Hypertension in Pregnancy
Hypertension Canada and Society of Obstetricians and Gynaecologists of Canada
Women should have their BP measured using a standardized protocol after a period of rest in a quiet environment and be in a sitting position with their arm at the level of the heart using an appropriately sized cuff (ie, length 1.5 times the circumference of the arm).
The arm with higher BP values should be used for hypertension diagnosis and BP monitoring.
Nonsevere elevated BP should be remeasured at the same visit, with at least a gap of 15 minutes from the first measurement.
More than 50% of women with a first BP reading of ≥140/90 mm Hg have white-coat effect.
Hypertension in pregnancy is defined as an SBP ≥140 mm Hg and/or a DBP ≥90 mm Hg (average of at least 2 measurements taken at least 15 minutes apart).
Severity of hypertension in pregnancy is considered on the basis of the presence of target organ involvement (ie, maternal or the fetus itself) as well as the actual BP level.
BP levels between 140/90 mm Hg and <160/110 mm Hg are considered nonsevere hypertension in pregnancy.
A BP level of ≥160/110 mm Hg is associated with increased risk of maternal stroke in pregnancy and is therefore considered the diagnostic threshold of severe hypertension in pregnancy.
Antihypertensive therapy is recommended for average SBP measurements of ≥140 mm Hg or DBP measurements of ≥90 mm Hg in pregnant women with chronic hypertension, gestational hypertension, or preeclampsia.
Initial antihypertensive therapy should be monotherapy from the following first-line drugs: oral labetalol, oral methyldopa, long-acting oral nifedipine, or other oral β-blockers (acebutolol, metoprolol, pindolol, and propranolol).
Other antihypertensive drugs can be considered as second-line drugs, including clonidine, hydralazine, and thiazide diuretics.
ACE inhibitors and angiotensin receptor blockers should not be used in pregnant women.
A DBP of 85 mm Hg should be targeted for pregnant women receiving antihypertensive therapy with chronic hypertension or gestational hypertension. A similar target could be considered for pregnant women with preeclampsia.
Additional antihypertensive drugs should be used if target BP levels are not achieved with standard-dose monotherapy. Add-on drugs should be from a different drug class chosen from first-line or second-line options.
Women with severe hypertension with SBP ≥160 or DBP ≥110 mm Hg in pregnancy require urgent antihypertensive therapy because it is considered an obstetric emergency.
Reference
Butalia S, Audibert F, Cote AM, Hypertension Canada's 2018 Guidelines for the Management of Hypertension in Pregnancy. Can J Cardiol. 2018 May;34(5):526-531. https://www.onlinecjc.ca/article/S0828-282X(18)30182-X/fulltext
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