In a newly married woman of child‑bearing age with chronic hypertension (blood pressure 150/95 mm Hg) managed only with lifestyle modification who plans to conceive in the next few months, what is the appropriate next step?

Management of Chronic Hypertension Before Conception

Start antihypertensive treatment immediately to achieve blood pressure control below 140/90 mm Hg before conception (Option C). With a blood pressure of 150/95 mm Hg, this woman has uncontrolled Stage 1 hypertension that requires pharmacological intervention, not continued lifestyle modification alone.

Why Immediate Treatment is Essential

• Poorly-controlled hypertension in the first trimester significantly increases maternal and fetal morbidity and mortality 1
• Blood pressure of 150/95 mm Hg exceeds the treatment threshold of 140/90 mm Hg recommended for women with chronic hypertension planning pregnancy 2, 1
• The CHAP trial demonstrated that treating chronic hypertension to goal <140/90 mm Hg reduces the composite risk of superimposed severe preeclampsia, indicated preterm birth <35 weeks, placental abruption, and fetal/neonatal death 3
• Women with chronic hypertension face a 20-25% risk of developing superimposed preeclampsia during pregnancy 2, 4

Recommended Antihypertensive Medications Before Conception

First-line options for preconception treatment:

• Extended-release nifedipine (30-60 mg once daily, up to 120 mg daily) is preferred due to once-daily dosing that improves adherence and established safety in pregnancy 4, 5
• Labetalol (starting 100 mg twice daily, up to 2400 mg per day) is equally effective with comparable safety profile 4, 3
• Methyldopa (750 mg to 4 g per day in divided doses) has the longest safety record with documented follow-up of children up to 7.5 years, though it has inferior side effect profile and should be switched postpartum due to depression risk 2, 4, 6

Medications That Must Be Discontinued

Absolutely contraindicated throughout pregnancy:

• ACE inhibitors, angiotensin receptor blockers (ARBs), direct renin inhibitors, and mineralocorticoid receptor antagonists must be discontinued before conception attempts due to severe fetotoxicity, renal dysgenesis, and oligohydramnios 2, 4, 1

Why Other Options Are Incorrect

Option A (Continue lifestyle modification alone):

• Lifestyle modification alone is insufficient when blood pressure reaches 150/95 mm Hg 2, 1
• Treatment should be initiated at BP ≥140/90 mm Hg in women planning pregnancy to prevent first-trimester complications 5, 1

Option B (Give aspirin only):

• While low-dose aspirin (81-162 mg daily starting at 12-16 weeks' gestation) reduces preeclampsia risk in high-risk women, it does not control blood pressure 7
• Aspirin is adjunctive therapy, not a substitute for antihypertensive treatment when BP is elevated 7

Option D (Postpone pregnancy):

• Unnecessarily delays conception when blood pressure can be rapidly controlled with safe medications 4, 5
• With appropriate antihypertensive therapy, blood pressure can be optimized within weeks, allowing conception to proceed safely 1

Treatment Target and Monitoring

• Target blood pressure: 110-140/85-90 mm Hg before and during pregnancy 4, 5
• Never reduce diastolic BP below 80 mm Hg to avoid compromising uteroplacental perfusion 5
• Confirm true hypertension with home BP monitoring or 24-hour ambulatory BP monitoring to exclude white-coat hypertension (present in up to 25% of patients with elevated clinic readings) 2

Preconception Counseling Essentials

Baseline evaluation before conception:

• Complete blood count, liver enzymes, serum creatinine, electrolytes, uric acid 2
• Urinalysis with protein-to-creatinine ratio or albumin-to-creatinine ratio 2
• Renal ultrasound if serum creatinine or urine testing abnormal 2
• Screen for secondary causes of hypertension only if clinical clues present (not routine) 2

Patient education:

• Discuss 20-25% risk of superimposed preeclampsia 2, 4
• Plan for low-dose aspirin initiation at 12-16 weeks' gestation 7
• Emphasize importance of early prenatal care and close BP monitoring throughout pregnancy 1
• Counsel on maintaining dietary sodium restriction (<2.4 g daily) and healthy body weight 2, 1

Critical Pitfall to Avoid

Do not delay treatment waiting for "BP stabilization" before allowing conception. This woman can safely conceive once her blood pressure is controlled on pregnancy-safe medications (nifedipine or labetalol), which typically occurs within 2-4 weeks of initiating therapy 4, 5. The key is achieving control before conception, not postponing pregnancy indefinitely.