What once‑daily, pregnancy‑compatible antihypertensive regimen is recommended for a 26‑year‑old woman with hypertension planning pregnancy who frequently misses the evening labetalol dose?

Once-Daily Antihypertensive for Pregnancy Planning

Switch to extended-release nifedipine as your once-daily, pregnancy-compatible antihypertensive regimen. 1

Why Extended-Release Nifedipine is the Optimal Choice

Extended-release nifedipine addresses both your adherence challenge and pregnancy safety requirements:

• Once-daily dosing eliminates the missed evening dose problem that plagued your labetalol regimen 1
• Consistently recommended as first-line by the European Society of Cardiology, American Heart Association, and American College of Cardiology for pregnancy hypertension 1
• Equivalent efficacy and safety to labetalol demonstrated in post-hoc analysis of the CHAP trial (Chronic Hypertension and Pregnancy), showing no difference in maternal or neonatal outcomes 1
• Maximum dose of 120 mg daily provides adequate therapeutic range for maintenance therapy 1

Dosing and Initiation Strategy

• Start with 30-60 mg once daily of the extended-release formulation 1
• Target blood pressure of 110-140/85 mmHg during pregnancy to prevent severe maternal hypertension while maintaining uteroplacental perfusion 1
• Initiate treatment at ≥140/90 mmHg for women planning pregnancy with chronic hypertension 1

Critical Safety Considerations

Never use immediate-release nifedipine for maintenance therapy—reserve it exclusively for acute severe hypertension, as the short-acting formulation can cause uncontrolled hypotension, particularly when combined with magnesium sulfate 1

Discontinue any ACE inhibitors, ARBs, or direct renin inhibitors immediately if you're currently taking them, as these cause severe fetotoxicity, renal dysgenesis, and oligohydramnios throughout pregnancy 1, 2

Alternative if Nifedipine is Not Tolerated

If you develop headaches, tachycardia, or edema from nifedipine (common side effects), you can return to labetalol but consider:

• Using a medication reminder app or alarm for the evening dose 1
• Switching to once-daily agents postpartum (amlodipine or enalapril) for better long-term adherence 1

Preconception Optimization

Before attempting pregnancy:

• Confirm your blood pressure is controlled below 140/90 mmHg on your current regimen 1
• Obtain baseline labs: complete blood count, liver function tests, serum creatinine, electrolytes, and urine protein-to-creatinine ratio 1
• Plan for low-dose aspirin 75-100 mg at bedtime starting before 16 weeks gestation if you have additional risk factors for preeclampsia 3
• Maintain calcium supplementation of at least 1 g daily to reduce preeclampsia risk 3

Monitoring During Pregnancy

• You have a 20-25% risk of developing superimposed preeclampsia given your chronic hypertension, requiring close monitoring after 20 weeks gestation 1
• Home blood pressure monitoring is strongly recommended throughout pregnancy 1
• Severe hypertension (≥160/110 mmHg) requires treatment within 60 minutes to prevent maternal stroke 2

Common Pitfall to Avoid

Do not allow diastolic blood pressure to fall below 80 mmHg, as this can compromise uteroplacental perfusion and fetal growth 1, 2