First-line drugs of choice
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Central alpha-2 adrenergic agonists |
Methyldopa (0.5–3 g/day in 2 divided doses) |
Fetal and neonatal safety with FDA class B, class I level B |
Particular concern for hemolytic anemia and hepatic disturbance |
ACOG report [12] |
Drug choice for severe hypertension |
May aggravate depressive disorder |
Williams et al. [14] |
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Brown et al. [20] |
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Easterling et al. [22] |
Beta-blockers |
Labetalol (200–1,200 mg/day PO in 2–3 divided doses) |
Safe and FDA class C, class I level |
May be associated with fetal growth restriction |
ACOG report [12] |
Drug choice for severe hypertension |
Neonatal hypoglycemia with larger doses |
Williams et al. [14] |
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Easterling et al. [22] |
Second-line drugs of choice
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Calcium channel blockers |
Nifedipine (slow-release tablet, 10–30 mg PO) |
Safe and FDA class C, class I level C, avoid sublingual capsule use (risk of fetal distress) |
Tocolytic effect may inhibit birth delivery |
Williams et al. [14] |
Drug of choice for severe hypertension |
Concern that using a short-acting agent in combination with magnesium may induce profound hypotension |
Brown et al. [20] |
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Easterling et al. [22] |
Central alpha-2 adrenergic agonists |
Clonidine (0.1–0.6 mg/day in 2 divided doses) |
Limited data in pregnancy, FDA class C |
Similar to methyldopa |
Brown et al. [20] |
Alternative option
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Diuretics |
Hydrochlorothiazide (12.5–25 mg/day) |
FDA class B, and few studies in patients with hypertension |
Should not be used for preeclampsia prevention because it may aggravate volume depletion and electrolyte abnormalities |
Brown et al. [20] |
Direct vasodilators |
Hydralazine (50–300 mg/day in 2–4 divided doses) |
FDA class D |
Drug-induced symptoms: nausea, headache, light-headedness, flushing, and palpitation |
Brown et al. [20] |
May be orally used as a third choice or used intravenously for hypertensive crisis |
Drug-induced lupus, neonatal lupus, maternal polyneuropathy, tachyphylaxis, and thrombocytopenia |
Alpha-1 adrenergic-blockers |
Prazosin (0.5–5 mg three times a day) |
No fetal adverse effects reported |
Associated with palpitations and postural hypotension |
Brown et al. [20] |
Considered a second-line agent |
Proscribed or not recommended
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Renin-angiotensin system inhibitors |
Angiotensin 2 converting enzyme inhibitors |
FDA class C in first trimester |
Associated with adverse fetal effects |
Williams et al. [14] |
FDA class D second and third semester |
Brown et al. [20] |
Teratogenic effect on fetus, class III level C |
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Angiotensin 2 receptor antagonists |
Teratogenic effect on fetus, class III level C |
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Williams et al. [14] |
Bortolotto et al. [21] |
Aldosterone receptor antagonists |
Spironolactone |
Not recommended in pregnancy due to antiandrogenic effects |
Feminization of male infants |
Brown et al. [20] |
Bortolotto et al. [21] |