{"paper_id":"28a8341c-24f2-460f-91fe-c792e87d580c","body_text":"Pharmacotherapy for Hypertensive Disorders of Pregnancy: A Systematic Review and Narrative Synthesis of Clinical Practice Guidelines | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Pharmacotherapy for Hypertensive Disorders of Pregnancy: A Systematic Review and Narrative Synthesis of Clinical Practice Guidelines Godfrey Mudhune, Ebenezer Wiafe, Frasia Oosthuizen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8889945/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives We sought to determine the consistency of recent guideline recommendations on pharmacotherapy with antihypertensive agents during pregnancy, and regional variations. Methods PubMed, Web of Science and Google Scholar databases were searched between 12 th and 21 st August 2025 for recent guidelines. Included reports were: published between January 2014 and December 2024; written in or officially translated to English; covered the pharmacological management of at least one HDP; issued by a professional medical society, government body or similar organization and were the most recent versions. Reports were excluded if they were: adapted entirely from existing guidelines; not referencing primary literature or sub-national in scope in the presence of a national document. The strength of recommendations and quality of evidence followed the GRADE or USPSTF criteria. Results were presented thematically across the three outcomes of interest: BP threshold, target and choice of agent. Results Overall, 12 guidelines were included: American Congress of Obstetrics and Gynaecology Task Force 2014; ACOG 2017/19/20; FSH 2016; Hypertension Canada 2018; ISSHP 2021; SOGC 2022; SOMANZ 2023; ESH 2023; WHO 2020 and NICE 2023. Regional scope included: Oceania, Europe, UK, USA, Canada, France and global. Treatment initiation at lower thresholds (BP≥ 140/90 mmHg) and tight control (target DBP 85 mmHg) have gained preference, regardless of comorbidities. Higher thresholds and less tight control more evident in the USA. Labetalol, nifedipine, methyldopa and hydralazine are almost consistently recommended, oral for maintenance and IV for acute treatment, where available. Conclusion Increasing consistency of guideline recommendations is evident, but observations limited to peer-reviewed literature. To optimise outcomes, practitioners should adapt lower thresholds and tight control, with more frequent BP monitoring to inform treatment modification. The review received no specific funding. The protocol was registered with PROSPERO CRD420251118765. Obstetrics & Gynecology Antihypertensives pregnancy HDP guideline threshold target Figures Figure 1 1. Introduction The burden of hypertensive disorders of pregnancy (HDPs), which account for 14% of all maternal deaths globally [1], is expected to rise in most regions, given an increasing prevalence of associated risk factors. In the United States (US) for instance, increases in the prevalence of high risk factors such as chronic hypertension and pre-gestational diabetes, 125% and 57.1%, respectively, and moderate risk factors such as obesity and advanced maternal age, 35.6% and 36.7%, respectively, accompanied an increase in HDP prevalence by 113.6% between 2010 and 2021 [2]. However, due to obvious limitations on the conduct of randomized controlled trials (RCTs) in this vulnerable population, there’s been a paucity of high quality scientific evidence that would more definitively inform treatment strategies. Resultantly, decisions on the blood pressure (BP) treatment thresholds, choice of antihypertensive agents and BP targets have largely remained unclear, sometimes at the discretion of the practitioner [3]. Since most HDP-related maternal deaths arise from sub-optimal care [4], efforts should be made to ensure pharmacotherapy approaches are standardised. Several HDP clinical practice guidelines (CPGs) have routinely been developed by various organisations and professional societies. However, the impact of new and emerging scientific evidence on the practice guidance offered is generally unknown. Abalos and colleagues, in their 2018 meta-analysis, demonstrated that the use of antihypertensive agents for non-severe hypertension, systolic blood pressure (SBP) 140 – 159 mmHg or diastolic blood pressure (DBP) 90 – 109 mmHg, can half the risk of progression to severe disease, BP ≥ 160/110 mmHg, relative risk (RR) 0.49 (95% confidence interval (CI) 0.40 – 0.60; 2,258 women; moderate certainty) [5], therapy that was often reserved for severe hypertension. More recently, the Chronic Hypertension and Pregnancy (CHAP) trial demonstrated an 18% lower risk of placental abruption, foetal death, pre-term birth and neonatal death, (RR 0.82; 95% CI 0.74 – 0.92) with the initiation of antihypertensive treatment at a lower BP of 140/90 mmHg [6, 7]. Further, the Control of Hypertension in Pregnancy Study (CHIPS) demonstrated that tight BP control with a DBP target of 85 mmHg, relative to less tight control with a DBP target of 100 mmHg, is associated with a lower risk of severe hypertension [8], with subsequent post-hoc analysis additionally highlighting a lower risk of serious maternal complications, including pre-eclampsia, symptomatic elevation of liver enzymes and thrombocytopenia [9]. Increasingly, new evidence has been contrary to traditional practice. The strategies for the development, dissemination and implementation of CPGs for the management of HDPs, as with all other CPGs, is often specific to the practice setting. However, the consistency of existing recommendations on treatment with antihypertensive agents across societies, organizations or regions has not been previously determined. Such synthesis would provide a more comprehensive guidance to individual practitioners. Existing guideline reviews on HDPs are either non-specific on key aspects of care that should be provided or precede significant new evidence from RCTs [3, 10-14]. However, they have drawn attention to differing recommendations, specifically on the need to treat mild or moderate BP elevation, order of preference as first or second line antihypertensive agents and the optimal BP targets, all influenced by the type of HDP and associated comorbidities. Scott and colleagues highlighted variability on the thresholds for non-severe hypertension, with similar observations on the targets for both severe and non-severe hypertension. However, they demonstrated some consistency in the choice of antihypertensive agents [3]. Similarly, Tsakiridis and colleagues, in their review of recommendations for chronic hypertension, reported variable thresholds, including BP ≥140/90 mmHg, ≥150/95 mmHg or ≥160/110 mmHg in the absence of comorbidities, with lower thresholds proposed for gestational hypertension superimposed with subclinical organ damage or symptoms. Additionally, variability in the targets was evident, with lower values preferred in the presence of comorbidities such as diabetes and chronic kidney disease. However, similar to Scott and colleagues, some consistency in the choice of antihypertensive agents was evident [10] The primary aim of this review, in light of findings from the CHAP and CHIPS trials, among other evidence, was to provide an updated and more specific determination on the consistency of recent CPG recommendations on pharmacotherapy with antihypertensive agents for HDPs. The outcomes of interest included the BP thresholds, the choice of antihypertensive agents and the BP targets. Additionally, the review sought to investigate any variations in these recommendations across regions. It is anticipated that the findings will contribute towards standardizing clinical practice. 2. Materials and methods The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO), registration number CRD420251118765, and the review is reported in line with the PRISMA recommendations [15]. 2.1 Search strategy A search of the PubMED (Ovid), Web of Science (Clarivate), and Google Scholar databases were run on 12 th , 14 th and 21 st August 2025, respectively. The PICO elements were: population (P), included all pregnant women on follow-up, without any specific restrictions on their characteristics or healthcare setting; intervention/exposure (I), included any diagnosis of a HDP and outcomes (O), included recommendations for pharmacological treatment. The search terms used were: pregnant, gravid, expectant, prenatal, gestational , antenatal, perinatal, maternity, woman, women, female, mother, hypertensive disorder of pregnancy, HDP, chronic hypertension, gestational hypertension, pre-eclampsia, eclampsia , pregnancy-induced hypertension, elevated blood pressure, high blood pressure, uncontrolled blood pressure, hypertension, pharmacological management, medication management, drug therapy, medication therapy, pharmacotherapy, drug treatment, pharmaceutical treatment, medical treatment, drug regimen, antihypertensive treatment, recommendation and guideline. The electronic search strategies are as illustrated (Appendix A). The search was limited to guidelines, government publications, documents or technical reports. However, for the Google Scholar search, only the first 488 results were screened, based on the assumption that the most relevant reports were listed first. Additionally, the reference lists from any retrieved summary reports, consensus documents and position statements were searched for the respective primary guidelines, and the most recent versions included, when appropriate. 2.2 Eligibility criteria Based on the report characteristics, included guidelines were: published between January 1 st 2014 and December 31 st 2024, to capture the most recent recommendations; written in or officially translated to English, due to language restrictions; covered the pharmacological management of at least 1 HDP in human pregnancy and were issued by a government body, professional medical society or similar organization offering structured advice for healthcare professionals, as these sources are more credible. Further, to avoid duplications, only the most recent versions, or updates to any retrieved guidelines were included. Based on the publication characteristics, we excluded guidelines that: did not reference primary literature, as these were not evidence-based; were adapted entirely from existing guidelines, as these did not offer original information and those that were sub-national in scope when there was a relevant national document, as these were unlikely to be comprehensive (Appendix B). 2.3 Guideline selection The selection of guidelines was done through two stages. In the first stage, a preliminary screening of titles and abstracts from retrieved records was performed by two reviewers (GM & EW). Relevant records from each database were identified, merged and duplicates automatically excluded using EndNote 2025 [16]. In the second stage, two reviewers (GM and EW) independently selected guidelines to review and extract relevant data to structured forms, with discrepancies on inclusion resolved by consensus or the inclusion of a third reviewer (FO). 2.4 Data extraction Ultimately, relevant data were extracted by one reviewer (GM) from all eligible guidelines, with a repeat process to enhance validity. Information was obtained on the recommendations relevant to three focus areas of pharmacotherapy: the BP treatment threshold, choice of antihypertensive agent and BP target, with the strength of each recommendation specified. Other data included year of publication, target patient population, organization and region. Where information was insufficient, correspondence with the authors was made via email. 2.5 Synthesis Due to inherent differences in guideline formats, the review adapted a narrative approach to synthesis based on the three focus areas of pharmacotherapy. The specific recommendations were presented in a table, ordered based on the year of publication for correlation with the emergence of new scientific evidence. Additionally, a comparison of the recommendations based on the regional scope of the guidelines was presented, a likely cause of heterogeneity. 3. Results Overall, 896 records were identified from database searches. Excluding 17 duplicates, the titles and abstracts from 879 records were screened, and 39 reports subsequently sought for retrieval and assessed against the eligibility criteria (Figure I). In total 12 guidelines were included in the review. They were developed mostly by professional medical societies, including 8: the American Congress of Obstetrics and Gynaecology Taskforce (n= 1) [17] ; French Society of Hypertension (FSH; n= 1) [18]; American College of Obstetricians and Gynaecologists (ACOG; n= 3) [19-21]; Hypertension Canada (n= 1) [22]; International Society for the Study of Hypertension in Pregnancy (ISSHP; n= 1) [23]; Society of Obstetrician and Gynaecologists of Canada (SOGC; n= 1) [24]; Society of Obstetric Medicine of Australia and New Zealand (SOMANZ; n= 1) [25] and the European Society of Hypertension (ESH; n= 1) [26]. However, some were developed by government bodies or similar organizations, including 2: the World Health Organization (WHO; n= 1) [1] and United Kingdom’s National Institute for Health and Care Excellence (NICE; n= 1) [27]. The guidelines covered diverse regional scope, including Oceania [25] , Europe [26], United Kingdom [27] or even global [1, 23]. Specific to countries included USA [17, 19-21], Canada [22, 24] and France [18] (Table I). The recommendations targeted various sub-types of HDPs, including: severe hypertension [19], chronic hypertension [20], gestational hypertension [21], pre-eclampsia [21], non-severe hypertension [1], arterial hypertension [26] or were unspecific on sub-types [17, 18, 22-25, 27] (Table I). The strength of recommendations and quality of evidence was determined based on criteria adapted by the respective report, mainly GRADE approach [28] or the US Preventive Services Task Force Rating [29] (Online Resource 1 – Supplementary Tables S1 – S7). Table I : Summary characteristics and recommendations from included guidelines Guideline Year Patient condition Organization Region Treatment threshold Treatment choice Treatment target 1. Management of Hypertensive Disorders in Pregnancy [17] 2014 Unspecific HDP American Congress of Obstetrics and Gynaecology Taskforce USA Recommendation: Unspecified SBP ≥160 mmHg or DBP ≥105 mmHg; for severe chronic hypertension Recommendation: Unspecified Acute treatment 1 st line: IV labetalol; IV hydralazine; oral nifepidine 2 nd line: nicardipine; sodium nitroprusside Long-term management 1 st line: labetalol; alpha-methyldopa; clonidine; nifedipine; verapamil; diltiazem 2 nd line: thiazide and loop diuretics Caution ACEIs; ARBs; atenolol and pure alpha blockers Unspecified 2. Hypertension and Pregnancy: Expert Consensus Statement from The French Society of Hypertension, an Affiliate of The French Society of Cardiology [18] 2016 Unspecific HDP FSH France Recommendation: Grade A, Class 1 SBP ≥160 mmHg or DBP ≥110 mmHg Recommendation: Grade C, Class 2 Office SBP 140-159 mmHg or DBP 90-109 mmHg; confirmed with HBPM or daytime average ABPM SBP ≥135 mmHg or DBP ≥85 mmHg; with history of CVD, PD, CKD. Recommendation: Grade B, Class 2 1 st line: alpha-methyldopa; labetalol; nicardipine; nifedipine Recommendation: Grade A, Class 1 Contraindicated ACEIs, ARBs, aliskiren Caution Thiazide diuretics, atenolol, aldosterone antagonists Recommendation: Grade A, Class 1 Office DBP 85-100 mmHg and SBP ˂160 mmHg 3. Committee Opinion No. 692: Emergent Therapy for Acute-Onset, Severe Hypertension During Pregnancy and the Postpartum Period [19] 2017 Severe hypertension ACOG USA Recommendation: Unspecified SBP ≥160 mmHg and/or DBP ≥110 mmHg Recommendation: Unspecified 1 st line: IV labetalol; IV hydralazine; IR nifedipine 2 nd line: Nicardipine infusion pump; Esmolol infusion