Management of Hypertension in Pregnant Women

First-Line Medications

The American College of Obstetricians and Gynecologists recommends labetalol, extended-release nifedipine, and methyldopa as first-line antihypertensive medications for pregnant women with hypertension 1, 2
Labetalol is considered a first-line agent with efficacy comparable to methyldopa, and can be administered orally for non-severe hypertension or intravenously for severe hypertension 1, 5, 6
Extended-release nifedipine is recommended as a first-line calcium channel blocker for use during pregnancy, with the long-acting formulation used for maintenance therapy and the short-acting formulation reserved for rapid treatment of severe hypertension 1, 3, 4
Methyldopa has the longest safety record with long-term infant follow-up data, but should be used with caution in women at risk of developing depression and switched to an alternative agent in the postpartum period 3, 4, 5, 6

The European Society of Cardiology recommends lowering blood pressure below 140/90 mmHg but not below 80 mmHg for diastolic blood pressure in women with chronic and gestational hypertension 2
The American College of Obstetricians and Gynecologists recommends initiating treatment for confirmed office systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg 2, 7
The target blood pressure during pregnancy should be 110-135/85 mmHg to reduce the risk of accelerated maternal hypertension while minimizing impairment of fetal growth 3

The European Society of Cardiology strictly contraindicates the use of ACE inhibitors, angiotensin receptor blockers, and direct renin inhibitors during pregnancy due to severe fetotoxicity 2, 3, 6, 8
Diuretics are generally not recommended as first-line agents due to the risk of reducing uteroplacental perfusion 3, 7
Atenolol should be avoided, especially in early pregnancy, due to concerns about fetal safety 1

The European Society of Cardiology recommends low to moderate-intensity exercise for all pregnant women without contraindications to reduce the risk of gestational hypertension and pre-eclampsia 2
Normal diet without salt restriction is advised, particularly close to delivery, as salt restriction may induce low intravascular volume 6, 8
Calcium supplementation of at least 1g daily during pregnancy may help reduce the risk of pre-eclampsia 6, 8
Blood pressure may worsen after delivery, particularly between days 3-6 postpartum or within the first 1-2 weeks, and home blood pressure monitoring is recommended during the postpartum period 1, 4
Women with hypertension during pregnancy have increased risk of developing cardiovascular disease later in life and should receive appropriate follow-up 3, 4

For severe hypertension, immediate treatment is necessary, with IV labetalol, oral nifedipine, or IV hydralazine being the preferred options 1, 4
Pregnant women with severe hypertension should be referred to hospital for management 1
Preeclampsia may worsen or appear for the first time after delivery 1, 4