CARDIOVASCULAR JOURNAL OF AFRICA • Vol 22, No 6, November/December 2011
330
AFRICA
Review Article
Potentially increasing rates of hypertension in women of
childbearing age and during pregnancy – be prepared!
J MOODLEY
Abstract
The incidence of hypertension in young women is likely to
increase in the near future because of the rising rates of the
metabolic syndrome, obesity and dyslipidaemia worldwide.
Consequently, more women will be on antihypertensive
agents, which have the potential for teratogenecity. It is also
likely that the increasing number of young women with
essential hypertension who become pregnant will develop
pregnancy-specific disorders such as pre-eclampsia. Health
professionals should be aware of the effects of hyperten-
sion in women during the childbearing years, as well as the
impact of pre-eclampsia on cardiovascular disease in later
life. Pre-conception counselling skills, and knowledge on the
use of antihypertensives and the changes that occur during
pregnancy should be added to the clinical armamentarium of
all health professionals.
Keywords:
pregnancy hypertension, childbearing years, antihy-
pertensive medication
Submitted 27/11/09, accepted 31/8/10
Cardiovasc J
Afr 2011;
22
: 330–334
DOI: 10.5830/CVJA-2010-074
Hypertensive disorders are the commonest medical complica-
tions occurring in pregnancy. They occur in approximately 6–8%
of all pregnancies in the USA and cover a spectrum of disorders,
such as chronic hypertension, gestational hypertension and
pre-eclampsia/eclampsia syndrome.
1
In South Africa, rates of
hypertensive disorders in pregnancy are higher. A community-
based study found a 12% incidence of hypertensive disorders
in pregnancy in KwaZulu-Natal,
2
while a tertiary facility-based
study reported a rate of prevalence of 18%.
3
Of recent concern is the increasing prevalence worldwide
of obesity and the metabolic syndrome. Pregnant women who
develop pre-eclampsia
de novo
share many of the risk features
of the metabolic syndrome, namely, dyslipidaemia, obesity and
insulin insensitivity. Therefore, increasing numbers of women
could develop hypertension in their childbearing years and
during pregnancy.
An increase in the numbers of young women presenting
with hypertension would create challenges for general medical
practitioners, obstetricians and specialist physicians. Firstly,
significant hypertension requires investigation for an underlying
cause. Secondly, the selection of antihypertensive agents for the
treatment of essential hypertension in women of childbearing
age poses challenges, as most antihypertensive medications are
potentially teratogenic. Thirdly, several well-defined clinical
hypertensive conditions, such as pre-eclampsia, are associated
with high rates of maternal and neonatal morbidity and mortal-
ity. Lastly, hypertensive pregnancy disorders were tradition-
ally not considered to have any long-term deleterious effects on
cardiovascular health. However, recent studies have shown that
pregnancy-specific hypertension is a risk factor for cardiovascu-
lar health later in life.
4,5
Intensive counselling on the long-term impact of hypertensive
disorders in pregnancy, the potential teratogenic effects of anti-
hypertensive agents, appropriate diagnosis of pregnancy-specif-
ic hypertensive conditions and timely interventions therefore
require an interdisciplinary approach if complications arising
from these conditions are to be minimised.
Treatment of essential hypertension in women
of childbearing age
Although the Joint National Committee (JNC7) definition of
hypertension and the treatment goals do not vary according to
age and gender, the use of antihypertensive drugs in women
of childbearing age and during pregnancy should be carefully
considered in respect of their teratogenic potential.
6
It is well
established that angiotensin converting enzymes and receptor
blockers have similar foetal effects in that they are associated
with foetal renal agenesis, especially if used in the first trimester.
However, several other antihypertensive agents seem to carry
minimal teratogenic risks to the foetus (Table 1).
Women of childbearing age with class I hypertension usually
do not require antihypertensive mediations.
6
Successful lifestyle
modifications and exercise in this group have been reported to
demonstrate better blood pressure control.
7-10
Furthermore, essen-
tial hypertension is independently associated with pre-eclampsia,
and antihypertensive therapy in this group does not prevent the
development of pre-eclampsia/eclampsia.
Normal haemodynamic changes in pregnancy
Physiological changes in pregnancy may mimic signs of early
congestive cardiac failure, and all health professionals should be
aware of this. Briefly, changes in the cardiovascular system begin
early in pregnancy, reaching a maximum at 28 weeks’ gestation.
Within the first 12 weeks of pregnancy, the total intravascular
Women’s Health and HIV Research Unit, Department of
Obstetrics and Gynaecology, Nelson R Mandela School of
Medicine, University of KwaZulu-Natal, Durban, South Africa
J MOODLEY, MB ChB
