Skip to main content

Advertisement

SpringerLink
Log in

Mechanisms and Management of Hypertension in Pregnant Women

  • Published:
Current Hypertension Reports Aims and scope Submit manuscript

Abstract

Hypertension is the most common medical disorder encountered during pregnancy. A recent report highlighted hypertensive disorders as one of the major causes of pregnancy-related maternal deaths in the United States. Significant advances in our understanding of preeclampsia, a form of hypertension unique to pregnancy, have occurred in recent years. The optimal timing and choice of therapy for hypertensive pregnancy disorders involves carefully weighing the risk-versus-benefit ratio for each individual patient, with an overall goal of improving maternal and fetal outcomes. In this review, we summarize the mechanisms thought to be involved, review the current management guidelines for hypertensive pregnancy disorders as recommended by international guideline groups, and outline some newer perspectives on management.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Report of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. Am J Obstet Gynecol 2000, 183(1):S1-S22.

    Google Scholar 

  2. Trogstad L, Magnus P, Stoltenberg C: Pre-eclampsia: Risk factors and causal models. Best Pract Res Clin Obstet Gynaecol 2011 Feb 22 (Epub ahead of print).

  3. Duley L. The global impact of pre-eclampsia and eclampsia. Semin Perinatol. 2009;33(3):130–7.

    Article  PubMed  Google Scholar 

  4. McLaughlin MK, Roberts JM. Hemodynamic changes. In: Lindheimer MD, Roberts JM, Cunningham FG, editors. Chesley’s hypertensive disorders in pregnancy. 2nd ed. Stamford: Appleton & Lange; 1999. p. 69–102.

    Google Scholar 

  5. •• James JL, Whitley GS, Cartwright JE: Pre-eclampsia: fitting together the placental, immune and cardiovascular pieces. J Pathol 2010, 221(4):363–378. This is a comprehensive review of pathological changes in preeclampsia.

    Article  PubMed  CAS  Google Scholar 

  6. •• Wang A, Rana S, Karumanchi SA: Preeclampsia: the role of angiogenic factors in its pathogenesis. Physiology (Bethesda) 2009, 24:147–158. This article provides one of the most up-to-date reviews of angiogenesis in preeclampsia.

    Article  Google Scholar 

  7. • Hertig A, Liere P: New markers in preeclampsia. Clin Chim Acta 2010, 411(21–22):1591–1595. This review provides information on new biomarkers in preeclampsia.

    Article  PubMed  CAS  Google Scholar 

  8. •• Steegers EA, von Dadelszen P, Duvekot JJ, Pijnenborg R: Pre-eclampsia. Lancet 2010, 376(9741):631–644. This is one of the few reviews to provide both an overview of pathogenesis and clinical aspects of preeclampsia.

    Article  PubMed  Google Scholar 

  9. •• Cetin I, Huppertz B, Burton G, et al: Pregenesys pre-eclampsia markers consensus meeting: What do we require from markers, risk assessment and model systems to tailor preventive strategies? Placenta 2011, 32 Suppl:S4-16. This article provides the most comprehensive review of markers of preeclampsia and summarizes the conclusions of a recent consensus meeting on the topic.

    Article  PubMed  Google Scholar 

  10. Roberts JM, Hubel CA. The two stage model of preeclampsia: variations on the theme. Placenta. 2009;Suppl A:S32–37.

    Article  Google Scholar 

  11. Staff AC, Dechend R, Pijnenborg R. Learning from the placenta: acute atherosis and vascular remodeling in preeclampsia—novel aspects for atherosclerosis and future cardiovascular health. Hypertension. 2010;56(6):1026–34.

    Article  PubMed  CAS  Google Scholar 

  12. Rajakumar A, Brandon HM, Daftary A, et al. Evidence for the functional activity of hypoxia-inducible transcription factors overexpressed in preeclamptic placentae. Placenta. 2004;25(10):763–9.

    Article  PubMed  CAS  Google Scholar 

  13. Zhou Y, McMaster M, Woo K, et al. Vascular endothelial growth factor ligands and receptors that regulate human cytotrophoblast survival are dysregulated in severe preeclampsia and hemolysis, elevated liver enzymes, and low platelets syndrome. Am J Pathol. 2002;160(4):1405–23.

