Abstract
Purpose of Review
The concept of resistant hypertension may be changed during pregnancy by the physiological hemodynamic changes and the particularities of therapy choices in this period. This review discusses the management of pregnant patients with preexisting resistant hypertension and also of those who develop severe hypertension in gestation and puerperium.
Recent Findings
The main cause of severe hypertension in pregnancy is preeclampsia, and differential diagnosis must be done with secondary or primary hypertension. Women with preexisting resistant hypertension may need pharmacological therapy adjustment. Several drugs can be used to treat severe hypertension, with exception of angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists. The most used drugs are methyldopa, beta-blockers, and calcium channel antagonists. There is a general agreement that severe hypertension must be treated, but there are still debates over the goals of the treatment. Delivery is indicated in viable pregnancies in which blood pressure control is not achieved with three drugs in full doses. Resistant hypertension may arise in postpartum.
Summary
The management of resistant hypertension in pregnancy must regard the possible etiology, the fetal well-being, and the mother’s risk. Good care is mandatory to reduce maternal mortality risk.
Similar content being viewed by others
References
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014;2(6):323–33.
Abalos E, Cuesta C, Carroli G, Qureshi Z, Widmer M, Vogel JP, et al. Pre-eclampsia, eclampsia and adverse maternal and perinatal outcomes: a secondary analysis of the World Health Organization Multicountry Survey on Maternal and Newborn Health. BJOG. 2014;121:S1:14–24.
Lo JO, Mission JF, Caughey AB. Hypertensive disease of pregnancy and maternal mortality. Curr Opin Obstet Gynecol. 2013;25(2):124–32.
Bramham K, Parnell B, Nelson-Piercy C, Seed PT, Poston L, Chappell LC. Chronic hypertension and pregnancy outcomes: systematic review and meta-analysis. BMJ. 2014;348:g2301.
• ACOG. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ task force on hypertension in pregnancy. Obstet Gynecol. 2013;122(5):1122–31. Commentary—this document revises the diagnosis of preeclampsia and focuses on the signs of severity of the disease.
Kattah AG, Garovic VD. The management of hypertension in pregnancy. Adv Chronic Kidney Dis. 2013;20:229–39.
Lowe SA, Bowyer L, Lust K, McMahon LP, Morton MR, North RA, et al. The SOMANZ guidelines for the management of hypertensive disorders of pregnancy 2014. Aust N Z J Obstet Gynaecol. 2015;55(1):11–6.
•• Tranquilli A, Dekker G, Magee L, Roberts J, Sibai B, Steyn W, et al. The classification, diagnosis and management of the hypertensive disorders of pregnancy: a revised statement from the ISSHP. Pregnancy Hypertens An Int J Women’s Cardiovasc Heal. 2014;4:97–104. A revision of diagnosis and classifications, as well as the management of hypertension in pregnancy.
Royal Collegue of Obstetricians and Gynaecologists, The Royal Collegue of Midwives. Hypertension in pregnancy: the management of hypertensive disorders during pregnancy. NICE Clin Guidel. 2011;1–295.
Kahhale S, Zugaib M. Sindromes Hipertensivas na Gravidez. Rio de Janeiro: Atheneu; 1995.
Zugaib M, Francisco R. Zugaib Obstetricia. 3a ed. Zugaib M, Francisco R, editors. Sao Paulo: Manole; 2016.
Khalil A, O’Brien P, Townsend R. Current best practice in the management of hypertensive disorders in pregnancy. Integr Blood Press Control. 2016;9:79–94.
Malha L, August P. Secondary hypertension in pregnancy. Curr Hypertens Rep. 2015;17:53.
Bateman BT, Bansil P, Hernandez-Diaz S, Mhyre JM, Callaghan WM, Kuklina EV. Prevalence, trends, and outcomes of chronic hypertension: a nationwide sample of delivery admissions. Am J Obstet Gynecol. 2012;206(2):134.e1-8.
Bullo M, Tschumi S, Bucher BS, Bianchetti MG, Simonetti GD. Pregnancy outcome following exposure to angiotensin-converting enzyme inhibitors or angiotensin receptor antagonists: a systematic review. Hypertens (Dallas, Tex 1979). American Heart Association, Inc.; 2012 Aug 1 [cited 2018 Feb 13];60(2):444–50.
Bateman BT, Huybrechts KF, Fischer MA, Seely EW, Ecker JL, Oberg AS, et al. Chronic hypertension in pregnancy and the risk of congenital malformations: a cohort study. Am J Obstet Gynecol. 2015;212(3):337.e1–337.e14.
Brown CM, Garovic VD. Drug treatment of hypertension in pregnancy. Drugs. 2014;74:283–96.
