case study on hypertension in pregnancy

A 21-Year-Old Pregnant Woman with Hypertension and Proteinuria

• Andrea Luk,

* To whom correspondence should be addressed. E-mail: [email protected]

• Ching Wan Lam,
• Wing Hung Tam,
• Anthony W. I Lo,
• Enders K. W Ng,
• Alice P. S Kong,
• Wing Yee So,
• Chun Chung Chow
• Andrea Luk, 
• Ronald C. W Ma, 
• Ching Wan Lam, 
• Wing Hung Tam, 
• Anthony W. I Lo, 
• Enders K. W Ng, 
• Alice P. S Kong, 
• Wing Yee So, 

Published: February 24, 2009

• https://doi.org/10.1371/journal.pmed.1000037
• Reader Comments

Citation: Luk A, Ma RCW, Lam CW, Tam WH, Lo AWI, Ng EKW, et al. (2009) A 21-Year-Old Pregnant Woman with Hypertension and Proteinuria. PLoS Med 6(2): e1000037. https://doi.org/10.1371/journal.pmed.1000037

Copyright: © 2009 Luk et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: The authors received no specific funding for this article.

Competing interests: RCWM is Section Editor of the Learning Forum. The remaining authors have declared that no competing interests exist.

Abbreviations: CT, computer tomography; I, iodine; MIBG, metaiodobenzylguanidine; MRI, magnetic resonance imaging; SDH, succinate dehydrogenase; SDHD, succinate dehydrogenase subunit D

Provenance: Commissioned; externally peer reviewed

Description of Case

A 21-year-old pregnant woman, gravida 2 para 1, presented with hypertension and proteinuria at 20 weeks of gestation. She had a history of pre-eclampsia in her first pregnancy one year ago. During that pregnancy, at 39 weeks of gestation, she developed high blood pressure, proteinuria, and deranged liver function. She eventually delivered by emergency caesarean section following failed induction of labour. Blood pressure returned to normal post-partum and she received no further medical follow-up. Family history was remarkable for her mother's diagnosis of hypertension in her fourth decade. Her father and five siblings, including a twin sister, were healthy. She did not smoke nor drink any alcohol. She was not taking any regular medications, health products, or herbs.

At 20 weeks of gestation, blood pressure was found to be elevated at 145/100 mmHg during a routine antenatal clinic visit. Aside from a mild headache, she reported no other symptoms. On physical examination, she was tachycardic with heart rate 100 beats per minute. Body mass index was 16.9 kg/m 2 and she had no cushingoid features. Heart sounds were normal, and there were no signs suggestive of congestive heart failure. Radial-femoral pulses were congruent, and there were no audible renal bruits.

Baseline laboratory investigations showed normal renal and liver function with normal serum urate concentration. Random glucose was 3.8 mmol/l. Complete blood count revealed microcytic anaemia with haemoglobin level 8.3 g/dl (normal range 11.5–14.3 g/dl) and a slightly raised platelet count of 446 × 10 9 /l (normal range 140–380 × 10 9 /l). Iron-deficient state was subsequently confirmed. Quantitation of urine protein indicated mild proteinuria with protein:creatinine ratio of 40.6 mg/mmol (normal range <30 mg/mmol in pregnancy).

What Were Our Differential Diagnoses?

An important cause of hypertension that occurs during pregnancy is pre-eclampsia. It is a condition unique to the gravid state and is characterised by the onset of raised blood pressure and proteinuria in late pregnancy, at or after 20 weeks of gestation [ 1 ]. Pre-eclampsia may be associated with hyperuricaemia, deranged liver function, and signs of neurologic irritability such as headaches, hyper-reflexia, and seizures. In our patient, hypertension developed at a relatively early stage of pregnancy than is customarily observed in pre-eclampsia. Although she had proteinuria, it should be remembered that this could also reflect underlying renal damage due to chronic untreated hypertension. Additionally, her electrocardiogram showed left ventricular hypertrophy, which was another indicator of chronicity.

While pre-eclampsia might still be a potential cause of hypertension in our case, the possibility of pre-existing hypertension needed to be considered. Box 1 shows the differential diagnoses of chronic hypertension, including essential hypertension, primary hyperaldosteronism related to Conn's adenoma or bilateral adrenal hyperplasia, Cushing's syndrome, phaeochromocytoma, renal artery stenosis, glomerulopathy, and coarctation of the aorta.

Box 1: Causes of Hypertension in Pregnancy

• Pre-eclampsia
• Essential hypertension
• Renal artery stenosis
• Glomerulopathy
• Renal parenchyma disease
• Primary hyperaldosteronism (Conn's adenoma or bilateral adrenal hyperplasia)
• Cushing's syndrome
• Phaeochromocytoma
• Coarctation of aorta
• Obstructive sleep apnoea

Renal causes of hypertension were excluded based on normal serum creatinine and a bland urinalysis. Serology for anti-nuclear antibodies was negative. Doppler ultrasonography of renal arteries showed normal flow and no evidence of stenosis. Cushing's syndrome was unlikely as she had no clinical features indicative of hypercortisolism, such as moon face, buffalo hump, violaceous striae, thin skin, proximal muscle weakness, or hyperglycaemia. Plasma potassium concentration was normal, although normokalaemia does not rule out primary hyperaldosteronism. Progesterone has anti-mineralocorticoid effects, and increased placental production of progesterone may mask hypokalaemia. Besides, measurements of renin activity and aldosterone concentration are difficult to interpret as the renin-angiotensin-aldosterone axis is typically stimulated in pregnancy. Phaeochromocytoma is a rare cause of hypertension in pregnancy that, if unrecognised, is associated with significant maternal and foetal morbidity and mortality. The diagnosis can be established by measuring levels of catecholamines (noradrenaline and adrenaline) and/or their metabolites (normetanephrine and metanephrine) in plasma or urine.

What Was the Diagnosis?

Catecholamine levels in 24-hour urine collections were found to be markedly raised. Urinary noradrenaline excretion was markedly elevated at 5,659 nmol, 8,225 nmol, and 9,601 nmol/day in repeated collections at 21 weeks of gestation (normal range 63–416 nmol/day). Urinary adrenaline excretion was normal. Pregnancy may induce mild elevation of catecholamine levels, but the marked elevation of urinary catecholamine observed was diagnostic of phaeochromocytoma. Conditions that are associated with false positive results, such as acute myocardial infarction, congestive heart failure, acute cerebrovascular event, withdrawal from alcohol, withdrawal from clonidine, and cocaine abuse, were not present in our patient.

The working diagnosis was therefore phaeochromocytoma complicating pregnancy. Magnetic resonance imaging (MRI) of neck to pelvis, without gadolinium enhancement, was performed at 24 weeks of gestation. It showed a 4.2 cm solid lesion in the mid-abdominal aorto-caval region, while both adrenals were unremarkable. There were no ectopic lesions seen in the rest of the examined areas. Based on existing investigation findings, it was concluded that she had extra-adrenal paraganglioma resulting in hypertension.

What Was the Next Step in Management?

At 22 weeks of gestation, the patient was started on phenoxybenzamine titrated to a dose of 30 mg in the morning and 10 mg in the evening. Propranolol was added several days after the commencement of phenoxybenzamine. Apart from mild postural dizziness, the medical therapy was well tolerated during the remainder of the pregnancy. In the third trimester, systolic and diastolic blood pressures were maintained to below 90 mmHg and 60 mmHg, respectively. During this period, she developed mild elevation of alkaline phosphatase ranging from 91 to 188 IU/l (reference 35–85 IU/l). However, liver transaminases were normal and the patient had no seizures. Repeated urinalysis showed resolution of proteinuria. At 38 weeks of gestation, the patient proceeded to elective caesarean section because of previous caesarean section, and a live female baby weighing 3.14 kg was delivered. The delivery was uncomplicated and blood pressure remained stable.

Following the delivery, computer tomography (CT) scan of neck, abdomen, and pelvis was performed as part of pre-operative planning to better delineate the relationship of the tumour to neighbouring structures. In addition to the previously identified extra-adrenal paraganglioma in the abdomen ( Figure 1 ), the CT revealed a 9 mm hypervascular nodule at the left carotid bifurcation, suggestive of a carotid body tumour ( Figure 2 ). The patient subsequently underwent an iodine (I) 131 metaiodobenzylguanidine (MIBG) scan, which demonstrated marked MIBG-avidity of the paraganglioma in the mid-abdomen. The reported left carotid body tumour, however, did not demonstrate any significant uptake. This could indicate either that the MIBG scan had poor sensitivity in detecting a small tumour, or that the carotid body tumour was not functional.

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In June 2008, four months after the delivery, the patient had a laparotomy with removal of the abdominal paraganglioma. The operation was uncomplicated. There was no wide fluctuation of blood pressures intra- and postoperatively. Phenoxybenzamine and propranolol were stopped after the operation. Histology of the excised tumour was consistent with paraganglioma with cells staining positive for chromogranin ( Figures 3 and 4 ) and synaptophysin. Adrenal tissues were notably absent.

The tumour is a well-circumscribed fleshy yellowish mass with maximal dimension of 5.5 cm.

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The tumour cells are polygonal with bland nuclei. The cells are arranged in nests and are immunoreactive to chromogranin (shown here) and synaptophysin.

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The patient was counselled for genetic testing for hereditary phaeochromocytoma/paraganglioma. She was found to be heterozygous for c.449_453dup mutation of the succinate dehydrogenase subunit D (SDHD) gene ( Figure 5 ). This mutation is a novel frameshift mutation, and leads to SDHD deficiency (GenBank accession number: 1162563). At the latest clinic visit in August 2008, she was asymptomatic and normotensive. Measurements of catecholamine in 24-hour urine collections had normalised. Resection of the left carotid body tumour was planned for a later date. She was to be followed up indefinitely to monitor for recurrences. She was also advised to contact family members for genetic testing. Our patient gave written consent for this case to be published.

https://doi.org/10.1371/journal.pmed.1000037.g005

Phaeochromocytoma in Pregnancy

Hypertension during pregnancy is a frequently encountered obstetric complication that occurs in 6%–8% of pregnancies [ 2 ]. Phaeochromocytoma presenting for the first time in pregnancy is rare, and only several hundred cases have been reported in the English literature. In a recent review of 41 cases that presented during 1988 to 1997, maternal mortality was 4% while the rate of foetal loss was 11% [ 3 ]. Antenatal diagnosis was associated with substantial reduction in maternal mortality but had little impact on foetal mortality. Further, chronic hypertension, regardless of aetiology, increases the risk of pre-eclampsia by 10-fold [ 1 ].

Classically, patients with phaeochromocytoma present with spells of palpitation, headaches, and diaphoresis [ 4 ]. Hypertension may be sustained or sporadic, and is associated with orthostatic blood pressure drop because of hypovolaemia and impaired vasoconstricting response to posture change. During pregnancy, catecholamine surge may be triggered by pressure from the enlarging uterus and foetal movements. In the majority of cases, catecholamine-secreting tumours develop in the adrenal medulla and are termed phaeochromocytoma. Ten percent of tumours arise from extra-adrenal chromaffin tissues located in the abdomen, pelvis, or thorax to form paraganglioma that may or may not be biochemically active. The malignant potential of phaeochromocytoma or paraganglioma cannot be determined from histology and is inferred by finding tumours in areas of the body not known to contain chromaffin tissues. The risk of malignancy is higher in extra-adrenal tumours and in tumours that secrete dopamine.

Making the Correct Diagnosis

The diagnosis of phaeochromocytoma requires a combination of biochemical and anatomical confirmation. Catecholamines and their metabolites, metanephrines, can be easily measured in urine or plasma samples. Day collection of urinary fractionated metanephrine is considered the most sensitive in detecting phaeochromocytoma [ 5 ]. In contrast to sporadic release of catecholamine, secretion of metanephrine is continuous and is less subjective to momentary stress. Localisation of tumour can be accomplished by either CT or MRI of the abdomen [ 6 ]. Sensitivities are comparable, although MRI is preferable in pregnancy because of minimal radiation exposure. Once a tumour is identified, nuclear medicine imaging should be performed to determine its activity, as well as to search for extra-adrenal diseases. I 131 or I 123 MIBG scan is the imaging modality of choice. Metaiodobenzylguanidine structurally resembles noradrenaline and is concentrated in chromaffin cells of phaeochromocytoma or paraganglioma that express noradrenaline transporters. Radionucleotide imaging is contraindicated in pregnancy and should be deferred until after the delivery.

Treatment Approach

Upon confirming the diagnosis, medical therapy should be initiated promptly to block the cardiovascular effects of catecholamine release. Phenoxybenzamine is a long-acting non-selective alpha-blocker commonly used in phaeochromocytoma to control blood pressure and prevent cardiovascular complications [ 7 ]. The main side-effects of phenoxybenzamine are postural hypotension and reflex tachycardia. The latter can be circumvented by the addition of a beta-blocker. It is important to note that beta-blockers should not be used in isolation, since blockade of ß2-adrenoceptors, which have a vasodilatory effect, can cause unopposed vasoconstriction by a1-adrenoceptor stimulation and precipitate severe hypertension. There is little data on the safety of use of phenoxybenzamine in pregnancy, although its use is deemed necessary and probably life-saving in this precarious situation.

The definitive treatment of phaeochromocytoma or paraganglioma is surgical excision. The timing of surgery is critical, and the decision must take into consideration risks to the foetus, technical difficulty regarding access to the tumour in the presence of a gravid uterus, and whether the patient's symptoms can be satisfactorily controlled with medical therapy [ 8 , 9 ]. It has been suggested that surgical resection is reasonable if the diagnosis is confirmed and the tumour identified before 24 weeks of gestation. Otherwise, it may be preferable to allow the pregnancy to progress under adequate alpha- and beta-blockade until foetal maturity is reached. Unprepared delivery is associated with a high risk of phaeochromocytoma crisis, characterised by labile blood pressure, tachycardia, fever, myocardial ischaemia, congestive heart failure, and intracerebral bleeding.

Patients with phaeochromocytoma or paraganglioma should be followed up for life. The rate of recurrence is estimated to be 2%–4% at five years [ 10 ]. Assessment for recurrent disease can be accomplished by periodic blood pressure monitoring and 24-hour urine catecholamine and/or metanephrine measurements.

Genetics of Phaeochromocytoma

Approximately one quarter of patients presenting with phaeochromocytoma may carry germline mutations, even in the absence of apparent family history [ 11 ]. The common syndromes of hereditary phaeochromocytoma/paraganglioma are listed in Box 2 . These include Von Hippel-Lindau syndrome, multiple endocrine neoplasia type 2, neurofibromatosis type 1, and succinate dehydrogenase (SDH) gene mutations. Our patient has a novel frameshift mutation in the SDHD gene located at Chromosome 11q. SDH is a mitochondrial enzyme that is involved in oxidative phosphorylation. Characteristically, SDHD mutation is associated with head or neck non-functional paraganglioma, and infrequently, sympathetic paraganglioma or phaeochromocytoma [ 12 ]. Tumours associated with SDHD mutation are rarely malignant, in contrast to those arisen from mutation of the SDHB gene. Like all other syndromes of hereditary phaeochromocytoma, SDHD mutation is transmitted in an autosomal dominant fashion. However, not all carriers of the SDHD mutation develop tumours, and inheritance is further complicated by maternal imprinting in gene expression. While it may not be practical to screen for genetic alterations in all cases of phaeochromocytoma, most authorities advocate genetic screening for patients with positive family history, young age of tumour onset, co-existence with other neoplasms, bilateral phaeochromocytoma, and extra-adrenal paraganglioma. The confirmation of genetic mutation should prompt evaluation of other family members.

Box 2: Hereditary Phaeochromocytoma/Paraganglioma Syndromes

• Von Hippel-Lindau syndrome
• Multiple endocrine neoplasia type 2A and type 2B
• Neurofibromatosis type 1
• Mutation of SDHB , SDHC , SDHD
• Ataxia-telangiectasia
• Tuberous sclerosis
• Sturge-Weber syndrome

Key Learning Points

• Hypertension complicating pregnancy is a commonly encountered medical condition.
• Pre-existing chronic hypertension must be considered in patients with hypertension presenting in pregnancy, particularly if elevation of blood pressure is detected early during pregnancy or if persists post-partum.
• Secondary causes of chronic hypertension include renal artery stenosis, renal parenchyma disease, primary hyperaldosteronism, phaeochromocytoma, Cushing's syndrome, coarctation of the aorta, and obstructive sleep apnoea.
• Phaeochromocytoma presenting during pregnancy is rare but carries high rates of maternal and foetal morbidity and mortality if unrecognised.
• Successful outcomes depend on early disease identification, prompt initiation of alpha- and beta-blockers, carefully planned delivery, and timely resection of the tumour.

Phaeochromocytoma complicating pregnancy is uncommon. Nonetheless, in view of the potential for catastrophic consequences if unrecognised, a high index of suspicion and careful evaluation for secondary causes of hypertension is of utmost importance. Blood pressure should be monitored in the post-partum period and persistence of hypertension must be thoroughly investigated.

