Chronic hypertension complicates 3–5% of pregnancies and is defined as elevated blood pressure before pregnancy or identified before 20 weeks’ gestation. Chronic hypertension doubles the risk of superimposed preeclampsia, fetal growth restriction, placental abruption, preterm birth, and maternal morbidity. Emerging evidence highlights the prognostic value of a comprehensive cardiovascular evaluation—assessing cardiac output, total peripheral vascular resistance (TPVR), and left ventricular geometry—both before and early in gestation. Preconception studies highlight how a hypodynamic profile (low cardiac output/high TPVR) might predict subsequent adverse outcomes and identify candidates for targeted interventions such as weight optimization, exercise, or specific prepregnancy therapy to regress or modulate left ventricular geometry. In pregnancy, echocardiographic screening at 4–6 and 22–24 weeks distinguishes hypodynamic (low output/high resistance) from hyperdynamic profiles, with hypodynamic circulation correlating strongly with early complications and fetal growth restriction. Small trials employing hemodynamic-guided antihypertensive regimens—including calcium-channel blockers, β-blockers, nitric oxide donors, and increased fluid therapy—suggest reductions in severe hypertension, preeclampsia recurrence, and fetal compromise. The integration of routine hemodynamic assessment into chronic hypertension management holds promise for personalized risk stratification and therapeutic optimization. Large-scale, randomized studies are needed to standardize methods, define thresholds, and confirm long-term benefits of this hemodynamic-guided approach.