Principles of treatment of arterial hypertension during pregnancy

If the blood pressure (BP) of the expectant mother increased slightly and only once, she is not diagnosed with hypertension in pregnant women, and special treatment is not required. But when high blood pressure is constantly recorded, it is very important not to let the situation take its course, but to consult a doctor to solve the problem.

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How does arterial hypertension develop in pregnant women?

During pregnancy, a woman's body undergoes restructuring. In particular, she has an additional circle of blood circulation - the uterine one. To provide the fetus with oxygen and nutrients, the amount of blood in the body increases: if a non-pregnant woman has about 5-5.5 liters, then a pregnant woman has about 6-7 liters of blood.

Hormones released in the body while expecting a baby dilate blood vessels, so blood pressure remains normal in most pregnant women. If the balance of these two processes - blood formation and vasodilation - is disturbed, then arterial hypertension occurs.

It often becomes an unexpected discovery among women expecting a child. High blood pressure increases the risk of severe complications in both mother and fetus. That is why every case when a pregnant woman is diagnosed with hypertension requires close attention from specialists.

Causes of high blood pressure in pregnant women

Arterial hypertension in expectant mothers usually develops after the twentieth week as part of the so-called gestosis, a complication of the second half of pregnancy.

If an increase in pressure is detected before the midterm, this indicates that the pregnant woman had hypertension even before conception, even if the woman herself was not aware of its existence. How is this possible? Quite simple actually.

It must be said that hypertension among young women is not at all uncommon: even among 18-29 year olds its prevalence reaches 23%, and in older age the percentage of hypertensive patients is even higher. But due to the fact that in the initial stages of hypertension many do not feel unwell, they do not go to the doctor, their blood pressure is not measured, and the disease remains unrecognized. And with the onset of pregnancy, attention to the health of the expectant mother becomes more intense, so high blood pressure is quickly detected.

In addition to gestosis, there is another serious cause of arterial hypertension in pregnant women - obstructive sleep apnea syndrome. It affects about 5-7% of the population. During pregnancy, it can progress, leading to very serious consequences.

If your family tells you that you snore, be sure to ask them to watch you sleep. If it turns out that during sleep your snoring is interrupted by pauses in breathing lasting 10 seconds or more, this is a good reason to visit a sleep specialist. The fact is that respiratory arrests during sleep with apnea syndrome lead to acute oxygen starvation in the child. In response to stress, the expectant mother's body responds with the release of adrenaline, norepinephrine and other anxiety hormones, which leads to vasoconstriction and increased blood pressure.

Other causes of hypertension in pregnant women are also possible, usually they are renal and endocrine disorders that appeared or worsened while expecting a child.

Emergency care for hypertensive crisis

Category: Prevention.

Hypertensive crisis is a dangerous complication of arterial hypertension that requires emergency care. Every person suffering from hypertension must remember that this hypertensive crisis can occur at almost any time, and it does not matter whether the patient is in stage I or stage III of the disease. Therefore, not only all hypertensive patients, but also their loved ones should know how to provide first aid in case of a sharp increase in blood pressure.

There are many reasons for the development of a hypertensive crisis. Most often this condition occurs for the following reasons

• self-cessation of antihypertensive drugs or their irregular use, emotional stress
• changes in weather, especially changes in atmospheric pressure
• overwork, alcohol abuse
• overeating, large meals
• excessive physical activity;
• disturbances in the functioning of the blood pressure regulation center in the brain caused by various reasons.

Some patients mistakenly believe that quickly lowering blood pressure to normal levels will help quickly get rid of the symptoms accompanying a hypertensive crisis. Under no circumstances should you sharply reduce blood pressure; this can lead to collapse, accompanied by loss of consciousness. In severe cases, this can lead to the development of ischemic changes in the brain and other organs as a result of depletion of blood flow. It is believed that blood pressure should be reduced gradually, by no more than 20-30 mm. rt. Art. at one o'clock. If signs of a hypertensive crisis appear in a patient for the first time, then it is necessary to immediately consult a doctor or call an ambulance.

The attending cardiologist teaches his patients suffering from arterial hypertension what to do during a hypertensive crisis. Many patients are able to cope with this condition on their own and do not seek medical help. But sometimes a hypertensive crisis can be the first manifestation of hypertension, the existence of which a person might not have known before.

