What Is the Best Drug to Prescribe for a Young Woman in Her Childbearing Years With Essential Hypertension?

Physicians are often faced with a decision as to what therapy to start in a young woman who may consider a planned pregnancy in the near future or who may become pregnant while on antihypertensive therapy. Usual guidelines regarding starting antihypertensive treatment and BP goals should be adhered to—with some precautions. If a patient does not have an absolute indication for an angiotensin‐converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB), these drugs should be used with caution in young women and avoided in those who intend to become pregnant. In the past, it was believed that ACEIs were safe to use in the first trimester of pregnancy. Recent data, however, from a Medicaid study in Tennessee have reported an increase in fetal abnormalities in patients who received an ACEI in all 3 trimesters of pregnancy. ¹ , ²

For uncomplicated essential hypertension in a young woman, we would recommend a dihydropyridine calcium channel blocker (CCB), such as amlodipine or extended release nifedipine. CCBs have generally been considered to be safe to continue if a woman becomes pregnant while taking these drugs. ³ , ⁴ Alternatively, using the combination α/β‐blocker drug labetalol in a young woman is reasonable, as there is experience with the drug in pregnancy. Beta‐blockers are also generally considered safe; nonselective β‐blockers, however, have less effect on decreasing uteroplacental blood flow. Labetalol may preserve uteroplacental blood flow to a greater extent than β‐blockers and is, therefore, the preferred agent of choice. ⁵ , ⁶ Diuretics are probably safe if a woman becomes pregnant and sodium intake is fairly constant and the patient does not become volume depleted. ⁷ , ⁸ If adhering to the Seventh Report of the Joint National Commission on Prevention, Detection, Evaluation, and Treatment (JNC 7) guidelines, a physician should still use diuretics as first‐line therapy in a young woman, yet would need to be fairly cautious in assessing volume status if the patient becomes pregnant.

If a patient becomes pregnant while on antihypertensive therapy, it is reasonable to taper or discontinue therapy when readings are <120/80 mm Hg. During pregnancy, BPs begin to decrease in the first half of pregnancy reaching a low at about 20 weeks. BP returns to prepregnancy levels at the end of the third trimester around the time of delivery.

We generally avoid the use of ACEIs or ARBs entirely in a young woman with essential hypertension unless a specific indication exists. We would recommend first‐step therapy with a CCB or α/β‐blocker combination, as these provide safe options should the patient become pregnant. Diuretics are also a safe option to consider.