Management of Hypertension in Pregnancy

First-Line Medication Options

The American Heart Association recommends extended-release nifedipine and labetalol as first-line antihypertensive medications for pregnant women with hypertension, with nifedipine often preferred due to once-daily dosing that improves adherence 1
The American Heart Association suggests that labetalol serves as a reasonable alternative or can be combined with nifedipine for uncontrolled blood pressure 1
Methyldopa remains an option, although it has fallen out of favor in high-income countries due to poor tolerability, according to the European Society of Cardiology 1

The European Society of Cardiology recommends initiating pharmacologic therapy in women with gestational hypertension, pre-existing hypertension with superimposed gestational hypertension, or hypertension with subclinical organ damage or symptoms at any time during pregnancy, with a blood pressure threshold of ≥140/90 mmHg 2
The European Society of Cardiology suggests a blood pressure threshold of ≥150/95 mmHg for initiating pharmacologic therapy in all other circumstances 3

The American Heart Association recommends maintaining blood pressure below 140/90 mmHg, but never allowing diastolic blood pressure to fall below 80 mmHg, to preserve adequate uteroplacental perfusion 1

The American Heart Association recommends using only extended-release formulation of nifedipine for maintenance therapy, and reserving short-acting nifedipine for acute severe hypertension 1
Labetalol may cause fetal growth restriction, fetal bradycardia, and hypoglycemia, although these risks are minimal, according to the American Heart Association 1

The American Heart Association strictly contraindicates the use of ACE inhibitors, angiotensin II receptor blockers, mineralocorticoid receptor antagonists, and direct renin inhibitors in pregnancy due to associations with fetal teratogenicity and oligohydramnios 1
Atenolol should be avoided in pregnancy due to associations with intrauterine growth retardation, according to the American Heart Association 4

The European Society of Cardiology recommends immediate hospitalization for severe hypertension (≥160/110 mmHg), which constitutes a hypertensive emergency 3
Acute treatment options include IV labetalol, oral methyldopa, and oral nifedipine, according to the European Society of Cardiology 3

The American Heart Association recommends never lowering diastolic blood pressure below 80 mmHg, as this impairs uteroplacental perfusion and increases the risk of small-for-gestational-age infants 1
The American Heart Association advises against using short-acting nifedipine for maintenance therapy, as it is not FDA-approved for hypertension management and can cause precipitous blood pressure drops 4

The European Society of Cardiology recommends switching from methyldopa to alternative agents postpartum due to the risk of depression 3
Patients with hypertensive disorders of pregnancy should be counseled about the increased risk of future chronic hypertension and ischemic heart disease, according to the American Heart Association 4