Controlled trials of antihypertensive drugs in pregnancy

It is taken for granted that severe hypertension in pregnancy should be treated, although the principle has not been formally tested by properly controlled trials. There is less certainty about treating mild to moderate hypertension (140/90 to 169/109 mm Hg). The risk of chronic hypertension in pregnancy depends on that of superimposed preeclampsia, which must be prevented by control of the blood pressure if antihypertensive treatment is to be beneficial. There is not a priori reason why lowering the blood pressure should have this effect. Most of the trials of treatment have been too small to provide conclusive answers. Usually treatment has been started too late to give a realistic expectation of influencing the evolution of superimposed preeclampsia. However, the largest trial of the early use of methyldopa in women with mild chronic hypertension, showed clearly that treatment does not prevent the superimposition of preeclampsia. beta-Adrenergic blocking agents, if used from the second start of the trimester, are associated with a major risk of severe growth retardation and are therefore contraindicated. Methyldopa has the best safety record, which includes long-term follow-up to assess the development of children exposed to methyldopa in utero. The ineffectiveness of antihypertensive drugs in preventing or ameliorating preeclampsia needs to be contrasted with the consistent evidence for the effectiveness of antiplatelet therapy. This is consistent with the increasing evidence that preeclampsia is not primarily, or even necessarily, a hypertensive disease.