Hypertension in Pregnancy: A Potential Window into Long-Term Cardiovascular Risk in Women

Ellen W. Seely
1999 Journal of Clinical Endocrinology and Metabolism  
Hypertensive disorders of pregnancy affect approximately 6 -8% of pregnancies and are the second leading cause of maternal mortality in the United States. They are also a leading cause of maternal and neonatal morbidity (1). Despite the frequency of these disorders, their cause is unknown and their treatment is inadequate. Hypertension in pregnancy is a gender specific condition by definition. As with many other disorders that affect women, hypertension in pregnancy involves the overlap of the
more » ... ields of internal medicine and obstetrics. Whereas most essential hypertension is managed by internists, when a pregnant woman is hypertensive, the care of the hypertension is managed primarily by obstetricians. This leads to an interesting potential duality in the focus and approach of each specialty. In general, hypertension in pregnancy has been viewed as an obstetrical disorder and has not been an area of investigation for most internists. For the obstetrician, the disorder is one of pregnancy itself, and the focus is on the outcome of the individual pregnancy. On the other hand, for the internist an emerging focus is on the potential implications of hypertensive pregnancy for the future health of the individual woman. Terminology Hypertension in pregnancy is categorized according to the American College of Obstetrics and Gynecology as: 1) preexisting essential hypertension, 2) preeclampsia, 3) gestational hypertension, or 4) preeclampsia superimposed upon preexisting hypertension (1). These categories are important in that the various forms of hypertension that occur during pregnancy may imply different prognoses for the pregnancy itself as well as potentially for the long-term health of the mother. They may also represent different etiologies. Preeclampsia and gestational hypertension are defined as an increase in systolic blood pressure to 140 mm Hg or more, or diastolic to 90 mm Hg or more after 20 weeks of pregnancy and resolving postpartum. Preeclampsia differs from gestational hypertension due to its multisystem involvement, such as proteinuria as described below. When a women with preexisting hypertension develops an exacerbation of her hypertension during pregnancy accompanied by proteinuria or other systemic signs, this is termed hypertension with superimposed preeclampsia. Diagnosis and clinical course When a woman presents with hypertension in pregnancy, the first step is to establish whether it is of new onset or is preexisting. With more women delaying child bearing until later ages, pregnancies are occurring more frequently at an age when women have already developed essential hypertension. Essential hypertension carries with it an excellent prognosis in pregnancy unless superimposed preeclampsia develops. Two major areas of difference in management between hypertension during pregnancy vs. hypertension outside of pregnancy are in the choice of antihypertensive and the goal of treatment. A major issue in antihypertensive use is the avoidance of certain classes of antihypertensives such as converting enzyme inhibitors, which can cause renal damage and fetal and neonatal demise (2), and angiotensin II receptor blockers, which may have similar effects. Therefore, practitioners caring for women with essential hypertension should discuss family planning with their patients and alter pharmacological treatment accordingly. Alpha-methyl dopamine remains the most widely used antihypertensive in pregnancy and is recommended by the American College of Obstetrics and Gynecology (1) and by the National Working Group on High Blood Pressure in Pregnancy (3) as the first line antihypertensive. This recommendation is based on its long history of successful use in pregnancy without negative sequelae to the fetus or neonate. When alpha methyldopa is insufficient to control blood pressure, calcium channel blockers and beta-blockers are considered the second line agents. More studies are needed on comparative effectiveness and side effects of antihypertensive drugs in pregnancy to allow more informed clinical decision making. In addition to differences in medication choice during pregnancy, goals for blood pressure control differ as well. Although there is controversy about the exact level of blood
doi:10.1210/jcem.84.6.5785 pmid:10372675 fatcat:qjqhvkpufnbubmw4rb475gayki