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CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2025;152:e114–e218. DOI: 10.1161/CIR.0000000000001356 September 16, 2025 e175

negative predictive value to rule out preeclampsia.6–9 To date, the heterogeneity in prospective studies limits definitive conclusions about their clinical utility for di­ agnosing preeclampsia.

5.5.3 Short- and Long-Term Follow-Up of

Pregnancy-Associated Hypertension Synopsis

BP measurement and medication titration in the early postpartum period should be individualized and patient centered. ACOG recommends a BP check for individu­ als with an HDP within 3 to 10 days of discharge,1 and HBPM has been shown to improve BP ascertainment. When combined in a team-based approach, including medication self-management and telehealth, HBPM for postpartum individuals with a history of HDP has been associated with lower BP and improved measures of car­ diac structure and function at 6 and 9 months’ postpar­ tum compared with usual care.2,3 These remote strategies may also help compensate for racial disparities in officecentric follow-up strategies, although there is insufficient evidence to definitively confirm reduction of maternal mor­ bidity or mortality or racial disparity outcomes.4 Individuals with a history of gestational hypertension and preeclamp­ sia are at increased risk for the development of CKM risk factors, including chronic hypertension and overt cardio­ vascular and cerebrovascular morbidity and mortality that often occurs prematurely.5–7 Much of this increased risk is mediated through the development of chronic hyperten­ sion; thus, early detection, diagnosis, and management of hypertension in this high-risk group is essential. Postpar­ tum individuals with a history of pregnancy-associated hy­ pertension in whom BP elevations resolve and antihyper­ tensive medications are discontinued are encouraged to have their BP measured at least annually.8 HDP are also recognized as sex-specific risk enhancers that should be taken into consideration when stratifying individuals and discussing the initiation of a statin for primary prevention of CVD.9,10 A discussion of effective contraception in preg­ nancy-capable individuals with chronic hypertension being treated with potentially teratogenic medications is essen­ tial.11–13 Barring no medical contraindications, individuals with a history of HDP should be educated about the ben­ efits of low-dose aspirin and prescribed low-dose aspirin to be taken starting at 12 weeks of gestation during sub­ sequent pregnancies to reduce the risk of preeclampsia.

Table 22.  Common Oral Antihypertensive Agents in Pregnancy Drug Dosage Comments Labetalol 200-2400 mg/d orally in 2 to 3 divided doses. Commonly initiated at 100-200 mg twice daily. Potential bronchoconstrictive effects.

Avoid in women with asthma, preexisting myocardial disease, decompensated cardiac function, and heart block and bradycardia.

Nifedipine 30-120 mg/d orally of an extendedrelease preparation. Commonly initiated at 30- 60 mg once daily (extended release). Do not use sublingual form.

Immediate-release formulation should generally be reserved for control of severe, acutely elevated blood pressures in hospitalized patients. Should be avoided in tachycardia.

Methyldopa 500-3000 mg/d orally in 2 to 4 divided doses. Commonly initiated at 250 mg 2 or 3 times daily. Safety data up to 7 y of age in offspring.

May not be as effective as other medications, especially in control of severe hypertension. Use limited by side effect profile (sedation, depression, dizziness).

Hydrochlorothiazide 12.5-50 mg daily Second- or third-line agent. Reprinted with permission from American College of Obstetricians and Gynecologists.20 Copyright 2019 American College of Obstetricians and Gynecologists. IM indicates intramuscular; and IV, intravenous.

Table 23.  Antihypertensive Agents Used for Urgent Blood Pressure Control in Pregnancy Drug Dose Comments Onset of Action Labetalol 10-20 mg IV, then 20-80 mg every 10-30 min to a maximum cumulative dosage of 300 mg; or constant infusion 1-3 mg/min IV Tachycardia is less common with fewer adverse effects.

Avoid in women with asthma, preexisting myocardial disease, decompensated cardiac function, and heart block and bradycardia. 1-2 min

Hydralazine 5 mg IV or IM, then 5-10 mg IV every 20-40 min to a maximum cumulative dosage of 20 mg; or constant infusion of 0.5-10 mg/h Higher or frequent dosage associated with ma­ ternal hypotension, headaches, and abnormal fetal heart rate tracings; may be more common than other agents. 10-20 min Nifedipine (immediate release) 10-20 mg orally, repeat in 20 min if needed; then 10- 20 mg every 2-6 h; maximum daily dose is 180 mg May observe reflex tachycardia and headaches. 5-10 min Reprinted with permission from American College of Obstetricians and Gynecologists.6 Copyright 2020 American College of Obstetricians and Gynecologists. IM indicates intramuscular; and IV, intravenous.

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