Table 1.
Main anti-hypertensive drugs in pregnant patients with CKD
| Drug | Main features | FDA | SOGC |
|---|---|---|---|
| Usually considered FIRST CHOICE drugs [141, 142, 340, 368] | |||
| Alpha-methyl dopa | Widely used in pregnancy, with no reported negative effects on the foetus or on its subsequent development. May not be able to correct severe hypertension in CKD | B | 1-A |
| Niphedipine | The long acting drug most commonly used in hypertension in pregnancy. The increase in peripheral oedema may be a relevant side effect in CKD patients | C | 1-A |
| Labetalole | Usually well tolerated, should be avoided in subjects with asthma. In a RCT it was shown to be comparable to alphamethyldopa [143, 149] | C | 1-A |
| Usually considered SECOND CHOICE drugs [141, 340] | |||
| Beta blockers | The main drawback in older studies was foetal growth restriction, possibly as an effect of overzealous correction [142]. Beta1 selective beta blockers (atenolole) are more often involved. Beta blockers may be more effective than alpha-methyldopa in severe hypertension, alone or in combined therapy. At delivery they may induce hypoglycaemia, hypotension and bradycardia (usually mild and transient) | D atenolole B pindolole C metoprolol |
1-B |
| Clonidine | The effect is similar to alpha-methyldopa; side effects may be more common and hypertensive rebounds at discontinuation are common; slowing foetal growth is occasionally reported [144] | C | |
| Alpha blockers | Other drugs should be preferred as controlled studies are missing | C | |
| Diuretics | They are usually avoided in pregnancy except when there are nephrological or cardiological indications. Thiazides may be continued in patients previously on treatment [145, 158]. In selected cases with Gitelman syndrome, amiloride may be employed | B hydrochloro-thiazide amiloride | |
| To be avoided [141, 340] | |||
| Short acting niphedipine | Contraindicated by the FDA, RCOG and AIPE due to the risk of severe sudden hypotension with detrimental effects on placental flows | D | |
| ACE-i ARB and related drugs | Both drugs are contraindicated in all phases of pregnancy because of the risk of several major malformations, including cardiovascular, central nervous system, renal and bone malformations [153–155] | C 1st D 2nd 3rd trimester |
II 2E |
FDA site of the Food and Drug Administration [340]; FDA rating: A, controlled human studies show no risk; B, no evidence of risk in studies; C, risk cannot be ruled out; D, positive evidence of risk; X, contraindicated in pregnancy; SOGC, Society of Obstetrics and Gynaecology of Canada: guidelines 2014 [102]