Treating hypertension in women of child-bearing age and during pregnancy

Hypertension is found among 1 to 6% of young women, Treatment aims to decre ase cardiovascular risk, the magnitude of which is less dependent on the ab solute level of blood pressure (BP) than on associated cardiovascular risk factors, hypertension-related target organ damage and/or concomitant diseas e. Lifestyle modifications are recommended for all hypertensive individuals . The threshold of BP at which antihypertensive therapy should be initiated is based on absolute cardiovascular risk. Most young women are at low risk and not in need of anti-hypertensive therapy. All antihypertensive agents appear to be equally efficacious: choice depends on personal preference, so cial circumstances and an agent's effect on cardiovascular risk factors, ta rget organ damage and/or concomitant disease. Although most agents are appropriate for, and tolerated well by, young wome n, another consideration remains that of pregnancy, 50% of which are unplan ned. A clinician must be aware of a woman's method of contraception and the potential of an antihypertensive agent to cause birth defects following in advertent exposure in earl pregnancy. Conversely, if an oral contraceptive is effective and well tolerated, but the woman's BP becomes mildly elevated , continuing the contraceptive and initiating antihypertensive treatment ma t; not be contraindicated, especially if the ability to plan pregnancy is i mportant (e.g, in type 1 diabetes mellitus). No commonly used antihypertens ive is known to he teratogenic, although ACE inhibitors and angiotensin rec eptor antagonists should be discontinued, and any antihypertensive drugs sh ould be continued in pregnancy only if anticipated benefits out-weigh poten tial reproductive risk(s). The hypertensive disorders of pregnancy complicate 5 to 10% of pregnancies and are a leading cause of maternal and perinatal mortality and morbidity. Treatment aims to improve pregnancy outcome. There is consensus that severe maternal hypertension (systolic BP greater than or equal to 170mm Hg and/o r diastolic BP greater than or equal to 110mm Hg) should be treated immedia tely to avoid maternal stroke, death and, possibly, eclampsia. Parenteral h ydralazine may he associated with a higher risk of maternal hypotension, an d intravenous labetalol with neonatal bradycardia. There is no consensus as to whether mild-to-moderate hyper tension in pregnancy should be treated: the risks of transient severe hypertension, antenatal hospitalisation, prot einuria at delivery and neonatal respiratory distress syndrome, may be decr eased by therapy, but intrauterine fetal grow th may also be impaired, part icularly by atenolol. Methyldopa and other beta -blockers have been used mo st extensively. Reporting bias and the uncertainty of outcomes as defined w arrant cautious interpretation of these findings and preclude treatment rec ommendations.