What is the recommended blood pressure (BP) medication for pregnant women with hypertension?

Recommended Blood Pressure Medications in Pregnancy

Extended-release nifedipine and labetalol are the first-line antihypertensive medications for pregnant women with hypertension, with nifedipine often preferred due to once-daily dosing that improves adherence. 1

First-Line Medication Options

The most recent 2025 Circulation guidelines establish clear first-line agents based on the strongest available safety and efficacy data:

• Extended-release nifedipine is frequently selected as initial treatment due to once-daily administration, which significantly improves patient adherence 1
• Labetalol serves as a reasonable alternative or can be combined with nifedipine for uncontrolled blood pressure 1
• Methyldopa remains an option and is the only medication with long-term follow-up data on infant outcomes, though it has fallen out of favor in high-income countries due to poor tolerability (peripheral edema, dry mouth, drowsiness, mood effects) 1

No compelling data supports using one first-line agent over another for maternal or neonatal outcomes. 1 A post-hoc analysis of the CHAP trial found no difference in outcomes between labetalol and nifedipine users. 1

Treatment Thresholds

Initiate pharmacologic therapy based on these specific criteria 1:

• BP ≥140/90 mmHg in women with:
  • Gestational hypertension (with or without proteinuria)
  • Pre-existing hypertension with superimposed gestational hypertension
  • Hypertension with subclinical organ damage or symptoms at any time during pregnancy
• BP ≥150/95 mmHg in all other circumstances 1

Target Blood Pressure

Maintain BP below 140/90 mmHg but never allow diastolic BP to fall below 80 mmHg to preserve adequate uteroplacental perfusion. 1, 2 Meta-analysis of 45 trials demonstrated a direct linear relationship between treatment-induced fall in mean arterial pressure and proportion of small-for-gestational-age infants. 2

Medication-Specific Considerations

Nifedipine

• Use only extended-release formulation for maintenance therapy 1
• Short-acting nifedipine reserved exclusively for acute severe hypertension 1
• May cause headaches, tachycardia, or edema as side effects 1

Labetalol

• Potential risks include fetal growth restriction, fetal bradycardia, and hypoglycemia, though these are minimal with no reports of teratogenicity 1
• Contraindicated in reactive airway disease 1
• May require TID or QID dosing due to accelerated drug metabolism during pregnancy 1
• Appears in breast milk in small amounts (approximately 0.004% of maternal dose) 3

Methyldopa

• Avoid postpartum due to risk of postnatal depression 1
• More poorly tolerated than other first-line agents 1
• May interfere with laboratory tests including urinary catecholamines and serum creatinine 4

Absolutely Contraindicated Medications

ACE inhibitors, angiotensin II receptor blockers (ARBs), mineralocorticoid receptor antagonists, and direct renin inhibitors are strictly contraindicated due to associations with fetal teratogenicity and oligohydramnios. 1 These agents cause fetotoxicity particularly in the second and third trimesters. 1

Atenolol should be avoided as it is specifically contraindicated in pregnancy due to associations with intrauterine growth retardation. 2

Severe Hypertension Management (≥160/110 mmHg)

This constitutes a hypertensive emergency requiring immediate hospitalization. 1

Acute treatment options include 1:

• IV labetalol (first-line for acute severe hypertension)
• Oral methyldopa
• Oral nifedipine
• IV hydralazine is no longer the drug of choice as it is associated with more perinatal adverse effects 1

Critical Pitfalls to Avoid

• Never lower diastolic BP below 80 mmHg as this impairs uteroplacental perfusion and increases risk of small-for-gestational-age infants 1, 2
• Do not use short-acting nifedipine for maintenance therapy—it is not FDA-approved for hypertension management and can cause precipitous BP drops 2
• Do not continue ACE inhibitors or ARBs if inadvertently discovered in early pregnancy—switch immediately to safe alternatives and arrange close fetal ultrasound monitoring 2
• Do not assume beta-blockers are interchangeable—atenolol specifically should be avoided while labetalol is acceptable 1, 2

Postpartum Considerations

• Monitor BP for 72 hours in hospital and 7-10 days postpartum 2
• Switch from methyldopa to alternative agents postpartum due to depression risk 1
• Counsel patients that hypertensive disorders of pregnancy confer 4-fold increased risk of future chronic hypertension and 2-fold increased risk of ischemic heart disease 2
• Annual cardiovascular risk assessment should be performed lifelong 2