    Article  PubMed  CAS  Google Scholar 

  14. • Myatt L, Webster RP: Vascular biology of preeclampsia. J Thromb Haemost 2009, 7(3):375–384. This article provides important knowledge of the vascular biology of preeclampsia.

    Article  PubMed  CAS  Google Scholar 

  15. Hanna J, Goldman-Wohl D, Hamani Y, et al. Decidual NK cells regulate key developmental processes at the human fetal-maternal interface. Nat Med. 2006;12(9):1065–74.

    Article  PubMed  CAS  Google Scholar 

  16. Maynard SE, Min JY, Merchan J, et al. Excess placental soluble fms-like tyrosine kinase 1 (sFlt1) may contribute to endothelial dysfunction, hypertension, and proteinuria in preeclampsia. J Clin Invest. 2003;111(5):649–58.

    PubMed  CAS  Google Scholar 

  17. Ahmad S, Ahmed A. Elevated placental soluble vascular endothelial growth factor receptor-1 inhibits angiogenesis in preeclampsia. Circ Res. 2004;95(9):884–91.

    Article  PubMed  CAS  Google Scholar 

  18. Levine RJ, Lam C, Qian C, et al. Soluble endoglin and other circulating antiangiogenic factors in preeclampsia. N Engl J Med. 2006;355(10):992–1005.

    Article  PubMed  CAS  Google Scholar 

  19. Tam Tam KB, Lamarca B, Arany M, et al. Role of reactive oxygen species during hypertension in response to chronic antiangiogenic factor (sFlt-1) excess in pregnant rats. Am J Hypertens. 2011;24(1):110–3.

    Article  PubMed  CAS  Google Scholar 

  20. Myatt L. Review: Reactive oxygen and nitrogen species and functional adaptation of the placenta. Placenta. 2010;31(Suppl):S66–69.

    Article  PubMed  Google Scholar 

  21. Hertig A, Liere P, Chabbert-Buffet N, et al. Steroid profiling in preeclamptic women: evidence for aromatase deficiency. Am J Obstet Gynecol. 2010;203(5):477.e1. 9.

    Article  Google Scholar 

  22. Yallampalli C, Garfield RE. Inhibition of nitric oxide synthesis in rats during pregnancy produces signs similar to those of preeclampsia. Am J Obstet Gynecol. 1993;169(5):1316–20.

    PubMed  CAS  Google Scholar 

  23. Wallukat G, Homuth V, Fischer T, et al. Patients with preeclampsia develop agonistic autoantibodies against the angiotensin AT1 receptor. J Clin Invest. 1999;103(7):945–52.

    Article  PubMed  CAS  Google Scholar 

  24. Zhou CC, Zhang Y, Irani RA, et al. Angiotensin receptor agonistic autoantibodies induce pre-eclampsia in pregnant mice. Nat Med. 2008;14(8):855–62.

    Article  PubMed  CAS  Google Scholar 

  25. Craici I, Wagner S, Garovic VD. Preeclampsia and future cardiovascular risk: formal risk factor or failed stress test? Ther Adv Cardiovasc Dis. 2008;2(4):249–59.

    Article  PubMed  Google Scholar 

  26. Kupferminc MJ. Thrombophilia and pregnancy. Reprod Biol Endocrinol. 2003;1:111.

    Article  PubMed  Google Scholar 

  27. do Prado AD, Piovesan DM, Staub HL, Horta BL. Association of anticardiolipin antibodies with preeclampsia: a systematic review and meta-analysis. Obstet Gynecol. 2010;116(6):1433–43.

    Article  PubMed  Google Scholar 

  28. Qing X, Redecha PB, Burmeister MA, et al. Targeted inhibition of complement activation prevents features of preeclampsia in mice. Kidney Int. 2011;79(3):331–9.

    Article  PubMed  CAS  Google Scholar 

  29. Fakhouri F, Jablonski M, Lepercq J, et al. Factor H, membrane cofactor protein, and factor I mutations in patients with hemolysis, elevated liver enzymes, and low platelet count syndrome. Blood. 2008;112(12):4542–5.

    Article  PubMed  CAS  Google Scholar 

  30. Salmon JE, Heuser C, Triebwasser M, et al. Mutations in complement regulatory proteins predispose to preeclampsia: a genetic analysis of the PROMISSE cohort. PLoS Med. 2011;8(3):e1001013.