Author Contributions

All authors participated in the management of the patient or writing of the article. AL and RCWM wrote the article, with contributions from all the authors.

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Hypertension in Pregnancy: A Diagnostic and Therapeutic Overview

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• Published: 13 June 2023
• Volume 30 , pages 289–303, ( 2023 )

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Hypertensive disorders in pregnancy are associated with increased risk of maternal, fetal, and neonatal morbidity and mortality. It is important to distinguish between pre-existing (chronic) hypertension and gestational hypertension, developing after 20 weeks of gestation and usually resolving within 6 weeks postpartum. There is a consensus that systolic blood pressure ≥ 170 or diastolic blood pressure ≥ 110 mmHg is an emergency and hospitalization is indicated. The selection of the antihypertensive drug and its route of administration depend on the expected time of delivery. The current European guidelines recommend initiating drug treatment in pregnant women with persistent elevation of blood pressure ≥ 150/95 mmHg and at values > 140/90 mmHg in women with gestational hypertension (with or without proteinuria), with pre-existing hypertension with the superimposition of gestational hypertension, and with hypertension with subclinical organ damage or symptoms at any time during pregnancy. Methyldopa, labetalol, and calcium antagonists (the most data are available for nifedipine) are the drugs of choice. The results of the CHIPS and CHAP studies are likely to reduce the threshold for initiating treatment. Women with a history of hypertensive disorders in pregnancy, particularly those with pre-eclampsia, are at high risk of developing cardiovascular disease later in life. Obstetric history should become a part of the cardiovascular risk assessment in women.

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Hypertension in pregnancy: natural history and treatment options.

Treating Hypertension in Pregnancy

Hypertensive Disorders in Pregnancy

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1 Introduction

Hypertensive disorders in pregnancy (HDP) are a major cause of maternal, fetal, and neonatal morbidity and mortality complicating about 10% of pregnancies worldwide. This rate is likely to rise due to the increasing age and obesity of conceiving women. Pregnant women with HDP are at risk of developing placental abruption, stroke, pulmonary edema, thromboembolic events, disseminated intravascular coagulation, and multiple organ failure. The fetal risk includes intrauterine growth retardation, prematurity, and intrauterine death, all of which are particularly high in pre-eclampsia. Neonates are at increased risk of preterm birth with low birthweight, prolonged high-level neonatal care, and postnatal death [ 1 ].

2 Physiological Changes in Blood Pressure During Pregnancy

Due to vasodilation induced by local mediators such as prostacycline and nitric oxide, there is a fall in blood pressure (BP) early in the first trimester. This reduction in BP primarily affects diastolic BP (DBP), with the lowest values being achieved at weeks 20–24 (reduction of DBP by 8–15 mmHg), further followed by a gradual increase to pre-pregnancy values at week 36 [ 2 ].

This BP fluctuation is seen both in normotensive and hypertensive pregnant women. Women with pre-existing hypertension may have a greater BP decrease in early pregnancy and therefore the BP rise in the third trimester may be misdiagnosed as gestational hypertension.

Blood pressure usually falls immediately after delivery and then progressively rises over the first five postnatal days peaking on days 3–6 after delivery. It should be emphasized that 10% of maternal deaths due to hypertensive disorders in pregnancy occur in the postpartum period.

A summary of hemodynamic changes in pregnancy is provided in Table 1 .

3 Blood Pressure Measurement

The initial BP measurement should be taken in both upper arms, with following measurements taken in the arm with the higher BP value, preferably in the sitting position or in the left lateral recumbent position during labor. A cuff of appropriate size should always be used with the arm being supported at heart level.

The mercury sphygmomanometer is still considered the gold standard for BP measurement in pregnancy with Korotkoff V phase to be used for DBP. However, as the sale of mercury sphygmomanometers has been banned in Europe, other devices for standard sphygmomanometry or automatic/semiautomatic (usually oscillometric) BP devices, validated according to standardized protocols (specifically for pregnancy and pre-eclampsia) should be used [ 3 ]. It is important to note that not all automatic devices are validated for use in pregnancy and pre-eclampsia. Those that are not specifically validated for this condition showed a tendency to underestimate actual BP levels and are thus unreliable in severe pre-eclampsia. A reasonable solution may be an auscultatory hybrid device with a liquid-crystal display on a vertical column simulating a mercury sphygmomanometer [ 4 ], however, these devices are not presently widely used. Wrist BP monitors are not recommended [ 5 ].

In hypertensive emergencies, BP should also be measured in both arms and in lower limbs if there is a clinical suspicion of aortic dissection [ 6 ].

Ambulatory BP monitoring (ABPM) is superior to routine BP measurement for the prediction of pregnancy outcome [ 7 ]. It can help to rule out white-coat hypertension, which is quite frequent in pregnancy [ 8 ], and may identify nocturnal hypertension, a finding commonly reported in pre-eclampsia [ 9 ].

Home BP measurement (HBPM) is suitable for long-term monitoring, particularly in patients treated with antihypertensive drugs, despite two recently published studies (BUMP 1 and BUMP 2) not showing any convincing evidence. In BUMP 1 (Blood Pressure Monitoring in High Risk Pregnancy to Improve the Detection and Monitoring of Hypertension 1) in women at high risk of pre-eclampsia, self-monitoring with telemonitoring did not lead to earlier clinic-based detection of hypertension [ 10 ]. BUMP 2, a randomized clinical trial initiated by the same group of investigators [ 11 ], did not find differences in mean systolic BP recorded by healthcare professionals in women whose BP was measured at regular antenatal clinics compared with those who performed BP self-monitoring. Together with tele-transmission of BP data, self-monitoring may become a future solution, saving repeated office visits and hospital admissions [ 12 ].

4 Diagnosis of Hypertension

Hypertension in pregnancy is diagnosed if systolic BP (SBP) ≥ 140 mmHg and/or diastolic BP (DBP) ≥ 90 mmHg, measured in the office or in hospital; it has to be confirmed, preferably on 2 separate occasions or at least 15 min apart in severe hypertension (i.e. ≥ 160/110 mmHg in the obstetric literature which usually recognizes only mild and severe hypertension rather than the three grades used by the European hypertension guidelines) [ 13 ].

5 Classification of Hypertensive Disorders

Hypertension in pregnancy is not a single entity but comprises [ 1 , 13 ] (Table 2 ):

Pre-existing hypertension: either preceding pregnancy or developing before 20 weeks’ gestation. It usually persists for more than 42 days postpartum and may be associated with proteinuria.

Gestational hypertension: developing after 20 weeks’ gestation and usually resolving within 42 days postpartum.

Pre-eclampsia: gestational hypertension with significant proteinuria (> 0.3 g/24 h or ≥ 30 mg/mmol urinary protein: creatinine ratio in a spot random urine sample).

Pre-eclampsia is a systemic disorder with both maternal and fetal manifestation occurring more frequently during the first pregnancy, in multiple pregnancy, in hydatidiform mole, in antiphospholipid syndrome, in renal disease or diabetes, or with pre-existing hypertension. It is often associated with fetal growth restriction due to placental insufficiency and is a common cause of prematurity. The only cure is delivery [ 14 ]. As proteinuria may be a late manifestation of pre-eclampsia, it should be suspected when de novo hypertension is accompanied by headache, visual disturbances, abdominal pain, or abnormal laboratory tests, specifically low platelet count and abnormal liver enzymes; it is recommended to treat such patients as having pre-eclampsia.

Pre-existing hypertension plus superimposed gestational hypertension with proteinuria.

Antenatally unclassifiable hypertension: this term is used when BP is first recorded after 20 weeks' gestation and hypertension is diagnosed; re-assessment is necessary at or after 42 days postpartum.

The above definition of pre-eclampsia is in concordance with the 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy [ 1 ]. However, the International Society for the Study of Hypertension in Pregnancy (ISSHP) introduced a new, broader definition of pre-eclampsia, now being defined as gestational hypertension accompanied by one or more of the following new‐onset conditions at or after 20 weeks of gestation: (1) proteinuria; (2) evidence of other maternal organ dysfunction (including acute kidney injury [serum creatinine ≥ 1 mg/dl; 90 µ/l], liver involvement [elevated transaminases > 40 UI/L; 67 µkat/L]) with or without right upper quadrant or epigastric pain, neurological complications [convulsions, altered mental status, blindness, scotomata or headache], hematological complications [platelet count < 150,000/μL, disseminated intravascular coagulation, hemolysis]; or (3) uteroplacental dysfunction (e.g., fetal growth restrictions, abnormal umbilical artery Doppler wave form analysis for stillbirth) [ 15 ]. The combination of hemolysis, thrombocytopenia, and elevated transaminases defines HELLP syndrome as one manifestation of pre-eclampsia and therefore additional features of pre-eclampsia should be evaluated.

Pre-existing hypertension is associated with a 25% increased risk of developing superimposed pre-eclampsia [ 16 ], which is usually associated with a sharp increase in BP, and de novo development of proteinuria or any other maternal organ dysfunction as defined by the ISSHP.

The 2018 ISSHP recommendations [ 15 ] included transient gestational hypertension, which is usually detected in the clinic but settles with repeated BP measurements taken over the course of several hours. It is not a benign disorder, as it is associated with a 40% risk of developing true gestational hypertension or pre-eclampsia later in the same pregnancy. Therefore, these patients should have a careful follow-up with home BP measurements.

6 Laboratory Tests and Other Recommended Examinations

Hypertensive disorders in pregnancy, particularly gestational hypertension with or without proteinuria, may induce changes in the hematologic, renal, and hepatic profiles that may adversely affect both neonatal and maternal outcomes.

Basic laboratory investigations recommended for monitoring patients with hypertension in pregnancy are presented in Table 3 . All pregnant women should be assessed for proteinuria in early pregnancy to rule out pre-existing renal disease and, in the second half of pregnancy, to screen for pre-eclampsia. A positive dipstick test (≥ 1+) should prompt further investigations including an albumin-to-creatinine ratio (ACR), which can be quickly determined in a single spot urine sample. A value < 30 mg/mmol (0.3 mg/mg) can reliably rule out proteinuria, but a positive test should possibly be followed by a 24-h urine collection. If proteinuria exceeds 2 g/day, close monitoring is warranted. It should be noted that 24-h urine collection is often inaccurate and delays the diagnosis of pre-eclampsia. Thus, an ACR cutoff of ≥ 30 mg/mmol (0.3 mg/mg) can be used to identify significant proteinuria.

The following investigations may be considered additionally to the basic laboratory tests:

Determination of the soluble fms-like tyrosine kinase-1 (sFlt-1) to placental growth factor (PlGF) ratio is now widely available to exclude the development of pre-eclampsia when suspected clinically [ 17 ]; a value of (sFlt-1: PlGF) < 38 is used to possibly rule out the development of pre-eclampsia in the next week. The test has a high negative predictive value. The sFlt-1/PlGF ratio is suggested to be used from 20 weeks through to 32 + 6 weeks for short-term prediction and diagnostic support in high-risk women or in women clinically suspected of pre-eclampsia [ 18 ]. It could also be used in women after 37 weeks with suspected pre-eclampsia or to evaluate uteroplacental dysfunction [ 19 ]. Women with a sFlt-1/PlGF ratio ≥ 85 most likely have or will develop pre-eclampsia within the next 4 weeks and require intensive monitoring, preferably during hospitalization [ 20 ]. A recent study showed that the increased sFlt-1/PlGF ratio in pre-eclampsia is mostly driven by the increased placental sFlt-1 [ 21 ].

Doppler ultrasound of uterine arteries after 20 weeks of gestation is useful in detecting women at high risk of gestational hypertension, pre-eclampsia, and intrauterine growth retardation.

Performing an ultrasound examination of the adrenals, urine metanephrine, and normetanephrine assays in all pregnant women with hypertension is recommended by some authors [ 22 ] as a screening for pheochromocytma.

7 Pre-conception Counselling

All women with known pre-existing hypertension should receive pre-conception counselling aimed at ruling out possible secondary causes of hypertension and informing them about the high risk of developing pre-eclampsia, which could be reduced by a low dose of aspirin [ 23 ]. Renal Doppler ultrasound is suggested to be performed in all hypertensive women planning pregnancy. If fibromuscular dysplasia (FMD) is diagnosed before pregnancy, a search for other potential arterial damage in other vascular beds should follow [ 24 ]. Determination of urine metanephrine and normetanephrine assays in all pregnant women with hypertension is recommended by some authors [ 22 ] as a screening for pheochromocytma, which may be completely asymptomatic and, if not diagnosed before labor, fatal.

8 Management of Secondary Hypertension in Pregnancy

8.1 pheochromocytoma.

During pregnancy, a pheochromocytoma is among the most life-threatening conditions for both the mother and fetus. Although extremely rare (0.002% of all pregnancies), this tumor is infamous for its devastating consequences [ 25 ]. The signs and symptoms are variable but not specific, as is the case with non-pregnant women. Hypertension is only of one of the most dominant signs. If left undiagnosed, maternal and fetal mortality is around 50%. Early detection and adequate treatment during pregnancy lower the maternal and fetal mortality to < 5 and < 15%, respectively. For the biochemical diagnosis, plasma or urinary metanephrines are the test of choice since they have the highest sensitivity and the highest negative predictive value. For reliable localization, magnetic resonance imaging is the most suitable technique, having a sensitivity of more than 90%. When a pheochromocytoma is diagnosed in pregnancy, a laparoscopic adrenalectomy should be performed after 10–14 days of drug pretreatment (as in non-pregnant patients), using alpha-adrenoreceptor blockade combined with beta-adrenergic blockade started some days later. If the pheochromocytoma is diagnosed during the third trimester, the patient should be managed until the fetus is viable using the same drug regimen as for the surgical preparation. Caesarian section with tumor removal in the same session or at a later stage is preferred, as vaginal delivery is possibly associated with higher mortality.

8.2 Primary Aldosteronism

Primary aldosteronism (PA), the most common cause of secondary hypertension outside of pregnancy, is underdiagnosed in pregnancy. Women with known PA before pregnancy or with clinical suspicion in early pregnancy should have a close laboratory work-up. However, optimal management of PA during pregnancy has not been established regarding the safety of mineralocorticoid antagonists and amiloride. It is also unclear if laparoscopic adrenalectomy of adrenal adenoma will improve the prognosis [ 26 ]. Eplerenone on top of the usual BP lowering treatment may be considered for uncontrolled hypertension in the second trimester [ 27 ]. Hypokalemia and BP may be aggravated postpartum due to the decrease in progesterone [ 26 , 27 ].

9 Prevention of Pre-eclampsia

Women at high or moderate risk of pre-eclampsia should be advised to take 100–150 mg of aspirin daily from 12 weeks to weeks 36–37 [ 1 , 13 , 23 ].

High risk of pre-eclampsia includes any of the following:

hypertensive disease during a previous pregnancy

chronic kidney disease

autoimmune disease such as systemic lupus erythematosus or antiphospholipid syndrome

type 1 or type 2 diabetes

chronic hypertension

Moderate risk of pre-eclampsia includes ≥ 1 of the following risk factors:

first pregnancy

age 40 years or older

pregnancy interval of more than 10 years

body mass index (BMI) of 35 kg/m 2 or more at first visit

family history of pre-eclampsia

multiple pregnancy.

There is growing evidence that assisted reproductive technology (ART) is associated with an increased risk of developing pre-eclampsia [ 28 , 29 ]. The risk is particularly high in frozen embryo transfers [ 30 ]. Thus, it is very likely that ART in the current pregnancy will be listed as an additional high-risk condition of pre-eclampsia recommending a low dose of aspirin to prevent it.

Calcium supplementation (at least 1 g/day, orally) is recommended for prevention of pre-eclampsia in women with a low dietary intake of calcium (< 600 mg/day)[ 31 ]. Vitamin D deficiency is very common in pregnant women and increases the risk of pre-eclampsia [ 32 ]. The beneficial role of vitamin D in the prevention of pre-eclampsia, independent of timing of supplementation, dosage, and maternal age, was shown by a meta-analysis of randomized clinical trials. [ 33 ]. Further research should be focused on the recommended regimen (daily, weekly or a single dose).

There is no evidence that vitamins C and E decrease the risk of pre-eclampsia [ 34 , 35 ]. On the contrary, they are associated with low birth weight (< 2.5 kg) and adverse perinatal outcomes [ 36 ].

10 Management of Hypertension in Pregnancy

The majority of women with pre-existing hypertension in pregnancy have mild to moderate hypertension (140–179/90–109 mmHg) and are at low risk for cardiovascular complications within the short timeframe of pregnancy. Women with essential hypertension and normal renal function have good maternal and neonatal outcomes. Some women with treated pre-existing, mild hypertension may be able to have their medication withdrawn or reduced in the first half of pregnancy because of the physiological fall in BP during this period. However, close monitoring and, if necessary, resumption of treatment is essential.