What to do for emergency care during a hypertensive crisis

• First of all, it is necessary to calm the patient. Panic is a bad ally in any emergency, and in this situation, anxiety will contribute to an even greater increase in pressure.
• You can take Corvalol, tincture of valerian or motherwort.
• It is necessary to restore breathing. To do this, you need to take several deep breaths and exhalations.
• You also need to ensure a flow of fresh air into the room where the patient is located by opening a window or vent.
• It is advisable to put the patient to bed, giving him a semi-sitting position with the help of pillows, to warm him up and ensure peace.
• You need to apply an ice pack or a cold compress to your head, and put mustard plasters on your calves or the back of your head, or apply warm heating pads to your feet and legs (for 15-20 minutes).
• It is necessary to take an extraordinary dose of blood pressure medication prescribed by your doctor.
• If chest pain and shortness of breath occur, take 1 tablet of nitroglycerin and call an ambulance.
• While waiting for the doctor to arrive, you can, if necessary, take 2 more tablets at 5-minute intervals. You cannot take more than 3 tablets of nitroglycerin. For people suffering from arterial hypertension, doctors recommend that they always keep on hand antihypertensive drugs such as captopril (Capoten) or (nifedipine Corinfar, Cordaflex). It is better to discuss the use of these drugs during a hypertensive crisis with your doctor at a scheduled appointment. If signs of a hypertensive crisis appear, you can take ½ tablet of captopril (meaning a dosage of 25 mg) or 10 mg of nifedipine sublingually (under the tongue). If the expected effect after taking these drugs in the indicated dosage does not occur after half an hour, then you can take another same dose, but no more!
• If there is no effect, you must call a doctor after another 30 minutes. Blood pressure should be measured at least once every 20 minutes.
• If blood pressure does not decrease during the measures taken, the patient’s condition worsens, chest pain or other alarming symptoms appear, then it is necessary to urgently call an ambulance team. In some cases, a hypertensive crisis is stopped by intravenous or intramuscular administration of drugs by a doctor.

In case of a complicated hypertensive crisis, as well as when this condition occurs for the first time, emergency hospitalization in a hospital is necessary, which should not be refused. To avoid dangerous complications of hypertension, the patient must constantly independently monitor his blood pressure, record its readings in a special diary and not skip taking antihypertensive drugs prescribed by the doctor. After all, just one missed dose of medication can lead to a jump in blood pressure.

Symptoms of arterial hypertension

The most common symptoms of high blood pressure are headache, dizziness, fatigue, and nausea. Sleep may also be disturbed, chest pain, palpitations, and shortness of breath often appear.

If you feel unwell, especially if you have previously had arterial hypertension, it is important to measure the pressure in both arms. If the numbers turn out to be different, you need to choose a larger value - this will be the real indicator. With figures of 140/90 mmHg. or higher, you must consult a doctor.

Treatment of arterial hypertension in pregnant women

Medical studies of cases of hypertension in pregnant women have found that an episodic increase in pressure over 28 weeks to 150/95 mmHg. (caused by excitement or stress) does not have a negative effect on either the fetus or the expectant mother.

If such values ​​persist constantly or if high blood pressure is detected before 28 weeks of pregnancy, women require treatment for hypertension even if blood pressure has increased to 140/90 mmHg.

Journal "Arterial Hypertension" 4(18) 2011

Arterial hypertension (HTN) is the most common therapeutic problem encountered during pregnancy. In European countries, hypertension complicates the course of 10% of pregnancies, while in Ukraine such complications account for 6–10%, and according to the All-Russian Society of Cardiology, hypertension complicates 5–30% of pregnancies. Hypertension is the cause of 20–30% of maternal deaths. In the United States, hypertension complicates the course of every tenth pregnancy and affects 240,000 women annually. Pregnant women with hypertension constitute a risk group for the development of preeclampsia, premature placental abruption, fetal growth restriction and other maternal and perinatal complications.

The management of pregnant women with hypertension receives great attention all over the world, and every year more and more new information appears on this problem. However, not all therapeutic approaches to the treatment of hypertension during pregnancy have been definitively established. Therefore, discussion of therapeutic measures for hypertension in pregnant women is very relevant.

It should be noted that foreign specialists are more restrained about pharmacotherapy than domestic ones, and pay more attention to strict adherence to regimen recommendations.

Pharmacotherapy for hypertension during pregnancy is indicated for blood pressure (BP) ≥ 140/90 mmHg. in cases where it is gestational hypertension, stage II hypertension (damage to target organs), when proteinuria appears.

Pharmacotherapy is indicated for blood pressure ≥ 150/95 mmHg. in case of previous stage I headache. At the same time, English recommendations (2010) increase this threshold to 160/100 mmHg.

Hospitalization of pregnant women is recommended when blood pressure is ≥ 160/110 mm Hg, and when blood pressure is ≥ 170/110 mm Hg. or if signs of preeclampsia appear, pregnant women are hospitalized immediately.

Women with hypertension are routinely hospitalized three times during pregnancy:

1. In the early stages of pregnancy (up to 12 weeks) to clarify the genesis of hypertension and resolve the issue of the possibility of prolonging pregnancy.

2. At 26–30 weeks. - during the period of maximum hemodynamic load for correction of the antihypertensive therapy regimen, which is often necessary during this period of pregnancy.

3. In 2–3 weeks. before birth to determine labor management tactics and prenatal preparation.

When gestosis occurs (combined gestosis), a pregnant woman with hypertension is hospitalized immediately, regardless of gestational age.

Treatment of hypertension during pregnancy consists of general measures recommended for pregnant women with hypertension, regardless of blood pressure level, and antihypertensive pharmacotherapy, for which there are specific indications.

