O60. Treatment of hypertension in pregnancy

Abstract

Several international (2013 ESH/ESC guidelines, AHA/ISH guidelines, JNC-8) and national (NICE, French, Canadian, Hungarian, Chinese) guidelines have been published recently with recommendations for management of hypertension in pregnancy. Data-based opinions onantihypertensive treatment initiation and target blood pressure (BP), and drugs of choice are not similarly described in these guidelines. Main objectives of the presentation are to summarise data of the relevant literature. Review of the recently published guidelines. Treatment initiation: in addition to life-style changes, there is consensus that drug treatment of severe hypertension (⩾160/110 mmHg) in pregnancy is indicated and beneficial. The suggestion, in the 2007 European Society of Hypertension (ESH) and European Society of Cardiology (ESC) Guidelines, for considering treatment in all pregnant women with persistent elevation of BP ⩾150/95 mmHg is supported by recent US data, showing an increasing trend in the rate of pregnancy-related hospitalizations with stroke — especially during the postpartum period — and by an analysis of stroke victims with severe pre-eclampsia and eclampsia. However, the benefits of antihypertensive therapy are uncertain in pregnant women with mildly to moderately elevated blood pressure (⩽160/110 mmHg), either pre-existing or pregnancy-induced, except for a lower risk of developing severe hypertension. Despite lack of evidence, the Task Force of 2013 ESH/ESC Guidelines reconfirms that physicians should consider early initiation of antihypertensive treatment at values of BP ⩾140/90 mmHg in women with (i) gestational hypertension (with or without proteinuria), (ii) pre-existing hypertension with the superimposition of gestational hypertension or (iii) hypertension with asymptomatic organ damage (OD) or symptoms at any time during pregnancy. Target blood pressure: Guidelines mostly agree on that BP should be normalised (to <140/90 mmHg) in pregnant women with hypertension. Drug treatment: Drug treatment can be considered in pregnant women with persistent elevation of BP ⩾150/95 mmHg, and in those with BP ⩾140/90 mmHg in the presence of gestational hypertension, subclinical OD or symptoms due to increased BP. The recommendations to use methyldopa, labetalol and nifedipine as the only calcium antagonist really tested in pregnancy was confirmed in recent European and US guidelines. Beta-blockers (possibly causing foetal growth retardation if given in early pregnancy) anddiuretics (in pre-existing reduction of plasma volume) should be used with caution, only if other indications exist (e.g. ischemic heart disease, severe tachycardia, excess fluid retention). All agents interfering with the renin-angiotensin system (ACE inhibitors, angiotensin AT-1 receptor blockers, renin inhibitors) should absolutely be avoided. In emergency (pre-eclampsia), intravenous labetalol is the drug of choice with sodium nitroprusside (only for short term) or nitroglycerin in intravenous infusion being other options. According to recent guidelines, in the absence of randomised clinical trials recommendations how hypertension should be treated in pregnant women, can only be guided by experts’ opinion based on case reports and their meta-analyses.