There are not sufficient data regarding treatment of hypertension in pregnancy as pharmaceutical companies have been reluctant to test drugs in this small market with a high potential of litigation. Child-bearing potential without reliable contraception is an exclusion criterion in basically all clinical trials testing antihypertensive drugs.

The only trial of treatment of hypertension in pregnancy with adequate infant follow-up (7.5 years) was performed almost 50 years ago with alpha-methyldopa, now rarely used in non-pregnant women [ 37 , 38 ]. Past clinical trials also have not supported a beneficial effect on pregnancy outcome of treating mild to moderate hypertension. There has been no reduction in perinatal mortality, placental abruption, or superimposed pre-eclampsia [ 39 , 40 ]. The most recent Cochrane Review on this topic showed only a halving of the risk of developing severe hypertension [ 41 ]. More recently, a systematic review and network meta-and trial sequential analyses found that all commonly prescribed antihypertensive drugs in pregnancy reduce the risk of severe hypertension, but labetalol may also decrease the development of proteinuria/pre-eclampsia and fetal/newborn death [ 42 ].

10.1 Non-drug Treatment

A normal diet without salt restriction is advised, particularly close to the time of delivery as salt restriction may induce a low intravascular volume. However, women with pre-existing hypertension should continue any salt-restricted diet they already follow [ 43 ].

Aerobic exercise three to four times per week (30–60 min/session) is recommended to prevent weight gain and reduce adverse pregnancy outcomes, including hypertensive disorders and gestational diabetes mellitus, unless contraindicated [ 44 , 45 , 46 , 47 ]. Exercise of low to moderate intensity during pregnancy is particularly effective in decreasing the development of gestational diabetes and gestational hypertension, especially when supervised and when initiated in the first trimester [ 48 ].

As maternal obesity may be associated with poor outcomes for both mother and fetus, obese women (BMI ≥ 30 kg/m 2 ) are advised to avoid a weight gain of more than 6.8 kg. The recommended weight gain range for overweight pregnant women (BMI 25.0–29.9 kg/m 2 ) is 6.8–11.2 kg [ 49 , 50 , 51 ].

11 Drug Treatment

The goal of treating hypertension is to reduce maternal risk without compromising the health of the fetus.

11.1 Treatment of Severe Hypertension

With values ranging between 160 and 180 mmHg/> 110 mmHg, there is no agreement on the definition of severe hypertension in pregnancy. However, there is a consensus that SBP ≥ 170 or DBP ≥ 110 mmHg in a pregnant woman should be considered an emergency, and hospitalization is indicated [ 1 ] (Table 4 ). The selection of the antihypertensive drug and its route of administration depend on the expected time of delivery. ACE inhibitors, ARBs, and direct renin inhibitors are strictly contraindicated.

Labetalol, methyldopa, or nifedipine XL can be used for oral treatment. If parenteral treatment is needed, intravenous labetalol seems to be the drug of choice. Intravenous hydralazine should no longer be thought of as the drug of choice, as its use is associated with more adverse effects than other drugs [ 52 ] and should only be used when labetalol is contraindicated or other drugs prove ineffective. However, recent analyses of safety and efficacy, found hydralazine to be comparable to both labetalol and nifedipine [ 53 , 54 ]. Oral short-acting nifedipine should only be used temporarily, e.g. until i.v. access is available, with the second dose administered only after one hour if severe hypertension persists. Short-acting sublingual nifedipine is contraindicated.

11.2 Hypertensive Emergencies

The definition of hypertensive emergency in pregnancy is: pre-eclampsia/eclampsia and SBP ≥ 160 mmHg and DBP ≥ 110 mm Hg or severely elevated BP (DBP > 120 mmHg) and progressive acute end-organ damage such as acute myocardial infarction, pulmonary edema, respiratory failure, or aortic dissection. BP should be decreased immediately by 15–25% with the goal being SBP 140–150 mmHg and DBP 90–100 mmHg. The list of the most frequently used drugs for treatment of hypertensive emergencies is shown in Table 5 .

Prolonged treatment with sodium nitroprusside is associated with an increased risk of fetal cyanide poisoning as nitroprusside is metabolized into thiocyanate excreted into urine [ 55 ]. Therefore, sodium nitroprusside should be reserved for extreme emergencies and used for the shortest possible duration.

The drug of choice in pre-eclampsia associated with pulmonary edema is nitroglycerine (given as intravenous infusion of 5 µg/min, gradually increased every 3–5 min to a maximum dose of 100 µg/min).

11.3 Prevention of Eclampsia

For prevention of eclampsia and for treatment of seizures, magnesium sulfate i.v. is recommended [ 56 , 57 ]. Most guidelines suggest primary prevention of eclampsia in severe pre-eclampsia with persistent neurological symptoms (severe headache, visual disturbances, hyperactive deep-tendon reflexes). The recommended loading dose is 4 g i.v., followed by continuous infusion of 1 g per hour until delivery for a maximum of 24 h while monitoring the mother closely.

11.4 Treatment of Mild-to-Moderate Hypertension

In the absence of randomized controlled trials, recommendations can only be guided by expert opinion. The European guidelines [ 1 , 13 ] recommend initiating drug treatment in all women with persistent elevation of BP ≥ 150/95 mmHg and at values > 140/90 mmHg in women with:

gestational hypertension (with or without proteinuria)

pre-existing hypertension with the superimposition of gestational hypertension

hypertension with subclinical organ damage or symptoms at any time during pregnancy.

Methyldopa, labetalol, and calcium antagonists (the most data are available for nifedipine) are the drugs of choice (Table 6 ). Beta-blockers appear to be less effective than calcium antagonists and may induce fetal bradycardia, growth retardation, and hypoglycemia; the type and dose should be carefully selected with atenolol avoided, as it was shown to be fetotoxic. Calcium-channel blockers are considered safe if not given concomitantly with magnesium sulfate (risk of hypotension due to potential synergism). Women with pre-existing hypertension may continue their current antihypertensive medication except for RAS blockers which are strictly contraindicated in pregnancy. As there is a reduction of plasma volume in pre-eclampsia, diuretic therapy is therefore inappropriate unless there is oliguria when low-dose furosemide may be considered. (Table 7 ). Magnesium sulfate i.v. is recommended for the prevention of eclampsia and treatment of seizures [ 56 ].

Future guidelines are likely to be influenced by two randomized clinical trials conducted in women with non-severe hypertension in pregnancy. The Control of Hypertension in Pregnancy Study (CHIPS) assessed whether “more tight” or “less tight” control of hypertension was associated with better outcomes [ 58 ]. Most women included in this study had non-severe and non-proteinuric chronic hypertension (75%, 736 out of 987) and 25% had gestational hypertension. Similar to previous meta-analyses [ 39 , 40 ], the development of severe hypertension was significantly reduced in the “more tight” arm of the study. In the subgroup of women with chronic hypertension, “less tight” BP control was associated with lower rates of small-for-gestational age newborns. Unfortunately, the study has several limitations: (a) the sample size was limited, not allowing for subgroup analyses, including that of small-for-gestational age newborns; (b) chronic and gestational hypertension were analyzed together as one group; (c) women with newly detected hypertension before week 14 did not qualify for enrollment ; (d) labetalol, being considered the drug of choice, was used only by 2/3 of women in the study; (e) systolic BP was ignored when assessing the study outcomes; (f) women with prior severe hypertension were more often randomly allocated to the “less tight” control group. Nevertheless, despite all the above limitations, most experts concluded that the study demonstrated that lowering BP in pregnancy to levels which are routinely achieved by non-pregnant women is safe for the fetus [ 59 ]. The investigator-initiated Chronic Hypertension and Pregnancy (CHAP) project included a much larger study group of women with mild chronic hypertension of gestational age less than 23 weeks [ 60 ]. A total of 2,408 women were randomized to a BP goal of < 140/90 mmHg (active treatment) or to control treatment, in which antihypertensive medication was withdrawn or never given unless severe hypertension (SBP ≥ 160 mmHg or DBP ≥ 105 mmHg) developed. In the active treatment group, the study participants were supplied with labetalol or extended release nifedipine or other medication such as amlodipine or methyldopa, based on the patient´s preference. The primary outcome was defined as a composite of pre-eclampsia with severe features, medically indicated preterm birth before 35 weeks gestation, placental abruption, or fetal or neonatal death. The primary-outcome events were reduced in the active treatment group (adjusted risk ratio 0.82; 95% CI 0.74–0.92). The overall mean BP was lower in the active treatment group (129.5/79.1 mmHg vs. 132.6/81.5 mmHg). The pre-specified composite maternal or neonatal secondary outcomes did not differ between groups, including small-for-gestational-age newborns. Severe hypertension was less frequent in the active treatment group, with no stroke in either group. The study results support antihypertensive treatment in women with mild pre-existing hypertension to achieve a target BP of < 140/90 mmHg. It should be noted that BP differences were more evident in the first half of the pregnancy. Low doses of aspirin were administered equally in the active treatment and control group (44.6% vs 44.7%).

12 Delivery

Induction of labor is advisable for women with gestational hypertension or mild pre-eclampsia beyond 37 weeks of gestation, as it has been shown to be associated with improved maternal outcome [ 61 ]. Factors such as fetal well-being, gestational age, and type of hypertensive disorder determine the optimal timing of delivery. Pre-eclampsia lacking severe features is possibly manageable by expectation. On the other hand, eclampsia requires delivery shortly after the mother is stabilized.

Cesarean delivery should be considered only for obstetric indications and in the rare case of pheochromocytoma. Otherwise, vaginal delivery is preferable for women with hypertension in pregnancy. Severe pre-eclampsia, regardless of gestational age, requires prompt delivery either vaginally or by cesarean section.

During labor and delivery, antihypertensive treatment should continue with the aim of keeping SBP < 160 mmHg and DBP < 90 mmHg.

13 Blood Pressure Postpartum

Fluctuations of blood pressure in the postpartum period are common. After the usual fall in BP following delivery, there is a progressive rise over the subsequent five days. The postpartum period is also associated with a risk of the late onset of pre-eclampsia. Therefore, BP should be checked in all women within six hours of delivery. Transient hypertension may develop postpartum in women who were previously normotensive. This could be due to pain (because of inadequate analgesia), some drugs (non-steroid anti-inflammatory drugs for pain relief, ergot derivatives for postpartum bleeding, or ephedrine), hypervolemia after regional anesthesia, salt and water redistribution into the intravascular compartment, or restoration of non-pregnant vascular tone. Mild hypertension postpartum usually resolves spontaneously. However, as late presentation pre-eclampsia is a possibility, it is necessary to check BP at least once a day for the first five days after delivery. It is advised to continue with BP measuring every other day for at least one week after discharge from hospital.

In the postpartum period up to 4 weeks, hypertensive women with the following symptoms should be suspected of having de novo pre-eclampsia: headaches, epigastric pain (possibly accompanied by nausea and vomiting), visual disturbances (blurred vision, flashing lights, double vision, floating spots, etc., dyspnea (potentially due to pulmonary edema), sudden swelling in the face, hands, or feet, or seizures.

14 Lactation

Generally, breast feeding is not associated with an increase in BP in mothers. Bromocryptin, used to suppress lactation in some countries, may induce hypertension. All antihypertensive drugs are excreted into breast milk, mostly at very low concentrations, except for propranolol, atenolol, acebutolol (potentially inducing signs of neonatal betablockade), and nifedipine, achieving similar levels to those in maternal plasma. According to many guidelines, methyldopa is still considered the drug of choice for breastfeeding mothers, except for women prone to depression.

Labetalol, nifedipine, and enalapril are suggested as first line antihypertensive drugs for breastfeeding mothers by most guidelines. A list of antihypertensive drugs usually compatible with breastfeeding is provided in Table 8 . ACE inhibitors can be used in lactating mothers except in cases of premature birth or renal failure in the newborn. Enalapril is the most widely prescribed ACE inhibitor to breastfeeding mothers because of its safety and favorable pharmacokinetics. It is also used for treatment of peripartum cardiomyopathy.

Calcium channel blockers, particularly felodipine and nifedipine, are considered safe and are therefore frequently used, despite nifedipine not being recommended to nursing mothers by the manufacturer. Nifedipine may be the drug of choice in Black women of African or Caribbean origin.

Labetalol and some beta-1 selective blockers, with the most favorable data being available on metoprolol, are also compatible with breastfeeding and are therefore recommended.

Diuretics should be used with caution, as they may reduce milk production.

15 Prognosis After Pregnancy

Women with a history of gestational hypertension or pre-eclampsia are at higher risk of developing hypertension and stroke later in life [ 62 ]. Pre-eclampsia was associated with a four-fold increase in heart failure and hypertension, and doubled the risk of ischemic heart disease, stroke, and cardiovascular death [ 63 , 64 ]. Women with a history of HDP developing hypertension within a decade postpartum were shown to have the most pronounced abnormal echocardiographic findings in left ventricular remodeling and diastolic function, compared to hypertensive women without previous history of HDP [ 65 ]. The 2018 American College of Cardiology/American Heart Association cholesterol guidelines suggest initiating treatment with statins in asymptomatic, middle-aged women with an intermediate 10-year risk and history of pre-eclampsia [ 66 ]. HDPs are also associated with an increased risk of developing peripartum cardiomyopathy [ 67 , 68 ].

Women with previous gestational hypertension may develop endothelial dysfunction and early alterations of carbohydrate and lipid metabolism. They may also experience a relative hyperandrogenism which could, together with the metabolic abnormalities, partly explain the increased risk of developing CVD in later life [ 69 ].

A recent meta-analysis of 5 cohort studies with a total of more than 180,000 women with HDP and more than 2,300,000 women without HDP showed that the risk of all-cause and vascular dementia was substantially elevated in women with HDP (adjusted HR, 1.38; 95% CI 1.18–1.61, p < 0.01) [ 70 ]. There is also growing evidence for an increased risk of alterations in developmental cognition in the offspring [ 71 ].

Despite women with HDPs being recognized as high-risk individuals by the 2018 ESC/ESH hypertension guidelines, recommendations on systematic check-ups are still lacking. BP monitoring in the first postpartum months is strongly suggested, possibly by implementing BP self-measurement to be reported to the primary care physician or using e-health technology [ 72 ]. Larger validation studies with BP self-measurement are ongoing [ 73 ].

Cardiologists and general practitioners should include an obstetric history, regardless of the woman’s age, as part of the cardiovascular risk assessment. Unfortunately, this area is currently lacking data from randomized studies. There is general agreement that women with a history of HDP, particularly when associated with gestational diabetes, metabolic syndrome, or fetal growth restriction, should be closely monitored for the development of CVD. The timing of this recommendation is unclear, but experts suggest setting up an initial review 6–12 weeks postpartum and then at 6–12 months [ 74 ]. The examination should include BP evaluation and assessment of other modifiable risk factors [ 74 ]. There is a need to develop a CVD risk calculator assessing female-specific risk factors, including hypertensive and metabolic disorders of pregnancy [ 75 ].

16 Assisted Reproductive Technology

In high-income countries 2–6% of children are conceived using ART, meaning that, worldwide, at least 8,000,000 children have been born using ART [ 76 ]. There is convincing evidence that HDPs are increased in all pregnancies following ART, regardless of the type of treatment [ 77 ]. This meta-analysis included 66 longitudinal studies (7,038,029 pregnancies and 203,375 following any ART). These results are confirmed by another meta-analysis showing higher odds of HDP and pre-eclampsia in pregnancies after in vitro fertilization (IVF) or in intracytoplasmic sperm fertilization (ICSI). The risk was particularly high in frozen embryo transfer and oocyte donation pregnancies [ 29 ]. Women who conceived via ART in their current pregnancy are advised to take a low dose of aspirin to prevent pre-eclampsia [ 78 ].

In 2015 a group of Swiss researchers declared that children conceived by ART have cardiovascular dysfunction and could potentially have increased CV risk later in life [ 79 ]. A total of 54 young individuals (mean age 16.5 ± 2.3 years) conceived by ART were compared with 43 spontaneously conceived controls of similar age [ 80 ]. Both groups were re-examined 5 years later. Premature vascular aging persisted in ART conceived individuals (impaired flow-mediated dilatation of the brachial artery, increased pulse-wave velocity, and carotid intima-media thickness). They also showed significantly higher SBP and DBP values by ambulatory BP monitoring (ABPM), and 8 of them (15.4%) met the ABPM criteria for hypertension. A significantly lower left ventricular diastolic function was found in another study including children conceived by ART (mean age 12.85 ± 5.8 years) compared to spontaneously conceived controls of roughly the same age [ 81 ]. The risk of developing left ventricular diastolic alterations was particularly high in individuals born preterm.

17 Conclusions

HDPs complicate about 10% of pregnancies and are associated with increased risk of morbidity and mortality for the mother, fetus, and the newborn. Diagnosis of hypertension in pregnancy is based on BP values (SBP ≥ 140 mmHg and/or diastolic DBP ≥ 90 mmHg) measured in the office or in hospital, preferably on two separate occasions. Ambulatory BP monitoring should be used to rule out white coat hypertension to avoid unnecessary treatment.