Regime recommendations include:

— limitation of physical and emotional stress (if blood pressure is 140–149/90–95 mm Hg — daily observation — close supervision (strict supervision), blood pressure measurement 5–6 times a day;

— periodic rest lying on the left side (at least 2 hours/day);

— sleep ≥ 10 hours/day.

Dietary recommendations:

- nutritious nutrition, rich in protein, vitamins, microelements (Mg2+, K+), antioxidants, including seafood high in polyunsaturated fatty acids in the diet;

- table salt is not significantly limited (circulating blood volume (CBV) may decrease);

- fasting is not allowed. Weight loss is not recommended, even if you are obese;

- inclusion of garlic in the diet and for nausea in pregnant women - ginger and mint infusion.

The question of the advisability of physical therapy for hypertension remains controversial; it is recommended by Ukrainian doctors and is not mentioned in European and American guidelines. Walking in the fresh air is definitely indicated.

General recommendations include daily monitoring of water balance, which is mandatory in pregnant women with hypertension. Average water consumption is 1.5 l/day, taking into account all products, including vegetables, fruits, soups, etc. It is better to control the water balance based on daily diuresis, defining water consumption as daily diuresis + 300.0 ml. Fluid intake may be limited depending on obstetric indications. However, the amount of urine excreted in any case should be more than 750 ml/day.

Drug treatment should be started as gradually as possible, introducing new drugs in the following order.

I. _ Magnesium preparations.

Magnesium-containing drugs have some hypotensive effect as chemical antagonists of Ca2+ (CA). They mainly belong to group A (FDA, USA, 2010). This means that controlled studies have shown that there is no risk for the mother and fetus (including the first trimester). In most cases, the magnesium-containing drugs listed in this section are not considered by the FDA to be potentially harmful to mother or fetus at all. Vitamins C and E contained in the preparations (antioxidants) also promote vasodilation.

II. Sedative herbal preparations should occupy an important place in the treatment of hypertension in pregnant women, especially in the first trimester. In some cases, pregnant women turn out to be emotionally labile, and if “white coat” hypertension in general is observed in 10–15% of cases in patients with hypertension, then in pregnant women - in 30%. If there are significant discrepancies in blood pressure values ​​between office and self-measurement at home, 24-hour blood pressure monitoring (Holter) is necessary. Basically, various dosage forms of valerian and motherwort are recommended.

III . Drugs that improve microcirculation.

ESC (2007) recommended only aspirin in low doses (75 mg 1 time / day) as a drug that reduces cardiovascular risk in hypertension. It should be remembered that category A (FDA, USA, 2010) includes aspirin only in doses of 40–150 mg/day. In large (analgesic, anti-inflammatory) doses, the drug belongs to category D, which has data on the risk for the mother and fetus. Increases the risk of bleeding and prolongs gestation.

Domestic recommendations also mention other drugs in this area, in particular dipyridamole (25–75 mg 3 times a day). Allowed from 14–16 weeks. pregnancy. Category B (animal studies show no risk to mother or fetus, but studies have not been conducted in pregnant women).

Drugs in this group are strictly recommended for preeclampsia and antiphospholipid syndrome.

IV. Domestic recommendations allow the use of myotropic antispasmodics, and in particular papaverine. It should be remembered that the drug belongs to category C, i.e. animal studies have shown relative side effects (including teratogenicity), and studies in women have not been conducted or the data are conflicting. Drugs in this group are recommended for use in cases where the benefit outweighs the potential risk. Can be used from the second trimester before starting the use of antihypertensive drugs.

V. Calcium preparations (calcium carbonate, calcium gluconate, etc.) not only reduce bone resorption in a pregnant woman, but also stabilize the function of the nervous system. The recommended dose is about 2 g/day starting from the 16th week of pregnancy. It should be remembered that category A (FDA, USA, 2010) includes mineral calcium (calcium carbonate), while calciferol is safe only in doses not exceeding 400 IU/day.

VI . For hypertension in pregnant women, various vitamins (B, C, E, folic acid) and antioxidants are widely used.

If the regimen and dietary measures, as well as the drugs listed above, are ineffective, antihypertensive drugs should be prescribed. Of course, such tactics of gradually increasing therapy are appropriate in the absence of signs of hypertensive crisis and preeclampsia.

VII. Antihypertensive drugs.

When prescribing pharmacotherapy to pregnant women, it should be remembered that none of the existing antihypertensive drugs is absolutely safe for the embryo and fetus. Of the antihypertensive drugs available in the doctor’s arsenal, only methyldopa belongs to category B (FDA, USA, 2010) (Table 1).

Most of the antihypertensive drugs used belong to category C and are not prescribed in the first trimester. Their purpose must be strictly justified.

For pregnant women with mild to moderate hypertension who received antihypertensive therapy before pregnancy, the drugs are gradually (carefully!) withdrawn. In the future, if necessary, medications approved for pregnancy are prescribed.

During pregnancy, the renin-angiotensin system is activated against the background of a decrease in blood volume, however, the use of angiotensin-converting enzyme inhibitors and angiotensin receptor antagonists is contraindicated due to a proven teratogenic effect. The use of reserpine is contraindicated.