pump; Sodium nitroprusside Recommendation: Unspecified SBP 140 – 150 mmHg DBP 90 – 100 mmHg 4. Guidelines for the Management of Hypertension in Pregnancy [22] 2018 Unspecific HDP Hypertension Canada Canada Recommendation: Grade D SBP ≥160 mmHg or DBP≥110 mmHg Recommendation: Grade C SBP ≥140 mmHg or DBP ≥90 mmHg; for chronic, gestational or pre-eclampsia Non-severe hypertension Recommendation: Grade C 1 st line: labetalol, methyldopa, long acting nifedipine, acebutolol, metoprolol, pindolol, propranolol Recommendation: Grade D 2 nd line: clonidine, hydralazine, thiazide diuretics Contraindicated ACEIs (Grade C); ARBs (Grade D) Recommendation: Grade B DBP 85 mmHg; for chronic or gestational hypertension Recommendation: Grade D DBP 85 mmHg; for pre-eclampsia 5. Practice Bulletin, Clinical Management Guideline for Obstetrician Gynaecologists No. 203: Chronic Hypertension in Pregnancy [20] 2019 Chronic hypertension ACOG USA Recommendation: Level B SBP 160 mmHg and/or DBP 110 mmHg or SBP 150 mmHg / DBP 100 mmHg in presence of comorbidities, impaired renal function, LV hypertrophy, severe thrombocytopenia Recommendation: Level B Severe hypertension 1 st line: IV labetalol; IV/IM hydralazine; IR nifedipine 2 nd line: nicardipine infusion pump, esmolol infusion pump; IV enalapril Maintenance treatment 1 st line: Labetalol; nifedipine; methyldopa 2 nd line: clonidine; prazosin; HCTZ Contraindicated ACEIs; ARBs; renin inhibitors; mineralocorticoid receptor antagonists; atenolol Recommendation: Level C SBP 120 to ˂160 mmHg DBP 80 to ˂110 mmHg or lower SBP / DBP in presence of diabetes or renal disease 6. Practice Bulletin, Clinical Management Guideline for Obstetrician Gynaecologists No. 222: Gestational Hypertension and Pre-eclampsia [21] 2020 Gestational hypertension; Pre-eclampsia ACOG USA Recommendation: Level B SBP ≥160 mmHg and/or DBP ≥110 mmHg Recommendation: Unspecified Severe hypertension IV hydralazine; IV labetalol; IR nifedipine Expectant management Labetalol; short-acting nifedipine Recommendation: Unspecified Unspecified 7. Recommendations on Drug Treatment for Non-Severe Hypertension in Pregnancy [1] 2020 Non-severe hypertension WHO International Recommendation: Context-specific SBP 140-159 mmHg or DBP 90-109 mmHg; with good quality ANC follow-up Recommendation: Context-specific Oral alpha agonist: methyldopa Beta-lockers: acebutolol; atenolol; labetalol; mepindolol; metoprolol; oxprenolol; pindolol; propranolol Caution CCBs; ACEIs; ARBs; sodium nitroprusside Unspecified 8. Classification, Diagnosis and Management Recommendations for International Practice [23] 2021 Unspecific HDP ISSHP International Recommendation: +3 strong BP ≥140/90 mmHg Recommendation: +3 strong Severe hypertension 1 st line: oral nifedipine, oral labetalol, IV hydralazine, IV labetalol 2 nd line: other beta-blockers, other CCBs, prazosin Non-severe hypertension 1 st line: oral methyldopa, labetalol, nifedipine 2 nd line: metoprolol Other: amlodipine, diltiazem, oral hydralazine, prazosin, diuretics Contraindicated ACEIs, ARBs Recommendation: +4 strong DBP 85 mmHg 9. Guideline No. 426: Hypertensive Disorders of Pregnancy; Diagnosis, Prediction, Prevention and Management [24] 2022 Unspecific HDP SOGC Canada Recommendation: Strong, moderate SBP ≥140 mmHg or DBP ≥ 90 mmHg Recommendation: Strong, low SBP ≥160 mmHg or DBP ≥110 mmHg Recommendation: Unspecified Urgent control Oral labetalol, IV labetalol, nifedipine oral capsule, IV hydralazine Non-urgent control Labetalol, extended release nifedipine, methyldopa Recommendation: Strong, moderate DBP 85 mmHg; for chronic or gestational hypertension or Recommendation: Conditional, low DBP 85 mmHg; for pre-eclampsia 10. Hypertension in Pregnancy Guideline [25] 2023 Unspecific HDP SOMANZ Oceania Recommendation: Unspecified SBP ≥140 mmHg and/or DBP ≥90 mmHg or SBP ≥160 mmHg and/or DBP ≥110 mmHg Stable hypertension Recommendation: 2C 1 st line: oral labetalol; oral methyldopa; oral SR nifedipine Recommendation: PP Oral hydralazine Other agents: oral clonidine; oral IR nifedipine Acute severe hypertension Recommendation: 2C 1 st line: IV hydralazine; IV labetalol; oral IR nifedipine; IV diazoxide Recommendation: PP 2 nd /3 rd line: IV infusion labetalol; IV infusion hydralazine Other agents: oral methyldopa (1g STAT); oral labetalol (200mg/hr) Recommendation: 1C SBP ≤135 mmHg and DBP ≤85 mmHg; for gestational or chronic hypertension Recommendation: PP BP <160/110 mmHg; for acute severe hypertension 11. Guidelines for the Management of Arterial Hypertension [26] 2023 Arterial hypertension ESH Europe Recommendation: Class 1, Level C SBP≥140 mmHg and/or DBP ≥90 mmHg Recommendation: Class 1, Level B Pre-existing and gestational hypertension 1 st line: labetalol; alpha-methyldopa Alternative: ER nifepidine Recommendation: Unspecified Severe hypertension 1 st line: IV labetalol; IV urapidil 2 nd line: IV hydralazine 3 rd line: IV sodium nitroprusside Other: IV nitroglycerin, if pulmonary oedema present; short-acting oral nifedipine (10mg) Recommendation: Class III, Level C Contraindicated ACEIs; ARBs; direct renin inhibitors Others for caution: sublingual short-acting nifepidine (unspecified); hydralazine (unspecified) Recommendation: Class 1, Level A BP <140/90 mmHg; for pre-existing hypertension Recommendation: Class 1, Level C BP <140/90 mmHg; for gestational hypertension Recommendation: Unspecified SBP <160 mmHg and DBP <105 mmHg; for eclampsia and severe pre-eclampsia 12. Hypertension in Pregnancy: Diagnosis and Management [27] 2023 Unspecific HDP NICE United Kingdom Recommendation: Unspecified SBP ≥140 mmHg or DBP ≥90 mmHg; for chronic, gestational hypertension, or pre-eclampsia or SBP ≥160 mmHg or DBP ≥110 mmHg; for all women Recommendation: Unspecified Chronic hypertension Labetalol; nifedipine; methyldopa; in order of preference Severe hypertension Oral/IV labetalol; oral nifedipine; IV hydralazine Recommendation: Unspecified SBP 135 mmHg, DBP 85 mmHg; for chronic, gestational, severe hypertension and pre-eclampsia Abbreviations: ACOG – American College of Obstetricians and Gynaecologists; ESH – European Society of Hypertension; FSH – French Society of Hypertension; NICE – National Institute for Health and Care Excellence; SOMANZ – Society of Obstetric Medicine of Australia and New Zealand; USA – United States of America; WHO – World Health Organization; SBP – systolic blood pressure; DBP – diastolic blood pressure; IV – intravenous; IR – immediate release; SR – sustained release; LV – left ventricular; HCTZ – hydrochlorothiazide; ACEI – angiotensin converting enzyme inhibitor; ARB – angiotensin II receptor blocker; CCB – calcium channel blocker; ISSHP – International Society for the Study of Hypertension in Pregnancy; HBPM – home blood pressure monitoring; ABPM – ambulatory blood pressure monitoring; CVD – cardiovascular disease; PD – pre-gestational diabetes; CKD – chronic kidney disease; ANC – ante-natal care; HDP – hypertensive disorder of pregnancy 3.1 Treatment threshold The strength of recommendations and/or quality of evidence varied, including: unspecified by the American Congress of Obstetrics and Gynaecology Taskforce, ACOG, SOMANZ and NICE; Class 1/2, Grade A/C by FSH; Grade C/D by Hypertension Canada; Level B by ACOG; context-specific by WHO; Strong /Strong Moderate/ Strong Low by ISSHP and SOGC and Class 1, Level C by ESH (Table I) (Online Resource 1 – Supplementary Tables S1 – S7). Earlier guidelines, developed between 2014 and 2020 by the American Congress of Obstetrics and Gynaecology Taskforce, FSH, ACOG and Hypertension Canada, mainly recommend the initiation of pharmacotherapy with antihypertensive agents for severe BP elevation, confirmed through persistent SBP ≥160 mmHg and/or DBP ≥110 mmHg over a 15-minute period [17-22]. However, lower thresholds, including: SBP 140-159 mmHg or DBP 90 -109 mmHg; SBP ≥140 mmHg or DBP ≥90 mmHg and SBP 150 mmHg or DBP 100 mmHg, have been recommended by FSH [18], Hypertension Canada [22] and ACOG [20], respectively, for women with histories of cardiovascular disease, pre-gestational diabetes, chronic kidney disease, chronic or gestational hypertension, pre-eclampsia, left ventricular hypertrophy and severe thrombocytopenia (Table I). Subsequent guidelines, developed between 2020 and 2023 by the WHO, ISSHP, SOGC, SOMANZ, ESH and NICE more consistently recommend treatment initiation at lower thresholds of sustained SBP ≥140 mmHg and/or DBP ≥90 mmHg, determined through repeat BP measurements [1, 23-27] (Table I). Notably, only the FSH recommends triangulation of office BP measurements with home-based or daytime ambulatory measurements, with a diagnosis of a HDP only confirmed with SBP ≥ 135 mmHg or DBP ≥ 85 mmHg from the latter [18] (Table I). 3.2 Treatment choice The strength of the recommendations and/or quality of evidence varied, including unspecified by the American Congress of Obstetrics and Gynaecology Taskforce, ACOG, SOGC, NICE and ESH’s guidance on severe hypertension; Class 1/2, Grade A/B by FSH; Grade C/D by Hypertension Canada; Level B by ACOG; context-specific by WHO; Strong by ISSHP; 2C/Practice Point by SOMANZ and Class I/III, Level B/C by ESH (Table I) (Online Resource 1 – Supplementary Tables S1 – S7). The choice of agent should be individualised, based on: the presence of any contraindications, risks or potential adverse events; the patient characteristics and pre-existing treatments, if any; cost; local availability; and both clinician and patient preferences [1, 20, 23, 25]. Generally, the FSH discourages the use of any antihypertensive agent in the absence of specialist advice [18]. Similarly, the WHO contextually recommends limiting use to settings with good quality ANC follow-up, minimising potential maternal and foetal risks of unmonitored therapy [1]. In the management of acute or severe hypertension, antihypertensive agents should be initiated within 30 – 60 minutes in a monitored setting to support identification of adverse effects and treatment modification [27]. The aim is to prevent renal injury, myocardial ischaemia, congestive heart failure and stroke [19, 21, 23]. The preferred first-line agents, mostly administered intravenously (IV), are not necessarily considered as complimentary but alternate treatments as patients may respond to one drug class and not the other [19-21]. They include IV labetalol, IV/intramuscular (IM) hydralazine, IV sodium nitroprusside for extreme emergencies, and in the absence of IV access, oral capsules or immediate release (IR) nifedipine [17, 19-21, 23, 24]. More recently, IV diazoxide [25] and IV urapidil [26] have also been recommended (Table I). The preferred second-line agents include nicardipine and esmolol by infusion pumps, IV enalapril, other beta-blockers, other calcium channel blockers (CCBs) and prazosin [17, 19, 20, 23]. Further, IV infusions of labetalol and hydralazine, oral methyldopa as a single dose of 1gram, and oral labetalol at a dose of 200mg/hour, have also been proposed as alternative treatment strategies [25, 27], with IV infusion nitroglycerin, initially at 5mg/min, also preferred in the presence of pulmonary oedema [26] (Table I). The use of institutional order sets to guide treatment intensification is recommended by ACOG [19-21] (Table II). Table II. Order sets for the intensification of antihypertensive agents during acute emergencies in pregnancy. Guideline First-line Antihypertensive Agent Hydralazine Labetalol Nifedipine ACOG 2017 [19] Initial 5/10 mg IV; if BP target still exceeded after 20 min. administer 10mg IV; if target persistently exceeded after 20 min. administer labetalol 20 mg IV; if target still exceeded after 10 min. repeat labetalol 40 mg IV a Initial 20 mg IV; if BP target still exceeded after 10 min. administer 40 mg IV; if target still exceeded after 10 min. administer 80 mg IV; if target persistently exceeded after 10 min. administer hydralazine 10 mg IV a Initial 10 mg orally; if BP target still exceeded after 20 min. administer capsule 20 mg orally; if target still exceeded after 20 min repeat 20 mg capsule; if target persistently exceeded after 20 min. administer labetalol 40 mg IV a ACOG 2020 [21] Initial 5mg IV/IM; then 5-10 mg every 20-40 minutes, max. cumulative dose of 20mg OR Constant infusion of 0.5-10 mg/hr Initial 10-20mg IV, then 20-80 mg every 10-30 min, max. cumulative dose of 300mg OR Constant infusion of 1-2mg/min IV Initial 10-20 mg orally, repeat in 20 min if needed, then 10-20 mg every 2-6 hours, max. dose of 180 mg/day a If foetus is undelivered and still viable, foetal surveillance should always be instituted. If target is achieved, always monitor BP over subsequent 7 hours. If target remains persistently exceeded, administer additional agent per specific order set after specialist consultation. Abbreviations: ACOG – American College of Obstetricians and Gynaecologists; IV – intravenous; IM – intramuscular; mg – milligrams; hr – hour; min – minute In the expectant management of stable non-severe hypertension, initial treatment should generally be monotherapy, with subsequent combination agents selected from dissimilar drug classes [22, 23]. The preferred first-line agents include labetalol, alpha-methyldopa, long-acting nifedipine, verapamil, diltiazem, nicardipine, acebutolol, mepindolol, oxprenolol, pindolol, and propranolol, all administered orally [1, 17, 18, 20-27]. The second-line agents, also administered orally, include thiazide and loop diuretics, clonidine, amlodipine, hydralazine, prazosin, and metoprolol [17, 20-23, 26]. However, labetalol, nifedipine and methyldopa, in order of preference, are generally considered the superior options for long term chronic maintenance [20, 26, 27] (Table I) The doses for maintenance treatment include: oral labetalol 200 - 2400 mg/day in 2 to 3 divided doses, initiated at 100 – 200 mg twice daily [20, 21]; oral extended release nifedipine 30 – 120 mg/day, initiated at 30 – 60 mg once daily and oral methyldopa 500 – 3000 mg/day in 2 to 4 divided doses, initiated at 250 mg twice or thrice daily [20]. Monotherapy should be up-titrated to a mid-range dose before any combination is considered [26]. If an additional agent is necessary, it is best initiated at a standard dose, with the existing treatment maintained at the mid-range dose. The use of maximum doses for any single agent is discouraged [23, 25]. The CCBs, which are additionally renal protective, may offer extra benefit in diabetics, with verapamil and diltiazem further advantageous in patients with cardiac disease [17]. However, the nifedipine formulations recommended vary based on the patient presentation, with use discouraged in the presence of aortic stenosis [25]. For acute treatment of severe hypertension, if IV access is not available, oral short-acting capsules and IR formulations are recommended by the American Congress of Obstetricians and Gynaecologists Taskforce, ACOG, ISSHP, SOGC, SOMANZ, ESH and NICE, while for expectant management of stable hypertension, long-acting, extended-release (ER) and sustained-release (SR) formulations are recommended (Table I). The use of agents that affect the renin-angiotensin-aldosterone system (RAAS), including angiotensin converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs) and direct renin inhibitors, all associated with foetal nephrotoxicity, and other adverse outcomes more common with second and third trimester use, including severe hypotension, pulmonary hypoplasia, growth restriction, foetal death, anhydramnios, oligohydramnios and hypocalvaria [17, 18, 27], is consistently contraindicated by the American Congress of Obstetricians and Gynaecologists Taskforce, FSH, Hypertension Canada, ACOG, WHO, ISSHP, ESH and NICE (Table I). Other agents with caution advised include: methyldopa, risks of somnolence and postnatal depression [1, 20]; clonidine, risk of rebound hypertension after sudden withdrawal [25]; atenolol, intra-uterine growth restriction (IUGR) and oligohydramnios [17, 18]; pure alpha blockers such as prazosin, increased risk of heart failure [17]; thiazide diuretics, theoretical risk of volume depletion [17], with FSH limiting use as a last resort therapy for high-grade hypertension pre-dating pregnancy [18]; aldosterone and mineralocorticoid receptor antagonists, teratogenic effects in animal models and anti-androgen effects [18]; sodium nitroprusside, cyanide and thiocynate toxicity in mother, foetus or neonate if use is prolonged [1, 19]; and sublingual short-acting nifedipine and hydralazine, associated with maternal hypotension, abnormal foetal heart rate and headaches [19-21, 23]. The hydralazine-induced hypotension is avoidable through crystalloid fluid pre-loading [25, 27]. However, the ESH categorically discourages its use due to worse perinatal effects, relative to other drugs, limiting it to unavailability of other first-line IV agents, unresolved or severe postpartum hypertension, severe heart failure, 2 nd or 3 rd degree atrioventricular (AV) block, bradycardia or asthma [26]. Ultimately, the use of labetalol, and other beta-blockers, in women with a history of uncontrolled asthma and heart disease is discouraged, as exacerbations may occur, with IV administration further associated with a risk of neonatal bradycardia, hence foetal heart rate monitoring is encouraged [19, 20, 23]. 