Hypertension in pregnancy should be classified as pre-existing hypertension or gestational hypertension. Pre-eclampsia used to be defined as gestational hypertension with significant proteinuria. In 2018 a new definition of pre-eclampsia was introduced, no longer insisting on the presence of proteinuria, but requiring evidence of other maternal organ dysfunction.

Pre-existing hypertension is associated with a 25% increased risk of developing superimposed pre-eclampsia. A low dose of aspirin should be initiated in these women from week 12 to weeks 36 to 37. The same preventive measure is recommended to all women at high risk of pre-eclampsia, such as having had hypertension during a previous pregnancy, currently having chronic kidney disease, autoimmune disease, or diabetes. A low dose of aspirin should also be given to women at moderate risk of pre-eclampsia.

Calcium supplementation is recommended for the prevention of pre-eclampsia only in women with a low dietary intake of calcium (< 600 mg daily). Vitamin D is also suggested in the prevention of pre-eclampsia.

Women with pre-existing hypertension should continue their salt-restricted diet, otherwise a normal diet without salt restriction is advised. Exercise of low to moderate intensity during pregnancy is effective in reducing the risk of developing gestational diabetes and gestational hypertension. Obese women are advised to avoid a weight gain of more than 6.8 kg.

There is a consensus that SBP ≥ 170 or DBP ≥ 110 mmHg is considered an emergency and hospitalization should follow. The selection of antihypertensive drugs and their route of administration should be determined based on the expected time of delivery. Intravenous labetalol seems to be an almost universal drug of choice. For mild and moderate hypertension, methyldopa, oral labetalol, and calcium antagonists (with the most data available for long-acting nifedipine), are drugs of choice. Based on the CHIPS and CHAP projects, the threshold for initiating drug treatment for hypertension in pregnancy may be reduced to 140/90 mmHg.

Vaginal delivery is preferred for women with hypertension in pregnancy, provided there is no obstetric indication for cesarean delivery. Induction of labor after the 37th week, compared with the expectant approach, is associated with a better prognosis in women with gestational hypertension or mild pre-eclampsia. Pre-eclampsia can also newly develop in the postpartum period and should be suspected if a rise in BP is associated with some symptoms (headache, epigastric pain, visual disturbances, dyspnea, edema in the face, hands, feet, or seizures).

All antihypertensive drugs are excreted into breast milk, most of them at very low concentrations. Labetalol, nifedipine, and enalapril are considered safe and are recommended by most guidelines. However, ACE inhibitors should not be used in cases of premature birth or renal failure of the newborn.

Women with a history of HDPs are at higher risk of developing CVD prematurely in later life.

Data availability

Not applicable.

Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, Blomström-Lundqvist C, Cífková R, De Bonis M, et al. 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J. 2018;39(34):3165–241.

Article   PubMed   Google Scholar  

Shen M, Tan H, Zhou S, Smith GN, Walker MC, Wen SW. Trajectory of blood pressure change during pregnancy and the role of pre-gravid blood pressure: a functional data analysis approach. Sci Rep. 2017;7(1):6227.

Article   PubMed   PubMed Central   Google Scholar  

Stergiou GS, Palatini P, Asmar R, Ioannidis JP, Kollias A, Lacy P, et al. Recommendations and Practical Guidance for performing and reporting validation studies according to the Universal Standard for the validation of blood pressure measuring devices by the Association for the Advancement of Medical Instrumentation/European Society of Hypertension/International Organization for Standardization (AAMI/ESH/ISO). J Hypertens. 2019;37(3):459–66.

Article   CAS   PubMed   Google Scholar  

Davis GK, Roberts LM, Mangos GJ, Brown MA. Comparisons of auscultatory hybrid and automated sphygmomanometers with mercury sphygmomanometry in hypertensive and normotensive pregnant women: parallel validation studies. J Hypertens. 2015;33(3):499–505 ( discussion -6 ).

Mounier-Vehier C, Amar J, Boivin JM, Denolle T, Fauvel JP, Plu-Bureau G, et al. Hypertension and pregnancy: expert consensus statement from the French Society of Hypertension, an affiliate of the French Society of Cardiology. Fundam Clin Pharmacol. 2017;31(1):83–103.

van den Born BH, Lip GYH, Brguljan-Hitij J, Cremer A, Segura J, Morales E, et al. ESC Council on hypertension position document on the management of hypertensive emergencies. Eur Heart J Cardiovasc Pharmacother. 2019;5(1):37–46.

O’Brien E, Parati G, Stergiou G, Asmar R, Beilin L, Bilo G, et al. European Society of Hypertension position paper on ambulatory blood pressure monitoring. J Hypertens. 2013;31(9):1731–68.

Magee LA, Ramsay G, von Dadelszen P. What is the role of out-of-office BP measurement in hypertensive pregnancy? Hypertens Preg. 2008;27(2):95–101.

Article   CAS   Google Scholar  

Ditisheim A, Wuerzner G, Ponte B, Vial Y, Irion O, Burnier M, et al. Prevalence of hypertensive phenotypes after preeclampsia: a prospective cohort study. Hypertension. 2018;71(1):103–9.

Tucker KL, Mort S, Yu LM, Campbell H, Rivero-Arias O, Wilson HM, et al. Effect of self-monitoring of blood pressure on diagnosis of hypertension during higher-risk pregnancy: the BUMP 1 randomized clinical trial. JAMA. 2022;327(17):1656–65.

Chappell LC, Tucker KL, Galal U, Yu LM, Campbell H, Rivero-Arias O, et al. Effect of self-monitoring of blood pressure on blood pressure control in pregnant individuals with chronic or gestational hypertension: the BUMP 2 Randomized Clinical Trial. JAMA. 2022;327(17):1666–78.

Denolle T, Weber JL, Calvez C, Getin Y, Daniel JC, Lurton O, et al. Diagnosis of white coat hypertension in pregnant women with teletransmitted home blood pressure. Hypertens Preg. 2008;27(3):305–13.

Article   Google Scholar  

Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension. J Hypertens. 2018;36(10):1953–2041.

Ives CW, Sinkey R, Rajapreyar I, Tita ATN, Oparil S. Preeclampsia-pathophysiology and clinical presentations: JACC state-of-the-art review. J Am Coll Cardiol. 2020;76(14):1690–702.

Brown MA, Magee LA, Kenny LC, Karumanchi SA, McCarthy FP, Saito S, et al. The hypertensive disorders of pregnancy: ISSHP classification, diagnosis & management recommendations for international practice. Preg Hypertens. 2018;13:291–310.

Seely EW, Ecker J. Chronic hypertension in pregnancy. Circulation. 2014;129(11):1254–61.

Zeisler H, Llurba E, Chantraine F, Vatish M, Staff AC, Sennström M, et al. Predictive value of the sFlt-1:PlGF ratio in women with suspected preeclampsia. N Engl J Med. 2016;374(1):13–22.

Verlohren S, Brennecke SP, Galindo A, Karumanchi SA, Mirkovic LB, Schlembach D, et al. Clinical interpretation and implementation of the sFlt-1/PlGF ratio in the prediction, diagnosis and management of preeclampsia. Preg Hypertens. 2022;27:42–50.

Huhn EA, Kreienbühl A, Hoffmann I, Schoetzau A, Lange S, de Tejada BM, et al. Diagnostic accuracy of different soluble fms-like tyrosine kinase 1 and placental growth factor cut-off values in the assessment of preterm and term preeclampsia: a gestational age matched case-control study. Front Med (Lausanne). 2018;5:325.

Cerdeira AS, O’Sullivan J, Ohuma EO, James T, Papageorghiou AT, Knight M, et al. Performance of soluble fms-like tyrosine kinase-1-to-placental growth factor ratio of ≥85 for ruling in preeclampsia within 4 weeks. Am J Obstet Gynecol. 2021;224(3):322–3.

Gaccioli F, Sovio U, Gong S, Cook E, Charnock-Jones DS, Smith GCS. Increased placental sFLT1 (Soluble fms-Like Tyrosine Kinase Receptor-1) drives the antiangiogenic profile of maternal serum preceding preeclampsia but not fetal growth restriction. Hypertension. 2023;80(2):325–34.

Rossi GP, Seccia TM, Pessina AC. Clinical use of laboratory tests for the identification of secondary forms of arterial hypertension. Crit Rev Clin Lab Sci. 2007;44(1):1–85.

Rolnik DL, Wright D, Poon LC, O’Gorman N, Syngelaki A, de Paco MC, et al. Aspirin versus placebo in pregnancies at high risk for preterm preeclampsia. N Engl J Med. 2017;377(7):613–22.

Gornik HL, Persu A, Adlam D, Aparicio LS, Azizi M, Boulanger M, et al. First international consensus on the diagnosis and management of fibromuscular dysplasia. J Hypertens. 2019;37(2):229–52.

Lenders JW. Pheochromocytoma and pregnancy: a deceptive connection. Eur J Endocrinol. 2012;166(2):143–50.

Morton A. Primary aldosteronism and pregnancy. Pregnancy Hypertens. 2015;5(4):259–62.

Landau E, Amar L. Primary aldosteronism and pregnancy. Ann Endocrinol (Paris). 2016;77(2):148–60.

Almasi-Hashiani A, Omani-Samani R, Mohammadi M, Amini P, Navid B, Alizadeh A, et al. Assisted reproductive technology and the risk of preeclampsia: an updated systematic review and meta-analysis. BMC Preg Childb. 2019;19(1):149.

Chih HJ, Elias FTS, Gaudet L, Velez MP. Assisted reproductive technology and hypertensive disorders of pregnancy: systematic review and meta-analyses. BMC Preg Childb. 2021;21(1):449.

Sindre HP, Westvik-Johari K, Spangmose AL, Pinborg A, Romundstad LB, Bergh C, et al. Risk of hypertensive disorders in pregnancy after fresh and frozen embryo transfer in assisted reproduction: a population-based cohort study with within-sibship analysis. Hypertension. 2023;80(2):e6–16.

Google Scholar  

Hofmeyr GJ, Lawrie TA, Atallah ÁN, Torloni MR. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database Syst Rev. 2018;10(10):Cd001059.

PubMed   Google Scholar  

Woo J, Giurgescu C, Wagner CL. Evidence of an association between vitamin D deficiency and preterm birth and preeclampsia: a critical review. J Midwif Womens Health. 2019;64(5):613–29.

Fogacci S, Fogacci F, Banach M, Michos ED, Hernandez AV, Lip GYH, et al. Vitamin D supplementation and incident preeclampsia: a systematic review and meta-analysis of randomized clinical trials. Clin Nutr. 2020;39(6):1742–52.

Rossi AC, Mullin PM. Prevention of pre-eclampsia with low-dose aspirin or vitamins C and E in women at high or low risk: a systematic review with meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2011;158(1):9–16.

Villar J, Purwar M, Merialdi M, Zavaleta N, Thi Nhu Ngoc N, Anthony J, et al. World Health Organisation multicentre randomised trial of supplementation with vitamins C and E among pregnant women at high risk for pre-eclampsia in populations of low nutritional status from developing countries. BJOG. 2009;116(6):780–8.

Poston L, Briley AL, Seed PT, Kelly FJ, Shennan AH. Vitamin C and vitamin E in pregnant women at risk for pre-eclampsia (VIP trial): randomised placebo-controlled trial. Lancet. 2006;367(9517):1145–54.

Cockburn J, Moar VA, Ounsted M, Redman CW. Final report of study on hypertension during pregnancy: the effects of specific treatment on the growth and development of the children. Lancet. 1982;1(8273):647–9.

Redman CW, Beilin LJ, Bonnar J. Treatment of hypertension in pregnancy with methyldopa: blood pressure control and side effects. Br J Obstet Gynaecol. 1977;84(6):419–26.

Abalos E, Duley L, Steyn DW. Antihypertensive drug therapy for mild to moderate hypertension during pregnancy. Cochrane Database Syst Rev. 2014;2014(2):Cd002252.

Abalos E, Duley L, Steyn DW, Henderson-Smart DJ. Antihypertensive drug therapy for mild to moderate hypertension during pregnancy. Cochrane Database Syst Rev. 2007;207(1):Cd002252.

Abalos E, Duley L, Steyn DW, Gialdini C. Antihypertensive drug therapy for mild to moderate hypertension during pregnancy. Cochrane Database Syst Rev. 2018;10(10):Cd002252.

Bone JN, Sandhu A, Abalos ED, Khalil A, Singer J, Prasad S, et al. Oral antihypertensives for nonsevere pregnancy hypertension: systematic review, network meta- and trial sequential analyses. Hypertension. 2022;79(3):614–28.

Webster K, Fishburn S, Maresh M, Findlay SC, Chappell LC. Diagnosis and management of hypertension in pregnancy: summary of updated NICE guidance. BMJ. 2019;366: l5119.

Physical activity and exercise during pregnancy and the postpartum period: ACOG Committee Opinion Summary, Number 804. Obstet Gynecol. 2020;135(4):991–3.

Di Mascio D, Magro-Malosso ER, Saccone G, Marhefka GD, Berghella V. Exercise during pregnancy in normal-weight women and risk of preterm birth: a systematic review and meta-analysis of randomized controlled trials. Am J Obstet Gynecol. 2016;215(5):561–71.

Barakat R, Pelaez M, Cordero Y, Perales M, Lopez C, Coteron J, et al. Exercise during pregnancy protects against hypertension and macrosomia: randomized clinical trial. Am J Obstet Gynecol. 2016;214(5):649.e1-8.

Santos S, Voerman E, Amiano P, Barros H, Beilin LJ, Bergström A, et al. Impact of maternal body mass index and gestational weight gain on pregnancy complications: an individual participant data meta-analysis of European, North American and Australian cohorts. BJOG. 2019;126(8):984–95.

CAS   PubMed   PubMed Central   Google Scholar  

Martínez-Vizcaíno V, Sanabria-Martínez G, Fernández-Rodríguez R, Cavero-Redondo I, Pascual-Morena C, Álvarez-Bueno C, et al. Exercise during pregnancy for preventing gestational diabetes mellitus and hypertensive disorders: an umbrella review of randomised controlled trials and an updated meta-analysis. BJOG. 2023;130(3):264–75.

Dodd JM, Turnbull D, McPhee AJ, Deussen AR, Grivell RM, Yelland LN, et al. Antenatal lifestyle advice for women who are overweight or obese: LIMIT randomised trial. BMJ. 2014;348: g1285.

Maxwell C, Gaudet L, Cassir G, Nowik C, McLeod NL, Jacob C, et al. Guideline no. 391-pregnancy and maternal obesity part 1: pre-conception and prenatal care. J Obstet Gynaecol Can. 2019;41(11):1623–40.

Maxwell C, Gaudet L, Cassir G, Nowik C, McLeod NL, Jacob C, et al. Guideline no. 392-pregnancy and maternal obesity part 2: team planning for delivery and postpartum care. J Obstet Gynaecol Can. 2019;41(11):1660–75.

Magee LA, Cham C, Waterman EJ, Ohlsson A, von Dadelszen P. Hydralazine for treatment of severe hypertension in pregnancy: meta-analysis. BMJ. 2003;327(7421):955–60.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Antza C, Dimou C, Doundoulakis I, Akrivos E, Stabouli S, Haidich AB, et al. The flipside of hydralazine in pregnancy: a systematic review and meta-analysis. Preg Hypertens. 2020;19:177–86.

Sridharan K, Sequeira RP. Drugs for treating severe hypertension in pregnancy: a network meta-analysis and trial sequential analysis of randomized clinical trials. Br J Clin Pharmacol. 2018;84(9):1906–16.

Cífková R, Johnson MR, Kahan T, Brguljan J, Williams B, Coca A, et al. Peripartum management of hypertension: a position paper of the ESC Council on Hypertension and the European Society of Hypertension. Eur Heart J Cardiovasc Pharmacother. 2020;6(6):384–93.

Altman D, Carroli G, Duley L, Farrell B, Moodley J, Neilson J, et al. Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial: a randomised placebo-controlled trial. Lancet. 2002;359(9321):1877–90.

Duley L, Gülmezoglu AM, Henderson-Smart DJ, Chou D. Magnesium sulphate and other anticonvulsants for women with pre-eclampsia. Cochrane Database Syst Rev. 2010;2010(11):Cd000025.

PubMed   PubMed Central   Google Scholar  

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(5):407–17.

August P. Lowering diastolic blood pressure in non-proteinuric hypertension in pregnancy is not harmful to the fetus and is associated with reduced frequency of severe maternal hypertension. Evid Based Med. 2015;20(4):141.

Tita AT, Szychowski JM, Boggess K, Dugoff L, Sibai B, Lawrence K, et al. Treatment for mild chronic hypertension during pregnancy. N Engl J Med. 2022;386(19):1781–92.

