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............................................................................................................................................................................. High risk of pre-eclampsia includes any of the following:

• hypertensive disease during a previous pregnancy • chronic kidney disease • autoimmune disease such as systemic lupus erythematosus or antiphospholipid syndrome • type 1 or type 2 diabetes • chronic hypertension. Moderate risk of pre-eclampsia includes more than one of the following risk factors: • first pregnancy • age 40 years or older • pregnancy interval of more than 10 years • BMI of >_35 kg/m2 at first visit • family history of pre-eclampsia • multiple pregnancy. Calcium supplementation (1.5–2 g/day, orally) is recommended for the prevention of pre-eclampsia in women with low dietary intake of calcium (<600 mg/day),366 to be commenced at the first antenatal clinic. Vitamins C and E do not decrease pre-eclampsia risk; on the contrary, they are more frequently associated with a birth weight <2.5 kg and adverse perinatal outcomes.367–370

10.4 Management of hypertension in

pregnancy 10.4.1 Background Management of hypertension in pregnancy depends on the BP, gestational age, and the presence of associated maternal and foetal risk factors. Most women with pre-existing hypertension and normal renal function have non-severe hypertension (140–159/90–109 mmHg) and are at low-risk for cardiovascular complications. Some are able to withdraw their medication in the first half of pregnancy because of the physiological fall in BP. Evidence-based data regarding treatment of hypertension in pregnancy are lacking. The only trial of treatment of hypertension in pregnancy with adequate infant follow-up (7.5 years) was performed 40 years ago with a-methyldopa.371,372 In terms of treatment benefit, tight vs. less-tight control of hypertension in pregnancy in the Control of Hypertension in Pregnancy Study was associated with less severe maternal hypertension, but no difference in the risk of adverse perinatal outcomes and overall serious maternal complications.373 However, a secondary analysis of the data showed that women developing severe hypertension had higher rates of adverse maternal (pre-eclampsia, platelets <100  109/L, elevated liver enzymes with symptoms, and maternal length of hospital stay >_10 days) and perinatal outcomes (perinatal death, high-level neonatal care for >48 h, birth weight <10th percentile, preeclampsia, and pre-term delivery).374 Thus, there is no evidence currently supporting target BP values in pregnancy.373,375

10.4.2 Non-pharmacological management Non-pharmacological management of hypertension during pregnancy has a limited role to play, with randomized studies of dietary and lifestyle interventions showing minimal effects on pregnancy outcome.376 Regular exercise might be continued with caution and obese women (>_30 kg/m2) are advised to avoid a weight gain of more than 6.8 kg.377

10.4.3 Pharmacological management While the goal of treating hypertension is to reduce maternal risk, the agents selected must be effective and safe for the foetus.

10.4.3.1 Treatment of severe hypertension There is no agreed definition of severe hypertension, with values ranging between 160–180 mmHg to >110 mmHg. This Task Force recommends considering an SBP >_170 mmHg or DBP >_110 mmHg in a pregnant woman an emergency, and hospitalization is indicated. The selection of the antihypertensive drug and its route of administration depend on the expected time of delivery. ACE inhibitors, ARBs, and direct renin inhibitors are strictly contraindicated (see section 12). Pharmacological treatment with i.v. labetalol, oral methyldopa, or nifedipine should be initiated; i.v. hydralazine is no longer the drug of choice as its use is associated with more perinatal adverse effects than other drugs.378 However, hydralazine is still commonly used when other treatment regimens have failed to achieve adequate BP control as most obstetricians find its side effect profile acceptable.379 Use of i.v. urapidil can also be considered. Sodium nitroprusside should only be used as the drug of last choice since prolonged treatment is associated with an increased risk of foetal cyanide poisoning.51 The drug of choice when pre-eclampsia is associated with pulmonary oedema is nitroglycerin (glyceryl trinitrate), given as an i.v. infusion of 5 lg/min, and gradually increased every 3–5 min to a maximum dose of 100 lg/min.

10.4.3.2 Treatment of mild–moderate hypertension Despite a lack of evidence, the European Guidelines9,348,375 recommend the initiation of drug treatment in all women with persistent elevation of BP 150/95 mmHg and at values >140/90 mmHg in women with: • gestational hypertension (with or without proteinuria) • pre-existing hypertension with the superimposition of gestational hypertension • hypertension with subclinical organ damage or symptoms at any time during pregnancy. Methyldopa, beta-blockers (most data available for labetalol), and calcium antagonists (most data available for nifedipine) are the drugs of choice.380,381 Beta-blockers appear to be less effective than calcium antagonists and may induce foetal bradycardia, growth retardation, and hypoglycaemia; consequently, their type and dose should be carefully selected, with atenolol best avoided (see section 12 and Table 7). Women with pre-existing hypertension may continue their current antihypertensive medication unless on ACE inhibitors, ARBs, and direct renin inhibitors, which are contraindicated due to adverse foetal and neonatal outcomes. The plasma volume is reduced in pre-eclampsia, therefore diuretic therapy is best avoided unless in the context of oliguria, when low-dose furosemide may be considered. Delivery of i.v. magnesium sulfate is recommended for the prevention of eclampsia and treatment of seizures, but should not be given concomitantly with CCBs (there is a risk of hypotension due to potential synergism).382

10.5 Delivery

Delivery is indicated in pre-eclampsia with visual disturbances or haemostatic disorders, and at 37 weeks in asymptomatic women.383 Downloaded from academic.oup.com/eurheartj/article/39/34/3165/5078465 by guest on 07 October 2026