3.3 Treatment target The recommendations on the BP targets are mostly based on moderate or inconsistent scientific evidence, similar to the choice of antihypertensive agents, with consensus statements and expert opinions frequently guiding practice. The strength of the recommendations and/or quality of evidence varied, including: unspecified by ACOG and NICE; Grade A, Class 1 by FSH; Grade B/D by Hypertension Canada; Level C by ACOG, Strong/Strong Moderate or Conditional Low by ISSHP and SOGC; 1C /Practice Point by SOMANZ; and Class 1, Level A/C by ESH (Online Resource 1 – Supplementary Tables S1 – S7) (Table I). However, the American Congress of Obstetrics and Gynaecology Taskforce, ACOG’s 2020 practice bulletin for gestational hypertension and pre-eclampsia and WHO’s 2020 recommendations for non-severe hypertension, did not explicitly specify any targets. A general consensus is that the aim of treatment is not to normalise BP, but to reduce the risk of complications that may arise from persistent elevation. Earlier guidelines, by FSH and ACOG, mainly recommended less tight BP control, including targets of: office SBP <160 mmHg and DBP 85 - 100 mmHg [18]; SBP 140 - 150 mmHg and DBP 90 - 100 mmHg for severe hypertension [19]; and SBP 120 to <160 mmHg and DBP 80 to <110 mmHg for chronic hypertension [20] (Table I). However, in more recent guidelines, less tight BP control, if at all proposed, is limited only to cases of acute severe hypertension, severe pre-eclampsia or eclampsia, with target BP <160/110 mmHg by SOMANZ or SBP <160 mmHg and DBP <105 mmHg by ESH (Table I). Generally, most guidelines recommend tight BP control, including: Hypertension Canada, ISSHP and SOGC, target DBP 85 mmHg regardless of HDP sub-type [22-24]; SOMANZ, SBP ≤135 mmHg and DBP ≤85 mmHg for gestational and chronic hypertension [25]; and NICE, SBP 135 mmHg with DBP 85 mmHg, also regardless of HDP sub-type [27] (Table I). Additionally, lower BP targets are advised for women with comorbid diabetes or renal disease [20]. 3.4 Regional variation A preference for higher BP treatment thresholds and less tight control, often influenced by patient characteristics, was evident within the USA, while most other regions adapted lower thresholds and tight control. However, this was period-dependent. No significant variations in the agent choice were observed, but differences exist in the order of preference as either first or second line. 4. Discussion This systematic review provides the first synthesis of recent CPG recommendations on the pharmacological treatment of hypertension during pregnancy, following significant RCT results over the preceding 10 years, and investigates any regional differences that may influence practice. The utility of CPGs is greatly dependent on the rigor of their development, and with rapidly evolving scientific evidence, updates are critical in ensuring relevance and applicability [30]. The leading role of professional medical societies in providing practice guidance for this critical pregnancy complication, relative to government bodies, is evident in this review. As important stakeholders in the development of global, regional and national policies that seek to advance maternal and new-born health, capacity building these societies, and establishment of memoranda of understanding with governments, can only be beneficial, as already demonstrated by the FIGO LOGIC initiative [31]. Signalling an increasing shift towards a more standardised treatment strategy, the scope and purpose of the reviewed guidelines was often unspecific on the HDP sub-type. Despite previous meta-analysis demonstrating a 50% reduction in the risk of severe hypertension with treatment initiation at lower BP thresholds, ≥140/90 mmHg [5], the lack of evidence on direct benefit to important clinical outcomes may not have supported change in practice. In majority of the retrieved guidelines, disseminated between 2014 and 2020, treatment preference was for severe hypertension, BP ≥160/110 mmHg, unless comorbidities were present. The findings from the CHAP trial, which focussed beyond surrogate outcomes and further demonstrated an 18% reduction in the risks of foetal and neonatal death [6, 7], may have tilted this balance. Subsequent guidelines, after the WHO’s context-specific recommendation for initiation of antihypertensive treatment at SBP 140-159 mmHg or DBP 90-109mmHg [1], have consistently been in favour of lower treatment thresholds, regardless of comorbidities. Arguably, a paucity of guideline recommendations exist on the practical application of out-of-office BP monitoring in pregnancy, both in the diagnosis of HDPs and monitoring of response to antihypertensive treatment. However, the FSH, in their 2016 guidelines, recommend its confirmatory use for diagnosis [18]. Pregnancy is often characterised by dynamic changes in BP, and its accurate measurement is important. To optimize treatment decisions, and reduce the risk of missed treatment opportunities or unnecessary treatment that may arise from masked or white coat hypertension, respectively, adjunctive use of home-based or ambulatory monitoring, in addition to office measurement, should be integrated into routine practice [32]. The initiation of antihypertensive treatment continues to demonstrate favourable outcomes, with the main preferred pharmacological classes including: centrally acting α2 adrenergic agonists, peripherally acting adrenergic receptor antagonists, CCBs, direct vasodilators and diuretics. In this review, despite consistency across most guidelines on the choice of antihypertensive agents, with labetalol, nifedipine, methyldopa and hydralazine being largely the preferred options, the recommendations are mostly based on moderate or inconsistent scientific evidence, drawn largely from studies with questionable internal validity or that report on un-validated surrogate outcomes, or even based purely on expert opinion. Further, almost half of the reviewed guidelines did not specify the strength of their recommendations on agent choice, highlighting underlying uncertainty. Limited RCTs on efficacy have demonstrated clear superiority or inferiority of any single agent in pregnancy, and recommendation as first or second line, observed to slightly vary, is probably based more on the safety profile and practice context, including cost, availability, clinician and patient preferences. This review highlights that the recommended IV agents during the management of acute severe hypertension in pregnancy may be more of substitutes than complimentary treatments. The use of order sets, such as those proposed by ACOG for the intensification of hydralazine, labetalol and nifedipine administration [19, 21], should be adapted across practice settings, to ensure effective BP control in emergencies. Pharmacogenetics is increasingly gaining significance in antihypertensive treatment during pregnancy. Drug classes such as beta-blockers, metabolised by CYP2D6 enzyme, have been thought to lose effectiveness over the course of pregnancy, as this enzyme activity progressively increases. Similarly, genetic polymorphisms, affecting the eNOS gene and NAT enzyme, may result in variations in response to atenolol and hydralazine, respectively, in this category of women [33]. Evidently, treatment approaches should be individualized. The CHIPS trial, a multicentre international study that included 987 women between 14 to 33 weeks of gestation with either chronic or gestational hypertension, compared less tight BP control, target DBP 100 mmHg, to tight, target DBP 85 mmHg. The onset of severe hypertension was more frequent with less tight control, relative to the tight, 40.6% and 27.5%, respectively [8]. Further, higher risk of serious maternal complications, including preeclampsia, thrombocytopenia, hepatic injury and prolonged hospital stay was evident [9]. Most guidelines, based on the findings from this review, increasingly advocate for tight BP control, a sure way of optimizing both maternal and foetal outcomes. Ultimately, this systematic review highlights that, over the years, there has been an increasing harmony in practice guideline recommendations on pharmacotherapy with antihypertensive agents for HDPs, despite minor regional variations in the BP threshold and target that were observed in earlier periods. 4.1 Implications to practice The management of women presenting with hypertension during pregnancy presents a clinical conundrum, given the need to balance maternal wellbeing and foetal safety. Therefore, care approaches should be individualised and evidence-based, encouraging shared and informed decision making that consider any associated risks and benefits. To optimize maternal and foetal outcomes, practitioners should embrace lower treatment thresholds and tight control, both increasingly recommended based on emerging scientific evidence. Further, to ensure the effectiveness of treatment in achieving set targets, and inform any modifications, routine blood pressure monitoring is important. The use of out-of-office measurements, and their timely reporting, should be encouraged across all practice settings. Future research should explore the utility of additional treatment options, including the increasing role of anti-angiogenic and pro-angiogenic factors, both associated with the onset of HDPs [14]. Metformin and esomeprazole, which decrease anti-angiogenic factors, and pravastatin, which upregulates pro-angiogenic factors, have been considered as potential treatment, if repurposed. 4.2 Limitations The search strategy only included peer-reviewed published recommendations from the selected databases. Hence, the consistency of recommendations from the grey literature, or other sources, with the observations made herein, is unknown. Declarations 5.1 Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. 5.2 Competing Interests The authors have no relevant financial or non-financial interests to disclose. 5.3 Author contributions Conceptualization: Godfrey Mudhune and Frasia Oosthuizen; Literature search and eligibility screening: Godfrey Mudhune and Ebenezer Wiafe; Data extraction and synthesis: Godfrey Mudhune; Writing – original draft preparation: Godfrey Mudhune; Writing – review and editing: Godfrey Mudhune, Ebenezer Wiafe and Frasia Oosthuizen. 5.4 Ethics approval No ethical approval was required for this study. References WHO. Recommendations on drug treatment for non-severe hypertension in pregnancy. Geneva, Switzerland: World Health Organization (WHO); 2020. Available from: https://iris.who.int/server/api/core/bitstreams/f989de9f-d3de-4d3f-baa7-9b31354f6c0d/content. Ayyash MK, McLaren RJ, Shaman M, Al-Kouatly HB. Trends in reeclampsia risk factors in the US from 2010 to 2021. JAMA. 2024;332(2):167-9. doi: 10.1001/jama.2024.8931. Scott G, Gillon TE, Pels A, von Dadelszen P, Magee LA. Guidelines-similarities and dissimilarities: a systematic review of international clinical practice guidelines for pregnancy hypertension. Am J Obstet Gynecol. 2022;226(2):S1222-S36. Epub 20082020. doi: 10.1016/j.ajog.2020.08.018. PubMed PMID: WOS:000759636700035. Shennan AH, Redman C, Cooper C, Milne F. Are most maternal deaths from pre-eclampsia avoidable? Lancet. 2012;379(9827):1686-7. Epub 14122011. doi: 10.1016/s0140-6736(11)60785-x. PubMed PMID: 22177535. Abalos E, Duley L, Steyn DW, Gialdini C. Antihypertensive drug therapy for mild to moderate hypertension during pregnancy. Cochrane Database Syst Rev. 2018;10(10):CD002252. Epub 20181001. doi: 10.1002/14651858.CD002252.pub4. PubMed PMID: 30277556; PubMed Central PMCID: PMCPMC6517078. Tita AT, Szychowski JM, Boggess K, Dugoff L, Sibai B, Lawrence K, et al. Treatment for mild chronic hypertension during pregnancy. N Engl J Med. 2022;386(19):1781-92. Epub 02042022. doi: 10.1056/NEJMoa2201295. Holliman KD, Lowe V, Nonni G. Management of blood pressure in pregnancy: new perspectives from the CHAP trial. Curr Opin Obstet Gynecol. 2023;35(2):81-6. Epub 03012023. doi: 10.1097/gco.0000000000000845. PubMed PMID: 36912258. Magee LA, von Dadelszen P, Rey E, Ross S, Asztalos E, Murphy KE, et al. Less-tight versus tight control of hypertension in pregnancy. N Engl J Med. 2015;372(5):407-17. doi: 10.1056/NEJMoa1404595. PubMed PMID: 25629739. Magee LA, von Dadelszen P, Singer J, Lee T, Rey E, Ross S, et al. The CHIPS randomized controlled trial (Control of Hypertension in Pregnancy Study): Is severe hypertension just an elevated blood pressure? Hypertension. 2016;68(5):1153-9. Epub 12092016. doi: 10.1161/hypertensionaha.116.07862. PubMed PMID: 27620393; PubMed Central PMCID: PMCPMC5058640. Tsakiridis I, Giouleka S, Arvanitaki A, Giannakoulas G, Papazisis G, Mamopoulos A, et al. Gestational hypertension and preeclampsia: an overview of national and international guidelines. Obstet Gynecol Surv. 2021;76(10):613-33. doi: 10.1097/OGX.0000000000000942. Brown CM, Garovic VD. Drug treatment of hypertension in pregnancy. Drugs. 2014;74(3):283-96. doi: 10.1007/s40265-014-0187-7. PubMed PMID: WOS:000332078100001. Sinkey RG, Battarbee AN, Bello NA, Ives CW, Oparil S, Tita ATN. Prevention, diagnosis, and management of hypertensive disorders of pregnancy: a comparison of international guidelines. Curr Hypertens Rep. 2020;22(9). Epub 27082020. doi: 10.1007/s11906-020-01082-w. PubMed PMID: WOS:000567404600006. Gillon TER, Pels A, von Dadelszen P, MacDonell K, Magee LA. Hypertensive disorders of pregnancy: A systematic review of international clinical practice guidelines. PLoS One. 2014;9(12). doi: 10.1371/journal.pone.0113715. PubMed PMID: WOS:000347114900068. Dymara-Konopka W, Laskowska M, Oleszczuk J. Preeclampsia: Current management and future approach. Curr Pharm Biotechnol. 2018;19(10):786-96. doi: 10.2174/1389201019666180925120109. PubMed PMID: WOS:000452533100005. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. doi: 10.1136/bmj.n71. The EndNote Team. EndNote. EndNote 2025 ed. Philadelphia, PA: Clarivate; 2013. Moussa HN, Arian SE, Sibai BM. Management of hypertensive disorders in pregnancy. Womens Health (Lond). 2014;10(4):385-404. doi: 10.2217/whe.14.32 Mounier‐Vehier C, Amar J, Boivin J, Denolle T, Fauvel J, Plu‐Bureau G, et al. Hypertension and pregnancy: expert consensus statement from the French Society of Hypertension, an affiliate of the French Society of Cardiology. Fundam Clin Pharmacol. 2017;31(1):83-103. Epub 21122016. doi: 10.1111/fcp.12254. ACOG. Committee opinion number 692: Emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period. Obstet Gynecol. 