Koopmans CM, Bijlenga D, Groen H, Vijgen SM, Aarnoudse JG, Bekedam DJ, et al. Induction of labour versus expectant monitoring for gestational hypertension or mild pre-eclampsia after 36 weeks’ gestation (HYPITAT): a multicentre, open-label randomised controlled trial. Lancet. 2009;374(9694):979–88.

Wilson BJ, Watson MS, Prescott GJ, Sunderland S, Campbell DM, Hannaford P, et al. Hypertensive diseases of pregnancy and risk of hypertension and stroke in later life: results from cohort study. BMJ. 2003;326(7394):845.

Søndergaard MM, Hlatky MA, Stefanick ML, Vittinghoff E, Nah G, Allison M, et al. Association of adverse pregnancy outcomes with risk of atherosclerotic cardiovascular disease in postmenopausal women. JAMA Cardiol. 2020;5(12):1390–8.

Wu P, Haththotuwa R, Kwok CS, Babu A, Kotronias RA, Rushton C, et al. Preeclampsia and future cardiovascular health: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes. 2017;10(2):e003497.

Countouris ME, Villanueva FS, Berlacher KL, Cavalcante JL, Parks WT, Catov JM. Association of hypertensive disorders of pregnancy with left ventricular remodeling later in life. J Am Coll Cardiol. 2021;77(8):1057–68.

Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2019;73(24):e285–350.

Hilfiker-Kleiner D, Haghikia A, Nonhoff J, Bauersachs J. Peripartum cardiomyopathy: current management and future perspectives. Eur Heart J. 2015;36(18):1090–7.

Gammill HS, Chettier R, Brewer A, Roberts JM, Shree R, Tsigas E, et al. Cardiomyopathy and preeclampsia. Circulation. 2018;138(21):2359–66.

Paradisi G, Biaggi A, Savone R, Ianniello F, Tomei C, Caforio L, et al. Cardiovascular risk factors in healthy women with previous gestational hypertension. J Clin Endocrinol Metab. 2006;91(4):1233–8.

Schliep KC, McLean H, Yan B, Qeadan F, Theilen LH, de Havenon A, et al. Association between hypertensive disorders of pregnancy and dementia: a systematic review and meta-analysis. Hypertension. 2023;80(2):257–67.

Escudero C, Kupka E, Ibañez B, Sandoval H, Troncoso F, Wikström AK, et al. Brain vascular dysfunction in mothers and their children exposed to preeclampsia. Hypertension. 2023;80(2):242–56.

Heida KY, Bots ML, de Groot CJ, van Dunné FM, Hammoud NM, Hoek A, et al. Cardiovascular risk management after reproductive and pregnancy-related disorders: a Dutch multidisciplinary evidence-based guideline. Eur J Prev Cardiol. 2016;23(17):1863–79.

Kitt J, Frost A, Mollison J, Tucker KL, Suriano K, Kenworthy Y, et al. Postpartum blood pressure self-management following hypertensive pregnancy: protocol of the Physician Optimised Post-partum Hypertension Treatment (POP-HT) trial. BMJ Open. 2022;12(2): e051180.

Spaan J, Peeters L, Spaanderman M, Brown M. Cardiovascular risk management after a hypertensive disorder of pregnancy. Hypertension. 2012;60(6):1368–73.

Arnott C, Patel S, Hyett J, Jennings G, Woodward M, Celermajer DS. Women and cardiovascular disease: pregnancy, the forgotten risk factor. Heart Lung Circ. 2020;29(5):662–7.

Yang H, Kuhn C, Kolben T, Ma Z, Lin P, Mahner S, et al. Early life oxidative stress and long-lasting cardiovascular effects on offspring conceived by assisted reproductive technologies: a review. Int J Mol Sci. 2020;21(15):5175.

Thomopoulos C, Salamalekis G, Kintis K, Andrianopoulou I, Michalopoulou H, Skalis G, et al. Risk of hypertensive disorders in pregnancy following assisted reproductive technology: overview and meta-analysis. J Clin Hypertens (Greenwich). 2017;19(2):173–83.

Brown MA, Magee LA, Kenny LC, Karumanchi SA, McCarthy FP, Saito S, et al. Hypertensive disorders of pregnancy: ISSHP classification, diagnosis, and management recommendations for international practice. Hypertension. 2018;72(1):24–43.

Scherrer U, Rexhaj E, Allemann Y, Sartori C, Rimoldi SF. Cardiovascular dysfunction in children conceived by assisted reproductive technologies. Eur Heart J. 2015;36(25):1583–9.

Meister TA, Rimoldi SF, Soria R, von Arx R, Messerli FH, Sartori C, et al. Association of assisted reproductive technologies with arterial hypertension during adolescence. J Am Coll Cardiol. 2018;72(11):1267–74.

Cui L, Zhao M, Zhang Z, Zhou W, Lv J, Hu J, et al. Assessment of cardiovascular health of children ages 6 to 10 years conceived by assisted reproductive technology. JAMA Netw Open. 2021;4(11): e2132602.

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Cífková, R. Hypertension in Pregnancy: A Diagnostic and Therapeutic Overview. High Blood Press Cardiovasc Prev 30 , 289–303 (2023). https://doi.org/10.1007/s40292-023-00582-5

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Case Study: Treating Chronic Hypertension in Pregnancy

Chronic hypertension during pregnancy increases the risk of poor pregnancy and birth outcomes.

Case: A 35-year-old female presents to clinic. She is actively trying for pregnancy and already stopped her birth control. Her medical history includes a 5-year history of hypertension treated with an ACE inhibitor.

Today her blood pressure is 124/68 mmHg and BMI 27 kg/ m 2 . What recommendations do you have for management of this patient’s situation?

Chronic hypertension in pregnancy is defined as >140/90mmHg. 1 The prevalence of hypertension in pregnant women is estimated to be around 3%, with potential association with women having children at a later age. 4

Chronic hypertension during pregnancy increases the risk of poor pregnancy and birth outcomes. 3,4 Although consensus exists to use antihypertensive therapy to treat severe hypertension (systolic ≥160, diastolic ≥105-110 mmHg) during pregnancy, the benefits and safety for treating mild chronic hypertension during pregnancy are unclear.

According to the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy, the controversy in mild to chronic hypertension in pregnancy is due to the lack of evidence to guide therapy. 1

Methyldopa, a centrally acting alpha agonist has traditionally been first line for hypertension in pregnancy. 3 But a common adverse effect (AE) of methyldopa is somnolence.

Drs Seely and Ecker, authors of “Chronic Hypertension in Pregnancy” recommend labetalol. Labetalol, a combined alpha and beta blocker, has fewer AEs than methyldopa. 3 A common AE of labetalol is dizziness. 2

Nifedipine, a long-acting calcium channel blocker, was also an alternative antihypertensive drug. 3,4 ACEis/ARBs are contraindicated because they cause oligohydramnios from impaired fetal growth. 3

The Chronic Hypertension and Pregnancy (CHAP) trial looked at treatment of mild chronic hypertension in pregnancy. This multi center, open label, randomized, controlled trial enrolled 2408 women with mild chronic hypertension and singleton fetus at <23 weeks’ gestation.

The active treatment group had 1202 women and wanted to achieve a systolic blood pressure <140/<90mmHg. The standard treatment group, also 1202 women, received no treatment unless severe hypertension developed ≥160/≥105 mmHg.

The active treatment group received labetalol or extended release nifedipine, or other drugs such as amlodipine or methyldopa by preference. 4 Doses were escalated to the maximum dose to achieve the target blood pressure.

The primary outcome was a composite of preeclampsia with severe features, medically indicated preterm birth before 35 weeks, placental abruption, or fetal or neonatal death. The active treatment group’s primary outcome was significantly lower than standard treatment, with an approximate incidence of 30.2% versus 37.0%. 4

The safety outcome of the incidence was small for gestational age birth weight below the 10th percentile and did not differ significantly between the active treatment group and standard treatment group. 4 In an analysis of secondary outcomes, composites of serious maternal complications or serious neonatal complications occurred infrequently.

The results suggest lower rates of pre-eclampsia and preterm birth with antihypertensive therapy. 4 Some limitations were that women were aware of their treatment, there was a high ratio of women screened to women enrolled, and this trial was not powered to see treatment effects across subgroups. The authors conclude that treating mild chronic hypertension during pregnancy reduced adverse pregnancy outcomes without impairing fetal growth. 4

Based on this information, the patient in our case should be counseled on contraception until she has her pre-pregnancy evaluation. If she has a reversible cause of chronic hypertension, that should be addressed along with changing her ACE inhibitor to a drug that is safe in pregnancy such as methyldopa, labetalol, or nifedipine. She should also be closely followed during her pregnancy, receive interdisciplinary care from obstetrics and gynecology practitioners, and be educated on pre-eclampsia.

About the Author

Momi Talukdar, PharmD candidate, Northeast Ohio Medical University, Class of 2024, 2022 Mayo Clinic pharmacy intern.

• Hypertension in Pregnancy. American College of Obstetricians and Gynecologists . 2013;122(5):1122-1133. Accessed June 27, 2022. https://oce.ovid.com/article/00006250-201311000-00036/PDF
• Labetalol. Lexi-Drugs. Lexicomp. Wolters Kluwer Health. Inc. Riverwoods, IL. Available at: http://online.lexi.com. Accessed July 3, 2022
• Seely,E., Ecker, J. 2011. Chronic Hypertension in Pregnancy | NEJM . [online] New England Journal of Medicine. Available at: <https://www/nejm.org/doi/full/10.1056/NEJMcp0804872> [Accessed 27 June 2022].
• Tita, A., Szychowski, J. and Boggess, K., 2022. Treatment for Mild Chronic Hypertension during Pregnancy | NEJM . [online] New England Journal of Medicine. Available at: <https://www.nejm.org/doi/full/10.1056/NEJMoa2201295> [Accessed 24 June 2022].

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Article Contents

Clinical management and treatment decisions, hypertension in black americans, pharmacologic treatment of hypertension in black americans.

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Suzanne Oparil, Case study, American Journal of Hypertension , Volume 11, Issue S8, November 1998, Pages 192S–194S, https://doi.org/10.1016/S0895-7061(98)00195-2

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Ms. C is a 42-year-old black American woman with a 7-year history of hypertension first diagnosed during her last pregnancy. Her family history is positive for hypertension, with her mother dying at 56 years of age from hypertension-related cardiovascular disease (CVD). In addition, both her maternal and paternal grandparents had CVD.

At physician visit one, Ms. C presented with complaints of headache and general weakness. She reported that she has been taking many medications for her hypertension in the past, but stopped taking them because of the side effects. She could not recall the names of the medications. Currently she is taking 100 mg/day atenolol and 12.5 mg/day hydrochlorothiazide (HCTZ), which she admits to taking irregularly because “... they bother me, and I forget to renew my prescription.” Despite this antihypertensive regimen, her blood pressure remains elevated, ranging from 150 to 155/110 to 114 mm Hg. In addition, Ms. C admits that she has found it difficult to exercise, stop smoking, and change her eating habits. Findings from a complete history and physical assessment are unremarkable except for the presence of moderate obesity (5 ft 6 in., 150 lbs), minimal retinopathy, and a 25-year history of smoking approximately one pack of cigarettes per day. Initial laboratory data revealed serum sodium 138 mEq/L (135 to 147 mEq/L); potassium 3.4 mEq/L (3.5 to 5 mEq/L); blood urea nitrogen (BUN) 19 mg/dL (10 to 20 mg/dL); creatinine 0.9 mg/dL (0.35 to 0.93 mg/dL); calcium 9.8 mg/dL (8.8 to 10 mg/dL); total cholesterol 268 mg/dL (< 245 mg/dL); triglycerides 230 mg/dL (< 160 mg/dL); and fasting glucose 105 mg/dL (70 to 110 mg/dL). The patient refused a 24-h urine test.

Taking into account the past history of compliance irregularities and the need to take immediate action to lower this patient’s blood pressure, Ms. C’s pharmacologic regimen was changed to a trial of the angiotensin-converting enzyme (ACE) inhibitor enalapril, 5 mg/day; her HCTZ was discontinued. In addition, recommendations for smoking cessation, weight reduction, and diet modification were reviewed as recommended by the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI). 1

After a 3-month trial of this treatment plan with escalation of the enalapril dose to 20 mg/day, the patient’s blood pressure remained uncontrolled. The patient’s medical status was reviewed, without notation of significant changes, and her antihypertensive therapy was modified. The ACE inhibitor was discontinued, and the patient was started on the angiotensin-II receptor blocker (ARB) losartan, 50 mg/day.

After 2 months of therapy with the ARB the patient experienced a modest, yet encouraging, reduction in blood pressure (140/100 mm Hg). Serum electrolyte laboratory values were within normal limits, and the physical assessment remained unchanged. The treatment plan was to continue the ARB and reevaluate the patient in 1 month. At that time, if blood pressure control remained marginal, low-dose HCTZ (12.5 mg/day) was to be added to the regimen.

Hypertension remains a significant health problem in the United States (US) despite recent advances in antihypertensive therapy. The role of hypertension as a risk factor for cardiovascular morbidity and mortality is well established. 2–7 The age-adjusted prevalence of hypertension in non-Hispanic black Americans is approximately 40% higher than in non-Hispanic whites. 8 Black Americans have an earlier onset of hypertension and greater incidence of stage 3 hypertension than whites, thereby raising the risk for hypertension-related target organ damage. 1 , 8 For example, hypertensive black Americans have a 320% greater incidence of hypertension-related end-stage renal disease (ESRD), 80% higher stroke mortality rate, and 50% higher CVD mortality rate, compared with that of the general population. 1 , 9 In addition, aging is associated with increases in the prevalence and severity of hypertension. 8

Research findings suggest that risk factors for coronary heart disease (CHD) and stroke, particularly the role of blood pressure, may be different for black American and white individuals. 10–12 Some studies indicate that effective treatment of hypertension in black Americans results in a decrease in the incidence of CVD to a level that is similar to that of nonblack American hypertensives. 13 , 14

Data also reveal differences between black American and white individuals in responsiveness to antihypertensive therapy. For instance, studies have shown that diuretics 15 , 16 and the calcium channel blocker diltiazem 16 , 17 are effective in lowering blood pressure in black American patients, whereas β-adrenergic receptor blockers and ACE inhibitors appear less effective. 15 , 16 In addition, recent studies indicate that ARB may also be effective in this patient population.

Angiotensin-II receptor blockers are a relatively new class of agents that are approved for the treatment of hypertension. Currently, four ARB have been approved by the US Food and Drug Administration (FDA): eprosartan, irbesartan, losartan, and valsartan. Recently, a 528-patient, 26-week study compared the efficacy of eprosartan (200 to 300 mg/twice daily) versus enalapril (5 to 20 mg/daily) in patients with essential hypertension (baseline sitting diastolic blood pressure [DBP] 95 to 114 mm Hg). After 3 to 5 weeks of placebo, patients were randomized to receive either eprosartan or enalapril. After 12 weeks of therapy within the titration phase, patients were supplemented with HCTZ as needed. In a prospectively defined subset analysis, black American patients in the eprosartan group (n = 21) achieved comparable reductions in DBP (−13.3 mm Hg with eprosartan; −12.4 mm Hg with enalapril) and greater reductions in systolic blood pressure (SBP) (−23.1 with eprosartan; −13.2 with enalapril), compared with black American patients in the enalapril group (n = 19) ( Fig. 1 ). 18 Additional trials enrolling more patients are clearly necessary, but this early experience with an ARB in black American patients is encouraging.

Efficacy of the angiotensin II receptor blocker eprosartan in black American with mild to moderate hypertension (baseline sitting DBP 95 to 114 mm Hg) in a 26-week study. Eprosartan, 200 to 300 mg twice daily (n = 21, solid bar), enalapril 5 to 20 mg daily (n = 19, diagonal bar). †10 of 21 eprosartan patients and seven of 19 enalapril patients also received HCTZ. Adapted from data in Levine: Subgroup analysis of black hypertensive patients treated with eprosartan or enalapril: results of a 26-week study, in Programs and abstracts from the 1st International Symposium on Angiotensin-II Antagonism, September 28–October 1, 1997, London, UK.

Approximately 30% of all deaths in hypertensive black American men and 20% of all deaths in hypertensive black American women are attributable to high blood pressure. Black Americans develop high blood pressure at an earlier age, and hypertension is more severe in every decade of life, compared with whites. As a result, black Americans have a 1.3 times greater rate of nonfatal stroke, a 1.8 times greater rate of fatal stroke, a 1.5 times greater rate of heart disease deaths, and a 5 times greater rate of ESRD when compared with whites. 19 Therefore, there is a need for aggressive antihypertensive treatment in this group. Newer, better tolerated antihypertensive drugs, which have the advantages of fewer adverse effects combined with greater antihypertensive efficacy, may be of great benefit to this patient population.

1. Joint National Committee : The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure . Arch Intern Med 1997 ; 24 157 : 2413 – 2446 .

Google Scholar

2. Veterans Administration Cooperative Study Group on Antihypertensive Agents : Effects of treatment on morbidity in hypertension: Results in patients with diastolic blood pressures averaging 115 through 129 mm Hg . JAMA 1967 ; 202 : 116 – 122 .

