Chronic Hypertension in Pregnancy: Risk Stratification, Management Strategies and Long-term Maternal-Fetal Outcomes.

INTRODUCTION/

OBJECTIVES

Chronic hypertension in pregnancy is increasingly prevalent and is associated with substantial maternal and fetal morbidity, including superimposed preeclampsia, placental abruption, fetal growth restriction, preterm birth and long-term cardiovascular disease. This review summarizes evidence on pathophysiology, risk stratification, management and outcomes in pregnancies complicated by chronic hypertension.

METHODS

A systematic literature search was conducted in PubMed in September 2025 using MeSH terms related to hypertension, pregnancy, risk assessment, antihypertensive therapy and pregnancy outcomes. Studies published in English between 2000 and 2025 were included. The review followed the PRISMA 2020 guidelines and a qualitative synthesis was performed.

RESULTS

A total of 141 studies were included. Chronic hypertension confers a 5-fold increased risk of pre-eclampsia and is associated with adverse maternal and perinatal outcomes through impaired cardiovascular adaptation, endothelial dysfunction and abnormal placentation. Evidence showed that targeting blood pressure below 140/90 mmHg reduced severe hypertension without increasing fetal growth restriction. First-trimester screening combining maternal characteristics, uterine artery doppler and angiogenic biomarkers improved pre-eclampsia prediction. Low-dose aspirin reduced risk, although effectiveness varied.

DISCUSSION: Uncertainties remain regarding optimal blood pressure targets, aspirin efficacy in chronic hypertension, and integration of angiogenic biomarkers into routine risk stratification. The sFlt-1/PlGF ratio showed value for short-term pre-eclampsia prediction but performed poorly as a standalone predictor of adverse outcomes. Remote monitoring showed promise for postpartum management, yet long-term cardiovascular benefits require confirmation.

CONCLUSIONS

Chronic hypertension requires individualized multidisciplinary care from preconception through the postpartum period. Pregnancy acts as an early marker of future cardiovascular risk, underscoring the need for structured long-term follow-up and integration of obstetric and cardiovascular care.