/CIRCULATIONAHA.113.003904
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