Choice of drug

1. Methyldopa and hydralazine have been most widely used in pregnant women and their long-term safety for the fetus has been demonstrated. ACE inhibitors should not be continued in pregnancy.

2. Beta-blockers are generally considered to be safe, although they may impair fetal growth when used early in pregnancy, particularly atenolol. Labetalol is the preferred agent. Nifedipine (30 to 90 mg once daily as sustained-release tablet, increase at 7 to 14 day intervals, maximum dose 120 mg/day) has been used.

3. The normal fall in blood pressure during the second trimester may allow a reduction in drug dosage or even cessation of therapy.

4. Start treatment with either labetolol or methyldopa. A long-acting calcium channel blocker (eg, nifedipine or amlodipine) can be added as either second- or third-line treatment.

5. Blood pressure goal. The goal of therapy in women without end-organ damage is systolic pressure between 140 and 150 mm Hg and diastolic pressure between 90 and 100 mm Hg. However, in women with end-organ damage, the blood pressure should be below 140/90 mm Hg.

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