128 Obstetrics and Gynecology Board Review •••
❍ Which antihypertensive medications are contraindicated during pregnancy?
Angiotensin converting enzyme (ACE) inhibitors, angiotensin II receptor blockers, the beta-blocker atenolol,
nitroprusside, and diuretics in the presence of uteroplacental insufficiency.
❍ What are the teratogenic effects associated with ACE inhibitors?
Underdeveloped calvarial bone, renal failure, oligohydramnios, anuria, renal agenesis, pulmonary hypoplasia,
IUGR, fetal death, neonatal renal failure, and neonatal death.
❍ Why is atenolol not recommended in pregnancy?
Atenolol may be associated with growth restriction.
❍ Why is nitroprusside contraindicated during pregnancy?
Nitroprusside in the later stages of pregnancy may cause fetal cyanide poisoning.
❍ Which medications should not be used postpartum if the patient is breastfeeding?
ACE inhibitors and angiotensin receptor antagonists should be avoided in the first few weeks. Diuretics should be
avoided as they can reduce the milk volume.
❍ Name a few acceptable medications for treatment of chronic hypertension during pregnancy.
Methyldopa, Labetalol, and nifedipine.
❍ What are the limitations of using antihypertensive agents for the treatment of chronic hypertension during
pregnancy?
Chronic hypertension with or without treatment during pregnancy is an independent and significant risk factor for
adverse perinatal outcomes such as IUGR, small for gestational age, and preterm delivery.
❍ What is the recommended fetal surveillance for pregnancies complicated by chronic hypertension?
It should be individualized. Some investigators recommend baseline ultrasound at 18 to 20 weeks, then repeat
at 28 to 32 weeks, and then monthly for fetal growth. NST or BPP is recommended in case of IUGR or
superimposed preeclampsia.
BIBLIOGRAPHY
- Chronic hypertension in pregnancy. Practice Bulletin No. 125. American College of Obstetricians and Gynecologists. Obstet
Gynecol. 2012;119:396-407. - Diagnosis and management of preeclampsia and eclampsia. ACOG Practice Bulletin No. 33. American College of Obstetricians
and Gynecologists. Obstet Gynecol. 2002;99:159-167. - Orbach H, Matok I, Gorodischer R, et al. Hypertension and antihypertensive drugs in pregnancy and perinatal outcomes. Obstet
Gynecol. 2012;S0002–9378(12)02066-2. - Sibai BM. Evaluation and management of severe preeclampsia before 34 weeks’ gestation. Obstet Gynecol. 2011;205(3):191-198.
- Sibai BM, Koch MA, Freire S, et al. The impact of prior preeclampsia on the risk of superimposed preeclampsia and other adverse
pregnancy outcomes in patients with chronic hypertension. Obstet Gynecol. 2011;204(4):345. - Cunningham FG, Leveno KJ, Bloom SL, et al., eds. Hypertensive Disorders in Pregnancy. Williams Obstetrics. 22nd ed. New
York, NY: McGraw-Hill; 2005:761-808.