Methyldopa and hydrochlorothiazide belong to category B, therefore they are approved for use in the first trimester of pregnancy, as the least dangerous drugs for the mother and fetus.

- Methyldopa - from 250 mg (1 tablet) 1 time / day with a gradual increase in dose h/w 2 days to 10-12 tablets / day, divided into 3-4 doses (max. 3,000 mg / day).

— Hypothiazide 12.5–25.0 mg 1 time/day.

Calcium antagonists are prescribed when methyldopa is ineffective, instead of or in addition to it.

The effectiveness of drugs from the group of dihydropyridines and phenylalkylamines during pregnancy has been proven. Belongs to category C (studies were conducted only on animals). Short-acting forms of drugs are used only during a crisis.

— Nifedipine retard 40 mg 1–2 times/day (max. 120 mg/day).

Due to their proven effectiveness and classification by the FDA (USA, 2010) in the same category C as nifedipine, amlodipine (Aladin, Farmak) and verapamil can be prescribed for the same indications as slow-release nifedipine.

— Verapamil retard – 180 (240) mg 1 r/day.

— Amlodipine (Aladin®, Farmak) – 5–10 mg 1 time/day.

Concomitant use of nifedipine and magnesium sulfate may lead to uncontrolled hypotension.

Selective b 1 blockers are used when the above drugs are insufficiently effective (category C). May lead to delayed fetal development, threat of miscarriage and postnatal maladjustment of the fetus (proven only for atenolol). They do not have a teratogenic effect. The higher the selectivity, the safer the use of the drug, however, in the order of the Ministry of Health of Ukraine No. 676 dated December 31, 2004, only metoprolol is indicated. It should be noted that two studies comparing beta blockers with placebo in pregnant women found that metoprolol did not demonstrate statistically significant results. In this regard, it is currently considered advisable to use other drugs in this group. The drug of choice - Bisoprol® (bisoprolol, Farmak) due to its high level of bioavailability - 90% and high selectivity index - 1: 75, has a high safety and effectiveness profile.

— Bisoprol® (bisoprolol, Farmak) – 2.5–10 mg 1 time/day.

Labetalol for oral administration (tablets) is recommended by international guidelines, but is not registered in Ukraine.

Peripheral vasodilators (category C). Leading world centers recommend hydralazine, which is not registered in Ukraine. Doxazazine has been significantly less studied. The risk of using other vasodilators in pregnant women has not been fully determined.

— Doxazosin 1–2 mg daily.

Clonidine , a centrally acting antihypertensive drug, is used instead of methyldopa when it is ineffective (category C). ESC (2003) recommends use from the third trimester. Currently not used in pregnant women in Europe and the USA.

— Clonidine – 0.15–0.075 mg 3–4 times/day (max. 1.2 mg/day)

Hypertensive crisis, preeclampsia

Increased blood pressure ≥ 170/110 mm Hg. requires immediate treatment. To stop an increase in blood pressure, use:

— labetalol — 10 mg IV bolus, in the absence of an adequate response after 10 minutes — 20 mg or 2 mg/min IV drip. With diastolic blood pressure > 110 mm Hg. the dose is doubled every 10 minutes (maximum 300 mg). A non-selective b- and a-blocker is not used for bradycardia;

— short-acting nifedipine — 10–20 mg sublingually;

— clonidine — 0.01% 0.5–1 ml IV, IM or tablets 0.075–0.3 g sublingually 4–6 times a day;

- sodium nitroprusside - intravenous drip 0.25–10 mcg/kg/min (50–100 mg in 250–500 ml of 5% glucose), short-term use, toxic;

— magnesium sulfate — iv 25% 10–20.0 ml — as an anticonvulsant for the treatment and prevention of eclampsia.

In the postpartum period and during breastfeeding, the same recommendations and sequence of drug prescriptions are followed as in the treatment of hypertension in pregnant women.

Undoubtedly, the choice of antihypertensive therapy in pregnant women should be treated very carefully. Farmak company offers drugs of choice (Aladin® (amlodipine) 5–10 mg 1 time / day, Bisoprol® (bisoprolol) 2.5–10 mg 1 time / day), which, with the right approach, can be an indispensable component of antihypertensive therapy in pregnant women.

What medications treat arterial hypertension in pregnant women?

Currently, Methyldopa (Dopegit) is considered the safest treatment for hypertension for both mother and baby. This drug reduces blood pressure well, but does not impair the blood supply to the placenta and does not cause developmental abnormalities in the fetus. During pregnancy, when the fetus is 16-20 weeks old, it is recommended to change the treatment regimen by replacing Dopegit with a drug from another group.

Beta blockers

If a pregnant woman is worried about a heartbeat more than 100 beats per minute and high blood pressure, and the doctor diagnoses gestosis, he may prescribe her treatment with drugs from the group of beta blockers. Pindolol (Viske, Viskaldix) and Acebutolol (Acecor, Sectral) are currently considered the safest. Metoprolol, Labetolol and some other beta blockers may be prescribed with caution. Of the negative effects of the listed drugs for arterial hypertension, some weight loss is known in those newborns whose mothers took beta blockers.