3. Veterans Administration Cooperative Study Group on Antihypertensive Agents : Effects of treatment on morbidity in hypertension: II. Results in patients with diastolic blood pressures averaging 90 through 114 mm Hg . JAMA 1970 ; 213 : 1143 – 1152 .

4. Pooling Project Research Group : Relationship of blood pressure, serum cholesterol, smoking habit, relative weight and ECG abnormalities to the incidence of major coronary events: Final report of the pooling project . J Chronic Dis 1978 ; 31 : 201 – 306 .

5. Hypertension Detection and Follow-Up Program Cooperative Group : Five-year findings of the hypertension detection and follow-up program: I. Reduction in mortality of persons with high blood pressure, including mild hypertension . JAMA 1979 ; 242 : 2562 – 2577 .

6. Kannel WB , Dawber TR , McGee DL : Perspectives on systolic hypertension: The Framingham Study . Circulation 1980 ; 61 : 1179 – 1182 .

7. Hypertension Detection and Follow-Up Program Cooperative Group : The effect of treatment on mortality in “mild” hypertension: Results of the Hypertension Detection and Follow-Up Program . N Engl J Med 1982 ; 307 : 976 – 980 .

8. Burt VL , Whelton P , Roccella EJ et al.  : Prevalence of hypertension in the US adult population: Results from the third National Health and Nutrition Examination Survey, 1988–1991 . Hypertension 1995 ; 25 : 305 – 313 .

9. Klag MJ , Whelton PK , Randall BL et al.  : End-stage renal disease in African-American and white men: 16-year MRFIT findings . JAMA 1997 ; 277 : 1293 – 1298 .

10. Neaton JD , Kuller LH , Wentworth D et al.  : Total and cardiovascular mortality in relation to cigarette smoking, serum cholesterol concentration, and diastolic blood pressure among black and white males followed up for five years . Am Heart J 1984 ; 3 : 759 – 769 .

11. Gillum RF , Grant CT : Coronary heart disease in black populations II: Risk factors . Heart J 1982 ; 104 : 852 – 864 .

12. M’Buyamba-Kabangu JR , Amery A , Lijnen P : Differences between black and white persons in blood pressure and related biological variables . J Hum Hypertens 1994 ; 8 : 163 – 170 .

13. Hypertension Detection and Follow-up Program Cooperative Group : Five-year findings of the Hypertension Detection and Follow-up Program: mortality by race-sex and blood pressure level: a further analysis . J Community Health 1984 ; 9 : 314 – 327 .

14. Ooi WL , Budner NS , Cohen H et al.  : Impact of race on treatment response and cardiovascular disease among hypertensives . Hypertension 1989 ; 14 : 227 – 234 .

15. Weinberger MH : Racial differences in antihypertensive therapy: evidence and implications . Cardiovasc Drugs Ther 1990 ; 4 ( suppl 2 ): 379 – 392 .

16. Materson BJ , Reda DJ , Cushman WC et al.  : Single-drug therapy for hypertension in men: A comparison of six antihypertensive agents with placebo . N Engl J Med 1993 ; 328 : 914 – 921 .

17. Materson BJ , Reda DJ , Cushman WC for the Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents : Department of Veterans Affairs single-drug therapy of hypertension study: Revised figures and new data . Am J Hypertens 1995 ; 8 : 189 – 192 .

18. Levine B : Subgroup analysis of black hypertensive patients treated with eprosartan or enalapril: results of a 26-week study , in Programs and abstracts from the first International Symposium on Angiotensin-II Antagonism , September 28 – October 1 , 1997 , London, UK .

19. American Heart Association: 1997 Heart and Stroke Statistical Update . American Heart Association , Dallas , 1997 .

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To Explore the Application Effect and Value of Evidence-Based Nursing in Patients with Pregnancy-Induced Hypertension Syndrome

Affiliations.

• 1 Philippine Women's University, Manila, Philippines.
• 2 Far Eastern University, Manila, Philippines.
• 3 Shenzhen Hospital of Southern Medical University, Shenzhen 518000, China.
• 4 The First People's Hospital of Hefei, Hefei, Anhui 23000, China.
• PMID: 36101809
• PMCID: PMC9439890
• DOI: 10.1155/2022/6476031

Objective: The objective is to explore the nursing methods of evidence-based nursing in preventing serious complications in patients with pregnancy-induced hypertension.

Methods: A total of 80 patients with pregnancy-induced hypertension from April 2020 to April 2022 were selected and randomly divided into a control group and a research group, with 40 cases in each group. The blood pressure, Self-Efficacy Scale score, Disease Uncertainty Scale score, the incidence of maternal and infant complications, the improvement of mental state, and the patients' satisfaction with the nursing program were observed and compared between the two groups.

Results: Compared with before the intervention, the self-efficacy scores of the two groups were significantly improved, and the blood pressure, disease uncertainty score, SAS, and SDS scores were significantly decreased, and the indicators in the study group were better than those before the intervention. In the control group, the difference was statistically significant ( P < 0.05). After the intervention, among the 40 patients in the study group, 10 cases (25.00%) of cesarean section were significantly lower than 19 cases (47.50%) in the control group, and the nursing work satisfaction in the study group was significantly higher than that in the control group ( P < 0.05).

Conclusion: The application of evidence-based nursing interventions and smart medical nursing interventions to patients with pregnancy-induced hypertension syndrome has significant effect and can effectively improve the blood pressure control effect of patients during pregnancy.

Copyright © 2022 Xueying Han et al.

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• Randomized Controlled Trial
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• Cesarean Section
• Evidence-Based Nursing
• Hypertension, Pregnancy-Induced* / epidemiology

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Arrhythmic Mitral Valve Prolapse Risk During Pregnancy

Quick Takes

• Arrhythmogenic mitral valve prolapse is a rare condition.
• The perinatal period may pose an increased risk for arrhythmias in these patients, but the risk may be mitigated by continuation of antiarrhythmic therapy.
• Beta-blockers, flecainide, and other medications can be used in pregnancy.

Study Questions:

What are the characteristics of women with high-risk arrhythmic mitral valve prolapse (MVP) who developed malignant ventricular arrhythmias (VA) during the perinatal period? And is there an increased risk of malignant VA during pregnancy and the postpartum period?

This was a case series of patients with arrhythmic MVP with at least one pregnancy and a history of malignant VA (defined as ventricular fibrillation, sustained ventricular tachycardia, or appropriate shock from an implantable cardioverter-defibrillator). The perinatal period was defined as during pregnancy and up to 6 months postpartum.

There were 18 women included from 11 centers with 7.5 (interquartile range, 5.8-16.6) years of follow-up. There were 37 episodes of malignant VA; of these, 18 occurred during pregnancy among 13 unique patients. Ten women were first diagnosed with arrhythmic MVP during the perinatal period due to malignant VA. Only 12 women were on antiarrhythmic medications including beta-blockers during pregnancy. The authors reported increased incidence of malignant VA during the perinatal period (pregnancy and up to 6 months postpartum) with univariate incidence rate ratio 2.66 (95% confidence interval, 1.23-5.76).

Conclusions:

The authors conclude that the perinatal period could impose an increased risk of malignant VA in women with known high-risk arrhythmic MVP.

Perspective:

MVP is a common diagnosis among young women of childbearing age. Additionally, palpitations and even syncope are common among pregnant patients; however, arrhythmogenic MVP remains a very rare diagnosis. This is evident as the authors contacted 27 large institutions and only 12 had data for the 18-patient cohort. While this study highlights the importance of properly identifying a higher-risk subset, the majority of pregnant patients with MVP will continue to benefit from reassurance.

If identified, patients with arrhythmogenic MVP should be monitored and treated. Beta-blockers, flecainide, and other medications are safe and effective during pregnancy. In this study, only one of eight women on flecainide treatment had malignant VA. Additionally, 10 women experienced their first arrhythmic episode during pregnancy, prior to starting medication. Therefore, when counseling a patient with arrhythmogenic MVP about the risks of pregnancy, the actual risk of arrhythmias will likely be lower than reported in this study, if the patient continues to receive appropriate antiarrhythmic therapy during pregnancy.

Clinical Topics: Arrhythmias and Clinical EP, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Prevention

Keywords: Arrhythmias, Cardiac, Mitral Valve Prolapse, Pregnancy

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Pregnant women’s experiences with the management of hypertensive disorders of pregnancy: a qualitative study

Amyna helou.

1 Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, Melbourne, Victoria Australia

Kay Stewart

2 Reading School of Pharmacy, University of Reading, Whiteknights, Reading, RG6 6AP UK

Johnson George

Associated data.

The datasets generated and/or analysed during the current study are not publicly available due to privacy surrounding participant information as stipulated in the written consent form, but are available from the corresponding author on reasonable request.

Hypertensive disorders are a leading cause of mortality and morbidity during pregnancy. Despite multiple national and international clinical guidelines and a plethora of research in the field of optimising management, there has been limited research describing the perspectives and experiences of pregnant women with the management of hypertensive disorders of pregnancy (HDP). Understanding these perceptions and experiences is imperative to the optimisation of HDP management.

A qualitative study involving face-to-face, in-depth interviews were undertaken with 27 pregnant women diagnosed with and being treated for HDP to explore their perspectives of and experiences with clinical management. Written consent was obtained individually from each participant, and the interviews ranged from 16 to 54 min. Inductive codes were generated systematically for the entire data set. Line-by-line analysis was then performed and nodes were created within NVivo, a qualitative data management software. Data collection was continued until thematic saturation was reached. Thematic analysis was employed to interpret the data.

Three major descriptive themes were discerned regarding the women’s perspectives on and experiences with the management of HDP: attitudes towards monitoring of HDP, attitudes and perceptions towards development and management of complications, and perceptions of pregnant women with chronic hypertension. Trust in the hospital system, positive attitudes towards close blood pressure monitoring as well as self-monitoring of blood pressure, and a realistic approach to emergency antenatal hospital admissions contributed to a positive attitude towards monitoring of HDP. Women with prior experiences of HDP complications, including pre-eclampsia, were more confident in their clinical management and knew what to expect. Those without prior experience were often in shock when they developed pre-eclampsia. Some women with chronic hypertension displayed limited understanding of the potential risks that they may experience during pregnancy and thus lacked comprehension of the seriousness of the condition.

Conclusions

The clinical management experiences of pregnant women with HDP were varied. Many women did not feel that they were well informed of management decisions and had a desire to be more informed and involved in decision-making. Clear, concise information about various facets of HDP management including blood pressure monitoring, prescription of the appropriate antihypertensive agent, and planning for potential early delivery are required .

Introduction

Hypertensive disorders of pregnancy (HDP) affect around 10% of pregnancies in Australia and around the world [ 1 ]. Combined, they are the second largest cause of maternal death, after haemorrhage, in the developed world [ 1 ].

In Australia, the public health system provides maternity care from pre-conception to postpartum. The main health professionals who care for the pregnant women are obstetricians, midwives, general practitioners (GP) and obstetric physicians [ 1 ]. The GP has an important role in pre-conception counselling, especially with women who have chronic diseases such as hypertension or asthma. It is also the responsibility of the GP to confirm the pregnancy and refer the woman to the relevant maternal hospital service.

Initially, the choice of model of care is given to the woman. The Midwifery Group Practice model [ 1 ] allows for one-to-one maternal care, often with the same midwife throughout the term of pregnancy, which is a suitable option for women without complications. Pregnant women with complications such as chronic hypertension or a previous pregnancy complicated by hypertensive disorders of pregnancy (HDP), however, need to be cared for by an obstetrician, who can monitor the progress of the pregnancy, blood pressure (BP), signs of pre-eclampsia, and fetal growth. The obstetric physician is usually involved in prescribing and monitoring antihypertensive medication and BP control. Pregnant women who have had pre-eclampsia previously or who have chronic hypertension are at risk of developing pre-eclampsia. Timely administration of low-dose (81-100 mg) aspirin before 16 weeks gestation has been found to reduce risk of pre-eclampsia [ 2 ].

Monitoring of BP occurs at each antenatal visit. If her BP is elevated, the woman may be referred to a day assessment unit for 4-h assessment of BP, which involves taking BP readings every half an hour for 4 h to observe the pattern of the BP and decide whether a diagnosis of HDP and/or prescription of an antihypertensive medication is warranted. In addition, test for urinary protein, full blood examination, renal function tests and fetal monitoring are performed [ 3 ]. This 4-h assessment is seen as a favourable alternative to overnight inpatient stays, both in terms of patient satisfaction and public health economics [ 3 ].

The timing of delivery in women with HDP is dependent on many maternal and fetal factors, including inability to stabilise BP, deteriorating liver and/or renal function, placental abruption, and severe fetal growth restriction [ 4 ]. Fetal morbidity and mortality are linked to the gestational age at delivery [ 4 ], so there is always a desire to prolong the pregnancy as close as possible to term (37 weeks) in the absence of an emergency. HYPITAT was a multicentre, open-label randomised controlled trial investigating induction of labour versus expectant monitoring for gestational hypertension or mild pre-eclampsia after 36 weeks’ gestation [ 5 ]. The study reported a reduction in the incidence of severe hypertension as result of induction of labour at 36 weeks gestation. No significant clinical differences were found in outcomes such as thromboembolism, eclampsia or placental abruption [ 5 ]. This study was followed by HYPITAT-II, which found that delivery should be deferred until 37 weeks as opposed to 36 weeks, unless maternal deterioration supervenes [ 6 ].

Despite multiple clinical guidelines [ 4 , 7 , 8 ] and a plethora of research in the field of optimising HDP management, there have been limited published studies describing the experiences of pregnant women with the management of HDP, as distinct from medication treatment.

A survey of women with pre-eclampsia or their partners, friends or relatives found that many had no knowledge of pre-eclampsia prior to diagnosis and once diagnosed, did not appreciate how serious or life threatening it was [ 9 ]. Women wanted access to information about pre-eclampsia and their experience contributed substantial anxiety towards future pregnancies. Partners/friends/relatives also had no prior understanding of pre-eclampsia and expressed fear for the woman and/or her baby [ 9 ]. A qualitative study of pregnant Moroccan women in the Netherlands or Morocco found that knowledge of symptoms related to hypertensive disorders of pregnancy was limited or absent [ 10 ]. The limited knowledge of hypertension-related symptoms and complications was based on their own experiences or on those of some family members or stories from their social network or internet, with little or no information on symptoms from their midwives or obstetricians [ 10 ]. The experiences, perceptions and behaviours of pregnant women with regard to the management of HDP during pregnancy remain largely unexplored. Understanding these perceptions and experiences is imperative to the optimisation of HDP management.

To explore pregnant women’s perspectives of and experiences with clinical management of HDP.

Study design

A qualitative study using in-depth interviews was conducted, with pregnant women in their second or third trimester, recruited from antenatal clinics in two large tertiary hospitals in Melbourne, Australia.

Participants were sourced via a larger mixed-methods study, which included 100 pregnant women with HDP. Eligible participants were identified by one researcher (AH), who reviewed the medical records of pregnant women attending antenatal clinics, and then approached them individually. Participants were provided with written information for the larger study and on receipt of written informed consent, a questionnaire was given for self-completion. At the end of the questionnaire, participants were asked to indicate their interest in undertaking an interview. Of the 98 women who responded to the questionnaire, 65 expressed interest in being interviewed. Combined convenience and purposive sampling was conducted among these 65 women to seek a breadth of views. All of the women who were invited accepted to participate in an interview. Informed written consent was obtained prior to each interview, which included permission to audio record the conversation and to use quotations when anonymously reporting and publishing the results.

Study sample

Face-to-face, qualitative in-depth interviews were conducted with 27 pregnant women who were diagnosed with HDP and had a prescription for an antihypertensive medication, in either the second or third trimester of pregnancy, recruited from the antenatal outpatient clinics of two large tertiary maternity hospitals in Melbourne, Australia. Together, these hospitals provide antenatal care to approximately 13,000 women annually. They were identified using hospital records and approached during subsequent clinic visits. Participation was voluntary and involved informed consent.

The study sample size was determined based on theme saturation during analysis and was not predetermined. Recruitment ceased when no new information was forthcoming from the last three interviews, with regard to replication of data relating to attitudes towards HDP monitoring, perceptions of the development and management of complications (including early delivery) and perceptions of the women who had chronic hypertension.

Data collection

Interviews were conducted face to face by a single researcher (AH) a female Pharmacist (who was a PhD candidate at the time) after receiving training in in-depth interviewing prior to the commencement of the study using an interview guide developed based on the literature [ 11 , 12 ] and was agreed upon by the authors (Table  1 ). Open-ended questions, such as “Tell me about …? ”, followed by appropriate prompts, such as “How did that make you feel?” or “Can you explain that in more detail?” were used to guide the interview and encourage the interviewee to speak freely and in-depth about their experiences and thoughts. As the interviewer had met the participants during the larger study, some rapport had been established prior to the interview. The interviewer did not disclose their healthcare background to participants to avoid requests for health advice during the interviews. Interviews on average lasted 35 min (range 16 to 54 min) and were conducted in a private room near the antenatal clinics. No repeat interviews were performed.