    Article  PubMed  CAS  Google Scholar 

  31. • Carty DM, Delles C, Dominiczak AF: Preeclampsia and future maternal health. J Hypertens 2010, 28(7):1349–1355. This summarizes very well the effects of preeclampsia on women’s cardiovascular health.

    Article  PubMed  CAS  Google Scholar 

  32. Duckitt K, Harrington D. Risk factors for pre-eclampsia at antenatal booking: systematic review of controlled studies. BMJ. 2005;330(7491):565.

    Article  PubMed  Google Scholar 

  33. Oglaend B, Forman MR, Romundstad PR, et al. Blood pressure in early adolescence in the offspring of preeclamptic and normotensive pregnancies. J Hypertens. 2009;27(10):2051–4.

    Article  PubMed  CAS  Google Scholar 

  34. Disentangling fetal and maternal susceptibility for pre-eclampsia: a British multicenter candidate-gene study. Am J Hum Genet 2005, 77(1):127–131.

  35. Carty DM, Siwy J, Brennand JE, et al. Urinary proteomics for prediction of preeclampsia. Hypertension. 2011;57(3):561–9.

    Article  PubMed  CAS  Google Scholar 

  36. Eremina V, Sood M, Haigh J, et al. Glomerular-specific alterations of VEGF-A expression lead to distinct congenital and acquired renal diseases. J Clin Invest. 2003;111(5):707–16.

    PubMed  CAS  Google Scholar 

  37. Garovic VD, Wagner SJ, Petrovic LM, et al. Glomerular expression of nephrin and synaptopodin, but not podocin, is decreased in kidney sections from women with preeclampsia. Nephrol Dial Transplant. 2007;22(4):1136–43.

    Article  PubMed  CAS  Google Scholar 

  38. Garovic VD, Wagner SJ, Turner ST, et al. Urinary podocyte excretion as a marker for preeclampsia. Am J Obstet Gynecol. 2007;196(4):320 e321–327.

    Article  Google Scholar 

  39. Roberts JM. Endothelial dysfunction in preeclampsia. Semin Reprod Endocrinol. 1998;16(1):5–15.

    Article  PubMed  CAS  Google Scholar 

  40. Cipolla MJ. Cerebrovascular function in pregnancy and eclampsia. Hypertension. 2007;50(1):14–24.

    Article  PubMed  CAS  Google Scholar 

  41. Hinchey J, Chaves C, Appignani B, et al. A reversible posterior leukoencephalopathy syndrome. N Engl J Med. 1996;334(8):494–500.

    Article  PubMed  CAS  Google Scholar 

  42. Sibai BM. Imitators of severe pre-eclampsia/eclampsia. Clin Perinatol. 2004;31(4):835–52.

    Article  PubMed  Google Scholar 

  43. ACOG Practice Bulletin no.29. Chronic hypertension in pregnancy. ACOG Committee on Practice Bulletins. Obstet Gynecol 2001, 98(1):177–185.

    Google Scholar 

  44. ACOG Practice Bulletin no.33. Diagnosis and management of preeclampsia and eclampsia. Obstet Gynecol 2002, 99(1):159–167.

    Google Scholar 

  45. Magee LA, Helewa M, Moutquin JM, von Dadelszen P, Hypertension Guideline Committee, Society of Obstetricians and Gynaecologists of Canada. Treatment of the hypertensive disorders of pregnancy. In: Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy. J Obstet Gynaecol Can. 2008;30(3 Suppl 1):S24–36.

    Google Scholar 

  46. Lowe SA, Brown MA, Dekker GA, et al. Guidelines for the management of hypertensive disorders of pregnancy 2008. Aust N Z J Obstet Gynaecol. 2009;49(3):242–6.

    Article  PubMed  Google Scholar 

  47. Mancia G, De Backer G, Dominiczak A, et al. 2007 Guidelines for the Management of Arterial Hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens. 2007;25(6):1105–87.

    Article  PubMed  CAS  Google Scholar 

  48. •• Podymow T, August P: Antihypertensive drugs in pregnancy. Semin Nephrol 2011, 31(1):70–85. This is a comprehensive and detailed review of the antihypertensive drugs used in pregnancy.

