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Chronic hypertension in early pregnancy — MSRA MCQ

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Hardall topics relevant for this examChronic hypertension in early pregnancyMSRA

A 32-year-old woman attends her booking appointment at 8+2 weeks’ gestation. She has chronic hypertension and type 2 diabetes mellitus. Before pregnancy, her blood pressure was controlled with ramipril 5 mg once daily. Two seated blood pressure measurements today, taken 15 minutes apart, are 148/94 mmHg and 146/92 mmHg. She is asymptomatic, urine dipstick is negative for protein, and creatinine is unchanged from baseline. She has moderate asthma, requiring budesonide/formoterol maintenance therapy, and previously developed wheeze after taking labetalol. She has no contraindication to aspirin. Which is the most appropriate management plan today?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: D — Stop ramipril, start a pregnancy-appropriate nifedipine preparation, prescribe aspirin to start at 12 weeks, and refer to the specialist obstetric hypertension service

She has chronic hypertension because hypertension is established before 20 weeks and she was already receiving antihypertensive treatment. Ramipril should be stopped promptly in pregnancy, preferably within 2 working days of notification, because ACE inhibitors are associated with fetal risk. Her repeated blood pressure is above the NICE treatment threshold of 140/90 mmHg, so simply withdrawing ramipril without replacement is inappropriate. Labetalol is generally the first option, but her asthma and previous labetalol-induced wheeze make it unsuitable; the SmPC lists asthma or a history of wheeze as a contraindication. NICE therefore supports nifedipine where labetalol is not suitable. A pregnancy-appropriate nifedipine product should be selected because individual product licences differ. She requires prescribed low-dose aspirin from 12 weeks until birth because chronic hypertension alone is a high-risk factor for pre-eclampsia; type 2 diabetes provides an additional high-risk factor. Aspirin should not be commenced at 8 weeks under this recommendation. Specialist obstetric hypertension referral is appropriate for women with chronic hypertension in pregnancy. Methyldopa is reserved for situations where both labetalol and nifedipine are unsuitable.

Reference: NICE NG133: Hypertension in pregnancy: diagnosis and management — Recommendations (Last updated 17 April 2023) — https://www.nice.org.uk/guidance/ng133/chapter/recommendations Labetalol 100 mg Film-coated Tablets — Summary of Product Characteristics (2021) — https://www.medicines.org.uk/emc/product/11602/smpc NICE NG133 visual summary: Chronic hypertension — antenatal care (17 April 2023) — https://www.nice.org.uk/guidance/ng133/resources/chronic-hypertension-antenatal-care-pdf-8720711393