What is the best approach for a 36-year-old woman with hypertension (HTN) and a blood pressure of 150/95, who is on lifestyle modification only and not taking any antihypertensive medication, prior to conception?

Preconception Management of Hypertension

Start antihypertensive medication immediately to achieve blood pressure control before pregnancy, using extended-release nifedipine or labetalol as first-line agents, and initiate low-dose aspirin (75-150 mg at bedtime) for preeclampsia prevention. 1, 2, 3

Rationale for Immediate Pharmacological Treatment

Your patient's BP of 150/95 mmHg meets the threshold for pharmacological intervention in women planning pregnancy:

• Treatment should be initiated when BP is ≥140/90 mmHg in women with chronic hypertension planning pregnancy 1, 3
• Poorly-controlled hypertension in the first trimester significantly increases maternal and fetal morbidity and mortality 4
• Lifestyle modification alone is insufficient at this BP level—pharmacological therapy must be added, not delayed 1

Specific Treatment Algorithm

Step 1: Initiate Antihypertensive Medication Immediately

First-line options (choose one):

• Extended-release nifedipine: Preferred first-line agent with strongest safety data and once-daily dosing advantage 1, 2
• Labetalol: Excellent alternative, particularly if no reactive airway disease history 1, 2
• Methyldopa: Longest safety record with long-term infant outcome data, but use cautiously if depression risk exists 1, 2

Step 2: Target Blood Pressure Goals

• Achieve BP <140/90 mmHg before conception 3
• During pregnancy, target 110-135/85 mmHg to balance maternal cardiovascular protection with adequate uteroplacental perfusion 1, 2
• Never allow diastolic BP to drop below 80 mmHg to maintain uteroplacental perfusion 1, 3

Step 3: Initiate Aspirin Prophylaxis

• Start low-dose aspirin 75-150 mg daily at bedtime immediately (can begin pre-pregnancy or upon pregnancy confirmation, but must start before 16 weeks gestation) 1, 3
• This reduces preeclampsia risk in women with chronic hypertension 1

Critical Medication Contraindications

Absolutely avoid these medications:

• ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, and direct renin inhibitors are contraindicated due to fetal teratogenicity and oligohydramnios 1, 2, 5
• Diuretics should generally be avoided due to risk of reducing uteroplacental perfusion 1, 2
• This is critical because 50% of pregnancies are unplanned, and early exposure causes fetal harm 1, 5

Preconception Assessment Requirements

Before initiating treatment, perform:

• Comprehensive screening for secondary hypertension (mandatory in women diagnosed with hypertension before age 40) 1
• 24-hour ambulatory BP monitoring to confirm hypertension diagnosis 1
• In obese women, prioritize obstructive sleep apnea evaluation first 1

Why Delaying Pregnancy is NOT the Answer

The question implies delaying pregnancy until BP is corrected, but this is a false dichotomy:

• BP control can be achieved rapidly with appropriate medication (typically within weeks) 1
• At age 36, unnecessary pregnancy delay increases age-related fertility decline and pregnancy complications
• The correct approach is concurrent BP optimization and pregnancy planning, not sequential 1, 3

Common Pitfalls to Avoid

• Failing to start medication immediately: Lifestyle modification alone is inadequate at BP 150/95 mmHg 1, 3
• Using short-acting nifedipine for maintenance: Only extended-release formulations should be used chronically; short-acting is reserved for hypertensive emergencies 1
• Inadequate BP control before conception: This increases complications significantly 4
• Forgetting aspirin prophylaxis: This is a separate intervention that must not be overlooked 1, 3

Monitoring Strategy

• Continue regular BP monitoring throughout preconception period, fertility treatment, and pregnancy 1
• Women with chronic hypertension require annual cardiovascular risk assessment lifelong due to significantly elevated lifetime cardiovascular disease risk 1, 3