2017;129(4):e90-e5. doi: 10.1097/aog.0000000000002019. PubMed PMID: 28333820. ACOG. Practice bulletin number 203: Chronic hypertension in pregnancy. Obstet Gynecol. 2019;133(1):e26-e50. doi: 10.1097/aog.0000000000003020. PubMed PMID: 30575676. ACOG. Gestational hypertension and preeclampsia: Practice bulletin number 222. Obstet Gynecol. 2020;135(6):e237-e60. doi: 10.1097/aog.0000000000003891. PubMed PMID: 32443079. Butalia S, Audibert F, Côté AM, Firoz T, Logan AG, Magee LA, et al. Hypertension Canada’s 2018 guidelines for the management of hypertension in pregnancy. Can J Cardiol. 2018;34(5):526-31. doi: 10.1016/j.cjca.2018.02.021. Magee LA, Brown MA, Hall DR, Gupte S, Hennessy A, Karumanchi SA, et al. The 2021 International Society for the Study of Hypertension in Pregnancy classification, diagnosis & management recommendations for international practice. Pregnancy Hypertens. 2022;27:148-69. Epub 09102021. doi: 10.1016/j.preghy.2021.09.008. PubMed PMID: 35066406. Magee LA, Smith GN, Bloch C, Côté AM, Jain V, Nerenberg K, et al. Guideline number 426: Hypertensive disorders of pregnancy - diagnosis, prediction, prevention and management. J Obstet Gynaecol Can. 2022;44(5):547-71. doi: 10.1016/j.jogc.2022.03.002. PubMed PMID: WOS:000797693200018. SOMANZ. Society of Obstetric Medicine of Australia and New Zealand, Hypertension in Pregnancy Guideline 2023. 2024 12/12/2025 [cited 23/12/2025]. Sydney, Australia: Society of Obstetric Medicine Australia and New Zealand (SOMANZ), [cited 23/12/2025]; [15-22]. Available from: https://somanz.org/content/uploads/2024/01/SOMANZ_Hypertension_in_Pregnancy_Guideline_2023.pdf. Mancia G, Kreutz R, Brunström M, Burnier M, Grassi G, Januszewicz A, et al. 2023 ESH guidelines for the management of arterial hypertension; The task force for the management of arterial hypertension of the European Society of Hypertension: Endorsed by the International Society of Hypertension (ISH) and the European Renal Association (ERA). J Hypertens. 2023;41(12):1874-2071. Epub 26092023. doi: 10.1097/hjh.0000000000003480. PubMed PMID: 37345492. NICE. Hypertension in pregnancy: diagnosis and management. UK: National Institute for Health and Care Excellence (NICE); 2023. p. 10-27. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336(7650):924-6. doi: 10.1136/bmj.39489.470347.AD. Barry MJ, Wolff TA, Pbert L, Davidson KW, Fan TM, Krist AH, et al. Putting evidence into practice: An update on the US Preventive Services Task Force methods for developing recommendations for preventive services. Ann Fam Med. 2023;21(2):165-71. doi: 10.1370/afm.2946. Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ. 2010;182(18):E839-E42. doi: 10.1503/cmaj.090449. Taylor DJ. The role of health professional organizations in improving maternal and newborn health: The FIGO LOGIC experience. Int J Gynaecol Obstet. 2015;131:S71-S4. Epub 25022015. doi: 10.1016/j.ijgo.2015.02.007. Bello NA, Miller E, Cleary K, Wapner R, Shimbo D, Tita AT. Out of office blood pressure measurement in pregnancy and the postpartum period. Curr Hypertens Rep. 2018;20(12):101. Epub 20181025. doi: 10.1007/s11906-018-0901-z. PubMed PMID: 30361886; PubMed Central PMCID: PMCPMC6327956. Haas DM. Pharmacogenetics and individualizing drug treatment during pregnancy. Pharmacogenomics. 2014;15(1):69-78. doi: 10.2217/pgs.13.228. PubMed PMID: 24329192; PubMed Central PMCID: PMCPMC4064360. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-8889945\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":true,\"archivedVersions\":[],\"articleType\":\"Systematic Review\",\"associatedPublications\":[],\"authors\":[{\"id\":591881357,\"identity\":\"50853fef-e636-4944-9063-ba0bed091493\",\"order_by\":0,\"name\":\"Godfrey Mudhune\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIiWNgGAWjYHACgw9QhhmIkAMRBx7g12I4A1mLMVhLAilaEhtAJD4t8u7NG5srKg4z6M5I3vaYd4dN+vywww+BttjJ6TbgsOLMscLGM2cOM5jdSCs35j2TlrvxdpoBUEuysdkBXK7KMX/Y2AbSkmMmzdt2OHfj7ASQlgOJ23BrMWxs/AfX8j/dcHb6B7xa5CVAWhrgWg4kyEvn4LfFgAfol4Zj6TxmZ56VSc5tSzbcIJ1TcCDBALdf5NubNzY21FjLmR1P3ibxts1OXn52+uYPHyrs5HBpMYCIN/OgiRhgVw62pQFM1WGIjIJRMApGwSiAAwDEzmYSjSVF6gAAAABJRU5ErkJggg==\",\"orcid\":\"https://orcid.org/0000-0003-3190-6457\",\"institution\":\"Discipline of Pharmaceutical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Godfrey\",\"middleName\":\"\",\"lastName\":\"Mudhune\",\"suffix\":\"\"},{\"id\":591881358,\"identity\":\"13062599-15a7-41f8-9ebb-f9dd095def6c\",\"order_by\":1,\"name\":\"Ebenezer Wiafe\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Centre of Excellence for Pharmacovigilance in Southern Africa, School of Public Health, University of the Western Cape, Bellville, South Africa\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Ebenezer\",\"middleName\":\"\",\"lastName\":\"Wiafe\",\"suffix\":\"\"},{\"id\":591881359,\"identity\":\"fd9689b0-2111-4dd6-99ed-ad9888b5de95\",\"order_by\":2,\"name\":\"Frasia Oosthuizen\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Discipline of Pharmaceutical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Frasia\",\"middleName\":\"\",\"lastName\":\"Oosthuizen\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2026-02-16 05:47:01\",\"currentVersionCode\":1,\"declarations\":{\"humanSubjects\":true,\"vertebrateSubjects\":false,\"conflictsOfInterestStatement\":false,\"humanSubjectEthicalGuidelines\":true,\"humanSubjectConsent\":true,\"humanSubjectClinicalTrial\":false,\"humanSubjectCaseReport\":false,\"vertebrateSubjectEthicalGuidelines\":false},\"doi\":\"10.21203/rs.3.rs-8889945/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-8889945/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":102902329,\"identity\":\"e3fa186e-72d5-45bf-878c-332e68a4ff0e\",\"added_by\":\"auto\",\"created_at\":\"2026-02-18 08:26:58\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":242394,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003ePRISMA flow diagram for guideline search across databases. Page MJ, et al. BMJ 2021;372:n71 doi: 10.1136/bmj.n71\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8889945/v1/edfb01acb0b4b34a2cf7398a.png\"}],\"financialInterests\":\"The authors declare no competing interests.\",\"formattedTitle\":\"\\u003cp\\u003ePharmacotherapy for Hypertensive Disorders of Pregnancy: A Systematic Review and Narrative Synthesis of Clinical Practice Guidelines\\u003c/p\\u003e\",\"fulltext\":[{\"header\":\"1. Introduction \",\"content\":\"\\u003cp\\u003eThe burden of hypertensive disorders of pregnancy (HDPs), which account for 14% of all maternal deaths globally [1], is expected to rise in most regions, given an increasing prevalence of associated risk factors. In the United States (US) for instance, increases in the prevalence of high risk factors such as chronic hypertension and pre-gestational diabetes, 125% and 57.1%, respectively, and moderate risk factors such as obesity and advanced maternal age, 35.6% and 36.7%, respectively, accompanied an increase in HDP prevalence by 113.6% between 2010 and 2021 [2]. However, due to obvious limitations on the conduct of randomized controlled trials (RCTs) in this vulnerable population, there’s been a paucity of high quality scientific evidence that would more definitively inform treatment strategies. Resultantly, decisions on the blood pressure (BP) treatment thresholds, choice of antihypertensive agents and BP targets have largely remained unclear, sometimes at the discretion of the practitioner [3]. Since most HDP-related maternal deaths arise from sub-optimal care [4], efforts should be made to ensure pharmacotherapy approaches are standardised.\\u003c/p\\u003e\\n\\u003cp\\u003eSeveral HDP clinical practice guidelines (CPGs) have routinely been developed by various organisations and professional societies. However, the impact of new and emerging scientific evidence on the practice guidance offered is generally unknown. Abalos and colleagues, in their 2018 meta-analysis, demonstrated that the use of antihypertensive agents for non-severe hypertension, systolic blood pressure (SBP) 140 – 159 mmHg or diastolic blood pressure (DBP) 90 – 109 mmHg, can half the risk of progression to severe disease, BP ≥ 160/110 mmHg, \\u0026nbsp;relative risk (RR) 0.49 (95% confidence interval (CI) 0.40 – 0.60; 2,258 women; moderate certainty) [5], therapy that was often reserved for severe hypertension. More recently, the Chronic Hypertension and Pregnancy (CHAP) trial demonstrated an 18% lower risk of placental abruption, foetal death, pre-term birth and neonatal death, (RR 0.82; 95% CI 0.74 – 0.92) with the initiation of antihypertensive treatment at a lower BP of 140/90 mmHg [6, 7]. Further, the Control of Hypertension in Pregnancy Study (CHIPS) demonstrated that tight BP control with a DBP target of 85 mmHg, relative to less tight control with a DBP target of 100 mmHg, is associated with a lower risk of severe hypertension [8], with subsequent post-hoc analysis additionally highlighting a lower risk of serious maternal complications, including pre-eclampsia, symptomatic elevation of liver enzymes and thrombocytopenia [9]. Increasingly, new evidence has been contrary to traditional practice.\\u003c/p\\u003e\\n\\u003cp\\u003eThe strategies for the development, dissemination and implementation of CPGs for the management of HDPs, as with all other CPGs, is often specific to the practice setting. However, the consistency of existing recommendations on treatment with antihypertensive agents across societies, organizations or regions has not been previously determined. Such synthesis would provide a more comprehensive guidance to individual practitioners.\\u003c/p\\u003e\\n\\u003cp\\u003eExisting guideline reviews on HDPs are either non-specific on key aspects of care that should be provided or precede significant new evidence from RCTs [3, 10-14]. \\u0026nbsp;However, they have drawn attention to differing recommendations, specifically on the need to treat mild or moderate BP elevation, order of preference as first or second line antihypertensive agents and the optimal BP targets, all influenced by the type of HDP and associated comorbidities. Scott and colleagues highlighted variability on the thresholds for non-severe hypertension, with similar observations on the targets for both severe and non-severe hypertension. However, they demonstrated some consistency in the choice of antihypertensive agents [3]. Similarly, Tsakiridis and colleagues, in their review of recommendations for chronic hypertension, reported variable thresholds, including BP ≥140/90 mmHg, ≥150/95 mmHg or ≥160/110 mmHg in the absence of comorbidities, with lower thresholds proposed for gestational hypertension superimposed with subclinical organ damage or symptoms. Additionally, variability in the targets was evident, with lower values preferred in the presence of comorbidities such as diabetes and chronic kidney disease. However, similar to Scott and colleagues, some consistency in the choice of antihypertensive agents was evident [10]\\u003c/p\\u003e\\n\\u003cp\\u003eThe primary aim of this review, in light of findings from the CHAP and CHIPS trials, among other evidence, was to provide an updated and more specific determination on the consistency of recent CPG recommendations on pharmacotherapy with antihypertensive agents for HDPs. The outcomes of interest included the BP thresholds, the choice of antihypertensive agents and the BP targets. Additionally, the review sought to investigate any variations in these recommendations across regions. It is anticipated that the findings will contribute towards standardizing clinical practice.\\u003c/p\\u003e\"},{\"header\":\"2. Materials and methods\",\"content\":\"\\u003cp\\u003eThe protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO), registration number CRD420251118765, and the review is reported in line with the PRISMA recommendations [15].\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e2.1 Search strategy\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eA search of the PubMED (Ovid), Web of Science (Clarivate), and Google Scholar databases were run on 12\\u003csup\\u003eth\\u003c/sup\\u003e, 14\\u003csup\\u003eth\\u003c/sup\\u003e and 21\\u003csup\\u003est\\u003c/sup\\u003e August 2025, respectively. The PICO elements were: population (P), included all pregnant women on follow-up, without any specific restrictions on their characteristics or healthcare setting; intervention/exposure (I), included any diagnosis of a HDP and outcomes (O), included recommendations for pharmacological treatment. The search terms used were: pregnant, gravid, expectant, prenatal, gestational , antenatal, perinatal, maternity, woman, women, female, mother, hypertensive disorder of pregnancy, HDP, chronic hypertension, gestational hypertension, pre-eclampsia, eclampsia , pregnancy-induced hypertension, elevated blood pressure, high blood pressure, uncontrolled blood pressure, hypertension, pharmacological management, medication management, drug therapy, medication therapy, pharmacotherapy, drug treatment, pharmaceutical treatment, medical treatment, drug regimen, antihypertensive treatment, recommendation and guideline. The electronic search strategies are as illustrated (Appendix A).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe search was limited to guidelines, government publications, documents or technical reports. However, for the Google Scholar search, only the first 488 results were screened, based on the assumption that the most relevant reports were listed first.\\u003c/p\\u003e\\n\\u003cp\\u003eAdditionally, the reference lists from any retrieved summary reports, consensus documents and position statements were searched for the respective primary guidelines, and the most recent versions included, when appropriate.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e2.2 Eligibility criteria\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eBased on the report characteristics, included guidelines were: published between January 1\\u003csup\\u003est\\u003c/sup\\u003e\\u0026nbsp; 2014 and December 31\\u003csup\\u003est\\u003c/sup\\u003e 2024, to capture the most recent recommendations; written in or officially translated to English, due to language restrictions; covered the pharmacological management of at least 1 HDP in human pregnancy and were issued by a government body, professional medical society or similar organization offering structured advice for healthcare professionals, as these sources are more credible. Further, to avoid duplications, only the most recent versions, or updates to any retrieved guidelines were included.\\u003c/p\\u003e\\n\\u003cp\\u003eBased on the publication characteristics, we excluded guidelines that: did not reference primary literature, as these were not evidence-based; were adapted entirely from existing guidelines, as these did not offer original information and those that were sub-national in scope when there was a relevant national document, as these were unlikely to be comprehensive (Appendix B).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e2.3 Guideline selection\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe selection of guidelines was done through two stages. In the first stage, a preliminary screening of titles and abstracts from retrieved records was performed by two reviewers (GM \\u0026amp; EW). Relevant records from each database were identified, merged and duplicates automatically excluded using EndNote 2025 [16].\\u003c/p\\u003e\\n\\u003cp\\u003eIn the second stage, two reviewers (GM and EW) independently selected guidelines to review and extract relevant data to structured forms, with discrepancies on inclusion resolved by consensus or the inclusion of a third reviewer (FO).