Moser M, Brown CM, Rose CH, Garovic VD. Hypertension in pregnancy: is it time for a new approach to treatment? J Hypertens. 2012;30(6):1092–100.
Abalos E, Duley L, Steyn DW. Antihypertensive drug therapy for mild to moderate hypertension during pregnancy. Cochrane Database Syst Rev. 2014;2:CD002252.
•• Magee LA, von Dadelszen P, Rey E, Ross S, Asztalos E, Murphy KE, et al. Less-tight versus tight control of hypertension in pregnancy. N Engl J Med. 2015;372:407–17. This study shows that proper therapy reduces maternal morbidity without changing perinal outcomes.
Ahmed RJ, Gafni A, Hutton EK, Hu ZJ, Pullenayegum E, von Dadelszen P, et al. The cost implications of less tight versus tight control of hypertension in pregnancy (CHIPS trial). Hypertens. 2016;68(4):1049–55.
Magee LA, von Dadelszen P, Singer J, Lee T, Rey E, Ross S, et al. Control of Hypertension In Pregnancy Study randomised controlled trial—are the results dependent on the choice of labetalol or methyldopa? BJOG An Int J Obstet Gynaecol. 2016;
Podymow T, August P. Postpartum course of gestational hypertension and preeclampsia. Hypertens Pregnancy. 2010;29(3):294–300.
• Podymow T, August P. New evidence in the management of chronic hypertension in pregnancy. Semin Nephrol. 2017;37:398–403. A revision of adequate therapy of hypertension in pregnancy.
Herrera-Perdigon J, Hopkins E, Marcalle M, Brooten D, Youngblut JM, Lizardo ML. Weight gain in high-risk pregnant women: comparison by primary diagnosis and type of care. Clin Excell Nurse Pract NIH Public Access. 2005;9(4):195–201.
Rasmussen KM, Yaktine AL, Institute of Medicine (U.S.). Committee to Reexamine IOM Pregnancy Weight Guidelines. Weight gain during pregnancy: reexamining the guidelines. National Academies Press; 2009. 854 p.
Taylor RN, Roberts JM, Cunningham FG, Lindheimer MD. Chesley’s hypertensive disorders in pregnancy. 500 p. 4th edition, Elsevier, 2015.
Hofmeyr GJ, Lawrie TA, Atallah AN, Duley L. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database Syst Rev. 2010;8:CD001059.
Magro-Malosso ER, Saccone G, Di Tommaso M, Roman A, Berghella V. Exercise during pregnancy and risk of gestational hypertensive disorders: a systematic review and meta-analysis. Acta Obstet Gynecol Scand. 2017;96(8):921–31.
Nascimento SL, Surita FG, Cecatti JG. Physical exercise during pregnancy. Curr Opin Obstet Gynecol. 2012;24(6):387–94.
Redman CWG. Hypertension in pregnancy: the NICE guidelines. Heart. 2011;97(23):1967–9.
Kahhale S, ZugaibM, CarraraW, Paula FJ, Sabbaga E, Neme B. Estudo comparativo de gestantes hipertensas crônicas tratadas e näo tratadas com betabloqueador - Pindolol. Ginecologia Obstetricia Brasileira. 1985;8(2):85–9.
Orbach H, Matok I, Gorodischer R, Sheiner E, Daniel S,Wiznitzer A, et al. Hypertension and antihypertensive drugs in pregnancy and perinatal outcomes. Am J Obstet Gynecol. 2013;208(4):301.e1–6.
Seely EW, Ecker J. Chronic hypertension in pregnancy. Circulation. 2014;129(11):1254–61.
Regitz-Zagrosek V. ESC guidelines on the management of cardiovascular diseases during pregnancy The Task Force on the Management of Cardiovascular Diseases during Pregnancy. Eur Heart J. 2011;32(24):3147–97.
Morton A, Laurie J. Eplerenone in the management of resistant hypertension with obstructive sleep apnoea in pregnancy. Pregnancy Hypertension. 2017;7:54–5.
•• Committee Opinion. Emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period. Obstet Gynecol. 2015;125(2):521–5. Commentary—highlights the importance of diagnosis and treatment of severe hypertension in postpartum.
Sibai BM. Etiology and management of postpartum hypertension-preeclampsia. Am J Obstet Gynecol. 2012;206(6):470–5.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of Interest
The authors declare no conflicts of interest relevant to this manuscript.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Additional information
This article is part of the Topical Collection on Resistant Hypertension
Rights and permissions
About this article
Cite this article
Bortolotto, M.R., Francisco, R.P.V. & Zugaib, M. Resistant Hypertension in Pregnancy: How to Manage?. Curr Hypertens Rep 20, 63 (2018). https://doi.org/10.1007/s11906-018-0865-z
Published:
DOI: https://doi.org/10.1007/s11906-018-0865-z