Calcium channel blockers

Another group of drugs approved for the treatment of pregnant women are calcium channel blockers. Amlodipine, Nifedipine with slow release can be prescribed to women who have arterial hypertension, even in the first trimester of pregnancy. Women who have been prescribed Amlodipine give birth to children with increased body weight.

Diuretics

Arterial hypertension in pregnant women is sometimes treated with diuretics - Hypothiazide, Torasemide (Diuver). Diuretics not only themselves reduce blood pressure in arterial hypertension, they also enhance the effect of other drugs with a similar effect. However, due to possible blood thickening, diuretics are used in expectant mothers only after the doctor has weighed the pros and cons of such therapy.

Principles of treatment of arterial hypertension during pregnancy

Hypertension increases the risk of abruption of a normally located placenta, massive coagulopathic bleeding as a result of placental abruption, and can also cause eclampsia, cerebrovascular accident, and retinal detachment [1,12]. Recently, there has been an increase in the prevalence of hypertension during pregnancy due to its chronic forms against the background of an increase in the number of patients with obesity, diabetes mellitus and due to the increasing age of pregnant women. And vice versa - women who develop hypertensive disorders during pregnancy are subsequently at risk for developing obesity, diabetes, and cardiovascular diseases. Children of these women have an increased risk of developing various metabolic and hormonal disorders, cardiovascular pathology [1,4]. The criteria for diagnosing hypertension during pregnancy, according to WHO, are a systolic blood pressure (SBP) level of 140 mmHg. or more or diastolic blood pressure (DBP) 90 mm Hg. or more or an increase in SBP by 25 mm Hg. or more or DBP by 15 mm Hg. Art. compared with blood pressure levels before pregnancy or in the first trimester of pregnancy. It should be noted that during a physiologically occurring pregnancy in the first and second trimesters, a physiological decrease in blood pressure occurs due to hormonal vasodilation; in the third trimester, blood pressure returns to the normal individual level or may slightly exceed it [1,6,8]. The following 4 forms of hypertension in pregnant women are distinguished. • Chronic hypertension (this is hypertension or secondary (symptomatic) hypertension diagnosed before pregnancy or before 20 weeks). • Gestational hypertension (increased blood pressure levels, first recorded after 20 weeks of pregnancy and not accompanied by proteinuria). Most recommendations suggest observation for at least 12 weeks to clarify the form of hypertension and understand the further prognosis. after childbirth. • Preeclampsia/eclampsia (PE) (a pregnancy-specific syndrome that occurs after the 20th week of pregnancy, determined by the presence of hypertension and proteinuria (more than 300 mg of protein in daily urine). However, the presence of edema is not a diagnostic criterion for PE, t .k. during a physiologically proceeding pregnancy, their frequency reaches 60%. Eclampsia is diagnosed if convulsions occur in women with PE that cannot be explained by other reasons. • Preeclampsia/eclampsia against the background of chronic hypertension: a) appearance after 20 weeks. pregnancy, proteinuria for the first time (0.3 g of protein or more in daily urine) or a noticeable increase in previously existing proteinuria; b) progression of hypertension in those women who have up to 20 weeks. pregnancy blood pressure was easily controlled; c) appearance after 20 weeks. signs of multiple organ failure. According to the degree of increase in blood pressure in pregnant women, they distinguish between moderate hypertension (with SBP 140–159 mm Hg and/or DBP 90–109 mm Hg) and severe hypertension (with SBP >160 and/or DBP >110 mm Hg .st.). Distinguishing two degrees of hypertension during pregnancy is of fundamental importance for assessing the prognosis and choosing tactics for managing patients. Severe hypertension in pregnant women is associated with a high risk of stroke. Strokes in women develop equally often both during childbirth and in the early postpartum period and in 90% of cases are hemorrhagic; ischemic strokes are extremely rare. An increase in SBP is more important than DBP in the development of stroke. It was noted that in those women who developed a stroke during pregnancy, childbirth, or shortly after delivery, in 100% of cases the SBP value was 155 mm Hg. and higher, in 95.8% of cases – 160 mm Hg. and higher. Increase in DBP to 110 mm Hg. and higher was observed only in 12.5% ​​of patients who suffered a stroke [4,8,9]. The optimal blood pressure level is below 150/95 mmHg. In the postpartum period, the patient needs additional examination to identify the etiology of hypertension and assess the condition of target organs. After 12 weeks. after childbirth, the diagnosis of gestational hypertension with persistent hypertension should be changed to “hypertension” or one of the possible options for the diagnosis of secondary (symptomatic) hypertension. In cases of spontaneous normalization of blood pressure levels within up to 12 weeks. after childbirth, a diagnosis of transient hypertension is retrospectively established. There is evidence that the recovery period after childbirth in the majority of women who have suffered gestational hypertension and PE, regardless of the severity of hypertension, lasts quite a long time. After 1 month after childbirth, only 