What is the best approach for a woman with stage 2 hypertension (blood pressure 150/95) who is not taking antihypertensive medication and is on lifestyle modification only, prior to becoming pregnant?

Start Antihypertensive Medication Immediately Before Attempting Pregnancy

This woman with stage 2 hypertension (150/95 mmHg) should start antihypertensive medication immediately with pregnancy-safe agents—specifically extended-release nifedipine, labetalol, or methyldopa—to achieve blood pressure control before conception, while simultaneously initiating low-dose aspirin (75-150 mg at bedtime) to reduce preeclampsia risk. 1, 2

Rationale for Immediate Pharmacological Treatment

Blood Pressure Threshold Requires Treatment

• Stage 2 hypertension at 150/95 mmHg mandates pharmacological intervention in women planning pregnancy, not lifestyle modification alone 1
• Treatment should be initiated when BP is ≥140/90 mmHg in women with chronic hypertension planning pregnancy 1
• The target BP should be 110-135/85 mmHg during pregnancy to balance maternal cardiovascular protection with adequate uteroplacental perfusion 1, 2

Pregnancy-Safe Medication Selection

Extended-release nifedipine is the preferred first-line agent with the strongest safety data and once-daily dosing advantage 1, 2, 3

Alternative options include:

• Labetalol (excellent alternative, particularly for women without reactive airway disease) 1, 2
• Methyldopa (longest safety record with long-term infant outcome data, though use cautiously in women at risk for depression) 1, 2

Critical Medication Contraindications

Never use ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, or direct renin inhibitors due to associations with fetal teratogenicity and oligohydramnios—these must be avoided entirely in women planning pregnancy 1, 2, 3

Diuretics should generally be avoided during pregnancy planning due to risk of reducing uteroplacental perfusion 1, 2

Aspirin Prophylaxis

Low-dose aspirin (75-150 mg daily at bedtime) should be started immediately, either pre-pregnancy or upon pregnancy confirmation, but before 16 weeks gestation, to reduce preeclampsia risk in women with chronic hypertension 1

Why Not Delay Pregnancy or Continue Lifestyle Modification Alone?

Lifestyle Modification Alone Is Insufficient

• Women with stage 1 hypertension (140-159/90-99 mmHg) during pregnancy may be candidates for lifestyle modification only 4
• However, this patient has stage 2 hypertension (150/95 mmHg), which requires pharmacological treatment 1
• The older 2003 guideline suggesting lifestyle modification for stage 1 hypertension has been superseded by more recent evidence showing benefits of treating BP ≥140/90 mmHg before pregnancy 4, 1

Delaying Pregnancy Is Unnecessary

• Once appropriate pregnancy-safe antihypertensives are initiated and BP is controlled to target (110-135/85 mmHg), pregnancy can proceed safely 1, 2
• There is no need to delay pregnancy for months if BP control is achieved with appropriate medications 1
• The goal is BP control with pregnancy-safe agents, not prolonged delay 1, 2

Monitoring Strategy

Preconception Phase

• Confirm hypertension with 24-hour ambulatory monitoring if not already done 1
• Comprehensive screening for secondary hypertension is mandatory in women diagnosed with hypertension before age 40 (except in obese women where obstructive sleep apnea evaluation should be prioritized first) 1
• Continue regular BP monitoring to ensure target achievement 1

During Pregnancy

• Monitor BP weekly or biweekly to ensure adequate control and detect progression to severe hypertension (≥160/110 mmHg) 3
• Assess for proteinuria to rule out superimposed preeclampsia 3
• Perform serial fetal growth ultrasounds every 3-4 weeks starting at 24-28 weeks to monitor for fetal growth restriction 3

Common Pitfalls to Avoid

Failing to transition to pregnancy-safe antihypertensives before conception is the most critical error, as 50% of pregnancies are unplanned and early exposure to teratogenic agents causes fetal harm 1

Inadequate blood pressure control before conception increases complications for both mother and fetus 1, 2

Using short-acting nifedipine formulations for maintenance therapy—only extended-release formulations should be used for chronic management, with short-acting reserved for hypertensive emergencies 1, 2

Long-Term Cardiovascular Risk

Women with hypertension during pregnancy have increased cardiovascular disease risk later in life, requiring annual cardiovascular risk assessment lifelong 1

Answer to the Question

The correct answer is B: Start antihypertensive medications to correct her blood pressure before pregnancy. Additionally, aspirin should be initiated. Lifestyle modification alone (option A) is insufficient for stage 2 hypertension. Delaying pregnancy (option D) is unnecessary once BP is controlled with appropriate medications. While aspirin (option C) should be started, it is not sufficient without antihypertensive medication for this BP level.