Table III.
Pharmacologic Treatment of Hypertensive Disorders of Pregnancy
| Medication Class | 1st, 2nd, 3rd‐Line, Treatment or Contraindicated | Teratogenicity/Fetotoxicity | Formulations | Considerations in DM Patients |
|---|---|---|---|---|
| α‐Adrenergic agonists | 1st | None | Methyldopa, PO/IV Clonidine, PO | No maternal renal protection |
| β‐Blockers | 1st or 2nd | Fetal growth restriction, fetal bradycardia | Labetolol, PO/IV Atenolol, PO | Maternal hypoglycemia unawareness (labetalol) |
| Vasodilators | 2nd (IV)a 3rd (PO) | Neonatal thrombocytopenia (hydralazine) Cyanide toxicity if used >4 hour (nitroprusside) | Hydralazine, PO/IV; Nitroprusside, IV | |
| Calcium channel blockers | 2nd | None | Verapamil, PO Diltiazem, PO Nifedipine, PO Nicardipine, IV | Potential decreased maternal albuminuria and CVDb |
| ACE inhibitors/ARBs | Contraindicated in 2nd and 3rd trimesters; Unknown in 1st trimester | Renal failure, anuria; pulmonary hypoplasia; skeletal/calvarial abnormalitiesc Cardiac and CNS defects due to 1st trimester exposure (?)d | eAny | May slow progression of DM renal disease when given prior to pregnancy and discontinued early in 1st trimester |
| Diuretics | 3rd Avoid when possible | Decreased uteroplacental flow due to volume contraction | Lasix, PO HCTZ, PO | Avoid aldosterone antagonists (spironolactone) due to anti‐androgenic effect on fetus; avoid completely in preeclampsia |
Abbreviations: ACE, angiotensin‐converting enzyme; ARB, angiotensin receptor blocker; CNS, central nervous system; CVD, cardiovascular disease; DM, diabetes mellitus; HCTZ, hydrochlorothiazide; IV, intravenous; PO, oral; aIV formulations used for hypertensive urgency. bHas been demonstrated in diabetic women but not during pregnancy. cProven teratogenic effects due to exposure during the 2nd and 3rd trimesters only. dPossible effect of 1st trimester exposure, although data are conflicting. eCaptopril, PO, has been shown to slow progression of DM nephropathy during pregnancy without teratogenic effects when used pre‐conception and stopped as soon as pregnancy is diagnosed.