Interview Topic Guide

Socio-demographic and self-reported health information was collected from participants through the questionnaire. Health information was verified, with consent, through medical records.

All interviews were audio-recorded, transcribed verbatim and de-identified. Interviews continued until data saturation was reached, deemed to be the point after which no new information for analysis was forthcoming [ 13 ]. The transcripts were not returned to the participants for comments or correction.

Data analysis

Data analysis occurred concurrently with the interviews. Initial coding was completed by AH using the qualitative data management software QSR NVivo 10 (QSR International) [ 14 ]. Inductive codes were generated systematically for the entire data set. Line-by-line analysis was then performed and nodes were created within NVivo. To ensure reliability, a random selection of 20% of the transcripts were coded independently by another member of the research team (KS). KS and KR read all the transcripts and any differences were discussed among all three to reach consensus. The researchers were all pharmacists; KS and KR had extensive experience in conducting qualitative research. Transcripts were reread by AH and KS to ensure that coding was accurate and all relevant data were included.

Thematic analysis was employed [ 15 ]. This was done across all HDP subtypes and severities to obtain a wide range of views. AH read and reread the codes, collapsed them into potential themes, compared the developing themes with the intact transcripts and cross referenced to HDP subtypes. When a pattern was seen within a certain subtype, coding was grouped specifically for that subgroup. Codes were arranged into potential themes. Themes were reviewed, refined and prepared into a final set with KS; sub-themes were identified within this process.

Participants

Of the 98 women who responded to the questionnaire, 65 expressed interest in being interviewed. A combination of convenience and purposive sampling was conducted among these women to seek a wide breadth of views. All participants had a diagnosis of HDP and were prescribed antihypertensive medication. Interviews occurred during pregnancy except for one, which happened 1 day postpartum. All participants were aged 18 years or over and were fluent in English. Twenty-seven women were interviewed to reach data saturation. Their demographics, clinical and obstetric characteristics are shown in Table  2 . Family members were present for some interviews but none of them participated in the interview or made comments. Field notes were taken by the interviewer during the interviews. No participants dropped out of the study or refused participation.

Demographics, clinical and obstetric characteristics ( n  = 27)

a Classification according to the Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) guidelines 2014 [ 1 ]

b some participants were prescribed more than one antihypertensive medication

Eight participants were primigravidae, the remainder were multigravidae, including six who had previous miscarriages. One participant had an assisted pregnancy (in vitro fertilisation). Twelve were prescribed aspirin for the prevention of pre-eclampsia. Participants ranged in age from 26 to 42 years. The annotations at the end of each quote give a description of the participant’s age, parity, gestational trimester and subtype of HDP at the time of the interview. The participants did not provide feedback on the findings.

Interview themes

Three major descriptive themes were discerned regarding the women’s experiences with the management of HDP:

• attitudes towards monitoring of hypertensive disorders of pregnancy;
• attitudes and perceptions towards development and management of complications; and
• perceptions of pregnant women with chronic hypertension.

Theme 1: Attitudes towards monitoring of hypertensive disorders of pregnancy.

Most women had general trust in the hospital system. Some felt extra confidence knowing that they were being managed at a maternity hospital:

“Hospital is for saving lives of people...as soon as I see the hospital I know that I am in safe hands.” (#14, 40 years, 2nd pregnancy, second trimester, severe pre-eclampsia).

“I felt very comfortable here...it seems like they are well prepared for these things...I was in the section of the hospital where all women were in the same [hypertension] situation.” (#9, 30 years, 1st pregnancy, second trimester, chronic hypertension).

One woman expressed some distrust in general hospitals, which she perceived as not managing her BP well:

“My own GP at that time increased it [methyldopa] to six a day … the hospital … increased to 10 a day … but I couldn’t lift my head up … so I ended up coming to the women’s hospital to Emergency, because I felt like no one’s helping me.” (# 71, 37 years, 3rd pregnancy, third trimester, severe pre-eclampsia superimposed on chronic hypertension).

Self-monitoring of BP was often recommended to women treated with antihypertensives. For some, it gave reassurance, but for others it was a source of confusion, with different messages coming from various members of the treating team:

“I take up to eight [methyldopa tablets] a day...I take two and then I’ll see what my readings are...at home, myself...I also do it if I have any other symptoms.....” (# 71, 37 years old, 3rd pregnancy, third trimester, severe pre-eclampsia superimposed on chronic hypertension).

“One of the physicians I saw told me to do it three times a day … three times in a row and then she said take the average of the second two readings each time...Then I told the obstetrician my readings and she said the machine that I had at home is under-measuring...but...the physician, he was quite interested...he wanted to see my readings because he likes to compare his machine to home machines.” (#53, 40 years, 6th pregnancy, third trimester, secondary chronic hypertension).

Some women had milder HDP in previous pregnancies, which gave them a sense that the monitoring and management was overstated. Others with more severe cases and their prior experience brought back memories initiating action to make plans:

“With [child 1] it was really bad during pregnancy. With [child 2] it was bad just in the last couple of weeks and straight afterwards...[child 3] was bad, but not really bad enough. They just called it hypertension, pregnancy induced hypertension and they just left it at that. They didn’t make a big song and dance about it...They made a big song and dance last time [child 4] and then this time [they said] ‘You’re going for your monitoring’...come back a week later...’You’re going for your monitoring’, couple of hours later – ‘You’re being admitted’...Then a couple of hours later...’You’re starting on medicine’.” (#6, 28 years, 4th pregnancy, 1 day postpartum, gestational hypertension).

“Last Wednesday when they [found] blood pressure’s up … it just brought back memories from last time because same thing. I just went in for an appointment and I never came home...Ten days later I came home with a baby. So I think those aspects freak me out a bit because it’s like ‘Oh, it’s happening again’ … every appointment...even this appointment, we’ve got contingency plans, just in case.” (#74, 36 years, 2nd pregnancy, third trimester, chronic hypertension).

Some women wondered about why they were not told their BP readings unless they asked:

“I find it funny that when they take your blood pressure they don’t tell it to you. I always have to ask, always, no matter who it is, midwife, physician, obstetrician. They take it and they walk away. It’s my body but they don’t tell me.” (#53, 40 years, 6th pregnancy, third trimester, secondary chronic hypertension).

Close monitoring was perceived as frustrating, but also as part of the life adjustments that come with having a baby. Some women considered spending four hours in the day assessment centre for monitoring their BP better than being an inpatient and staying overnight, whilst others saw it as an annoyance:

“I am happy to come back every day as long as I don’t have to spend overnight here. I am happy to be here for 12 hours a day, but I just can’t be away from my children at night time.” (#29, 26 years, 3rd pregnancy, second trimester, secondary chronic hypertension).

“They just monitor me at that perinatal care...you just sit here four hours a day...it’s shocking...worse than taking the tablet.” (#90, 35 years, 7th pregnancy, third trimester, chronic hypertension).

“The only thing that was slightly frustrating was [that] four hours is a long time to sit around, but again, you’re having a baby so you’ve got to make a few adjustments to your life.” (#99, 34 years, 1st pregnancy, third trimester, pre-eclampsia).

Some of the women required a short inpatient stay to stabilise their BP and avert an emergency premature delivery. For many, it was an emotional experience filled with apprehension and uncertainty about the future:

“It was very emotional, very scary, and at the same time still trying to stay strong. So that when my husband and my kids came in, I was like ‘I’ve just got a little bit high blood pressure, everything’s alright’...I didn’t know that a possible side effect of having the blood pressure is that they may have to deliver the baby [early].” (#32, 42 years, 3rd pregnancy, third trimester, severe early onset pre-eclampsia).

“B.P. at first was around 160...she came back 15 minutes – 170, another 15 minutes 180, within 10 minutes 190...I got nervous … After 160 they gave me ...labetalol...but [the BP] did not go down...There were other tablets they gave to me but [the BP still] didn’t go down...All the doctors came up...surrounded with those with scrub suits, I panic...blood pressure...went to 210..they were panicked...one just looked at me and said “AAAH”. I cried...of course you feel anxious, you feel sad...worried... what’s going on with me? I cried and cried. It was just like a movie, they push my bed out from the room and sent me quickly down to the birthing suite [in case delivery was imminent].” (#14, 40 years, 2nd pregnancy, second trimester, severe pre-eclampsia).

Theme 2: Attitudes and perceptions towards development and management of complications.

For many women, the diagnosis of pre-eclampsia came as a shock. Those with prior experience knew what to expect and were hesitant to cease antihypertensive treatment even if their BP was low. One woman without prior experience self-educated about pre-eclampsia, became concerned about the symptoms and developed anxiety about developing it:

“It was a shock and it was a bit scary...I thought ‘I’ve heard of pre-eclampsia but I don’t really know what it is’...but all the staff, they explained everything quite well... [I could see] how they were being very concerned about it, so that was making me realise this isn’t just a small thing, this is obviously a serious situation.” (#32, 42 years, 3rd pregnancy, third trimester, severe early onset pre-eclampsia).

“I didn’t want to stop the medication altogether, only because I just didn’t want to go through the path of having the high blood pressure affect the baby [intra-uterine growth restriction].” (#8, 36 years, 2nd pregnancy, third trimester, chronic hypertension).

“I was reading that if you do develop pre-eclampsia... it is a risk for the baby and the mother as well. Upon reading all that information...I became a bit paranoid, swollen foot, swollen hands, they’re part of the symptoms, headaches, generally not feeling well...I became quite paranoid looking at my symptoms and [thinking] have I got this, have I not got this? But the doctors actually did say that I have got borderline pre-eclampsia, so they were waiting to see if I was going to develop it. However, they haven’t been able to reassure me that I’m not going to develop it and...that was quite scary for me.” (# 24, 35 years, 1st pregnancy, third trimester, chronic hypertension diagnosed during pregnancy).

Some women understood that low-dose aspirin was being used for prevention of pre-eclampsia, whereas others did not always perceive it as being effective for this purpose. Many women thought that aspirin helped with controlling the BP rather than for prevention of pre-eclampsia:

“I started on aspirin throughout the pregnancy … just to...prevent mild pre-eclampsia happening again.” (#64, 30 years, 3rd pregnancy, third trimester, chronic hypertension).

“Obstetrician put me on one aspirin a day which is supposed to help control blood pressure. So perhaps that’s also why my blood pressure is being well controlled.” (#21, 35 years, 1st pregnancy, second trimester, chronic hypertension).

Most women had a general understanding that the only way to stop the direct effects of pre-eclampsia was to deliver the baby for the safety of both mother and child. The level of comfort with such a decision varied depending on the gestational stage of diagnosis of pre-eclampsia:

“I was really disappointed and very worried about the effect it [pre-eclampsia] would have on the baby [at 21 weeks] and whether or not I would be able to carry the baby to a safe week. I just thought...if something had happened and I was forced, like accidentally went into labour too early or something like that, the baby’s chances of survival would be very low and I was really upset.” (#21, 35 years, 1st pregnancy, second trimester, chronic hypertension).

“All I know is that you just need to get the baby out...I mean plenty of women and plenty of babies survive it...but you need to detect it pretty quickly before it turns into the full...is it eclampsia?” (#41, 34 years, 1st pregnancy, third trimester, chronic hypertension).

Although many women understood that they would not continue to full-term, their perceptions and fears about the potential for a premature delivery were related to their week of gestation, concern about the welfare of the baby, and fear of separation after the birth:

“I know from my reading that 24 weeks, it’s still not ideal obviously, but if you had the baby at 24 weeks that the chance of survival was higher. I think it was 43% chance of survival from this...prior to that it was like 16% chance of survival...My sister-in–law, who is a midwife, had said...they consider 26 weeks more viable. So after that it was like, right (a) to get to 24, (b) get to 26.”. (#21, 35 years, 1st pregnancy, second trimester, chronic hypertension).

“I am just worried about my baby [having] to be delivered earlier because you see the consequences...you see things happen in the future...they are still very weak...no sucking reflex yet, the lungs are not fully developed, so many things not developed...she may live but maybe there are some disabilities...I am just hoping that I will reach even up to 30 weeks or 32 weeks. That would make me feel better.” (#14, 40 years, 2nd pregnancy, second trimester, severe pre-eclampsia).

“I was 28 weeks [when I developed severe pre-eclampsia]...they gave me steroid injections to increase the lung capacity of the baby...One of the doctors came from the NICU with a leaflet about possibly having a premature baby...that was very upsetting...and to think of having the baby...then me going home with the baby staying here is just a very scary thought.”(#32, 42 years, 3rd pregnancy, third trimester, severe early onset pre-eclampsia).

Intervention with the delivery process was a likely reality for many women who had a prospect of early delivery. Some women were apprehensive about the prospect of induction of labour or caesarean section but understood that it was for their benefit and that of their child. Others were hesitant to allow for intervention unless the risks were made clear:

“So a little bit scary, but in a way I want it to, because I’m starting to feel the uncomfortable risk that’s associated with pregnancy in this condition. Knowing that she’s at full term now at 37 weeks and she’s fine and healthy, I don’t want to develop pre-eclampsia if I can help it.” (# 24, 35 years, 1st pregnancy, third trimester, chronic hypertension diagnosed during pregnancy).

“I’m trying to push it off because I don’t want to do it. I like to have the baby when the baby’s ready, not when they tell me to. But if they tell me to because it’s really dangerous for me then I’ll listen to them obviously ….” (#53, 40 years, 6th pregnancy, third trimester, secondary chronic hypertension).

Concerns about lack of information sharing by health professionals led some women to feel that they were left out of the planning for potential intervention in the delivery, whilst others voiced concern about having low-dose aspirin in the context of a possible emergency caesarean section:

“I even asked her last time actually because she said...I’m happy with the baby’s growth, but the blood pressure’s going up so … she said ‘I’m formulating a plan in my mind’ but she doesn’t like to disclose it. I don’t know why. It’s about me; I don’t know why she just doesn’t tell me.” (#53, 40 years, 6th pregnancy, third trimester, secondary chronic hypertension).

“I also thought...what if I have an emergency caesarean tomorrow and I haven’t gotten off the aspirin? Is it going to cause me issues?” (#29, 26 years, 3rd pregnancy, second trimester, secondary chronic hypertension).

Theme 3: Perceptions of pregnant women with chronic hypertension.

Many women with chronic hypertension were already on antihypertensive medication not deemed safe during pregnancy when they found out they were pregnant. For some, it was changed to a safer alternative as soon as possible, whilst for others, the decision to change the medication was delayed and the patient’s assessment of potential risks was downplayed:

“I was on medication [telmisartan]...then when I had the kidney scan and I found out [that I was pregnant], my G.P. said ‘You’ve got to stop taking that medication because it’s not safe...so then she gave me another one to take.” (#2, 30 years, 1st pregnancy, third trimester, secondary chronic hypertension).

“The first time I found out I was pregnant I went to a GP...I told the GP that I’m taking atenolol, and then she told me that...atenolol is not recommended for pregnancy... so I asked....What medication do you think that I should take?’...she said she doesn’t dare to prescribe me any medicine because she knows she is going to refer me to a hospital.” (#59, 34 years, 1st pregnancy, second trimester, chronic hypertension).

Other women had their antihypertensive changed during the pre-pregnancy planning stage:

“[To be safe during pregnancy] I would just have to change my medications. The medication I was on I couldn’t be on while being pregnant. So when we decided to try for our first child, I went on the Aldomet and oxprenolol and that’s what I pretty much stayed on because we always wanted a second child.” (#1, 39 years, 2nd pregnancy, third trimester, secondary chronic hypertension).

Some women with chronic hypertension had concerns about lack of information sharing by health professionals and felt that they were not well informed of the potential risks that their hypertension may have on the pregnancy. Some mentioned that they may have ‘taken it more seriously’ if they had known about the risk of premature delivery associated with uncontrolled hypertension, whilst others had some limited awareness of pre-eclampsia:

“When they told me I had protein in my urine, I was a bit scared because I don’t know if it’s related to my BP.” (#4, 33 years, 1st pregnancy, third trimester, chronic hypertension).

One woman was very anxious about her diagnosis of severe, early-onset pre-eclampsia so she did some ‘self-research’. Unfortunately, she misinterpreted the information and caused herself extra unwarranted fear:

“I read on [US website found on Google] and found that 80% die after/during birth that have pre-eclampsia. That was really scary.” (#71, 37 years, 2nd pregnancy, third trimester, severe pre-eclampsia superimposed on chronic hypertension).

The information on the US Preeclampsia Foundation website actually states that “Nearly 80% of women who die from pre-eclampsia die post-partum” [ 16 ].

For some women with chronic hypertension, lack of knowledge of the seriousness of the condition resulted in lack of comprehension of the importance of BP monitoring and treatment:

“I think it was about 140 over 110 or something like that … which is pretty normal for me but they think it’s high … I feel alright. It’s all good.” (#90, 35 years, 7th pregnancy, third trimester, chronic hypertension).

