Background:

Pregnant woman previously on lisinopril for a history of hypertension is at 7 weeks gestation. She has a history of high blood pressure and was on lisinopril, but she stopped it given the antihypertensive is not recommended during the pregnancy period, especially the second and third trimesters. Her blood pressure in the clinic averages 149/89. Urinalysis does not reveal albuminuria, with her urine albumin creatinine ratio less than 30.

Please answer the following questions:

What is the next step?
* Resume lisinopril
* Trend blood pressure
* Try losartan
* Order labetalol

Order labetalol

According to The American College of Obstetricians and Gynecologists (ACOG), chronic hypertension in pregnancy is defined as systolic blood pressure greater than or equal to 140 mm Hg or diastolic blood pressure greater than or equal to 90 mm Hg starting after 20 weeks of gestation.
A
True
B
False

False

Chronic hypertension in pregnancy is noted prior to 20 weeks of gestation.

The updated BP threshold recommended by ACOG and The Society for Maternal-Fetal Medicine (SMFM) in 2022 for treating hypertension in pregnancy is 140/90 mm Hg.
A
True
B
False

True

Patients with chronic hypertension who were on antihypertensive medication before pregnancy should discontinue their medication during pregnancy.
A
True
B
False

False

That said, some blood pressure medications are not recommended during pregnancy. Keep learning.

Lisinopril and losartan are safe to use during pregnancy.
A
True
B
False

False

If you are planning to get pregnant and are on one of these medicines, please consult with your provider for the next steps. Why? When used in pregnancy, there is a risk to the fetus and the mother if losartan and lisinopril are consumed. They should be safely discontinued before conception, with alternatives provided if indicated. Lisinopril and losartan should not be started during pregnancy.

Exposure to lisinopril or losartan during the second and third trimesters of pregnancy can lead to neonatal kidney failure and death.
A
True
B
False

True

Discussion:

➡️Learn More⬅️

Chronic Hypertension in Pregnancy – Management

Definition

Chronic hypertension in pregnancy is defined by ACOG as systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg starting before pregnancy or before 20 weeks of gestation. It is associated with poor maternal and fetal outcomes. Hypertension recognized before 20 weeks’ gestation usually indicates chronic hypertension.

Treatment Recommendations

ACOG and SMFM recommend maintaining BP <140/90 mm Hg in pregnant patients with hypertension.
Starting labetalol is recommended for patients with chronic hypertension because it is safe in pregnancy.
Patients on antihypertensive medication before pregnancy should continue therapy with safe options for pregnant patients which include labetalol, nifedipine, or methyldopa.

Medication Considerations

Lisinopril and losartan work in the body as renin-angiotensin system blockers and are contraindicated in pregnancy due to associated risks like neonatal kidney failure and death. These anti-hypertensives should be discontinued before conception and not started during pregnancy.

Importance of Treatment

Not treating hypertension in pregnant patients with chronic hypertension is not appropriate. ACOG and SMFM recommend treatment to maintain BP less than 140/90 mm Hg to prevent adverse outcomes for both the mother and the fetus.

Inspiration: Lisinopril: Mother To Baby, National Library of Medicine

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