Introduction

Effective management of hypertensive disorders of pregnancy is critical to reducing maternal morbidity, improving fetal outcomes, and mitigating long-term cardiovascular risk. This review provides a practical framework for antihypertensive medication selection in pregnancy and the postpartum period (Table 1).

Table 1: Antihypertensive Medications in Pregnancy and Lactation

ACEi = angiotensin-converting enzyme inhibitor; ARB = angiotensin-receptor blocker.

Practical Approach: Pregnancy

Preferred first-line oral antihypertensives in pregnancy are extended-release nifedipine (a dihydropyridine calcium channel blocker [CCB]) and labetalol (a combined beta-blocker and alpha-1 blocker).^1-3

• Nifedipine: starting dose 30 mg extended-release daily, uptitrated every 5-7 days to maximum 120 mg daily or 60 mg twice daily
  • Adverse effects: headache, edema, flushing
• Labetalol: starting dose 200 mg twice daily, uptitrated every 2-3 days to maximum 800 mg three times daily
  • Dosing frequency can be challenging for patients
  • Adverse effects: bradycardia, fatigue, bronchospasm in patients with asthma

Second-line oral antihypertensives include amlodipine, a dihydropyridine CCB that has less safety data in pregnancy compared with nifedipine. Metoprolol can be safely used in pregnancy; however, it does not have significant blood pressure-lowering effects. Carvedilol can also be used for management of hypertension, although safety data are more limited. Hydralazine, a direct vasodilator, has also been used safely in pregnancy, especially as part of guideline-directed medical therapy (GDMT) for cardiomyopathy.

Practical Approach: Postpartum

First-line oral antihypertensives for both breastfeeding and nonbreastfeeding individuals include extended-release nifedipine and amlodipine, enalapril (long-acting angiotensin-converting enzyme inhibitor [ACEi]), and labetalol.^2,4

• Nifedipine: starting dose 30 mg extended-release daily, increased every 5-7 days to maximum 120 mg daily or 60 mg twice daily
  • Adverse effects: headache, edema, flushing
• Amlodipine: starting dose 5 mg daily, increased every 5-7 days to maximum 10 mg daily
  • Adverse effects: headache, edema
• Enalapril: starting dose 5 mg daily, increased every 7-14 days to maximum 40 mg daily or 20 mg twice daily
  • Use with caution in chronic kidney disease stages ≥4
  • Adverse effects: hyperkalemia, acute kidney injury, nonproductive cough, rare angioedema
• Labetalol: starting dose 200 mg twice daily, increased every 2-3 days to maximum 800 mg three times daily
  • Dosing frequency can be challenging for patients
  • Adverse effects: bradycardia, fatigue, bronchospasm in patients with asthma

Second-line antihypertensives that are lactation-compatible include hydralazine, hydrochlorothiazide, metoprolol, and carvedilol. Spironolactone, a mineralocorticoid receptor antagonist (MRA), can also be used safely during lactation.

Safety Review by Antihypertensive Type

To find safety data on medications in pregnancy and lactation, please go to the following web pages:

MotherToBaby.org: Fact Sheets

MotherToBaby.org: LactRx App

NCBI Bookshelf: Drugs and Lactation Database (LactMed®)

Calcium Channel Blockers

Extended-release nifedipine has a well-established fetal safety profile in pregnancy.¹ Amlodipine is also considered safe in pregnancy with less data compared with nifedipine.⁵ Both nifedipine and amlodipine are compatible with lactation, with low transfer into breast milk.⁴ Nondihydropyridine CCBs (verapamil and diltiazem) are not recommended for antihypertensive treatment during pregnancy or lactation. Verapamil is associated with preterm delivery, growth restriction, and fetal bradycardia with even more limited data on diltiazem.⁶

Beta-Blockers

In pregnancy, labetalol, metoprolol, and carvedilol are considered preferred agents with minimal concerns for fetal bradycardia, hypoglycemia, and growth restriction.¹ Atenolol is contraindicated due to associations with fetal bradycardia, hypoglycemia, and growth restriction.⁷

During lactation, labetalol, metoprolol, and carvedilol are again preferred with minimal transfer into breast milk.⁴ Specifically, there are limited safety data for carvedilol; however, it is likely low risk. Atenolol is contraindicated due to moderate breast milk excretion and adverse infant effects including hypotension, cyanosis, and hypothermia.⁴

Methyldopa

Methyldopa, a centrally acting alpha-2 agonist, is safe in pregnancy and has been used in lower-income settings.^1,2 It is lactation-compatible with limited breast milk excretion. It can be associated with several adverse effects including peripheral edema, dry mouth, and lightheadedness, which can limit tolerability. When preferred agents are available, it is generally a second-line option.