43% of these patients have normal blood pressure levels, and even after 6 months. In half of women, blood pressure levels remain elevated. After 3 months (12 weeks) of observation after childbirth, 25% of women who have undergone PE still have hypertension; after 2 years, 40% of these patients show normalization of blood pressure levels [1,4,9]. After identifying hypertension in a pregnant woman, the patient should be examined to clarify the origin of the hypertensive syndrome, determine the severity of hypertension, and identify concomitant organ disorders, including the condition of target organs, placenta and fetus. The examination plan for hypertension includes: – consultations with a general practitioner (cardiologist), neurologist, ophthalmologist, endocrinologist; – instrumental studies: electrocardiography, echocardiography, 24-hour blood pressure monitoring, ultrasound examination of the kidneys, Doppler ultrasound of the renal vessels; – laboratory tests: general blood test, general urinalysis, biochemical blood test (with lipid spectrum), microalbuminuria (MAU). If the diagnosis was not clarified at the stage of pregnancy planning, additional examinations are necessary to exclude the secondary nature of hypertension. If the data obtained are sufficient to clarify the diagnosis, exclude secondary hypertension, and on their basis it is possible to clearly determine the patient’s risk group in accordance with the stratification criteria used for chronic hypertension, and, consequently, the management tactics for the pregnant woman, then the examination can be completed. The second stage involves the use of additional examination methods to clarify the form of secondary hypertension, if any, or to identify possible concomitant diseases [6,8]. One of the most difficult tasks in the treatment of hypertension is the choice of pharmacological drug. In the treatment of hypertension in pregnant women, antihypertensive drugs are often considered, but they have practically lost their clinical significance in other categories of patients with hypertension. For ethical reasons, randomized clinical trials of drugs in pregnant women are limited, and there is virtually no information about the effectiveness and safety of most new drugs for the treatment of hypertension. The main drugs that have justified their use for the treatment of hypertension during pregnancy are central α2-agonists, β-blockers (β-blockers), the α-β blocker labetalol, calcium antagonists (CA) and some myotropic vasodilators [3,5 ,7,11]. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor antagonists are contraindicated during pregnancy due to the high risk of intrauterine growth retardation, bone dysplasia with impaired ossification of the cranial vault, shortening of the limbs, oligohydramnios, neonatal renal failure (renal dysgenesis, acute renal failure in fetus or newborn), fetal death is possible [11,14]. Most international and domestic recommendations recognize methyldopa as a first-line drug, which has successfully proven its effectiveness and safety for the mother and fetus; it is used in a dose of 500–2000 mg/day. in 2–3 doses. Despite penetration through the placental barrier, numerous studies have confirmed the absence of serious adverse effects in children. During treatment with the drug, uteroplacental blood flow and fetal hemodynamics remain stable, and perinatal mortality decreases. It was noted that methyldopa does not affect the cardiac output and blood supply to the kidneys in the mother. However, methyldopa has a number of significant disadvantages, mainly associated with its relative “outdatedness” - in comparison with modern antihypertensive drugs, it has much less effectiveness, a short period of action, a fairly large number of adverse reactions with long-term use (depression, drowsiness, dry mouth and orthostatic hypotension), it is characterized by a lack of organoprotective action. Methyldopa may exacerbate the disproportionate fluid retention that is already common during pregnancy. In addition, methyldopa can cause anemia due to a toxic effect on the red bone marrow or on the red blood cells themselves, resulting in hemolysis. When taking methyldopa, antibodies to red blood cells are detected in approximately 20% of patients with hypertension; clinically hemolytic anemia develops in 2% of patients, including children exposed to the drug in utero. In addition, children born to mothers taking methyldopa may develop hypotension in the first day of life [10,13,15]. Another first-line drug for the treatment of hypertension in pregnant women in most foreign guidelines is considered to be the non-selective β- and α-adrenergic blocker labetalol, but labetalol is not registered in the Russian Federation, so there is no experience of its use in our country. According to numerous studies, it is recommended for the treatment of hypertension of varying severity, and appears to be quite safe for the mother and fetus [9,11]. There is caution regarding the use of AKs due to the potential risk of developing teratogenic effects, because calcium is actively involved in the processes of organogenesis. The most studied drug of the AK group is a representative of the dihydropyridine group - nifedipine. Short-acting nifedipine is recommended as a means to quickly lower blood pressure. Extended-release tablets and controlled-release tablets are used for long-term, planned basic therapy of hypertension during gestation. The hypotensive effect of nifedipine is quite stable; in clinical studies, no serious adverse