Guide use of BP meds during pregnancy

Guide hypertension treatment in pregnancy with BP goals and safe medication choices for better outcomes....

As a cardiovascular pharmacist, more questions arise about managing chronic hypertension in pregnancy due to increasing maternal age, obesity, etc. We know to treat all pregnant patients with severe hypertension 160/110 mm Hg or above. But treatment of nonsevere chronic hypertension, such as 140/90 or more, hasn’t been clear-cut, due to limited evidence.

NPS-adv

Now data suggest that aiming for a BP under 140/90 for nonsevere chronic hypertension in pregnancy improves outcomes (preeclampsia, etc) without increasing risk of low-birth-weight babies. That’s why recent guidance recommends 140/90 as the threshold for adding or stepping up treatment of chronic hypertension in pregnancy, which may lead to BP meds being used more often. Guide use of BP meds if patients are, or may become, pregnant...

Advise using nifedipine ER or labetalol first. These meds aren’t linked to significant fetal adverse outcomes.
Don’t jump to other CCBs, they don’t have as much safety data.
Avoid atenolol and caution about using beta-blockers other than labetalol, because they may impair fetal growth.
Methyldopa is often thought of if other first-line meds aren’t enough, based on its long history of safety in pregnancy. But point out that it’s been discontinued with no estimated return date.
Generally save thiazides as a second-line option due to possible hypovolemia, especially in the first couple weeks of therapy.
Avoid spironolactone or eplerenone due to limited data.
And continue to avoid an ACEI or ARB due to risk of serious fetal injury or death when used in the second or third trimester.

References

Tita AT, et al; Chronic Hypertension and Pregnancy (CHAP) Trial Consortium. Treatment for Mild Chronic Hypertension during Pregnancy. N Engl J Med. 2022 May 12;386(19):1781-1792.
American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Obstetrics. ACOG Practice Bulletin No. 203: Chronic Hypertension in Pregnancy. Obstet Gynecol. 2019 Jan;133(1):e26-e50.
Whelton PK, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018 Jun;71(6):1269-1324.