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Treatment of moderate hypertension in pregnancy.

The principal cause of maternal death in England and Wales is hypertensive disease, nearly half of the deaths being due to cerebral haemorrhage.1 The sudden increases in blood pressure characteristic of pre-eclampsia and eclampsia are enough to explain the terminal events.2 In consequence there is a compelling case for adequate hypotensive treatment of patients with severe pre-eclampsia, though this is still not universally accepted.3 Such treatment is, however, only a temporary adjunct to the definitive management, which is to expedite delivery. But what about women with only moderately increased blood pressure in pregnancy-those with systolic pressures of 140-170 and diastolic pressures of 90-110 mm Hg? In medical practice the treatment of moderate hypertension may span a decade or more, usually in middle or later life, and aims at preventing heart failure, aortic dissection, coronary vascular disease, and stroke. These aims do not necessarily apply to the management of young women for the brief period of pregnancy; nor do studies of patients who are not pregnant provide any guide to the effects on the fetus of treating moderate hypertension. True, moderate hypertension in pregnancy may predispose to aortic dissection,4 bleeding from cerebral aneurysms,5 and myocardial infarction.6 But the extreme rarity of these complications in pregnancy cannot justify the treatment of all moderate hypertension, whose chief danger, for both mother and fetus, is the risk of severe preeclampsia. If the moderate hypertension is caused by early pre-eclampsia, the risk depends on simple progression. If the hypertension was present before the woman became pregnant the risk is of superimposed pre-eclampsia, which is increased about fivefold.7 Most probably, the dangers of chronic hypertension for the baby arise entirely from superimposed preeclampsia, without which the perinatal mortality is no greater than average.8 The evidence in favour of hypotensive treatment for women with uncomplicated moderate hypertension is scanty and is derived from a few controlled trials. Leather et -al showed that once pre-eclampsia has developed treatment confers no benefit on the fetus9-though it may still be essential for the mother's safety. The same investigators showed that treatment of women with longstanding hypertension with methyldopa was associated with an improved rate of survival for the fetus; subsequently a larger trial seemed to confirm this.10 These benefits could not be attributed to the prevention of super-