Hypertension

Treatment of hypertension does not modify the course of the underlying disease process but may reduce the morbidity and mortality attributable to uncontrolled hypertension. Whether treatment of mild hypertension during pregnancy is worth while is unclear.

The first-line treatment of hypertension is usually methyldopa, which has a long safety record for the fetus, although randomised controlled trials are few. Labetalol and nifedipine have both been used increasingly in recent years, either instead of, or in addition to, methyldopa. Patients already receiving angiotensin-converting enzyme inhibitors or anti-angiotensin receptor agents should have them withdrawn because of their fetotoxic effects.

Hydralazine is the most commonly used agent for management of acute hypertension. Administration of small repeated intravenous boluses (e.g. 5mg) is preferable to continuous infusion. Hydralazine acts primarily as a vasodilator and should therefore be used with caution and preferably in conjunction with gentle volume replacement. Acute vasodilatation may cause an uncontrolled fall in blood pressure and thus provoke fetal distress. (Reduction in maternal blood pressure is associated with a significantly greater percentage reduction in uteroplacental perfusion.)

Labetalol (10 mg boluses) may be used parenterally in the acute situation, and oral nifedipine (5-10 mg) has also been used, acting within 15-30 minutes. Although there have been concerns over sublingual nifedipine and the risk of uncontrolled hypotension, particularly in combination with magnesium sulphate, this is not thought to be a common problem, especially with slow-release preparations.

Nitroprusside and glyceryl trinitrate have been used in North America for acute control of hypertension but are not commonly used in the UK.

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