Gestational hypertension is defined by BP readings of ≥140/90 mmHg on two occasions at least 4 hours apart during pregnancy after 20 weeks’ gestation in a previously normotensive patient, without the presence of proteinuria (<300 mg in 24 hours) or other clinical features suggestive of of pre-Eclampsia (thrombocytopenia, impaired renal or kidney function, pulmonary oedema, or new-onset headache)

1. MANAGEMENT OF ARTERIAL
HYPERTENSION IN WOMEN
Dr.Raghavendra S.Hegde, B.Pharm.,
Pharm.D

2. Introduction
 Women typically have lower SBP levels than men in the
30 to 44 year age groups. However, SBP rises more
steeply with age in females than in males.
 Given below is an excerpt from 2013 ESH/ESC
Guidelines for the Management of Arterial Hypertension,
with special mention of hypertension in women, use of
OCs and HRT and increase or decrease in the risk of
hypertension, anti-hypertensives safe to be used during
pregnancy and the long-term CV consequences in
gestational hypertension.

3. Oral Contraceptives
 OCs should be selected and initiated by weighing risks
and benefits for the individual patient.
 BP should be evaluated using measurements that
have been properly taken, and a single BP reading is
not sufficient to diagnose hypertension.
 Women aged > 35 years should be assessed for CV
risk factors, including hypertension.
 It is not recommended that OCs be used in women
with uncontrolled hypertension.
 Discontinuation of combined OCs in women with
hypertension may improve their BP control.
 In women who smoke and are over the age of 35
years, OCs should be prescribed with caution.

4. Hormone Replacement Therapy
 HRT and SERMs should not be used for
primary or secondary prevention of CVD.
 If occasionally treating younger,
perimenopausal women for severe
menopausal symptoms, the benefits should be
weighed against potential risks of HRT.
 The probability is low that BP will increase with
HRT in menopausal hypertensive women.

5. Pregnancy
 Physicians should consider early initiation of
antihypertensive treatment at values > 140/90
mmHg in women with: Gestational
hypertension (with or without proteinuria),
 Preexisting hypertension with the
superimposition of gestational hypertension, or
 Hypertension with asymptomatic OD or
symptoms at any time during pregnancy.

6. Antihypertensive drugs to be used in pregnant
hypertensive women:
 The recommendations to use methyldopa,
labetalol and nifedipine as the only calcium
antagonist really tested in pregnancy can be
confirmed.
 Beta-blockers (possibly causing foetal growth
retardation if given in early pregnancy) and
diuretics (in preexisting reduction of plasma
volume) should be used with caution.
 All agents interfering with the RAS (ACE
inhibitors, ARBs, renin inhibitors) should
absolutely be avoided.

7. Antihypertensive drugs to be used in pregnant
hypertensive women:
 In emergency (preeclampsia), intravenous labetalol is
the drug of choice with sodium nitroprusside or
nitroglycerin in intravenous infusion being the other
option.
 Women at high risk of preeclampsia (from hypertension
in a previous pregnancy, CKD, autoimmune disease
such as systemic lupus erythematosus, or
antiphospholipid syndrome, type 1 or 2 diabetes or
chronic hypertension) or with more than one moderate
risk factor for preeclampsia (first pregnancy, age > 40
years, pregnancy interval of > 10 years, BMI > 35 kg/m2
at first visit, family history of preeclampsia and multiple
pregnancy), may be advised to take 75 mg of aspirin
daily from 12 weeks until the birth of the baby, provided

8. Table I: Summary of Treatment Strategies in
Hypertensive Women
Recommendations Class
a
Lev
el b
Hormone therapy and selective oestrogen
receptor modulators are not recommended
and should not be used for primary or
secondary prevention of CVD. If treatment of
younger perimenopausal women is
considered for severe menopausal,
symptoms the benefits should be weighed
against potential risks.
III A

