Methyldopa Should Be Avoided in Postpartum Patients
Methyldopa is contraindicated in the postpartum period due to increased risk of postnatal depression and should be discontinued after delivery. 1, 2 First-line agents for postpartum hypertension include nifedipine, amlodipine, enalapril, and labetalol instead. 1
Why Methyldopa Is Contraindicated Postpartum
- The European Society of Cardiology explicitly recommends avoiding methyldopa postpartum because of the risk of postnatal depression, which is a critical quality of life and safety concern. 1, 2
- Blood pressure typically rises in the first 5 days postpartum before normalizing, and women who were hypertensive during pregnancy may become normotensive after birth but then hypertensive again in the first postnatal week—this requires different medication management than during pregnancy. 1
Recommended Postpartum Antihypertensive Regimen
First-Line Agents (in order of preference):
- Nifedipine or amlodipine (calcium channel blockers): Once-daily dosing, effective, and align with standard hypertension guidelines. 1
- Enalapril (ACE inhibitor): Once-daily dosing, safe with breastfeeding, effective for postpartum hypertension. 1
- Labetalol (beta-blocker): Commonly used but requires twice-daily or more frequent dosing, which is a disadvantage; recent data suggest it may be less effective postpartum compared to calcium channel blockers and associated with higher readmission risk. 1
Dosing Considerations:
- Nifedipine: Start 30-60 mg extended-release once daily
- Amlodipine: Start 5-10 mg once daily
- Enalapril: Start 5-10 mg once daily
- Labetalol: Start 200 mg twice daily (may need TID or QID dosing)
All of these agents are compatible with breastfeeding. 1
Critical Transition Point
- If a patient was on methyldopa during pregnancy, it must be switched to an alternative agent immediately postpartum. 1, 2
- The transition should occur at delivery or within the first 24 hours postpartum to avoid the depression risk while maintaining blood pressure control. 1
Alternative Agents
- Diuretics can be considered and may help early postpartum blood pressure recovery after hypertensive disorders of pregnancy, though higher doses may affect breastmilk production. 1
Special Circumstances
- If mild reduction in ejection fraction (40-50%) is present postpartum (common with hypertensive disorders of pregnancy), consider combination therapy with a beta-blocker plus ACE inhibitor or ARB, following heart failure guidelines. 1
- Ensure documented contraception plan before initiating ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists due to teratogenicity risk in future pregnancies. 1