How is orthostatic hypotension managed in pregnancy?

Management of Orthostatic Hypotension in Pregnancy

Non-pharmacological approaches should be the first-line treatment for orthostatic hypotension in pregnancy, focusing on lifestyle modifications and physical counter-maneuvers to minimize postural symptoms rather than restoring normotension. 1

Initial Assessment and Management

• Before initiating any treatment for orthostatic hypotension in pregnancy, test for orthostatic hypotension by having the patient sit or lie for 5 minutes and then measuring blood pressure at 1 and/or 3 minutes after standing 1
• Identify and discontinue medications that may exacerbate orthostatic hypotension, such as psychotropic drugs, diuretics, and alpha-adrenoreceptor antagonists 1, 2
• Correct any underlying volume depletion, which is a common reversible cause of orthostatic hypotension 1, 2

Non-Pharmacological Management

• Educate pregnant patients about gradual staged movements with postural change to minimize symptoms 1, 3
• Recommend physical counter-maneuvers such as leg-crossing, stooping, squatting, and tensing muscles when changing positions 1, 3
• Encourage increased fluid and salt intake if not contraindicated by other pregnancy conditions 1, 3
• Suggest use of elastic compression garments over the legs and abdomen to reduce venous pooling 1, 3
• Recommend head-up bed position during sleep to reduce nocturnal diuresis 1, 3
• Advise avoiding large carbohydrate-rich meals which can worsen postprandial hypotension 1
• In consultation with an obstetrician, recommend low- to moderate-intensity exercise for all pregnant women without contraindications 1

Pharmacological Management

If symptoms persist despite non-pharmacological measures, pharmacological treatment may be considered:

• Dihydropyridine calcium channel blockers (preferably extended-release nifedipine), labetalol, and methyldopa are recommended first-line blood pressure medications in pregnancy and can be considered for orthostatic hypotension management 1
• Midodrine (peripheral selective α1-adrenergic agonist) can be considered in severe cases, with careful dosing (up to 10 mg, 2-4 times daily) 1, 4, 5
• Fludrocortisone (9-α-fluorohydrocortisone) may be considered as an alternative option for treatment-resistant cases 1, 4, 5

Important Considerations and Cautions

• RAS blockers (ACE inhibitors, ARBs) are strictly contraindicated during pregnancy due to fetotoxicity 1
• When using pharmacological treatments, carefully balance the goal of increasing standing blood pressure against the risk of causing supine hypertension 1
• For pregnant women with both orthostatic hypotension and supine hypertension, consider shorter-acting agents at bedtime such as clonidine or shorter-acting calcium blockers 1
• Monitor closely for hemodynamic changes, especially during labor and delivery 4
• Be aware that the course of orthostatic hypotension in pregnancy is variable but has not been directly linked to adverse perinatal outcomes when properly managed 4, 6

Special Situations

• For severe postprandial hypotension in pregnancy, consider smaller, more frequent meals with lower carbohydrate content 1
• If orthostatic hypotension is accompanied by tachycardia (suggesting POTS), cardioselective beta blockers may be considered 1, 4
• In cases where orthostatic hypotension develops or worsens with advancing pregnancy, reassess medication needs and consider adjusting therapy 1, 4

The management approach should prioritize maternal symptom relief while ensuring fetal safety, with non-pharmacological measures forming the foundation of treatment in most cases.