    Article  PubMed  CAS  Google Scholar 

  49. Weber MA, Julius S, Kjeldsen SE, et al. Blood pressure dependent and independent effects of antihypertensive treatment on clinical events in the VALUE Trial. Lancet. 2004;363(9426):2049–51.

    Article  PubMed  CAS  Google Scholar 

  50. Gradman AH, Basile JN, Carter BL, Bakris GL. Combination therapy in hypertension. J Am Soc Hypertens. 2010;4(1):42–50.

    Article  PubMed  CAS  Google Scholar 

  51. Martin Jr JN, Thigpen BD, Moore RC, et al. Stroke and severe preeclampsia and eclampsia: a paradigm shift focusing on systolic blood pressure. Obstet Gynecol. 2005;105(2):246–54.

    Article  PubMed  Google Scholar 

  52. August P. Preeclampsia: new thoughts on an ancient problem. J Clin Hypertens (Greenwich). 2000;2(2):115–23.

    Google Scholar 

  53. • Duley L, Gulmezoglu AM, Henderson-Smart DJ, Chou D: Magnesium sulphate and other anticonvulsants for women with pre-eclampsia. Cochrane Database Syst Rev 2010, 11:CD000025. This Cochrane review provides a systematic and up-to-date review of magnesium sulphate treatment.

    PubMed  Google Scholar 

  54. Duley L, Henderson-Smart DJ, Meher S, King JF. Antiplatelet agents for preventing pre-eclampsia and its complications. Cochrane Database Syst Rev. 2007;2:CD004659.

    PubMed  Google Scholar 

  55. •• Roberts JM, Myatt L, Spong CY, et al: Vitamins C and E to prevent complications of pregnancy-associated hypertension. N Engl J Med 2010, 362(14):1282–1291. The findings in this article provide important information on the treatment of preeclampsia.

    Article  PubMed  CAS  Google Scholar 

  56. Hofmeyr GJ, Lawrie TA, Atallah AN, Duley L. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database Syst Rev. 2010;8:CD001059.

    PubMed  Google Scholar 

  57. Mizutani S, Wright JW, Kobayashi H. Placental leucine aminopeptidase- and aminopeptidase A- deficient mice offer insight concerning the mechanisms underlying preterm labor and preeclampsia. J Biomed Biotechnol. 2011;2011:286947.

    Article  PubMed  Google Scholar 

  58. George EM, Cockrell K, Aranay M, et al. Induction of heme oxygenase 1 attenuates placental ischemia-induced hypertension. Hypertension. 2011;57(5):941–8.

    Article  PubMed  CAS  Google Scholar 

  59. Uddin MN, Horvat D, DeMorrow S, et al. Marinobufagenin is an upstream modulator of Gadd45a stress signaling in preeclampsia. Biochim Biophys Acta. 2011;1812(1):49–58.

    PubMed  CAS  Google Scholar 

  60. National Collaborating Centre for Women’s and Children’s Health: Hypertension in pregnancy: the management of hypertensive disorders during pregnancy. London: National Institute for Health and Clinical Excellence (CG107); 2010. http://www.nice.org.uk/nicemedia/live/13098/50475/50475.pdf.

  61. Magee LA, Helewa M, Moutquin JM, von Dadelszen P, Hypertension Guideline Committee, Society of Obstetricians and Gynaecologists of Canada. Prediction, prevention, and prognosis of preeclampsia. In: Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy. J Obstet Gynaecol Can. 2008;30:S16–23.

    Google Scholar 

Download references

Disclosure

Conflicts of Interest: C. Brown: None; V. Garovic: As inventor of technology detecting podocyturia in preeclampsia, has rights to receive royalties from licensing.

Author information

Authors and Affiliations

  1. Division of Nephrology and Hypertension, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN, 55905, USA

    Catherine M. Brown & Vesna D. Garovic

Authors
  1. Catherine M. Brown
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Vesna D. Garovic
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Vesna D. Garovic.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Brown, C.M., Garovic, V.D. Mechanisms and Management of Hypertension in Pregnant Women. Curr Hypertens Rep 13, 338–346 (2011). https://doi.org/10.1007/s11906-011-0214-y

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11906-011-0214-y

Keywords

Search

Navigation