OBJECTIVES: Chronic hypertension complicates 1-2% of pregnancies and it is increasingly common. Women with chronic hypertension are easily-recognized and in touch with a wide variety of healthcare providers before, during, and after pregnancy, mandating that chronic hypertension in pregnancy be within the scope of many practitioners. We reviewed recent data on management to inform current care and future research. STUDY DESIGN: Narrative review of published literature. RESULTS: Compared with normotensive women, women with chronic hypertension are at increased risk of maternal and perinatal complications. Women wish to be involved in their care and are capable of measuring blood pressure (BP) at home. Accurate devices for home BP monitoring are now available. The diagnostic criteria for superimposed preeclampsia remain problematic, as most guidelines continue to include deteriorating BP control in the definition. It has not been established how angiogenic markers may aid in confirmation of the diagnosis of superimposed preeclampsia when suspected, over and above information provided by routinely-available clinical data and laboratory results. While chronic hypertension is a strong risk factor for preeclampsia and aspirin decreases preeclampsia risk, the effectiveness specifically among women with chronic hypertension has been questioned. It is unclear whether calcium has an independent effect in preeclampsia prevention in such women. Treating hypertension with antihypertensive therapy halves the risk of progression to severe hypertension, thrombocytopenia, and elevated liver enzymes, but a reduction in preeclampsia or serious maternal complications has not been demonstrated; however, the latter lack of evidence is possibly due to few events. Also, treating chronic hypertension neither reduces nor increases fetal/newborn death or morbidity, regardless of the gestational age at which the antihypertensive treatment is started. Antihypertensive agents are not teratogenic, but there may be an increase in malformations associated with chronic hypertension itself. At present, BP treatment targets used in clinic are the same as those used at home; although BP values tend to be inconsistently lower at home among hypertensive women. While starting all women on the same antihypertensive medication is usually effective in reducing BP, it remains unclear whether there is an optimal agent for such an approach, or how best to use combinations of antihypertensive medications. An alternative approach is to individualize care, using maternal characteristics and BP features beyond BP level (e.g., variability) that are of prognostic value. Outcomes may be improved by timed birth between 38+0-39+6 weeks based on observational literature; confirmatory trial evidence is pending. Postnatal care is facilitated by the acceptability of most antihypertensives (included angiotensin converting enzymes inhibitors) for use in breastfeeding. CONCLUSIONS: The evidence base to guide the care of pregnant women with chronic hypertension is growing and aligning international guidance. Addressing outstanding research questions would inform personalized care of chronic hypertension in pregnancy.
Towards Personalized Management of Chronic Hypertension in Pregnancy