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e2.4 Data extraction\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eUltimately, relevant data were extracted by one reviewer (GM) from all eligible guidelines, with a repeat process to enhance validity. Information was obtained on the recommendations relevant to three focus areas of pharmacotherapy: the BP treatment threshold, choice of antihypertensive agent and BP target, with the strength of each recommendation specified. Other data included year of publication, target patient population, organization and region. Where information was insufficient, correspondence with the authors was made via email.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e2.5 Synthesis\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eDue to inherent differences in guideline formats, the review adapted a narrative approach to synthesis based on the three focus areas of pharmacotherapy. The specific recommendations were presented in a table, ordered based on the year of publication for correlation with the emergence of new scientific evidence.\\u003c/p\\u003e\\n\\u003cp\\u003eAdditionally, a comparison of the recommendations based on the regional scope of the guidelines was presented, a likely cause of heterogeneity.\\u003c/p\\u003e\"},{\"header\":\"3. Results\",\"content\":\"\\u003cp\\u003eOverall, 896 records were identified from database searches. Excluding 17 duplicates, the titles and abstracts from 879 records were screened, and 39 reports subsequently sought for retrieval and assessed against the eligibility criteria (Figure I).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eIn total 12 guidelines were included in the review. They were developed mostly by professional medical societies, including 8: the American Congress of Obstetrics and Gynaecology Taskforce (n= 1) [17] ; French Society of Hypertension (FSH; n= 1) [18]; American College of Obstetricians and Gynaecologists (ACOG; n= 3) [19-21]; Hypertension Canada (n= 1) [22]; International Society for the Study of Hypertension in Pregnancy (ISSHP; n= 1) [23]; Society of Obstetrician and Gynaecologists of Canada (SOGC; n= 1) [24]; Society of Obstetric Medicine of Australia and New Zealand (SOMANZ; n= 1) [25] and the European Society of Hypertension (ESH; n= 1) [26]. However, some were developed by government bodies or similar organizations, including 2: the World Health Organization (WHO; n= 1) [1] and United Kingdom\\u0026rsquo;s National Institute for Health and Care Excellence (NICE; n= 1) [27]. The guidelines covered diverse regional scope, including Oceania [25] , Europe [26], United Kingdom [27] or even global [1, 23]. Specific to countries included USA [17, 19-21], Canada [22, 24] and France [18] (Table I).\\u003c/p\\u003e\\n\\u003cp\\u003eThe recommendations targeted various sub-types of HDPs, including: severe hypertension [19], chronic hypertension [20], gestational hypertension [21], pre-eclampsia [21], non-severe hypertension [1], arterial hypertension [26] or were unspecific on sub-types [17, 18, 22-25, 27] (Table I).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe strength of recommendations and quality of evidence was determined based on criteria adapted by the respective report, mainly GRADE approach [28] or the US Preventive Services Task Force Rating [29] (Online Resource 1 \\u0026ndash; Supplementary Tables S1 \\u0026ndash; S7).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable I\\u003c/strong\\u003e: Summary characteristics and recommendations from included guidelines\\u003c/p\\u003e\\n\\u003ctable\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eGuideline\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eYear\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ePatient condition\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eOrganization\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRegion\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eTreatment threshold\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eTreatment choice\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eTreatment target\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e1.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eManagement of Hypertensive Disorders in Pregnancy [17]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e2014\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eUnspecific HDP\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eAmerican Congress of Obstetrics and Gynaecology Taskforce\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eUSA\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Unspecified\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eSBP \\u0026ge;160 mmHg or DBP \\u0026ge;105 mmHg; for severe chronic hypertension\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Unspecified\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cem\\u003e\\u003cu\\u003eAcute treatment\\u003c/u\\u003e\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e1\\u003csup\\u003est\\u003c/sup\\u003e line: IV labetalol; IV hydralazine; oral nifepidine\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e2\\u003csup\\u003end\\u003c/sup\\u003e line: nicardipine; sodium nitroprusside\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cem\\u003e\\u003cu\\u003eLong-term management\\u003c/u\\u003e\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e1\\u003csup\\u003est\\u003c/sup\\u003e line: labetalol; alpha-methyldopa; clonidine; nifedipine; verapamil; diltiazem\\u003c/p\\u003e\\n \\u003cp\\u003e2\\u003csup\\u003end\\u003c/sup\\u003e line: thiazide and loop diuretics\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cem\\u003e\\u003cu\\u003eCaution\\u003c/u\\u003e\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eACEIs; ARBs; atenolol and pure alpha blockers\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eUnspecified\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e2.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eHypertension and Pregnancy: Expert Consensus Statement from The French Society of Hypertension, an Affiliate of The French Society of Cardiology [18]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e2016\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eUnspecific HDP\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eFSH\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eFrance\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Grade A, Class 1\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eSBP \\u0026ge;160 mmHg or DBP \\u0026ge;110 mmHg\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Grade C, Class 2\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eOffice SBP 140-159 mmHg or DBP 90-109 mmHg; confirmed with HBPM or daytime average ABPM SBP \\u0026ge;135 mmHg or DBP \\u0026ge;85 mmHg; with history of CVD, PD, CKD.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Grade B, Class 2\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e1\\u003csup\\u003est\\u003c/sup\\u003e line: alpha-methyldopa; labetalol; nicardipine; nifedipine\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Grade A, Class 1\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cem\\u003e\\u003cu\\u003eContraindicated\\u003c/u\\u003e\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eACEIs, ARBs, aliskiren\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cem\\u003e\\u003cu\\u003eCaution\\u003c/u\\u003e\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eThiazide diuretics, atenolol, aldosterone antagonists\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Grade A, Class 1\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eOffice DBP 85-100 mmHg and SBP ˂160 mmHg\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e3.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eCommittee Opinion No. 692: Emergent Therapy for Acute-Onset, Severe Hypertension During Pregnancy and the Postpartum Period [19]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e2017\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eSevere hypertension\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eACOG\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eUSA\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Unspecified\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eSBP \\u0026ge;160 mmHg and/or DBP \\u0026ge;110 mmHg\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Unspecified\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e1\\u003csup\\u003est\\u003c/sup\\u003e line: IV labetalol; IV hydralazine; IR nifedipine\\u003c/p\\u003e\\n \\u003cp\\u003e2\\u003csup\\u003end\\u003c/sup\\u003e line: Nicardipine infusion pump; Esmolol infusion pump; Sodium nitroprusside\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Unspecified\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eSBP 140 \\u0026ndash; 150 mmHg\\u003c/p\\u003e\\n \\u003cp\\u003eDBP 90 \\u0026ndash; 100 mmHg\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e4.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eGuidelines for the Management of Hypertension in Pregnancy [22]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e2018\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eUnspecific HDP\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eHypertension Canada\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eCanada\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Grade D\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eSBP \\u0026ge;160 mmHg or DBP\\u0026ge;110 mmHg\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Grade C\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eSBP \\u0026ge;140 mmHg or DBP \\u0026ge;90 mmHg; for chronic, gestational or pre-eclampsia\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cu\\u003eNon-severe hypertension\\u003c/u\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eRecommendation: Grade C\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e1\\u003csup\\u003est\\u003c/sup\\u003e line: labetalol, methyldopa, long acting nifedipine, acebutolol, metoprolol, pindolol, propranolol\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eRecommendation: Grade D\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e2\\u003csup\\u003end\\u003c/sup\\u003e line: clonidine, hydralazine, thiazide diuretics\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cu\\u003eContraindicated\\u003c/u\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eACEIs (Grade C); ARBs (Grade D)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Grade B\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eDBP 85 mmHg; for chronic or gestational hypertension\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Grade D\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eDBP 85 mmHg; for pre-eclampsia\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e5.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003ePractice Bulletin, Clinical Management Guideline for Obstetrician Gynaecologists No. 203: Chronic Hypertension in Pregnancy [20]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e2019\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eChronic hypertension\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eACOG\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eUSA\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Level B\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eSBP 160 mmHg and/or DBP 110 mmHg\\u003c/p\\u003e\\n \\u003cp\\u003eor\\u003c/p\\u003e\\n \\u003cp\\u003eSBP 150 mmHg / DBP 100 mmHg in presence of comorbidities, impaired renal function, LV hypertrophy, severe thrombocytopenia\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Level B\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cu\\u003eSevere hypertension\\u003c/u\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e1\\u003csup\\u003est\\u003c/sup\\u003e line: IV labetalol; IV/IM hydralazine; IR nifedipine\\u003c/p\\u003e\\n \\u003cp\\u003e2\\u003csup\\u003end\\u003c/sup\\u003e line: nicardipine infusion pump, esmolol infusion pump; IV enalapril\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cu\\u003eMaintenance treatment\\u003c/u\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e1\\u003csup\\u003est\\u003c/sup\\u003e line: Labetalol; nifedipine; methyldopa\\u003c/p\\u003e\\n \\u003cp\\u003e2\\u003csup\\u003end\\u003c/sup\\u003e line: clonidine; \\u0026nbsp;prazosin; HCTZ\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cu\\u003eContraindicated\\u003c/u\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eACEIs; ARBs; renin inhibitors; mineralocorticoid receptor antagonists; atenolol\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Level C\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eSBP 120 to ˂160 mmHg\\u003c/p\\u003e\\n \\u003cp\\u003eDBP 80 to ˂110 mmHg\\u003c/p\\u003e\\n \\u003cp\\u003eor\\u003c/p\\u003e\\n \\u003cp\\u003elower SBP / DBP in presence of diabetes or renal disease\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e6.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003ePractice Bulletin, Clinical Management Guideline for Obstetrician Gynaecologists No. 222: Gestational Hypertension and Pre-eclampsia [21]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e2020\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eGestational hypertension; Pre-eclampsia\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eACOG\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eUSA\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Level B\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eSBP \\u0026ge;160 mmHg and/or DBP \\u0026ge;110 mmHg\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Unspecified\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cu\\u003eSevere hypertension\\u003c/u\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eIV hydralazine; IV labetalol; IR nifedipine\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cu\\u003eExpectant management\\u003c/u\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eLabetalol; short-acting nifedipine\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Unspecified\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eUnspecified\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e7.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eRecommendations on Drug Treatment for Non-Severe Hypertension in Pregnancy [1]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e2020\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eNon-severe hypertension\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eWHO\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eInternational\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Context-specific\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eSBP 140-159 mmHg or DBP 90-109 mmHg; with good quality ANC follow-up\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Context-specific\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eOral alpha agonist: methyldopa\\u003c/p\\u003e\\n \\u003cp\\u003eBeta-lockers: acebutolol; atenolol; labetalol; mepindolol; metoprolol; oxprenolol; pindolol; propranolol\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cu\\u003eCaution\\u003c/u\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eCCBs; ACEIs; ARBs; sodium nitroprusside\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eUnspecified\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e8.