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Update on the Use of Antihypertensive Drugs in Pregnancy Tiina Podymow and Phyllis August Hypertension 2008;51;960-969; originally published online Feb 7, 2008; DOI: 10.1161/HYPERTENSIONAHA.106.075895
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Update on the Use of Antihypertensive Drugs in Pregnancy
Tiina Podymow, Phyllis August
s the mostcommon medical disorder of pregnancy, hypertension is reported to complicate 1 in 10 pregnancies1,2 and affects an estimated 240 000 women in the United States each year.3 Antihypertensive treatment rationale in this group represents a departure from the nonpregnant adult Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressureguidelines.4 First, during pregnancy, the priority regarding hypertension is in making the correct diagnosis, with the emphasis on distinguishing preexisting (chronic) from pregnancy induced (gestational hypertension and the syndrome of preeclampsia). Second, much of the obstetric literature distinguishes blood pressure (BP) levels as either mild (140 to 159/90 to 109 mm Hg) or severe ( 160/110 mm Hg),rather than as stages (as in Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; Table 1). Third, in contrast to hypertension guidelines in adults, which emphasize the importance of systolic BP, much of the obstetric literature focuses on diastolic rather than systolic BP, in part because of the lack of clinical trials tosupport one approach versus another. The focus of treatment is the 9 months of pregnancy, during which untreated mild-to-moderate hypertension is unlikely to lead to unfavorable long-term maternal outcomes. In this setting, antihypertensive agents are mainly used to prevent and treat severe hypertension; to prolong pregnancy for as long as safely possible, thereby maximizing the gestational age of theinfant; and to minimize fetal exposure to medications that may have adverse effects. During pregnancy, the challenge is in deciding when to use antihypertensive medications and what level of BP to target. The choice of antihypertensive agents is less complex, because only a small proportion of currently available drugs have been adequately evaluated in pregnant women, and many others arecontraindicated. Appropriate use of antihypertensive drugs in specific pregnancy-associated hypertensive disorders, including therapeutic BP goals and criteria for selecting specific antihypertensive drugs, are discussed in this review.

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Principles of Treatment of Specific Hypertensive Disorders
There are 4 major hypertensive disorders in pregnancy, each with unique pathophysiologic features thathave implications for antihypertensive therapy, as described below.

Chronic hypertension, defined as BP 140/90 mm Hg either predating pregnancy or developing before 20 weeks’ gestation, complicates 3% of pregnancies. Because the cause is largely essential hypertension, it is more frequent in African American patients and women who are of advanced maternal age or who are obese. Women of...