How to manage hypertension (high blood pressure) in a 34-year-old female at 36 weeks gestation with a blood pressure of 143/95 mmHg and no proteinuria (protein in urine)?

From the Guidelines

For a 34-year-old female at 36 weeks gestation with a blood pressure of 143/95 mmHg and no proteinuria, I strongly recommend initiating antihypertensive therapy while closely monitoring both maternal and fetal well-being, as indicated by the most recent guidelines 1. The goal of antihypertensive treatment in this case is to maintain blood pressure below 140/90 mmHg while avoiding hypotension, as recommended by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1.

• Labetalol is typically the first-line medication, starting at 100-200 mg orally twice daily, with potential titration up to 800 mg daily in divided doses.
• Alternatively, nifedipine (extended-release) 30-60 mg daily or methyldopa 250-500 mg three times daily can be used. Key aspects of management include:
• Weekly prenatal visits to monitor blood pressure, assess for proteinuria development, and evaluate fetal growth via ultrasound.
• Home blood pressure monitoring twice daily.
• Watching for warning signs of preeclampsia, such as headache, visual disturbances, right upper quadrant pain, or decreased fetal movement.
• Discussing delivery planning, as gestational hypertension at 36 weeks may warrant delivery by 37-38 weeks if blood pressure remains difficult to control, as suggested by the ISSHP classification, diagnosis, and management recommendations for international practice 1. Antihypertensive treatment works by reducing peripheral vascular resistance, improving placental perfusion, and decreasing the risk of maternal complications like stroke or placental abruption, which is crucial for improving morbidity, mortality, and quality of life outcomes in this patient population 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Management of Hypertension in Pregnancy

The management of hypertension in a 34-year-old female at 36 weeks gestation with a blood pressure of 143/95 mmHg and no proteinuria requires careful consideration of the potential risks and benefits of various antihypertensive agents.

• The American College of Obstetricians and Gynecologists (ACOG) recommends that women with severe hypertension (systolic blood pressure ≥160 mmHg or diastolic blood pressure ≥110 mmHg) should be treated with antihypertensive medication to reduce the risk of maternal complications 2, 3, 4.
• However, the patient's blood pressure is not considered severe, and the decision to initiate antihypertensive therapy should be individualized based on the presence of other risk factors and the potential benefits and risks of treatment.
• Several studies have compared the efficacy and safety of different oral antihypertensive agents, including nifedipine, labetalol, and methyldopa, for the management of severe hypertension in pregnancy 2, 3, 5, 4.
• Nifedipine has been shown to be effective in reducing blood pressure and may be preferred as the first-line agent due to its ease of administration and lower risk of persistent hypertension compared to hydralazine and labetalol 5, 4.
• Labetalol and methyldopa are also viable options for treating severe hypertension in pregnancy, although they may have a higher risk of persistent hypertension compared to nifedipine 2, 3, 4.

Pharmacokinetics and Safety

• The pharmacokinetics of antihypertensive drugs during pregnancy are not well understood, and further studies are needed to determine the optimal dosing regimens and to minimize the risk of adverse effects 6.
• All three oral antihypertensive agents (nifedipine, labetalol, and methyldopa) have been shown to be safe and effective in reducing blood pressure in pregnant women, with no significant differences in maternal or fetal outcomes 2, 3, 5, 4.
• However, the risk of adverse effects, such as hypotension and fetal growth restriction, should be carefully monitored and managed to minimize potential harm to the mother and fetus.

Treatment Approach

• The treatment approach for hypertension in pregnancy should be individualized based on the severity of hypertension, the presence of other risk factors, and the potential benefits and risks of treatment.
• Women with severe hypertension should be treated with antihypertensive medication to reduce the risk of maternal complications, while those with mild or moderate hypertension may be managed with lifestyle modifications and close monitoring of blood pressure 2, 3, 4.