drugs, ,notably atenolol. It is not resolved, however, because diminished placental perfusion secondary to lowered maternal blood pressure is confounded by the fact that worsening blood pressure itself is associated with abnormal fetal growth. Some also posit that the drugs have a direct fetal action (Umans, 2015). In two of the larger randomized trials, however, the incidence of growth restriction was not altered in women randomly assigned to treatment (Gruppo di Studio Ipertensione in Gravidanza, 1998; Sibai, 1990a).
he observations of Morgan and colleagues (20 16a) support the findings of the Cochrane review by Abalos. Specifically, they reported that despite therapy for chronic h) pertension, there was frequent superimposed preeclampsia, fetal-growth restriction, preterm delivery, and perinatal mortality. Moreover, and as shown in Table 50-4, women with baseline proteinuria >300 mg/ d had even worse obstetrical outcomes.
During the past decade, the concept of tight control of blood pressure has been espoused as a means of optimizing maternal and perinatal outcomes. Such control is analogous to that of glycemic control for management of the pregnant diabetic patient. he observational study by Ankumah (2014) noted earlier lends credence to tighter control of blood pressure. hese investigators showed that the risk of adverse pregnancy outcomes in 759 women with chronic hypertension was lower when blood pressures before 20 weeks were < 140 mm Hg compared with higher pressure categories and increasing blood pressures. Unfortunately, this did not hold up when less-tight was compared with tight control. Speciically, Magee and coworkers (2015) randomized 987 women with chronic hypertension or gestational hypertension to either one of these two management schemes. Except for a lower rate of severe hypertension in the tightly controlled group, they found no signiicant diferences between these two groups' other adverse pregnancy outcomes (Table 50-5). Tight control was also not more costly (Ahmed, 2016). These and similar findings prompted an ongoing randomized controlled trial-Project CHAP (ClinicaITrials.gov, 2016)-to answer this question.
Until there are data to conirm any salutary efects of treatment of uncomplicated mild to moderate chronic hypertension in pregnancy, it seems reasonable to follow the guidelines of the American College of Obstetricians and Gynecologists (2013) and the Society for Maternal-Fetal Medicine (2015). Pregnant women with severe hypertension must be treated for maternal neuro-, cardio-, and renoprotection. Treatment is ap <0.001, all other comparisons p >0.05.
HELLP = hemolysis, elevated liver enzyme levels, low platelet count.
Data from Magee, 201n5.
also mandatory for women with prior adverse outcomes such as strokes, MIs, and evidence for cardiac or renal dysfunction.
With end-organ dysfunction, treatment to diastolic pressure level ;90 mm Hg is reasonable to mitigate further organ damage.
For most women with mild to moderate hypertension, the
College recommends that treatment be withheld as long as systolic blood pressure is < 160 mm Hg and diastolic blood pressure is < 105 mm Hg. Some find it reasonable to begin women with persistent systolic pressuresa> 150 mm Hg or dia stolic pressures of95 to 100 mm Hg or greater (August, 2015;