p.60 抽出テキスト
CLINICAL STATEMENTS AND GUIDELINES Circulation. 2025;152:e114–e218. DOI: 10.1161/CIR.0000000000001356 September 16, 2025 e173 The management of BP in pregnancy-capable individu als requires special considerations. The overarching goals of antihypertensive treatment during pregnancy are aimed at preventing severe hypertension and preeclampsia and optimizing maternal and fetal/neonatal clinical outcomes. Compared with the diagnostic criteria for hypertension in adults presented in this document, the American College of Obstetricians and Gynecologists (ACOG) defines hyper tension in pregnancy as an SBP ≥140 mm Hg or DBP ≥90 mm Hg on 2 occasions at least 4 hours apart, and severe-range hypertension as sustained SBP ≥160 mm Hg or DBP ≥110 mm Hg with verification in 15 minutes to avoid treatment delays (Table 20).6,20,21 Pregnant individu als with elevated BP are further classified as having 1 of the HDP based upon gestational age at diagnosis and the presence of target organ involvement (Table 21). Vascu lar and hemodynamic alterations in pregnancy result in a decline of BP by 10% in early pregnancy, reaching a nadir in the second trimester and slowly rising back to baseline by the end of the third trimester.22 It is because of these alterations that the classification of HDP depends on ges tational age, and the use of BP monitors that have been specifically validated for accuracy (www.validatebp.org) in pregnancy is advised.23,24 Recommendation-Specific Supportive Text 1 When antihypertensive therapy is indicated in individu als planning a pregnancy or who become pregnant, labetalol and extended-release nifedipine are the pre ferred first-line agents.6,20 Among them, no specific agent is preferred because there is a lack of data sup porting the use of 1 over the other, although nifedipine is dosed once daily, which may improve adherence.3–5,25 In a meta-analysis, BB and CCB appear more effective than methyldopa for the prevention of severe hyperten sion.1 Table 22 lists antihypertensive agents that can be used alone or in combination for chronic maintenance therapy in pregnant individuals. There are limited data available on the safety of amlodipine in pregnancy,26–28 but it does not appear to be associated with a height ened risk of major congenital malformations. 2. Chronic hypertension, defined as high BP that pre dates pregnancy or is diagnosed before 20 weeks’ gestation, is associated with a high risk of develop ing preeclampsia, a multiorgan system inflammatory syndrome that is thought to result from abnormali ties in placental development, leading to placental ischemia and oxidative stress.6 In a meta-analysis, daily low-dose aspirin taken during pregnancy after 12 weeks’ gestation has been shown to signifi cantly reduce the risk for preeclampsia in individu als at moderate or high risk compared with placebo (pooled relative risk: 0.85 [95% CI: 0.75-0.95]).2 Aspirin use was also associated with significantly reduced risk for preterm birth, small-for-gestational age/intrauterine growth restriction, and perinatal mortality in pregnant persons at increased risk for preeclampsia2 without increased risk of postpartum hemorrhage. Only individuals with no prior adverse events or allergy to aspirin should be advised to take low-dose aspirin for preeclampsia prevention. 3. Severe hypertension in pregnancy is defined as SBP ≥160 mm Hg or DBP ≥110 mm Hg. When left untreated, it can result in maternal stroke, renal insufficiency or kidney failure, MI, HF, placental abruption, preterm birth, fetal growth restriction, and maternal death from intracerebral hemor rhage and/or stillbirth or perinatal death. Table 23 describes the preferred agents, doses, and routes of administration for the expeditious treatment of severe-range hypertension in pregnant individuals. Immediate-release oral nifedipine has been shown in a meta-analysis to be associated with faster time to achieve target BP specifically in pregnancy, although it is not generally recommended for the acute treatment of other types of hypertension.3 4 A Cochrane review and meta-analysis of 58 tri als evaluating the treatment of nonsevere-range hypertension in pregnancy (SBP <160 mm Hg and DBP <110 mm Hg) concluded that the use of antihypertensive medications reduced the risk of severe-range hypertension (risk ratio: 0.49; 95% CI: 0.40-0.60) but did not significantly reduce the risk of preeclampsia.1 However, the CHAP (Chronic Hypertension and Pregnancy) trial, which random ized 2408 women with chronic hypertension to receive antihypertensive medications to reach tar get BP <140/90 mm Hg compared with no treat ment unless SBP ≥160 mm Hg or DBP ≥105 mm Hg, demonstrated an 18% absolute risk reduction in the primary composite endpoint of preeclamp sia with severe features, preterm birth, placental abruption, or fetal/neonatal death without evidence of increased risk of fetal growth restriction.8 5 BP management during pregnancy is complicated by the fact that many commonly used antihypertensive agents are contraindicated because of potential harm to the fetus. Therapeutic classes are not universally recommended or avoided because potential toxicity differs among agents within classes. Atenolol11 has been associated with growth restriction and lower fetal weight and should be avoided in pregnancy.12 This is likely not a class effect, as other beta-1-se lective agents like metoprolol have not demonstrated similar associations with growth restriction, and labet alol is a preferred agent with the most reassuring fetal safety data. ACEi, ARB, and direct renin inhibitors are Downloaded from http://ahajournals.org by on October 7, 2026