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MS WordPerinatologist Corner - C.E.U/C.M.E. Modules
Preconception Counseling for Women with Diabetes and Hypertension
Sponsored by The Indian Health Service Clinical Support Center
Step 4. Hypertension Medication: What you can use
So, what would be appropriate management for Ms. D with mild diabetes and hypertension?
We should probably start by evaluating her baseline 24 hour protein excretion. Weight reduction and moderate exercise are always good, though pregnancy is not a time for weight loss.
A low-dose thiazide diuretic might be a reasonable choice as a first line anti-hypertensive agent, although hypokalemia, worsening hyperlipidemia, and thrombocytopenia will have to be assessed after starting therapy. Hydrochlorothiazide is category B in pregnancy.
The calcium channel blockers (CCB), while having less of a protective effect on the diabetic kidney than ACE, do have some effect, and they are certainly effective at lowering the blood pressure. Unfortunately, the dihydropyridine class of CCB, e.g., nifedipine and amlodipine, do not demonstrate this same renal protective effect, so verapamil or diltiazem may be a better choice. Nifedipine and amlodipine are category C in pregnancy.
If Ms. D does become pregnant, CCB would not be expected to have significant teratogenic, or adverse fetal, effects. If renal protection is not a major issue at this time, methyldopa is another reasonable choice.
In patients with chronic hypertension, fetal growth restriction is always an issue, and use of beta blockers (BB) during pregnancy has been associated with this effect. This association has been more pronounced with the selective BB, such as atenolol and propranolol. It may be less common with a non-selective BB, such as labetalol, which has alpha-1 antagonist and beta-2 agonist effects, as well as beta-1 blocking action. Propranolol is class C in the first trimester and class D in the 2nd and 3rd trimesters by expert analysis.
The BB are likewise not teratogens. In general, most mild chronic hypertensives will usually not need any specific therapy after about 10 weeks gestation when the striking vasodilation and afterload reduction typical of pregnancy commences.
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