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eClassification, Diagnosis and Management Recommendations for International Practice [23]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e2021\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eUnspecific HDP\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eISSHP\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eInternational\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: +3 strong\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eBP \\u0026ge;140/90 mmHg\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: +3 strong\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cu\\u003eSevere hypertension\\u003c/u\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e1\\u003csup\\u003est\\u003c/sup\\u003e line: oral nifedipine, oral labetalol, IV hydralazine, IV labetalol\\u003c/p\\u003e\\n \\u003cp\\u003e2\\u003csup\\u003end\\u003c/sup\\u003e line: other beta-blockers, other CCBs, prazosin\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cu\\u003eNon-severe hypertension\\u003c/u\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e1\\u003csup\\u003est\\u003c/sup\\u003e line: oral methyldopa, labetalol, nifedipine\\u003c/p\\u003e\\n \\u003cp\\u003e2\\u003csup\\u003end\\u003c/sup\\u003e line: metoprolol\\u003c/p\\u003e\\n \\u003cp\\u003eOther: amlodipine, diltiazem, oral hydralazine, prazosin, diuretics\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cu\\u003eContraindicated\\u003c/u\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eACEIs, ARBs\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: +4 strong\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eDBP 85 mmHg\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e9.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eGuideline No. 426: Hypertensive Disorders of Pregnancy; Diagnosis, Prediction, Prevention and Management [24]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e2022\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eUnspecific HDP\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eSOGC\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eCanada\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Strong, moderate\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eSBP \\u0026ge;140 mmHg or DBP \\u0026ge; 90 mmHg\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Strong, low\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eSBP \\u0026ge;160 mmHg or DBP \\u0026ge;110 mmHg\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Unspecified\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cu\\u003eUrgent control\\u003c/u\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eOral labetalol, IV labetalol, nifedipine oral capsule, IV hydralazine\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cu\\u003eNon-urgent control\\u003c/u\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eLabetalol, extended release nifedipine, methyldopa\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Strong, moderate\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eDBP 85 mmHg; for chronic or gestational hypertension\\u003c/p\\u003e\\n \\u003cp\\u003eor\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Conditional, low\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eDBP 85 mmHg; for pre-eclampsia\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e10.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eHypertension in Pregnancy Guideline [25]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e2023\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eUnspecific HDP\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eSOMANZ\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eOceania\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Unspecified\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eSBP \\u0026ge;140 mmHg and/or DBP \\u0026ge;90 mmHg\\u003c/p\\u003e\\n \\u003cp\\u003eor\\u003c/p\\u003e\\n \\u003cp\\u003eSBP \\u0026ge;160 mmHg and/or DBP \\u0026ge;110 mmHg\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cu\\u003eStable hypertension\\u003c/u\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: 2C\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e1\\u003csup\\u003est\\u003c/sup\\u003e line: oral labetalol; oral methyldopa; oral SR nifedipine\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: PP\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eOral hydralazine\\u003c/p\\u003e\\n \\u003cp\\u003eOther agents: oral clonidine; oral IR nifedipine\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cu\\u003eAcute severe hypertension\\u003c/u\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: 2C\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e1\\u003csup\\u003est\\u003c/sup\\u003e line: IV hydralazine; IV labetalol; oral IR nifedipine; IV diazoxide\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: PP\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e2\\u003csup\\u003end\\u003c/sup\\u003e/3\\u003csup\\u003erd\\u003c/sup\\u003e line: IV infusion labetalol; IV infusion hydralazine\\u003c/p\\u003e\\n \\u003cp\\u003eOther agents: oral methyldopa (1g STAT); oral labetalol (200mg/hr)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: 1C\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eSBP \\u0026le;135 mmHg and DBP \\u0026le;85 mmHg; for gestational or chronic hypertension\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: PP\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eBP \\u0026lt;160/110 mmHg; for acute severe hypertension\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e11.\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eGuidelines for the Management of Arterial Hypertension [26]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e2023\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eArterial hypertension\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eESH\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eEurope\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Class 1, Level C\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eSBP\\u0026ge;140 mmHg and/or DBP \\u0026ge;90 mmHg\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Class 1, Level B\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cu\\u003ePre-existing and gestational hypertension\\u003c/u\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e1\\u003csup\\u003est\\u003c/sup\\u003e line: labetalol; alpha-methyldopa\\u003c/p\\u003e\\n \\u003cp\\u003eAlternative: ER nifepidine\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Unspecified\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cu\\u003eSevere hypertension\\u003c/u\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e1\\u003csup\\u003est\\u003c/sup\\u003e line: IV labetalol; IV urapidil\\u003c/p\\u003e\\n \\u003cp\\u003e2\\u003csup\\u003end\\u003c/sup\\u003e line: IV hydralazine\\u003c/p\\u003e\\n \\u003cp\\u003e3\\u003csup\\u003erd\\u003c/sup\\u003e line: IV sodium nitroprusside\\u003c/p\\u003e\\n \\u003cp\\u003eOther: IV nitroglycerin, if pulmonary oedema present; short-acting oral nifedipine (10mg)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Class III, Level C\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cu\\u003eContraindicated\\u003c/u\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eACEIs; ARBs; direct renin inhibitors\\u003c/p\\u003e\\n \\u003cp\\u003eOthers for caution: sublingual short-acting nifepidine (unspecified); hydralazine (unspecified)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Class 1, Level A\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eBP \\u0026lt;140/90 mmHg; for pre-existing hypertension\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Class 1, Level C\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eBP \\u0026lt;140/90 mmHg; for gestational hypertension\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Unspecified\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eSBP \\u0026lt;160 mmHg and DBP \\u0026lt;105 mmHg; for eclampsia and severe pre-eclampsia\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e12.\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eHypertension in Pregnancy: Diagnosis and Management [27]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e2023\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eUnspecific HDP\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eNICE\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eUnited Kingdom\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Unspecified\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eSBP \\u0026ge;140 mmHg or DBP \\u0026ge;90 mmHg; for chronic, gestational hypertension, or pre-eclampsia\\u003c/p\\u003e\\n \\u003cp\\u003eor\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003eSBP \\u0026ge;160 mmHg or DBP \\u0026ge;110 mmHg; for all women\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Unspecified\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cu\\u003eChronic hypertension\\u003c/u\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eLabetalol; nifedipine; methyldopa; in order of preference\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cu\\u003eSevere hypertension\\u003c/u\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eOral/IV labetalol; oral nifedipine; IV hydralazine\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecommendation: Unspecified\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eSBP 135 mmHg, DBP 85 mmHg; for chronic, gestational, severe hypertension and pre-eclampsia\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"9\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eAbbreviations:\\u003c/strong\\u003e ACOG \\u0026ndash; American College of Obstetricians and Gynaecologists; ESH \\u0026ndash; European Society of Hypertension; FSH \\u0026ndash; French Society of Hypertension; NICE \\u0026ndash; National Institute for Health and Care Excellence; SOMANZ \\u0026ndash; Society of Obstetric Medicine of Australia and New Zealand; USA \\u0026ndash; United States of America; WHO \\u0026ndash; World Health Organization; SBP \\u0026ndash; systolic blood pressure; DBP \\u0026ndash; diastolic blood pressure; IV \\u0026ndash; intravenous; IR \\u0026ndash; immediate release; SR \\u0026ndash; sustained release; LV \\u0026ndash; left ventricular; HCTZ \\u0026ndash; hydrochlorothiazide; ACEI \\u0026ndash; angiotensin converting enzyme inhibitor; ARB \\u0026ndash; angiotensin II receptor blocker; CCB \\u0026ndash; calcium channel blocker; \\u0026nbsp; \\u0026nbsp; ISSHP \\u0026ndash; International Society for the Study of Hypertension in Pregnancy; HBPM \\u0026ndash; home blood pressure monitoring; ABPM \\u0026ndash; ambulatory blood pressure monitoring; CVD \\u0026ndash; cardiovascular disease; PD \\u0026ndash; pre-gestational diabetes; CKD \\u0026ndash; chronic kidney disease; ANC \\u0026ndash; ante-natal care; HDP \\u0026ndash; hypertensive disorder of pregnancy\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e3.1 Treatment threshold\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe strength of recommendations and/or quality of evidence varied, including: unspecified by the American Congress of Obstetrics and Gynaecology Taskforce, ACOG, SOMANZ and NICE; Class 1/2, Grade A/C by FSH; Grade C/D by Hypertension Canada; Level B by ACOG; context-specific by WHO; Strong /Strong Moderate/ Strong Low by ISSHP and SOGC and Class 1, Level C by ESH (Table I) (Online Resource 1 \\u0026ndash; Supplementary Tables S1 \\u0026ndash; S7).\\u003c/p\\u003e\\n\\u003cp\\u003eEarlier guidelines, developed between 2014 and 2020 by the American Congress of Obstetrics and Gynaecology Taskforce, FSH, ACOG and Hypertension Canada, mainly recommend the initiation of pharmacotherapy with antihypertensive agents for severe BP elevation, confirmed through persistent SBP \\u0026ge;160 mmHg and/or DBP \\u0026ge;110 mmHg over a 15-minute period [17-22]. However, lower thresholds, including: SBP 140-159 mmHg or DBP 90 -109 mmHg; SBP \\u0026ge;140 mmHg or DBP \\u0026ge;90 mmHg and SBP 150 mmHg or DBP 100 mmHg, have been recommended by FSH [18], Hypertension Canada [22] and ACOG [20], respectively, for women with histories of cardiovascular disease, pre-gestational diabetes, chronic kidney disease, chronic or gestational hypertension, pre-eclampsia, left ventricular hypertrophy and severe thrombocytopenia (Table I).\\u003c/p\\u003e\\n\\u003cp\\u003eSubsequent guidelines, developed between 2020 and 2023 by the WHO, ISSHP, SOGC, SOMANZ, ESH and NICE more consistently recommend treatment initiation at lower thresholds of sustained SBP \\u0026ge;140 mmHg and/or DBP \\u0026ge;90 mmHg, determined through repeat BP measurements [1, 23-27] (Table I).\\u003c/p\\u003e\\n\\u003cp\\u003eNotably, only the FSH recommends triangulation of office BP measurements with home-based or daytime ambulatory measurements, with a diagnosis of a HDP only confirmed with SBP \\u0026ge; 135 mmHg or DBP \\u0026ge; 85 mmHg from the latter [18] (Table I).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e3.2 Treatment choice\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe strength of the recommendations and/or quality of evidence varied, including unspecified by the American Congress of Obstetrics and Gynaecology Taskforce, ACOG, SOGC, NICE and ESH\\u0026rsquo;s guidance on severe hypertension; Class 1/2, Grade A/B by FSH; Grade C/D by Hypertension Canada; Level B by ACOG; context-specific by WHO; Strong by ISSHP; 2C/Practice Point by SOMANZ and Class I/III, Level B/C by ESH (Table I) (Online Resource 1 \\u0026ndash; Supplementary Tables S1 \\u0026ndash; S7).\\u003c/p\\u003e\\n\\u003cp\\u003eThe choice of agent should be individualised, based on: the presence of any contraindications, risks or potential adverse events; the patient characteristics and pre-existing treatments, if any; cost; local availability; and both clinician and patient preferences [1, 20, 23, 25]. Generally, the FSH discourages the use of any antihypertensive agent in the absence of specialist advice [18]. Similarly, the WHO contextually recommends limiting use to settings with good quality ANC follow-up, minimising potential maternal and foetal risks of unmonitored therapy [1].\\u003c/p\\u003e\\n\\u003cp\\u003eIn the management of acute or severe hypertension, antihypertensive agents should be initiated within 30 \\u0026ndash; 60 minutes in a monitored setting to support identification of adverse effects and treatment modification [27]. The aim is to prevent renal injury, myocardial ischaemia, congestive heart failure and stroke [19, 21, 23].\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe preferred first-line agents, mostly administered intravenously (IV), are not necessarily considered as complimentary but alternate treatments as patients may respond to one drug class and not the other [19-21]. They include IV labetalol, IV/intramuscular (IM) hydralazine, IV sodium nitroprusside for extreme emergencies, and in the absence of IV access, oral capsules or immediate release (IR) nifedipine [17, 19-21, 23, 24]. More recently, IV diazoxide [25] and IV urapidil [26] have also been recommended (Table I).\\u003c/p\\u003e\\n\\u003cp\\u003eThe preferred second-line agents include nicardipine and esmolol by infusion pumps, IV enalapril, other beta-blockers, other calcium channel blockers (CCBs) and prazosin [17, 19, 20, 23]. Further, IV infusions of labetalol and hydralazine, oral methyldopa as a single dose of 1gram, and oral labetalol at a dose of 200mg/hour, have also been proposed as alternative treatment strategies [25, 27], with IV infusion nitroglycerin, initially at 5mg/min, also preferred in the presence of pulmonary oedema [26] (Table I).\\u003c/p\\u003e\\n\\u003cp\\u003eThe use of institutional order sets to guide treatment intensification is recommended by ACOG [19-21] (Table II).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable II.\\u003c/strong\\u003e Order sets for the intensification of antihypertensive agents during acute emergencies in pregnancy.