Hypertension Management in Pregnancy

First-Line and Second-Line Treatment Options

• The American Heart Association recommends labetalol and extended-release nifedipine as first-line antihypertensive medications during pregnancy, while amlodipine can be considered a second-line option when first-line agents are contraindicated or poorly tolerated 1
• Methyldopa is a viable option for pregnant patients due to its long-term information on infant outcomes 1

Postpartum Hypertension Management

• Amlodipine is considered a first-line agent for postpartum hypertension regardless of breastfeeding status, with advantages including once-daily dosing and alignment with general hypertension guidelines 1

Medications to Avoid

• Atenolol is associated with fetal growth restriction and should be used with caution in pregnant patients 1
• ACE inhibitors and Angiotensin II receptor blockers (Category D) are associated with renal dysplasia, oligohydramnion, growth retardation, and other serious complications, and should be avoided during pregnancy 2
• Warfarin (Category D) can cross the placenta and cause embryopathy, and is contraindicated during pregnancy 2
• The FDA classification system categorizes medications based on their potential risk to the fetus, as shown in the following table:

2

Medication Use During Breastfeeding

• ACE inhibitors, such as lisinopril, should be avoided during breastfeeding, particularly during the infant's first month of life, due to concerns about potential neonatal hypotension 3
• If possible, consider switching to alternative antihypertensives with better-established safety profiles during lactation, and monitor the infant for signs of hypotension, poor feeding, or lethargy if lisinopril must be used 3

General Principles of Medication Use During Pregnancy and Breastfeeding

• Always weigh the potential risk of a drug against the possible benefit of therapy, and consider the benefit-risk ratio when prescribing medications during pregnancy or breastfeeding, as recommended by the European Society of Cardiology 2
• In emergency situations, necessary medications should not be withheld even if not recommended during pregnancy, according to the European Society of Cardiology 2
• Discontinuing essential medications without considering the risk of untreated maternal disease can be harmful, and assuming all drugs in the same therapeutic class have the same safety profile is incorrect 2
• Choose drugs with established safety profiles, use the lowest effective dose for the shortest duration necessary, and avoid Category X drugs completely 2
• Online databases such as www.embryotox.de or www.safefetus.com can be consulted when FDA categories are insufficient, as recommended by the European Society of Cardiology 2