Hydralazine

Hydralazine, a direct vasodilator, is a safe option in both pregnancy and the postpartum period if breastfeeding. In pregnancy, it has rarely been associated with fetal thrombocytopenia.⁸ During lactation, hydralazine is present in breast milk in small amounts; however, it is considered lactation-compatible.⁴

Thiazide and Loop Diuretics

Diuretics, including thiazides and loops, can be used in pregnancy if first-line agents are insufficient.² Furosemide can be used for management of volume status in pregnancy and is compatible with lactation; however, there is a theoretical risk of placental hypoperfusion in pregnancy.⁹ Hydrochlorothiazide can also be used in pregnancy and the breastfeeding period, and it is the preferred alternative to chlorthalidone because hydrochlorothiazide is less likely to transfer into breast milk. Chlorthalidone and hydrochlorothiazide, at higher doses, can decrease breast milk production.⁴

Nitrates

Nitrates are not commonly used in pregnancy and are not first-line agents for the management of hypertension. They should be used with caution given insufficient data in pregnancy and lactation; however, in individuals with cardiomyopathy, they may be used in conjunction with hydralazine as a part of GDMT.¹⁰

Clonidine

Clonidine, a centrally acting alpha-2 agonist, should be used with caution in both pregnancy and lactation, especially given the potential for rebound hypertension.² In the presence of hyperemesis, transdermal clonidine patches may be of value. Although there are limited data, clonidine does transfer into breast milk. Infants should be monitored for hypotension, tachypnea, and bradycardia if used during breastfeeding.⁴

Mineralocorticoid Receptor Antagonists

MRAs are generally avoided in pregnancy due to concerns regarding antiandrogenic effects with spironolactone.² During lactation, spironolactone is considered safe with minimal excretion into breast milk.⁴ There is insufficient evidence on eplerenone in pregnancy and lactation.⁴

Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers

In pregnancy, ACEi and angiotensin II receptor blockers (ARBs) are contraindicated due to their association with adverse effects including skeletal malformations, fetal growth restriction, and oligohydramnios. During lactation, enalapril, benazepril, and captopril are preferred due to good safety data and low levels found in breast milk and can be used with fetal weight monitoring.⁴ Data on other ACEi and ARBs are limited and these agents are typically avoided during lactation.

Angiotensin Receptor–Neprilysin Inhibitor

Sacubitril/valsartan, an angiotensin receptor–neprilysin inhibitor (ARNI), is contraindicated in pregnancy because of the ARB component, valsartan.¹⁰ There are no established data on the pregnancy safety profile of the neprilysin component, sacubitril.¹⁰ In individuals with cardiomyopathy who are on an ARNI as a part of GDMT, alternatives such as hydralazine with a nitrate may be considered. One report suggests low breast milk levels of ARNI with no obvious adverse infant effects, although data are limited in establishing safety in lactation at higher doses.⁴

References

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6. Fahie S, Cassagnol M. Verapamil. In: StatPearls. StatPearls Publishing; 2026. Available at: https://www.ncbi.nlm.nih.gov/books/NBK538495/. Accessed 06/12/2026.
7. Easterling TR, Carr DB, Brateng D, Diederichs C, Schmucker B. Treatment of hypertension in pregnancy: effect of atenolol on maternal disease, preterm delivery, and fetal growth. Obstet Gynecol. 2001;98(3):427-433. doi:10.1016/s0029-7844(01)01477-6
8. Widerlöv E, Karlman I, Storsäter J. Hydralazine-induced neonatal thrombocytopenia. N Engl J Med. 1980;303(21):1235. doi:10.1056/nejm198011203032112
9. van der Zande JA, Greutmann M, Tobler D, et al. Diuretics in pregnancy: Data from the ESC Registry of Pregnancy and Cardiac disease (ROPAC). Eur J Heart Fail. 2024;26(7):1561-1570. doi:10.1002/ejhf.3301
10. Hoffman K, Mitchell JA, Simkowski J, et al. Guideline-directed medical therapy in pregnancy and lactation: navigating evidence gaps and clinical application. J Card Fail Intersect. Published online November 12, 2025. doi:10.1016/j.yjcafi.2025.10.012