9. Table I: Summary of Treatment
Strategies in Hypertensive Women
Drug treatment of severe hypertension in
pregnancy (SBP greater than 160 mmHg) or
DBP greater than 110 mmHg is recommended.
I C
Drug treatment may also be considered in
pregnant women with persistent elevation of
BP ≥ 150/95 mmHg, any and in those with BP
≥140/90 mmHg in the presence of gestational
hypertension subclinical OD or symptoms.
IIb C

10. Recommendations Clas
s a
Leve
l b
In women at high risk of pre-eclampsia,
provided they are at low risk of
gastrointestinal hemorrhage, treatment with
low dose Aspirin from 12 weeks until delivery
baby considered.
IIb B
In women with childbearing potential RAS
blockers are not recommended and should be
avoided.
III C
a Class of recommendation. b Level of evidence.
Table I: Summary of Treatment Strategies in
Hypertensive Women continued

11. Table I: Summary of Treatment
Strategies in Hypertensive Women
continued
Methyldopa, labetalol and nifedipine should
be considered preferential antihypertensive
drugs in pregnancy, intravenous labetalol or
infusion of nitroprusside should be considered
in case of emergency(Preeclampsia).
IIa B

12. Long-term CV Consequences in Gestational
Hypertension
 Women with a history of preeclampsia have a very high
risk of
 subsequent ischaemic heart disease
 stroke
 venous thromboembolic events over the 5 - 15 years
after pregnancy.
 Women with early-onset preeclampsia (delivery before
32 weeks of gestation), with stillbirth or foetal growth
retardation are considered at highest risk.

13. Risk factors before pregnancy for the
development of hypertensive disorders are
 High maternal age
 Elevated BP
 Dyslipidaemia
 Obesity
 Positive family history of CVD
 Antiphospholipid syndrome
 Glucose intolerance

14.  Hypertensive disorders have been recognized as an
important risk factor for CVD in women.
 Hence, lifestyle modifications (Table II) and regular
check-ups of BP and metabolic factors are
recommended after delivery to reduce future CVD.

15. Table II: Lifestyle Change Measures Recommended in all Patients
with Hypertension to Reduce BP and/or the Number of CV Risk
Factors
Recommendations Clas
s a
Level
b, d
Lev
el
b, e
Salt restriction 5-6 grams per day is
recommended.
I A B
Moderation of alcohol consumption to
not more than 25-30 grams of Ethanol
per day in men and to no more than
10 to 20 grams of Ethanol per day in
women is recommended.
I A B
Increased consumption of vegetables,
fruits and low fat dairy products is
recommended.
I A B

16. Table II: Lifestyle Change Measures Recommended in
all Patients with Hypertension to Reduce BP and/or the
Number of CV Risk Factors
Recommendations Class
a
Level
b, d
Level
b,e
Reduction of weight to BMI of 25
kg/m2and of waist circumference
to <102 cm in men, and less than
88 cm in women is
recommended unless
contraindicated
I A B

17. Table II: Lifestyle Change Measures Recommended in
all Patients with Hypertension to Reduce BP and/or the
Number of CV Risk Factors
Regular exercise, i.e. at least 30 minutes
of moderate dynamic exercise on 5 to 7
days per week is recommended
I A B
it is recommended to give all smokers
advised to quit smoking and to offer
assistance.
I A B

18. Abbreviations and Acronyms
 ACE - angiotensin-converting
enzyme;
 ARB - angiotensin receptor
blocker;
 BMI - body mass index;
 BP - blood pressure;
 CV - cardiovascular;
 CVD - cardiovascular
disease;
 CKD - chronic kidney
disease;
 DBP - diastolic blood
pressure;
 HRT - hormone replacement
therapy;
 OCs - oral contraceptives;
 OD - organ damage;
 RAS - enin angiotensin
system;
 SBP - systolic blood pressure;
 SERMs - selective oestrogen
receptor modulators.
Journal of Hypertension 2013, 31:1281-1357