A 28-year-old woman at 28 weeks of gestation presents with a blood pressure of 150/95 mmHg on two occasions 4 hours apart, with 2+ proteinuria on dipstick. She is asymptomatic with no headache or visual symptoms. What is the first-line antihypertensive drug of choice for this patient?

Explanation

## Hypertension in Pregnancy: First-Line Therapy **Key Point:** This patient has preeclampsia without severe features (BP ≥150/95 mmHg, proteinuria ≥1+ on dipstick, but no severe symptoms or laboratory abnormalities). First-line oral antihypertensives in pregnancy are methyldopa, labetalol, and nifedipine (sustained-release). Labetalol is increasingly preferred as first-line due to rapid onset and excellent safety profile. **High-Yield:** Labetalol is the preferred first-line agent in pregnancy because it has α- and β-blocking properties, rapid onset (30 min), good efficacy, and no adverse fetal effects. It can be used in all trimesters. ### Antihypertensive Drugs in Pregnancy: Comparative Safety | Drug | Category | Onset | Fetal Safety | Use in Pregnancy | Notes | |------|----------|-------|--------------|------------------|-------| | **Labetalol** | Safe | 30 min (oral) | Excellent | First-line | Combined α/β blocker; rapid; no fetal harm | | Methyldopa | Safe | 4–6 hours | Excellent | First-line (traditional) | Slow onset; less preferred now | | Nifedipine (SR) | Safe | 30 min | Excellent | First-line | Calcium channel blocker; good alternative | | Enalapril (ACE-I) | Contraindicated | — | Teratogenic (2nd/3rd trim) | Avoid | Renal dysgenesis, oligohydramnios, fetal death | | Atenolol | Caution | — | Associated with IUGR | Avoid if possible | Intrauterine growth restriction risk | **Clinical Pearl:** Labetalol is now preferred over methyldopa as first-line because of its faster onset (30 minutes), better efficacy, and superior tolerability. Methyldopa, though safe, has a slow onset (4–6 hours) and is now considered second-line. **Mnemonic: SAFE Antihypertensives in Pregnancy** — **S**ustained-release nifedipine, **A**cetazolamide (not for HTN), **F**irst-line labetalol, **E**nalapril (avoid). ### Why Other Options Are Suboptimal - **Enalapril (ACE inhibitor):** Contraindicated in pregnancy, especially 2nd and 3rd trimesters. Associated with fetal renal dysgenesis, oligohydramnios, IUGR, and fetal death. Avoid entirely. - **Methyldopa:** Safe but slow onset (4–6 hours) and less effective than labetalol. Now considered second-line; used when labetalol is contraindicated or ineffective. - **Nifedipine (sustained-release):** Safe and effective, but labetalol is preferred as first-line due to faster onset and superior efficacy in acute hypertension.