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Drug Treatment of Hypertension in Pregnancy

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Abstract

Hypertensive disorders represent major causes of pregnancy-related maternal mortality worldwide. Similar to the non-pregnant population, hypertension is the most common medical disorder encountered during pregnancy and is estimated to occur in about 6–8 % of pregnancies. A recent report highlighted hypertensive disorders as one of the major causes of pregnancy-related maternal deaths in the USA, accounting for 579 (12.3 %) of the 4,693 maternal deaths that occurred between 1998 and 2005. In low-income and middle-income countries, preeclampsia and its convulsive form, eclampsia, are associated with 10–15 % of direct maternal deaths. The optimal timing and choice of therapy for hypertensive pregnancy disorders involves carefully weighing the risk-versus-benefit ratio for each individual patient, with an overall goal of improving maternal and fetal outcomes. In this review, we have compared and contrasted the recommendations from different treatment guidelines and outlined some newer perspectives on management. We aim to provide a clinically oriented guide to the drug treatment of hypertension in pregnancy.

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Acknowledgments

The project described was supported by award number P50AG44170 from the National Institute on Aging (Vesna D. Garovic). Dr. Garovic is the inventor of technology referenced in this manuscript. That technology has been patented by the Mayo Clinic, but is currently not licensed. Dr. Brown has no potential conflicts of interest that might be relevant to the content of this manuscript.

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Authors and Affiliations

  1. Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN, 55905, USA

    Catherine M. Brown & Vesna D. Garovic

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  1. Catherine M. Brown
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  2. Vesna D. Garovic
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Correspondence to Vesna D. Garovic.

Appendices

Appendices

1.1 Appendix 1: The NHBPEP Working Group Report on High Blood Pressure in Pregnancy reviewed and classified studies providing evidence supporting their recommendations. They used the following explanatory symbols and appended them to some of their references and to some of their citations [1]

  • M: Meta-analysis; an analysis of a compendium of experimental studies

  • Ra: Randomized controlled studies

  • Re: Retrospective analyses; case-control studies

  • F: Prospective follow-up; cohort studies

  • X: Cross-sectional population studies

  • Pr: Previous review or position statements

  • C: Clinical interventions (nonrandomized)

1.2 Appendix 2: ACOG evidence base

  • I: Evidence obtained from at least one properly randomized controlled trial

  • II-1: Evidence from well designed controlled trials without randomization

  • II-2: Evidence from well designed cohort or case-control studies, preferably from more than one center or research group

  • II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments could also be regarded as this type of evidence

  • III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees

Recommendations are provided and graded according to the following categories:

  • Level A: Recommendations are based on good and consistent scientific evidence

  • Level B: Recommendations are based on limited or inconsistent scientific evidence

  • Level C: Recommendations are based primarily on consensus and expert opinion

1.3 Appendix 3: Key to evidence statements and grading of recommendations, using the ranking of the Canadian Task Force on Preventive Health Care

Quality of Evidence Assessmenta Classification of Recommendationsb

  • I: Evidence obtained from at least one properly randomized controlled trial

  • II-1: Evidence from well designed controlled trials without randomization

  • II-2: Evidence from well designed cohort (prospective or retrospective) or case-control studies, preferably from more than one center or research group

  • II-3: Evidence obtained from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be included in this category

  • III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees

  • A. There is good evidence to recommend the clinical preventive action

  • B. There is fair evidence to recommend the clinical preventive action

  • C. The existing evidence is conflicting and does not allow the making of a recommendation for or against use of the clinical preventive action; however, other factors may influence decision making

  • D. There is fair evidence to recommend against the clinical preventive action

  • E. There is good evidence to recommend against the clinical preventive action

  • I. There is insufficient evidence (in quantity or quality) to make a recommendation; however, other factors may influence decision making

aThe quality of evidence reported in these guidelines has been adapted from the Evaluation of Evidence criteria described in the Canadian Task Force on Preventive Health Care

bRecommendations included in these guidelines have been adapted from the Classification of Recommendations criteria described in the Canadian Task Force on Preventive Health Care

1.4 Appendix 4: Explanation of the class of recommendations and levels of evidence used by the ESH/ESC

Classes of recommendations

  • Class I: Evidence and/or general agreement that a given treatment or procedure is beneficial, useful, effective (is recommended/is indicated)

  • Class II: Conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of the given treatment or procedure

  • Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy (should be considered)

  • Class IIb: Usefulness/efficacy is less well established by evidence/opinion (may be considered)

  • Class III: Evidence or general agreement that the given treatment or procedure is not useful/effective, and in some cases may be harmful (is not recommended)

Levels of evidence

  • Level of evidence A: Data derived from multiple randomized clinical trials or meta-analyses

  • Level of evidence B: Data derived from a single randomized clinical trial or large non-randomized studies

  • Level of evidence C: Consensus of opinion of the experts and/or small studies, retrospective studies, registries

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Brown, C.M., Garovic, V.D. Drug Treatment of Hypertension in Pregnancy. Drugs 74, 283–296 (2014). https://doi.org/10.1007/s40265-014-0187-7

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