“I really tried for weeks not to go on [the antihypertensive], but then when she said that maybe you could have a stroke, I got a bit scared, a lot scared … I got really worried because then they said … you could have problems, the baby could die. And I got really upset when she said the baby could not get enough oxygen. I just felt, oh just have whatever it is.” (#22, 37 years, 3rd pregnancy, third trimester, chronic hypertension).

Most women who had chronic hypertension were under a model of care involving both an obstetrician and a physician. One was triaged to midwife-only care, despite having a diagnosis of chronic hypertension and being prescribed an antihypertensive medication. This then caused a delay in the change of the antihypertensive to a safer alternative:

“Actually, I asked the midwife whether it [atenolol] is safe or not [at 18 weeks gestation]...and then she said that...it should be okay, but to be safe discuss with the physician. And so, because she said it should be okay, I presumed that ‘Oh that is okay’ ... but then the physician said ‘No, it’s better not to...so from now onwards you have to take this medicine [oxprenolol]’.” (#59, 34 years, 1st pregnancy, second trimester, chronic hypertension).

Many women had their first antenatal appointment at the hospital between 16 and 20 weeks gestation. Some women, especially those with chronic hypertension, had concerns about the timing of this appointment:

“It takes a long time now for women to get their first appointment through the hospital. It wasn’t like that, I think, about 10 years ago, must’ve changed by now … Now you have to wait ‘til you’re about 18, 20 weeks before you get your first actual appointment...and if you’ve got other health issues, things can go wrong, which it did with me.” (#71, 37 years, 2nd pregnancy, third trimester, severe pre-eclampsia superimposed on chronic hypertension).

Some women did not know that they had high BP before pregnancy. This may have been because they did not get regular check-ups with the GP or that their BP was not routinely checked at regular GP visits:

“I think if I had never gotten pregnant, I definitely would not have had [high BP], would not have to be on medication … because I wouldn’t be under the strain that I am. And also I wouldn’t be in with the doctor. I don’t think I would’ve gone to the doctor and said put me on medication … because I didn’t, want anything to change. But my lifestyle is changing now so I don’t have a choice.” (#18, 35 years, 2nd pregnancy, second trimester, chronic hypertension).

“It [BP] was quite normal before the pregnancy, so obviously it’s pregnancy-related according to the doctors [despite having been diagnosed at 7 weeks].” (#24, 35 years, 1st pregnancy, third trimester, chronic hypertension diagnosed during pregnancy).

Many women had developed chronic hypertension after a previous pregnancy that involved either gestational hypertension or pre-eclampsia. Some of them had routine follow-up for their hypertension postpartum and understood that it was now chronic hypertension, whilst others did not:

“Once I’d had the baby they changed my medication to the perindopril...I was then checking my BP at home...the readings were fine...when they did get too high, I’d go back to my local GP who would then once again adjust the dosage accordingly...I have been told by my local GP that generally once you’re on a blood pressure medication, you’re on it for life, whether it’s a minimal dosage or, depending on what the readings are, what they need to give...I’m happy to stay on that.” (#8, 36 years, 2nd pregnancy, third trimester, chronic hypertension).

“I got increased blood pressure at the end [of the previous pregnancy] and they put me in perinatal care, but then afterwards it was okay....I honestly just didn’t go to the doctor, and I haven’t gone to the doctor since I fell pregnant with this one.” (#90, 35 years, 7th pregnancy, third trimester, chronic hypertension).

One woman described having been prescribed an antihypertensive during her previous pregnancy and never told to stop it, so she continued with no formal review of her hypertension until the current pregnancy:

“They never told me to stop taking the tablet [labetalol] after I had him [first child] so I just kept continuing with it ... I saw the physician [during this current pregnancy] and he just said just keep taking it...he actually questioned ‘Did they ask you to stop it?...I said no one spoke to me about anything...I was here for a week after I had him [first child]...no one ever discussed it.” (#58, 38 years, 2nd pregnancy, third trimester, chronic hypertension).

Trust in the hospital system, positive attitudes towards close BP monitoring as well as self-monitoring of BP (SMBP) and a realistic approach to emergency antenatal hospital admissions contributed to a positive attitude towards monitoring of HDP. Most of the women in our study had a general trust in the healthcare system. Distrust surfaced when health services outside the women’s hospital were not seen as able to control hypertension early in the pregnancy, triggering patient-initiated referral to the women’s hospital. Trust of healthcare systems in western countries is generally declining [ 17 ]. It is, however, important to note that pregnant women with HDP are considered to be in a high-risk pregnancy and are thus more vulnerable than the general population. Therein lies dependence on the hospital system, especially in urgent situations such as needing to lower BP or planning for an early delivery, similar to the dependence reported in patients with coronary heart disease [ 18 ].

Anecdotally, it is common for healthcare professionals to mention that the BP reading is ‘good’ or ‘too high’ without telling the patient the systolic/diastolic numbers. An important factor relating to patient evaluation of care is their involvement in decision-making [ 19 ]. Most of the women in our study were not involved in decision-making, leaving some to wonder why this was so. This suggests that pregnant women with HDP would like to be better informed of their situation and be part of the decision-making process when deemed appropriate. This is consistent with the women’s views from the pilot of the CHIPS study who enjoyed being heavily involved in their BP management [ 20 ]. One way to have women more involved in their BP management is to encourage SMBP. SMBP in the general population has been shown to reduce BP [ 21 ] and improve adherence to antihypertensive medication [ 22 ]. In our study, SMBP was often recommended to women who were prescribed antihypertensive medications. This was taken up well by most, similar to the CHIPS pilot study [ 20 ]. SMBP during pregnancy has also been shown to be reassuring and not anxiety provoking [ 23 ] which was seen in our study. A recent survey of 5555 pregnant women from antenatal clinics in 16 hospitals in England, found that nearly half of the 389 hypertensive women reported SMBP, and that the majority of them (79%) shared their BP readings with their treating doctor [ 24 ]. Such partnership has been shown to improve patient adherence in the general population [ 25 ]. There is however an assumption that because these women are in a high-risk pregnancy, the healthcare professionals (HCP) tend to take over and do not acknowledge that the women are quite competent and that with the correct information can be involved in SMBP in collaboration with the HCPs. It is thus important to have a good doctor-patient relationship to reduce confusion, instil confidence in SMBP and complete the circle of care.

Those with prior experience with HDP and monitoring had varied views, often depending on the severity of disease in the previous pregnancy (ies). Good communication about how HDP can vary from one pregnancy to another, being either worse or better, may assist in reducing the cynicism of some and reassure others. Similarly, those who had prior experience with pre-eclampsia were a lot more confident in their management and knew what to expect. Those who did not have prior experience were often in shock and were at times anxious about the diagnosis, a finding similar to another study relating to the understanding of pre-eclampsia [ 26 ]. Moreover, the use of low-dose aspirin to prevent pre-eclampsia was only partially understood by women in our study. This indication should be communicated clearly to women who are at high risk of developing pre-eclampsia. The plan for the cessation of aspirin before delivery should also be communicated clearly to reduce any anxiety that may be present, especially in terms of a potential emergency delivery.

At times, antenatal inpatient admission was required to stabilise BP and closely monitor both the mother and baby. This was a particularly apprehensive time, especially for women who had not experienced HDP during a previous pregnancy. It is important to have good, clear communication with women about the need for close monitoring, affirmation concerning their status as worthy of hospital care, provision of consistent information, inclusion in decision-making and good social support [ 27 ]. A possible alternative to inpatient admission can be pregnancy day assessment monitoring. Despite limited research into this model of care, pregnant women have been found to prefer a four-hour stay rather be admitted to hospital for one or more nights, if the situation is deemed safe to do so [ 3 ]. This is consistent with our findings. Once again, clear consistent information regarding the need for this type of monitoring should be given to women who require it. Recent advancements in the integration of telemedicine into antenatal care [ 28 ] have encouraged early research into the feasibility of incorporating this for women with HDP to reduce the burden of multiple antenatal hospital visits [ 29 ]. The unpredictable course of worsening BP and the development of pre-eclampsia pose specific challenges to this monitoring and would require a holistic approach. A recent single centre study in the UK [ 29 ] developed and trialled an innovative SMBP intervention including a downloadable mobile app in for women with HDP to monitor for signs of pre-eclampsia or worsening hypertension. Although this study showed positive acceptance and compliance from the women, further research is required to meet the standard of care required for them [ 29 ].

In general, most women desire to labour spontaneously and have a natural birth [ 30 ]. When the reality that the only way to stop the direct effects of pre-eclampsia is to deliver the baby at any given gestational week is revealed to some women, it is received with disappointment. Good communication by the treating doctor about the intention to preserve the pregnancy for as close as possible to term is required. Likewise, sound communication about the need for a premature delivery should be communicated clearly. Moreover, it has been shown that pregnant women who require induction of labour or caesarean section often feel left out of the decision-making process [ 30 ]. An Australian study of women’s experiences of decision-making and attitudes in relation to induction of labour, reported a clear need for women to be provided with more information and agency when making decisions about their timing of birth, particularly when there are multiple reasonable treatment options [ 30 ]. Furthermore, emergency caesarean sections have been found to negatively contribute to several psychosocial outcomes for women, in particular post-traumatic stress [ 31 ]. There is, thus, a need for careful consideration and counselling for women after an emergency caesarean delivery. This can involve the members of the antenatal treating team but also counsellors or psychologists. Moreover, counselling of pregnant women who are at risk of emergency caesarean, either because of their HDP or otherwise, about this possibility may help to pre-empt potential trauma.

Research into the management experiences of pregnant women with chronic hypertension, as distinct from medication treatment, is scant. Our study has highlighted the need for extra attention to be given to improve management pre-conception, during the pregnancy and postpartum. A qualitative study exploring knowledge and attitudes related to pregnancy and preconception health in women with chronic medical conditions, including chronic hypertension, found that the women had limited knowledge of the specific potential complications of pregnancy [ 32 ]. Some women in our study also displayed limited understanding of the potential risks that they may endure during pregnancy and thus had a lack of comprehension of the seriousness of the condition. Counselling women pre-conception regarding potential risks during pregnancy allows them to be more aware of what to expect [ 33 ]. Moreover, an open conversation about the information that the pregnant woman may have either from prior experience or ‘self-research’ would help to improve understanding as well as avoiding confusion and unnecessary anxiety. The provision of written material so that the women can refer to it when necessary would also be appropriate. Another facet of management of chronic hypertension pre-conception is the initial diagnosis of hypertension. Some women in our study were not aware of their BP readings before pregnancy and were diagnosed with hypertension quite early in pregnancy and thus classed as having chronic hypertension. Regular checking of BP in women of reproductive age at routine GP visits may help to identify chronic hypertension earlier. This can help in the planning of a pregnancy, or ensure that the BP is under control in the case of an unexpected pregnancy. Similarly, for those who have chronic hypertension and are prescribed antihypertensives, switching the medication to one that is safer during pregnancy, either pre-conception or as early as possible, can help to reduce fetal exposure and reduce the mother’s anxiety. Both GPs and community pharmacists have a role in counselling women of reproductive age who are prescribed an antihypertensive. A simple question as to whether the women is planning a pregnancy can help initiate the necessary conversation and trigger the switch to a safer alternative in a timely manner. Various resources are available to help make the decision to change the antihypertensive, including drug information lines at maternity hospitals. Moreover, a large number of women who had entered our study with chronic hypertension had developed the condition after a previous pregnancy that was affected by gestational hypertension or pre-eclampsia. Furthermore, our study found that many women developed chronic hypertension soon after a pregnancy complicated by HDP. This is supported by a recent systematic review and meta-analysis which reported that the risk of developing hypertension after HDP is highest in the early postpartum period [ 34 ]. The authors also suggested that diagnosis and targeted interventions to improve maternal cardiovascular health may need to be commenced in the immediate postpartum period [ 33 ]. We agree with this and call for a more integrated follow up with women in the postpartum period and beyond. This may involve the GP and the community pharmacist for easy accessibility for the women.

Although most women with chronic hypertension in our study were under a model of care involving an obstetrician and a physician, one was under midwifery care despite having chronic hypertension and being prescribed an antihypertensive. Although it is recognised by Australian guidelines for the management of HDP that midwives play a role in a multidisciplinary team in relation to management of HDP [ 4 , 35 ], they are not qualified to independently prescribe medication and manage cases of pregnant women with chronic hypertension requiring treatment. Similarly, a recent scoping review found that practising midwives worldwide lack knowledge on several aspects of pre-eclampsia diagnosis and care and have called for an increase in in-service training to increase midwives’ knowledge in this area [ 36 ]. It is therefore important that all pregnant women who have chronic hypertension be under the doctor model of care to monitor both mother and baby throughout the pregnancy.

Recommendations for practice

Good communication between the HCP and the patient is important to optimise management. Clear, direct and concise information about various facets of the management of HDP should be provided for all women who experience HDP.

Women who experience any form of HDP during pregnancy should be invited to be part of the decision-making pertaining to the monitoring of BP and progression to pre-eclampsia as well as the timing and mode of delivery when appropriate.

There should be a priority for women with chronic hypertension to be seen at the hospital under an obstetrician led model of care before 18 weeks, not only for the regular monitoring of BP and fetal progress but also for the timely prescription of low-dose aspirin before 16 weeks gestation for the prevention of pre-eclampsia. Furthermore, other health professionals, including psychologists and pharmacists, can be involved in the prenatal care of these women to address potential fear and anxiety as well as the optimal use of medication.

Women who have chronic hypertension and are of reproductive age should be informed of the potential risks of pregnancy and be switched to a pregnancy safe antihypertensive in the preconception stage.

Women who experience gestational hypertension or pre-eclampsia during pregnancy should have their BP monitored postpartum by the GP or the community pharmacist to identify any risk of developing severe cardiovascular events.

Recommendations for future research

Currently, much of the monitoring of HDP requires a hospital visit. Further research into the feasibility of telehealth for the monitoring of HDP, especially in mild cases will help to include patients in the decision-making. Moreover, future research into the role of the GP and the community pharmacist in the pre-pregnancy planning stage for those with chronic hypertension and postpartum for those with gestational hypertension or pre-eclampsia is warranted.

Strengths and limitations

This qualitative study is the first to use in-depth interviews to explore pregnant women’s experiences, perceptions and behaviours with regard to the management of HDP during pregnancy. Our study included women with all forms of HDP except HELLP and eclampsia, as the interviews were done when the women were in a comfortable, non-emergency situation. Participants varied in gestation stage, subtype of HDP, severity of HDP, ethnicity and socioeconomic status allowing for a wide range of views. The interviews were conducted during pregnancy thus reducing recall bias. This is in contrast to other qualitative studies which explored aspects of HDP in retrospect [ 27 , 35 , 37 ]. Recruitment was from two major public maternity referral hospitals in Melbourne with a widespread combined catchment including metropolitan, regional and rural areas. Participants did not include those in the first trimester of pregnancy, as most were scheduled to attend the antenatal clinics after 12 weeks gestation. Views of women with chronic hypertension during the first trimester of pregnancy may vary from those in the second and third trimesters and they were not captured . Women with poor English skills were excluded from the study, therefore, caution should be taken in the extrapolation of our findings to women from non-English speaking backgrounds.

The clinical management experiences of pregnant women with HDP were varied. Many women did not feel that they were well informed of treatment and management decisions and had a desire to be more informed and more involved in decision-making. Clear, concise information about various facets of HDP management including BP monitoring, administration of low dose aspirin in women with a high risk of developing pre-eclampsia, prescription of the appropriate antihypertensive, and planning for potential early delivery are required. In addition, cardiovascular pre-pregnancy planning and postpartum follow-up should be routinely offered to women.

Acknowledgements

We would like to thank the staff at both the Mercy Hospital for Women and the Royal Women’s Hospital for their help with this study. We would also like to thank all the women who participated.

Authors’ contributions

All authors contributed to the conception and design of the study. Patient recruitment and in-depth interviews were undertaken by AH. Data analyses and interpretation were performed by AH, KS and KR. The manuscript was written by AH and critically reviewed by all authors. All authors read and approved the final manuscript.

This study did not receive any funding.

Availability of data and materials

Declarations.

Ethical approval was obtained from Mercy Health Human Research Ethics Committee Heidelberg-Melbourne (R12/62) 08/01/2013, The Royal Women’s Hospital Research and Human Research Ethics Committee Parkville-Melbourne (R13/18) 12/07/2013 and Monash University Human Research Ethics Committee Clayton-Melbourne (CF13/117) 18/01/2013. Informed written consent was obtained prior to each interview, which included permission to audio record the conversation and use quotations when anonymously reporting and publishing the results. All methods were carried out in accordance with relevant guidelines and regulations of the ethics committees.

Not applicable.

The authors declare that they have no competing interests.

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Contributor Information

Amyna Helou, Email: [email protected] .

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