Intended for healthcare professionals

Practice Uncertainties

Which antihypertensive treatment is better for mild to moderate hypertension in pregnancy?

BMJ 2022; 376 doi: (Published 18 January 2022) Cite this as: BMJ 2022;376:e066333
  1. Danielle Ashworth, research associate1,
  2. Cheryl Battersby, NIHR clinician scientist in neonatal medicine2,
  3. Marcus Green, CEO of APEC3,
  4. Pollyanna Hardy, director4,
  5. Richard J McManus, professor of primary care research5,
  6. Catherine Cluver, associate professor6,
  7. Lucy C Chappell, professor of obstetrics1
  1. 1King's College London, UK
  2. 2Imperial College London, UK
  3. 3Action on Pre-eclampsia (APEC), Evesham WR11 4EU, UK
  4. 4National Perinatal Epidemiology Unit Clinical Trials Unit, University of Oxford, UK
  5. 5University of Oxford, UK
  6. 6Department of Obstetrics and Gynaecology, Stellenbosch University, Cape Town, South Africa
  1. Corresponding author: L C Chappell lucy.chappell{at}

What you need to know

  • Pregnancy hypertension (encompassing chronic hypertension, gestational hypertension, and pre-eclampsia) affects around 10% of women

  • Labetalol and nifedipine are recommended by national guidelines and commonly used in clinical practice to reduce the risk of developing severe hypertension in these women

  • There is little evidence from head-to-head comparisons of effectiveness and tolerability to guide choice of antihypertensive treatment in pregnancy, and uncertainty about impact on clinical outcomes such as stroke, pre-eclampsia, perinatal death, fetal growth restriction, or preterm birth

Around 18 million women have pregnancy hypertension each year, with approximately 27 800 maternal deaths as per 2019 Global Burden of Disease estimates. In the UK, approximately 8-10% of pregnant women (around 70 000 each year) have high blood pressure in pregnancy (also known as pregnancy hypertension).1 This includes chronic hypertension, gestational hypertension, and pre-eclampsia (fig 1). Age standardised incidence rates are highest in sub-Saharan African countries.2

Fig 1

Types of hypertension in pregnancy

Pregnancy hypertension is associated with adverse maternal and perinatal outcomes.34 These may be related to direct complications such as maternal stroke, pregnancy-specific disorders such as pre-eclampsia, and fetal growth restriction, often mediated through impaired placental function. These conditions may affect the infant through iatrogenic preterm delivery or perinatal death.

International guidelines recommend pharmacological treatment for pregnancy hypertension. Blood pressure thresholds for initiating treatment differ (table 1). The most widely recommended antihypertensive drugs in pregnancy are:

View this table:
Table 1

Clinical practice guidelines for antihypertensives for management of pregnancy hypertension

  • Labetalol—a mixed α and β blocker administered orally or intravenously

  • Nifedipine—an oral calcium channel blocker

  • Methyldopa—an oral antiadrenergic agent.

Antihypertensive therapies are applied similarly across chronic hypertension, gestational hypertension, and pre-eclampsia in most settings. These antihypertensives are not commonly used outside of pregnancy, because there are more effective drug classes (such as renin-angiotensin system blockers) that are contraindicated in pregnancy, or due to side …

View Full Text

Log in

Log in through your institution


* For online subscription