Chronic Hypertension

Chronic 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.

Etiology and Classification

Essential hypertension is by far the most common cause of chronic hypertension

during pregnancy. Despite their added risks for both mother and fetus, a
description of all causes of hypertension is beyond the scope of this chapter
(Table 1).

Table 1. Cause of Chronic Hypertension

Chronic hypertension in pregnancy is classified as mild or severe depending on

the systolic and diastolic blood pressure readings. The hypertension is classified
as either mild or severe. Mild hypertension has been traditionally defined by a
systolic blood pressure less than 160 mmHg, and diastolic blood pressure less
than 110 mmHg, although the American College of Obstetricians and
Gynecologists has recently changed its definition to include a systolic blood
pressure less than 180 mmHg. Beyond this, patients are further classified as either
having low- or high-risk hypertension. Patients with uncomplicated mild essential
hypertension are considered to be at low risk, whereas patients with severe
hypertension or having associated complicating factors are classified as being at
high risk (Table 2). Classification in this way will help to direct management and
initiation of antihypertensive medication. Most women with chronic hypertension
in pregnancy have the mild form of the disease.

Table 2. Criteria for High-Risk Chronic Hypertension

Severe Hypertension (SBP 180 mmHg, and/or DBP 110 mmHg) or Mild
hypertension in association with:

Presence of hypertension for > 4 y

Maternal age > 40 years

Renal disease

Cardiomyopathy

Coarctation of the aorta

Retinopathy

Diabetes (class B to F)

Collagen vascular disease

Antiphospholipid antibody syndrome, with perinatal loss

Previous severe preeclampsia with perinatal death

Complicaton in maternal and fetal risk

Although many women with chronic hypertension do well in pregnancy, they are
at increased risk for several pregnancy complications, including superimposed
preeclampsia, fetal growth restriction, placental abruption, and preterm birth. As
part of family planning before conception, they should be counseled about these
risks and the anticipated need for surveillance and management of any incident
complications during pregnancy. Rates of adverse pregnancy outcomes are
described in Tables 3

Table 3. Rates of Adverse Pregnancy Outcome in Mild and Severe Chronic

Hypertension

Treatment

Nonpharmacologic treatment

Treatment of hypertensive individuals who are not pregnant is focused on two

basic strategies: 1) lowering BP and 2) minimizing additional CV risk factors.
Nonpharmacologic approaches that have successfully lowered BP in individuals
who are not pregnant include regular aerobic exercise, maintaining ideal body
weight, moderation of alcohol intake, adopting specific diets (such as the DASH
[Dietary Approaches to Stop Hypertension] diet, a diet with abundant fruits and
vegetables, lowfat dairy products, and high fiber), and reducing sodium intake.

Pharmacologic treatment

Antihypertensive agent

Metyldopa

Methyldopa, a centrally acting alpha-2 adrenergic agonist, remains a commonly

used drug mainly because of the long history of use in pregnancy and childhood
safety data. Blood pressure control is gradual, over 68 hours, as a result of the
indirect mechanism of action. Methyldopa has been prospectively studied
specifically in chronic hypertension compared with placebo as well as in a mixed
group of hypertensive women. There are no apparent adverse effects on
uteroplacental or fetal hemodynamics or on fetal well-being. Birth weight,
neonatal complications, and development at 1 year were similar in infants exposed
to methyldopa in utero compared with no therapy. A follow-up study of children
at 7 years of age did not show any difference in neurocognitive development or
intelligence compared with controls. Serious adverse effects include hepatic
dysfunction and necrosis as well as hemolytic anemia. Methyldopa may be less
effective in preventing severe hypertension based on the Cochrane analysis of a
subset of studies compared with -blocker and calcium channel blocker classes
combined (OR, 0.75; 95% CI, 0.590.94).

Labetolol

Labetalol, a nonselective -blocker with vascular alpha receptor-blocking ability,

is commonly used in pregnancy. In women with chronic hypertension, there were
no significant differences in perinatal outcomes when compared with placebo or
methyldopa. Based on comparisons with placebo or other antihypertensive agents
for mild to moderate hypertension in pregnancy, labetalol is a reasonable choice
in women with chronic hypertension. Adverse effects include lethargy, fatigue,
sleep disturbances, and bronchoconstriction. Labetalol should be avoided in
women with asthma, heart disease, or congestive heart failure. Beta-blockers
alone have been used extensively in pregnancy and are effective in lowering BP.
However, -blockers may be associated with an increase in SGA infants (RR,
1.34; 95% CI, 1.011.79) compared with placebo or no treatment.

Calcium Channel Blocker

Calcium channel blockers are a class of drugs that has not been extensively
studied in pregnant women with chronic hypertension. Extrapolation from the
comparison trials for mild to moderate hypertension in pregnancy, in which
nifedipine was the most commonly prescribed calcium channel blocker, indicates
no increase in adverse perinatal outcomes. Furthermore, nifedipine does not
appear to adversely affect uterine or umbilical blood flow.
Diuretic

Diuretics are generally considered second-line drugs for the treatment of

hypertension in pregnancy. Theoretical concern has been raised regarding the
potential for diuretics to cause intravascular volume depletion and thereby lead to
fetal growth restriction. However, this is not supported based on data from a meta-
analysis of nine randomized trials as well as a Cochrane systematic review of
diuretics for the prevention of preeclampsia. Thus, diuretics may be used in
pregnancy with dose adjustments to minimize adverse effects and risks such as
hypokalemia. They may be especially useful in women with known salt-sensitive
hypertension, particularly in the setting of reduced renal function.

Angiotensin-Converting Enzim inhibitor

Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers used

in the second and third trimesters of pregnancy are associated with fetal
abnormalities (including renal failure, oligohydramnios, pulmonary hypoplasia,
calvarial abnormalities, and fetal growth restriction) as well as postdelivery effects
such as oliguria and anuria.
Daftar Pustaka

Seely, E. W., & Ecker, J. (2014). Chronic hypertension in pregnancy. Circulation, 129(11),
1254-1261.

American College of Obstetrician and Gynecologist (2013). Hypertension in pregnancy

Sibai, B. M. (2002). Chronic hypertension in pregnancy. Obstetrics & Gynecology, 100(2),

369-377.

American College of Obstetricians and Gynecologists. (2013). Hypertension in

pregnancy. Report of the American College of Obstetricians and Gynecologists task
force on hypertension in pregnancy. Obstetrics and gynecology, 122(5), 1122.