events were noted, in particular the development of severe hypotension in the mother [9,11]. Short-acting nifedipine, when used sublingually, in some cases can provoke a sharp uncontrolled drop in blood pressure, which leads to a decrease in placental blood flow. In this regard, even in emergency care, the drug should not be taken orally. Prolonged forms of nifedipine do not cause a pathological decrease in blood pressure levels, reflex activation of the sympathetic nervous system, and provide effective control over blood pressure levels throughout the day without a significant increase in its variability. In addition, ACs simulate hemodynamics characteristic of physiological pregnancy [3,11]. β-blockers are used as second-line drugs. Their use during pregnancy has been less studied than the use of labetalol. However, most of them, according to the FDA safety classification for use during pregnancy, are, like labetalol, in category C (“risk cannot be excluded”). One of the most significant advantages of drugs in this group is their high antihypertensive effectiveness, which was confirmed even when comparing them with labetalol. Thus, atenolol in a comparative study with labetalol caused a comparable hypotensive effect and did not cause teratogenic effects, bronchospasm or bradycardia. However, children born to mothers taking atenolol had lower body weight (2750±630 g) compared to the group of children whose mothers received labetalol (3280±555 g). Later, a number of other studies showed that antenatal use of atenolol was associated with slower intrauterine growth and lower birth weight. It should be noted that there is evidence of a decrease in the incidence of PE in patients taking atenolol. A study of 56 pregnant women showed that atenolol can reduce the incidence of PE in women with high cardiac output (more than 7.4 L/min before 24 weeks of gestation) from 18 to 3.8%. In 2009, it was revealed that in these women the concentration of fms-like tyrosine kinase type 1 (sFlt-1), recognized as the leading etiological factor of PE, decreases [2,7]. When using propranolol during pregnancy, multiple undesirable effects in the fetus and newborn have been described (intrauterine growth retardation, hypoglycemia, bradycardia, respiratory depression, polycythemia, hyperbilirubinemia, etc.), therefore the drug is not recommended for use during pregnancy. In many national recommendations, metoprolol is considered as the drug of choice among β-blockers in pregnant women, because it has proven to be highly effective, has no effect on fetal weight and has a minimal number of undesirable effects. Despite this, literature data allow us to discuss the possibility of using β-blockers with vasodilating properties as the drugs of choice [1,9]. Data from several randomized clinical trials generally suggest that β-blockers (β-blockers) are effective and safe as antihypertensive therapy in pregnant women. There is an opinion that beta-blockers prescribed in early pregnancy, especially atenolol and propranolol, can cause fetal growth retardation due to an increase in general vascular resistance. At the same time, in a placebo-controlled study using metoprolol, no data were obtained indicating a negative effect of the drug on fetal development. R. von Dadelszen in 2002 [16] conducted a meta-analysis of clinical studies on β-blockers and concluded that fetal growth retardation is not due to the effect of β-blockers, but to a decrease in blood pressure as a result of antihypertensive therapy with any drug, while all antihypertensive drugs are equally reduced the risk of developing severe hypertension by 2 times compared to placebo. When comparing various antihypertensive drugs with each other, no advantages were found regarding the effect on endpoints (development of severe hypertension, maternal and perinatal mortality). In connection with the above, in order to minimize side effects during gestation, it is advisable to give preference to cardioselective β-blockers with vasodilating properties, because this primarily avoids an increase in general peripheral vascular resistance and myometrial tone. The most promising for successful use in the treatment of hypertension in pregnant women is a highly selective β1-blocker with vasodilating and vasoprotective properties - bisoprolol (Bisogamma). By blocking β1-adrenergic receptors of the heart, reducing the formation of cAMP from ATP stimulated by catecholamines, bisoprolol reduces the intracellular current of calcium ions, reduces the heart rate, inhibits conductivity, and reduces myocardial contractility. With increasing dose, it has a β2-adrenergic blocking effect. In the first 24 hours after administration, it reduces cardiac output and increases total peripheral vascular resistance, which peaks after 3 days. returns to the original level. The hypotensive effect is associated with a decrease in minute blood volume, sympathetic stimulation of peripheral vessels, restoration of sensitivity in response to a decrease in blood pressure and an effect on the central nervous system. In addition, the hypotensive effect is due to a decrease in the activity of the renin-angiotensin system. In therapeutic doses, the use of Bisogamma does not have a cardiodepressive effect, does not affect glucose metabolism and does not cause sodium ion retention in the body. Bisogamma does not have direct cytotoxic, mutagenic or teratogenic effects. Its advantages in the treatment of hypertension during pregnancy are: gradual onset of hypotensive action, no effect on circulating blood