Pharmacotherapy for hypertension in pregnant patients: special considerations

ABSTRACT

Introduction: Hypertensive disorders of pregnancy (HDP) represent a major cause of maternal, fetal and neonatal morbidity and mortality and identifies women at risk for cardiovascular and other chronic diseases later in life. When antihypertensive drugs are used during pregnancy, their benefit and harm to both mother and fetus should be evaluated.

Areas covered: This review summarizes the pharmacological characteristics of the recommended antihypertensive drugs and their impact on mother and fetus when administered during pregnancy and/or post-partum. Drugs were identified using MEDLINE and the main international Guidelines for the management of HDP.

Expert opinion: Although there is a consensus that severe hypertension should be treated, treatment of mild hypertension without end-organ damage (140–159/90–109 mmHg) remains controversial and there is no agreement on when to initiate therapy, blood pressure targets or recommended drugs in the absence of robust evidence for the superiority of one drug over others. Furthermore, the long-term outcomes of in-utero antihypertensive exposure remain uncertain. Therefore, evidence-based data regarding the treatment of HDP is lacking and well designed randomized clinical trials are needed to resolve all these controversial issues related to the management of HDP.

KEYWORDS:

• Pregnancy
• hypertension
• gestational
• pre-eclampsia
• postpartum hypertension
• antihypertensive drugs
• treatment

Article highlights

• Hypertensive disorders during pregnancy (HDP) remain the most common medical complications in obstetric practice and a leading cause of maternal, fetal and neonatal morbidity and mortality worldwide.

• The therapeutic goal is to reduce maternal and fetal morbidity, and mortality and improve long-term clinical outcomes associated with uncontrolled hypertension using effective and safe antihypertensive drugs

• Therapy is complicated because HPD is not a single entity but comprises both chronic and de-novo forms of hypertension

• Treatment of mild hypertension without end-organ damage remains controversial and there is no agreement on the threshold to initiate therapy, BP targets or recommended drugs.

• Few adequately powered randomized clinical trials (RCTs) have analyzed head-to-head the efficacy and safety of antihypertensive drugs in women with HDP

• The teratogenic risk of antihypertensive drugs has not been adequately studied.

• We need well-designed RCTs that determine the optimal BP targets, the efficacy, and safety of antihypertensive drugs and the optimal drug regimens to improve long-term maternal and fetal outcomes in women with HDP

This box summarizes key points contained in the article.

Declaration of interest

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This work was supported by grants from the Ministry of Science, Innovation and Universities (SAF2017-88116-P), Carlos III Institute of Health [PI16/00398, CIBER-Cardiovascular (CB16/11/00303)] and the Comunidad de Madrid [B2017/BMD-3738].