Chronic Hypertension in Pregnancy

Abstract

1254C hronic hypertension in pregnancy is defined by the American College of Obstetrics and Gynecology (ACOG) as blood pressure ≥140 mm Hg systolic and/or 90 mm Hg diastolic before pregnancy or, in recognition that many women seek medical care only once pregnant, before 20 weeks of gestation, use of antihypertensive medications before pregnancy, or persistence of hypertension for >12 weeks after delivery. 1Chronic hypertension needs to be distinguished from new-onset hypertensive complications of pregnancy such as preeclampsia (elevated blood pressure and proteinuria often accompanied by evidence of maternal organ injury and fetal compromise from placental dysfunction) 2 and gestational hypertension (elevated blood pressure alone after 20 weeks of gestation and most commonly in the mid to late third trimester without evidence or history of hypertension before pregnancy; Table 1). EpidemiologyChronic hypertension is estimated to be present in ≈3% to 5% of pregnancies 1,3,4 and is increasingly more commonly encountered. Factors contributing to the increase in prevalence include 2 major risk factors for hypertension, obesity and older age, which are of increasing prevalence in pregnancy. These shifts in risk and childbearing have resulted in an increased number of women who will require counseling on the risks of chronic hypertension in pregnancy and management of their antihypertensive medications both in anticipation of and during pregnancy.5 Because many pregnancies are unplanned, 6 all women with chronic hypertension should receive regular counseling so that they can anticipate any issues that may arise if they become pregnant and optimize their health and care to temper risk. Because blacks have a higher prevalence of chronic hypertension 7 and onset occurs at younger ages, 8 it is more common to encounter chronic hypertension in blacks during pregnancy.Despite its increasing prevalence, the majority of women with chronic hypertension do well in pregnancy, but as we discuss below, some women develop complications such as superimposed preeclampsia, fetal growth restriction, placental abruption, 4,9,10 and preterm birth, and women with chronic hypertension have an increased likelihood of cesarean delivery. Physiological Changes in Blood Pressure During PregnancyWomen who are normotensive entering pregnancy typically experience a decrease in blood pressure toward the end of the first trimester. This decrease is thought to be secondary to the marked vasodilation that occurs despite the increase in plasma volume that comes with pregnancy. Blood pressure usually falls by 5 to 10 mm Hg and remains at this lower level throughout pregnancy until the third trimester, when it rises to return to prepregnancy values. For the majority of women with chronic hypertension, blood pressure changes also follow this same pattern. As a result, some hypertensive women become normotensive during pregnancy, and others who remain hypertensive can have their antihypertensive medications tapered. These physiological changes may confuse t...

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