volume, absence of orthostatic hypotension, reduction in the incidence of respiratory distress syndrome in the newborn. This drug has stable antihypertensive activity and has a mild chronotropic effect. Bisoprolol (Bisogamma) is characterized by high bioavailability, low individual variability in plasma concentrations, moderate lipophilicity and stereospecific structure, and a long half-life, which together makes it possible for its long-term use. The drug is characterized by a low discontinuation rate and the absence of side effects from biochemical, metabolic, renal and hematological parameters during long-term follow-up. Important advantages of this drug, especially when it comes to hypertension in pregnant women, are its high efficiency in correcting endothelial dysfunction and nephroprotective effect. There were no adverse effects of bisoprolol (Bisogamma) on the fetus, as well as on the health, growth and development of children during their first 18 months. life. Side effects of β-blockers include bradycardia, bronchospasm, weakness, drowsiness, dizziness, rarely depression, anxiety; in addition, one should remember the possibility of developing “withdrawal syndrome” [1,2]. Data from observational studies of bisoprolol (Bisogamma) suggest effectiveness and sufficient safety when used in the 2nd–3rd trimesters of pregnancy. In the Russian literature there is data on the effectiveness and absence of side effects of the use of bisoprolol, including as part of low -dose combined therapy, for the treatment of hypertension and heart rhythm disorders in pregnant women. No adverse effect on the fetus was noted [3]. In order to assess the influence of bisoprolol (bisogamma) on the level of daily blood pressure, the frequency of development of PE we examined 25 women aged 21–40 years with a pregnancy period of 20-30 weeks. and gestational ag. Bisoprolol (bisogamma) was used as antihypertensive drugs in a dosage of 2.5–5 mg/day. (13 women) - group 1 or Atenolol in a dosage of 25-50 mg/day. (12 women) - Group 2. Before and after a 4 -week course of hypotensive therapy, they performed a standard clinical and laboratory -diagnostic examination of the mother and fetus, daily blood monitoring. The hypotensive effects of Atenolol and Bisoprolol (Bisogamma) were comparable. The middle garden, when taking Atenolol, decreased from 158 to 121 mm Hg, DAD - from 102 to 80 mm Hg. Under the influence of Bisoprolol (Bisogamma), the middle garden decreased from 159 to 120 mm Hg. (p <0.01), DAD - from 121 to 78 mm Hg (p> 0.01). In the 3rd trimester, PE developed in 5 women group 2 and only in 1 patient of group 1. As a result of the study, it was concluded that Bisoprolol (Bisogamma) with gestational hypertension effectively reduces blood pressure and prevents the development of PE. Thus, the problem of AH in pregnant women is still far from permission and requires combining the efforts of obstetricians and therapists to select the optimal treatment method. Literature 1. Vertkin A.L., Tkacheva O.N., Murashko L.E. et al. Arterial hypertension of pregnant women: diagnosis, tactics of conducting and approaches to treatment. // Attending doctor. - 2006. - No. 3. - P. 25–8. 2. Osadchiy K.K. β -adrenoists for arterial hypertension: focus on bisoprolol // Cardiology. - 2010. - No. 1. - From 84–89. 3. Stryuk R.I., Brytkova Y.V., Bukhonkina Yu.M. et al. Clinical efficiency of antihypertensive therapy with prolonged nifedipine and Bisoprolol of pregnant women with arterial hypertension // Cardiology. - 2008. - No. 4. - S. 29–33. 4. Manukhin I.B., Markova E.V., Markova L.I., Stryuk R.I. Combined low -dos antihypertensive therapy in pregnant women with arterial hypertension and gestosis // Cardiology. - 2012. - No. 1. - p. 32–38. 5. CIFKOVA R. Who is the Treatment of Hypertension in Pregnancy Still So Difficult? // Expert Rev. Cardiovasc. Ther. 2011. Vol. 9 (6). P. 647–649. 6. Clivaz Mariotti L., Saudan P., Landau Cahana R., Pechere - Bertschi A. Hypertension in Pregnancy // Rev. Med. Suisse. 2007. Vol. 3 (124). P. 2015–2016. 7. Hebert MF, Carr DB, Anderson GD et al. Pharmacokinetics and Pharmacodynamics of Atenololo During Pregnancy and Postpartum // J. Clin. Pharmacol. 2005. Vol. 45 (1). P. 25–33. 8. LEEMAN M. Arterial Hypertension in Pregnancy // Rev. Med. Brux. 2008. Vol. 29 (4). P. 340–345. 9. Lindheimer MD, Taler SJ, Cunningham FG American Society of Hypertension. Ash Position Paper: Hypertension in Pregnancy // J. Clin. Hypertens. 2009. Vol. 11 (4). P. 214–225. 10. Mahmud H., Foller M., Lang F. Stimulation of Erythrocyte Cell Membrane Scrambling by Methyldopa // Kidney Blood Press Ress. 2008. Vol. 31 (5). P. 299–306. 11. Montan S. Drugs Used in Hypertensive Diseases in Pregnancy // Curr. Opin. Obstet. Gynecol. 2004. Vol. 16 (2). P. 111–115. 12. Mustafa R., Ahmed S., Gupta A., Venuto Rc a Comprehece Review of Hypertension in Preignancy // J. Pregnancy. 2012. Vol. 5 (3). P. 534–538. 13. Ozdemir OM, Ergin H., Ince T. A NewBorn with Positive Antiglobulin Test Whose Mother Methyldopa in Pregnancy // Turk. J. Pediatr. 2008. Vol. 50 (6). P. 592–594. 14. Podymow T., August P. Update on the Use of Antihypertensave Drugs in Pregnance // Hypertension. 2008. Vol. 51 (4). P. 960–969. 15. Seremak - Mrozikiewicz A., Drews K. Methyldopa in Therapy of Hypertension in Pregnant Women // Ginekol. Pol. 2004. Vol. 75 (2). P. 160–165. 16. Von Dadelszen P., Magee La Fall in Mean Arterial Pressure and Fetal Growth Restriction in Pregnancy Hypertension: An Updated Metaregrewsis // J. Obstet. Gynaecol. Can. 2002. Vol. 24 (12). P. 941–945.