A woman at 10 weeks with chronic hypertension on losartan (BMI 40) attends booking. What are the key management priorities?

• Stop losartan immediately - ARBs (and ACE inhibitors) are contraindicated; switch to a pregnancy-safe agent (labetalol, nifedipine or methyldopa)
• Start low-dose aspirin from 12 weeks (chronic hypertension is a high-risk factor)
• Counsel on weight/BMI and monitor for superimposed pre-eclampsia
• Baseline bloods (renal, urine PCR) and arrange close surveillance and growth scans

Clinical relevance. Stopping the ARB and starting aspirin are the key actions in chronic hypertension at booking.

More Detail

Chronic hypertension at booking

Chronic hypertension at booking requires attention to drug safety, prophylaxis and surveillance.

Drug change (the immediate priority)

Losartan is an ARB - contraindicated in pregnancy (fetal renal damage, oligohydramnios). Stop it and switch to a safe antihypertensive: labetalol (first-line), nifedipine, or methyldopa. ACE inhibitors, thiazides and spironolactone are likewise stopped.

Pre-eclampsia prophylaxis

Chronic hypertension is a high-risk factor, so start low-dose aspirin (75-150 mg) from 12 weeks; advise calcium if dietary intake is low.

Other priorities

• BMI 40 - counsel on weight, screen for diabetes; obesity adds further pre-eclampsia and other risks.
• Baseline investigations - renal function, urine PCR (to detect later superimposed pre-eclampsia against a baseline).
• Close surveillance - regular BP and urine checks, and serial growth scans, watching for superimposed pre-eclampsia and FGR.