\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd rowspan=\\\"2\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eGuideline\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"3\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eFirst-line Antihypertensive Agent\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eHydralazine\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eLabetalol\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eNifedipine\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eACOG 2017 [19]\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eInitial 5/10 mg IV; if BP target still exceeded after 20 min. administer 10mg IV; if target persistently exceeded after 20 min. administer labetalol 20 mg IV; if target still exceeded after 10 min. repeat labetalol 40 mg IV\\u003cstrong\\u003e\\u0026nbsp;\\u003csup\\u003ea\\u003c/sup\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eInitial 20 mg IV; if BP target still exceeded after 10 min. administer 40 mg IV; if target still exceeded after 10 min. administer 80 mg IV; if target persistently exceeded after 10 min. administer hydralazine 10 mg IV \\u003cstrong\\u003e\\u003csup\\u003ea\\u003c/sup\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eInitial 10 mg orally; if BP target still exceeded after 20 min. administer capsule 20 mg orally; if target still exceeded after 20 min repeat 20 mg capsule; if target persistently exceeded after 20 min. administer labetalol 40 mg IV \\u003cstrong\\u003e\\u003csup\\u003ea\\u003c/sup\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eACOG 2020 [21]\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eInitial 5mg IV/IM; then 5-10 mg every 20-40 minutes, max. cumulative dose of 20mg\\u003c/p\\u003e\\n \\u003cp\\u003eOR\\u003c/p\\u003e\\n \\u003cp\\u003eConstant infusion of 0.5-10 mg/hr\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eInitial 10-20mg IV, then 20-80 mg every 10-30 min, max. cumulative dose of 300mg\\u003c/p\\u003e\\n \\u003cp\\u003eOR\\u003c/p\\u003e\\n \\u003cp\\u003eConstant infusion of 1-2mg/min IV\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eInitial 10-20 mg orally, repeat in 20 min if needed, then 10-20 mg every 2-6 hours, max. dose of 180 mg/day\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"4\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003csup\\u003ea\\u0026nbsp;\\u003c/sup\\u003e\\u003c/strong\\u003eIf foetus is undelivered and still viable, foetal surveillance should always be instituted. If target is achieved, always monitor BP over subsequent 7 hours. If target remains persistently exceeded, administer additional agent per specific order set after specialist consultation.\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eAbbreviations:\\u003c/strong\\u003e ACOG \\u0026ndash; American College of Obstetricians and Gynaecologists; IV \\u0026ndash; intravenous; IM \\u0026ndash; intramuscular; mg \\u0026ndash; milligrams; hr \\u0026ndash; hour; min \\u0026ndash; minute\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003eIn the expectant management of stable non-severe hypertension, initial treatment should generally be monotherapy, with subsequent combination agents selected from dissimilar drug classes [22, 23].\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe preferred first-line agents include labetalol, alpha-methyldopa, long-acting nifedipine, verapamil, diltiazem, nicardipine, acebutolol, mepindolol, oxprenolol, pindolol, and propranolol, all administered orally [1, 17, 18, 20-27]. The second-line agents, also administered orally, include thiazide and loop diuretics, clonidine, amlodipine, hydralazine, prazosin, and metoprolol [17, 20-23, 26]. However, labetalol, nifedipine and methyldopa, in order of preference, are generally considered the superior options for long term chronic maintenance [20, 26, 27] (Table I)\\u003c/p\\u003e\\n\\u003cp\\u003eThe doses for maintenance treatment include: oral labetalol 200 - 2400 mg/day in 2 to 3 divided doses, initiated at 100 \\u0026ndash; 200 mg twice daily [20, 21]; oral extended release nifedipine 30 \\u0026ndash; 120 mg/day, initiated at 30 \\u0026ndash; 60 mg once daily and oral methyldopa 500 \\u0026ndash; 3000 mg/day in 2 to 4 divided doses, initiated at 250 mg twice or thrice daily [20]. Monotherapy should be up-titrated to a mid-range dose before any combination is considered [26]. If an additional agent is necessary, it is best initiated at a standard dose, with the existing treatment maintained at the mid-range dose. \\u0026nbsp; The use of maximum doses for any single agent is discouraged [23, 25].\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe CCBs, which are additionally renal protective, may offer extra benefit in diabetics, with verapamil and diltiazem further advantageous in patients with cardiac disease [17]. However, the nifedipine formulations recommended vary based on the patient presentation, with use discouraged in the presence of aortic stenosis [25]. For acute treatment of severe hypertension, if IV access is not available, oral short-acting capsules and IR formulations are recommended by the American Congress of Obstetricians and Gynaecologists Taskforce, ACOG, ISSHP, SOGC, SOMANZ, ESH and NICE, while for expectant management of stable hypertension, long-acting, extended-release (ER) and sustained-release (SR) formulations are recommended (Table I).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe use of agents that affect the renin-angiotensin-aldosterone system (RAAS), including angiotensin converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs) and direct renin inhibitors, all associated with foetal nephrotoxicity, and other adverse outcomes more common with second and third trimester use, including severe hypotension, pulmonary hypoplasia, growth restriction, foetal death, anhydramnios, oligohydramnios and hypocalvaria [17, 18, 27], is consistently contraindicated by the American Congress of Obstetricians and Gynaecologists Taskforce, FSH, Hypertension Canada, ACOG, WHO, ISSHP, ESH and NICE (Table I).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eOther agents with caution advised include: methyldopa, risks of somnolence and postnatal depression [1, 20]; clonidine, risk of rebound hypertension after sudden withdrawal [25]; atenolol, intra-uterine growth restriction (IUGR) and oligohydramnios [17, 18]; pure alpha blockers such as prazosin, increased risk of heart failure [17]; thiazide diuretics, theoretical risk of volume depletion [17], with FSH limiting use as a last resort therapy for high-grade hypertension pre-dating pregnancy [18]; aldosterone and mineralocorticoid receptor antagonists, teratogenic effects in animal models and anti-androgen effects [18]; sodium nitroprusside, cyanide and thiocynate toxicity in mother, foetus or neonate if use is prolonged [1, 19]; and sublingual short-acting nifedipine and hydralazine, associated with maternal hypotension, abnormal foetal heart rate and headaches \\u0026nbsp;[19-21, 23]. The hydralazine-induced hypotension is avoidable through crystalloid fluid pre-loading [25, 27]. However, the ESH categorically discourages its use due to worse perinatal effects, relative to other drugs, limiting it to unavailability of other first-line IV agents, unresolved or severe postpartum hypertension, severe heart failure, 2\\u003csup\\u003end\\u003c/sup\\u003e or 3\\u003csup\\u003erd\\u003c/sup\\u003e degree atrioventricular (AV) block, bradycardia or asthma [26].\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eUltimately, the use of labetalol, and other beta-blockers, \\u0026nbsp;in women with a history of uncontrolled asthma and heart disease is discouraged, as exacerbations may occur, with IV administration further associated with a risk of neonatal bradycardia, hence foetal heart rate monitoring is encouraged [19, 20, 23].\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e3.3 Treatment target\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe recommendations on the BP targets are mostly based on moderate or inconsistent scientific evidence, similar to the choice of antihypertensive agents, with consensus statements and expert opinions frequently guiding practice. The strength of the recommendations and/or quality of evidence varied, including: unspecified by ACOG and NICE; Grade A, Class 1 by FSH; Grade B/D by Hypertension Canada; Level C by ACOG, Strong/Strong Moderate or Conditional Low by ISSHP and SOGC; 1C /Practice Point by SOMANZ; and Class 1, Level A/C by ESH (Online Resource 1 \\u0026ndash; Supplementary Tables S1 \\u0026ndash; S7) (Table I). However, the American Congress of Obstetrics and Gynaecology Taskforce, ACOG\\u0026rsquo;s 2020 practice bulletin for gestational hypertension and pre-eclampsia and WHO\\u0026rsquo;s 2020 recommendations for non-severe hypertension, did not explicitly specify any targets.\\u003c/p\\u003e\\n\\u003cp\\u003eA general consensus is that the aim of treatment is not to normalise BP, but to reduce the risk of complications that may arise from persistent elevation.\\u003c/p\\u003e\\n\\u003cp\\u003eEarlier guidelines, by FSH and ACOG, mainly recommended less tight BP control, including targets of: office SBP \\u0026lt;160 mmHg and DBP 85 - 100 mmHg [18]; SBP 140 - 150 mmHg and DBP 90 - 100 mmHg for severe hypertension [19]; and SBP 120 to \\u0026lt;160 mmHg and DBP 80 to \\u0026lt;110 mmHg for chronic hypertension [20] (Table I). However, in more recent guidelines, less tight BP control, if at all proposed, is limited only to cases of acute severe hypertension, severe pre-eclampsia or eclampsia, with target BP \\u0026lt;160/110 mmHg by SOMANZ \\u0026nbsp;or SBP \\u0026lt;160 mmHg and DBP \\u0026lt;105 mmHg by ESH (Table I).\\u003c/p\\u003e\\n\\u003cp\\u003eGenerally, most guidelines recommend tight BP control, including: Hypertension Canada, ISSHP and SOGC, target DBP 85 mmHg regardless of HDP sub-type [22-24]; SOMANZ, SBP \\u0026le;135 mmHg and DBP \\u0026le;85 mmHg for gestational and chronic hypertension [25]; and NICE, SBP 135 mmHg with DBP 85 mmHg, \\u0026nbsp;also regardless of HDP sub-type [27] (Table I). Additionally, lower BP targets are advised for women with comorbid diabetes or renal disease [20].\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e3.4 Regional variation\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eA preference for higher BP treatment thresholds and less tight control, often influenced by patient characteristics, was evident within the USA, while most other regions adapted lower thresholds and tight control. However, this was period-dependent.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eNo significant variations in the agent choice were observed, but differences exist in the order of preference as either first or second line.\\u003c/p\\u003e\"},{\"header\":\"4. Discussion\",\"content\":\"\\u003cp\\u003eThis systematic review provides the first synthesis of recent CPG recommendations on the pharmacological treatment of hypertension during pregnancy, following significant RCT results over the preceding 10 years, and investigates any regional differences that may influence practice. The utility of CPGs is greatly dependent on the rigor of their development, and with rapidly evolving scientific evidence, updates are critical in ensuring relevance and applicability [30].\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe leading role of professional medical societies in providing practice guidance for this critical pregnancy complication, relative to government bodies, is evident in this review. As important stakeholders in the development of global, regional and national policies that seek to advance maternal and new-born health, capacity building these societies, and establishment of memoranda of understanding with governments, can only be beneficial, as already demonstrated by the FIGO LOGIC initiative [31].\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eSignalling an increasing shift towards a more standardised treatment strategy, the scope and purpose of the reviewed guidelines was often unspecific on the HDP sub-type. Despite previous meta-analysis demonstrating a 50% reduction in the risk of severe hypertension with treatment initiation at lower BP thresholds, ≥140/90 mmHg [5], the lack of evidence on direct benefit to important clinical outcomes may not have supported change in practice. In majority of the retrieved guidelines, disseminated between 2014 and 2020, treatment preference was for severe hypertension, BP ≥160/110 mmHg, unless comorbidities were present. The findings from the CHAP trial, which focussed beyond surrogate outcomes and further demonstrated an 18% reduction in the risks of foetal and neonatal death [6, 7], may have tilted this balance. Subsequent guidelines, after the WHO’s context-specific recommendation for initiation of antihypertensive treatment at SBP 140-159 mmHg or DBP 90-109mmHg [1], have consistently been in favour of lower treatment thresholds, regardless of comorbidities.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eArguably, a paucity of guideline recommendations exist on the practical application of out-of-office BP monitoring in pregnancy, both in the diagnosis of HDPs and monitoring of response to antihypertensive treatment. \\u0026nbsp;However, the FSH, in their 2016 guidelines, recommend its confirmatory use for diagnosis [18]. Pregnancy is often characterised by dynamic changes in BP, and its accurate measurement is important. To optimize treatment decisions, and reduce the risk of missed treatment opportunities or unnecessary treatment that may arise from masked or white coat hypertension, respectively, adjunctive use of home-based or ambulatory monitoring, in addition to office measurement, should be integrated into routine practice [32].\\u003c/p\\u003e\\n\\u003cp\\u003eThe initiation of antihypertensive treatment continues to demonstrate favourable outcomes, with the main preferred pharmacological classes including: centrally acting α2 adrenergic agonists, peripherally acting adrenergic receptor antagonists, CCBs, direct vasodilators and diuretics. In this review, despite consistency across most guidelines on the choice of antihypertensive agents, with labetalol, nifedipine, methyldopa and hydralazine being largely the preferred options, the recommendations are mostly based on moderate or inconsistent scientific evidence, drawn largely from studies with questionable internal validity or that report on un-validated surrogate outcomes, or even based purely on expert opinion. Further, almost half of the reviewed guidelines did not specify the strength of their recommendations on agent choice, highlighting underlying uncertainty. Limited RCTs on efficacy have demonstrated clear superiority or inferiority of any single agent in pregnancy, and recommendation as first or second line, observed to slightly vary, is probably based more on the safety profile and practice context, including cost, availability, clinician and patient preferences.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThis review highlights that the recommended IV agents during the management of acute severe hypertension in pregnancy may be more of substitutes than complimentary treatments. The use of order sets, such as those proposed by ACOG for the intensification of hydralazine, labetalol and nifedipine administration [19, 21], should be adapted across practice settings, to ensure effective BP control in emergencies. Pharmacogenetics is increasingly gaining significance in antihypertensive treatment during pregnancy. Drug classes such as beta-blockers, metabolised by CYP2D6 enzyme, have been thought to lose effectiveness over the course of pregnancy, as this enzyme activity progressively increases. Similarly, genetic polymorphisms, affecting the eNOS gene and NAT enzyme, may result in variations in response to atenolol and hydralazine, respectively, in this category of women [33]. Evidently, treatment approaches should be individualized. \\u0026nbsp;\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe CHIPS trial, a multicentre international study that included 987 women between 14 to 33 weeks of gestation with either chronic or gestational hypertension, compared less tight BP control, target DBP 100 mmHg, to tight, target DBP 85 mmHg. The onset of severe hypertension was more frequent with less tight control, relative to the tight, 40.6% and 27.5%, respectively [8]. Further, higher risk of serious maternal complications, including preeclampsia, thrombocytopenia, hepatic injury and prolonged hospital stay was evident [9]. Most guidelines, based on the findings from this review, increasingly advocate for tight BP control, a sure way of optimizing both maternal and foetal outcomes.\\u003c/p\\u003e\\n\\u003cp\\u003eUltimately, this systematic review highlights that, over the years, there has been an increasing harmony in practice guideline recommendations on pharmacotherapy with antihypertensive agents for HDPs, despite minor regional variations in the BP threshold and target that were observed in earlier periods.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e4.1 Implications to practice\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe management of women presenting with hypertension during pregnancy presents a clinical conundrum, given the need to balance maternal wellbeing and foetal safety. Therefore, care approaches should be individualised and evidence-based, encouraging shared and informed decision making that consider any associated risks and benefits.\\u003c/p\\u003e\\n\\u003cp\\u003eTo optimize maternal and foetal outcomes, practitioners should embrace lower treatment thresholds and tight control, both increasingly recommended based on emerging scientific evidence. Further, to ensure the effectiveness of treatment in achieving set targets, and inform any modifications, routine blood pressure monitoring is important. The use of out-of-office measurements, and their timely reporting, should be encouraged across all practice settings.\\u003c/p\\u003e\\n\\u003cp\\u003eFuture research should explore the utility of additional treatment options, including the increasing role of anti-angiogenic and pro-angiogenic factors, both associated with the onset of HDPs [14]. Metformin and esomeprazole, which decrease anti-angiogenic factors, and pravastatin, which upregulates pro-angiogenic factors, have been considered as potential treatment, if repurposed.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e4.2 Limitations\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe search strategy only included peer-reviewed published recommendations from the selected databases. Hence, the consistency of recommendations from the grey literature, or other sources, with the observations made herein, is unknown.\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003e5.1 Funding\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e5.2 Competing Interests\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors have no relevant financial or non-financial interests to disclose.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e5.3 Author contributions\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eConceptualization: Godfrey Mudhune and Frasia Oosthuizen; Literature search and eligibility screening: Godfrey Mudhune and Ebenezer Wiafe; Data extraction and synthesis: Godfrey Mudhune; Writing – original draft preparation: Godfrey Mudhune; Writing – review and editing: Godfrey Mudhune, Ebenezer Wiafe and Frasia Oosthuizen.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e5.4 Ethics approval\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNo ethical approval was required for this study.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eWHO. Recommendations on drug treatment for non-severe hypertension in pregnancy. Geneva, Switzerland: World Health Organization (WHO); 2020. Available from: https://iris.who.int/server/api/core/bitstreams/f989de9f-d3de-4d3f-baa7-9b31354f6c0d/content.\\u003c/li\\u003e\\n\\u003cli\\u003eAyyash MK, McLaren RJ, Shaman M, Al-Kouatly HB. Trends in reeclampsia risk factors in the US from 2010 to 2021. JAMA. 2024;332(2):167-9. doi: 10.1001/jama.2024.8931.\\u003c/li\\u003e\\n\\u003cli\\u003eScott G, Gillon TE, Pels A, von Dadelszen P, Magee LA. Guidelines-similarities and dissimilarities: a systematic review of international clinical practice guidelines for pregnancy hypertension. Am J Obstet Gynecol. 2022;226(2):S1222-S36. Epub 20082020. doi: 10.1016/j.ajog.2020.08.018. PubMed PMID: WOS:000759636700035.\\u003c/li\\u003e\\n\\u003cli\\u003eShennan AH, Redman C, Cooper C, Milne F. Are most maternal deaths from pre-eclampsia avoidable? Lancet. 2012;379(9827):1686-7. Epub 14122011. doi: 10.1016/s0140-6736(11)60785-x. PubMed PMID: 22177535.\\u003c/li\\u003e\\n\\u003cli\\u003eAbalos E, Duley L, Steyn DW, Gialdini C. Antihypertensive drug therapy for mild to moderate hypertension during pregnancy. Cochrane Database Syst Rev. 2018;10(10):CD002252. Epub 20181001. doi: 10.1002/14651858.CD002252.pub4. PubMed PMID: 30277556; PubMed Central PMCID: PMCPMC6517078.\\u003c/li\\u003e\\n\\u003cli\\u003eTita AT, Szychowski JM, Boggess K, Dugoff L, Sibai B, Lawrence K, et al. Treatment for mild chronic hypertension during pregnancy. N Engl J Med. 2022;386(19):1781-92. Epub 02042022. doi: 10.1056/NEJMoa2201295.\\u003c/li\\u003e\\n\\u003cli\\u003eHolliman KD, Lowe V, Nonni G. Management of blood pressure in pregnancy: new perspectives from the CHAP trial. Curr Opin Obstet Gynecol. 2023;35(2):81-6. Epub 03012023. doi: 10.1097/gco.0000000000000845. PubMed PMID: 36912258.\\u003c/li\\u003e\\n\\u003cli\\u003eMagee LA, von Dadelszen P, Rey E, Ross S, Asztalos E, Murphy KE, et al. Less-tight versus tight control of hypertension in pregnancy. N Engl J Med. 2015;372(5):407-17. doi: 10.1056/NEJMoa1404595. PubMed PMID: 25629739.\\u003c/li\\u003e\\n\\u003cli\\u003eMagee LA, von Dadelszen P, Singer J, Lee T, Rey E, Ross S, et al. The CHIPS randomized controlled trial (Control of Hypertension in Pregnancy Study): Is severe hypertension just an elevated blood pressure? Hypertension. 2016;68(5):1153-9. Epub 12092016. doi: 10.1161/hypertensionaha.116.07862. PubMed PMID: 27620393; PubMed Central PMCID: PMCPMC5058640.\\u003c/li\\u003e\\n\\u003cli\\u003eTsakiridis I, Giouleka S, Arvanitaki A, Giannakoulas G, Papazisis G, Mamopoulos A, et al. Gestational hypertension and preeclampsia: an overview of national and international guidelines. Obstet Gynecol Surv. 2021;76(10):613-33. doi: 10.1097/OGX.0000000000000942.\\u003c/li\\u003e\\n\\u003cli\\u003eBrown CM, Garovic VD. Drug treatment of hypertension in pregnancy. Drugs. 2014;74(3):283-96. doi: 10.1007/s40265-014-0187-7. PubMed PMID: WOS:000332078100001.\\u003c/li\\u003e\\n\\u003cli\\u003eSinkey RG, Battarbee AN, Bello NA, Ives CW, Oparil S, Tita ATN. Prevention, diagnosis, and management of hypertensive disorders of pregnancy: a comparison of international guidelines. Curr Hypertens Rep. 2020;22(9). Epub 27082020. doi: 10.1007/s11906-020-01082-w. PubMed PMID: WOS:000567404600006.\\u003c/li\\u003e\\n\\u003cli\\u003eGillon TER, Pels A, von Dadelszen P, MacDonell K, Magee LA. Hypertensive disorders of pregnancy: A systematic review of international clinical practice guidelines. PLoS One. 2014;9(12). doi: 10.1371/journal.pone.0113715. PubMed PMID: WOS:000347114900068.\\u003c/li\\u003e\\n\\u003cli\\u003eDymara-Konopka W, Laskowska M, Oleszczuk J. Preeclampsia: Current management and future approach. Curr Pharm Biotechnol. 2018;19(10):786-96. doi: 10.2174/1389201019666180925120109. PubMed PMID: WOS:000452533100005.\\u003c/li\\u003e\\n\\u003cli\\u003ePage MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. doi: 10.1136/bmj.n71.\\u003c/li\\u003e\\n\\u003cli\\u003eThe EndNote Team. EndNote. EndNote 2025 ed. Philadelphia, PA: Clarivate; 2013.\\u003c/li\\u003e\\n\\u003cli\\u003eMoussa HN, Arian SE, Sibai BM. Management of hypertensive disorders in pregnancy. Womens Health (Lond). 2014;10(4):385-404. doi: 10.2217/whe.14.32 \\u003c/li\\u003e\\n\\u003cli\\u003eMounier‐Vehier C, Amar J, Boivin J, Denolle T, Fauvel J, Plu‐Bureau G, et al. Hypertension and pregnancy: expert consensus statement from the French Society of Hypertension, an affiliate of the French Society of Cardiology. Fundam Clin Pharmacol. 2017;31(1):83-103. Epub 21122016. doi: 10.1111/fcp.12254.\\u003c/li\\u003e\\n\\u003cli\\u003eACOG. Committee opinion number 692: Emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period. Obstet Gynecol. 2017;129(4):e90-e5. doi: 10.1097/aog.0000000000002019. PubMed PMID: 28333820.\\u003c/li\\u003e\\n\\u003cli\\u003eACOG. Practice bulletin number 203: Chronic hypertension in pregnancy. Obstet Gynecol. 2019;133(1):e26-e50. doi: 10.1097/aog.0000000000003020. PubMed PMID: 30575676.\\u003c/li\\u003e\\n\\u003cli\\u003eACOG. Gestational hypertension and preeclampsia: Practice bulletin number 222. Obstet Gynecol. 2020;135(6):e237-e60. doi: 10.1097/aog.0000000000003891. PubMed PMID: 32443079.\\u003c/li\\u003e\\n\\u003cli\\u003eButalia S, Audibert F, C\\u0026ocirc;t\\u0026eacute; AM, Firoz T, Logan AG, Magee LA, et al. Hypertension Canada\\u0026rsquo;s 2018 guidelines for the management of hypertension in pregnancy. Can J Cardiol. 2018;34(5):526-31. doi: 10.1016/j.cjca.2018.02.021.\\u003c/li\\u003e\\n\\u003cli\\u003eMagee LA, Brown MA, Hall DR, Gupte S, Hennessy A, Karumanchi SA, et al. The 2021 International Society for the Study of Hypertension in Pregnancy classification, diagnosis \\u0026amp; management recommendations for international practice. Pregnancy Hypertens. 2022;27:148-69. Epub 09102021. doi: 10.1016/j.preghy.2021.09.008. PubMed PMID: 35066406.\\u003c/li\\u003e\\n\\u003cli\\u003eMagee LA, Smith GN, Bloch C, C\\u0026ocirc;t\\u0026eacute; AM, Jain V, Nerenberg K, et al. Guideline number 426: Hypertensive disorders of pregnancy - diagnosis, prediction, prevention and management. J Obstet Gynaecol Can. 2022;44(5):547-71. doi: 10.1016/j.jogc.2022.03.002. PubMed PMID: WOS:000797693200018.\\u003c/li\\u003e\\n\\u003cli\\u003eSOMANZ. Society of Obstetric Medicine of Australia and New Zealand, Hypertension in Pregnancy Guideline 2023. 2024 12/12/2025 [cited 23/12/2025]. Sydney, Australia: Society of Obstetric Medicine Australia and New Zealand (SOMANZ), [cited 23/12/2025]; [15-22]. Available from: https://somanz.org/content/uploads/2024/01/SOMANZ_Hypertension_in_Pregnancy_Guideline_2023.pdf.\\u003c/li\\u003e\\n\\u003cli\\u003eMancia G, Kreutz R, Brunstr\\u0026ouml;m M, Burnier M, Grassi G, Januszewicz A, et al. 2023 ESH guidelines for the management of arterial hypertension; The task force for the management of arterial hypertension of the European Society of Hypertension: Endorsed by the International Society of Hypertension (ISH) and the European Renal Association (ERA). J Hypertens. 2023;41(12):1874-2071. Epub 26092023. doi: 10.1097/hjh.0000000000003480. PubMed PMID: 37345492.\\u003c/li\\u003e\\n\\u003cli\\u003eNICE. Hypertension in pregnancy: diagnosis and management. UK: National Institute for Health and Care Excellence (NICE); 2023. p. 10-27.\\u003c/li\\u003e\\n\\u003cli\\u003eGuyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336(7650):924-6. doi: 10.1136/bmj.39489.470347.AD.\\u003c/li\\u003e\\n\\u003cli\\u003eBarry MJ, Wolff TA, Pbert L, Davidson KW, Fan TM, Krist AH, et al. Putting evidence into practice: An update on the US Preventive Services Task Force methods for developing recommendations for preventive services. Ann Fam Med. 2023;21(2):165-71. doi: 10.1370/afm.2946.\\u003c/li\\u003e\\n\\u003cli\\u003eBrouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ. 2010;182(18):E839-E42. doi: 10.1503/cmaj.090449.\\u003c/li\\u003e\\n\\u003cli\\u003eTaylor DJ. The role of health professional organizations in improving maternal and newborn health: The FIGO LOGIC experience. Int J Gynaecol Obstet. 2015;131:S71-S4. Epub 25022015. doi: 10.1016/j.ijgo.2015.02.007.\\u003c/li\\u003e\\n\\u003cli\\u003eBello NA, Miller E, Cleary K, Wapner R, Shimbo D, Tita AT. Out of office blood pressure measurement in pregnancy and the postpartum period. Curr Hypertens Rep. 2018;20(12):101. Epub 20181025. doi: 10.1007/s11906-018-0901-z. PubMed PMID: 30361886; PubMed Central PMCID: PMCPMC6327956.\\u003c/li\\u003e\\n\\u003cli\\u003eHaas DM. Pharmacogenetics and individualizing drug treatment during pregnancy. Pharmacogenomics. 2014;15(1):69-78. doi: 10.2217/pgs.13.228. PubMed PMID: 24329192; PubMed Central PMCID: PMCPMC4064360.\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":true,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"University of KwaZulu-Natal\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Antihypertensives, pregnancy, HDP, guideline, threshold, target\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-8889945/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-8889945/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eObjectives\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eWe sought to determine the consistency of recent guideline recommendations on pharmacotherapy with antihypertensive agents during pregnancy, and regional variations.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMethods\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003ePubMed, Web of Science and Google Scholar databases were searched between 12\\u003csup\\u003eth\\u003c/sup\\u003e and 21\\u003csup\\u003est\\u003c/sup\\u003e August 2025 for recent guidelines. Included reports were: published between January 2014 and December 2024; written in or officially translated to English; covered the pharmacological management of at least one HDP; issued by a professional medical society, government body or similar organization and were the most recent versions. Reports were excluded if they were: adapted entirely from existing guidelines; not referencing primary literature or sub-national in scope in the presence of a national document. The strength of recommendations and quality of evidence followed the GRADE or USPSTF criteria. Results were presented thematically across the three outcomes of interest: BP threshold, target and choice of agent.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eOverall, 12 guidelines were included: American Congress of Obstetrics and Gynaecology Task Force 2014; ACOG 2017/19/20; FSH 2016; Hypertension Canada 2018; ISSHP 2021; SOGC 2022; SOMANZ 2023; ESH 2023; WHO 2020 and NICE 2023. Regional scope included: Oceania, Europe, UK, USA, Canada, France and global. Treatment initiation at lower thresholds (BP≥ 140/90 mmHg) and tight control (target DBP 85 mmHg) have gained preference, regardless of comorbidities. Higher thresholds and less tight control more evident in the USA. Labetalol, nifedipine, methyldopa and hydralazine are almost consistently recommended, oral for maintenance and IV for acute treatment, where available.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusion\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eIncreasing consistency of guideline recommendations is evident, but observations limited to peer-reviewed literature. To optimise outcomes, practitioners should adapt lower thresholds and tight control, with more frequent BP monitoring to inform treatment modification.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe review received no specific funding. The protocol was registered with PROSPERO CRD420251118765.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Pharmacotherapy for Hypertensive Disorders of Pregnancy: A Systematic Review and Narrative Synthesis of Clinical Practice Guidelines\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-02-18 08:26:04\",\"doi\":\"10.21203/rs.3.rs-8889945/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"4daa4b71-91f4-4c56-8c8b-3dd79f77a4e1\",\"owner\":[],\"postedDate\":\"February 18th, 2026\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[{\"id\":63118016,\"name\":\"Obstetrics \\u0026 Gynecology\"}],\"tags\":[],\"updatedAt\":\"2026-02-18T08:26:04+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2026-02-18 08:26:04\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-8889945\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-8889945\",\"identity\":\"rs-8889945\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}