Previous changes

May 2022 — minor update. New adverse effects of nipple pain and Raynaud's phenomenon of the nipple added to the labetalol prescribing section in line with the manufacturers summary of product characteristics.

July 2020 — minor update. Typographical error corrected. 

September to October 2019 — reviewed. A literature search was conducted in September 2019 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The topic has undergone minor restructuring. No major changes to the recommendations have been made.

August 2019 — minor update. NICE Quality Standards added. 

October 2016 — minor update. Angioedema and urticaria added as adverse effects of methyldopa.

February to March 2015 — reviewed. A literature search was conducted in February 2015 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The topic has undergone minor restructuring. No major changes to the recommendations have been made.

November 2012 — minor update. The links to the electronic medicines website (www.medicines.org.uk) have been updated.

August to November 2010 — topic updated. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. There are no major changes to the recommendations.

January to March 2006 — rewritten. Validated in June 2006 and issued in July 2006.

November 2005 — minor technical update. 

March 2004 — reviewed. Validated in March 2003 and issued in April 2003.

November 1999 — written. Validated in March 2000 and issued in September 2000.

New evidence

Evidence-based guidelines

• De Backer, J., Haugaa, K.H, Hasselberg, N.E., (2025) 2025 ESC Guidelines for the management of cardiovascular disease and pregnancy: Developed by the task force on the management of cardiovascular disease and pregnancy of the European Society of Cardiology (ESC). European Heart Journal. https://academic.oup.com/eurheartj [Free Full-text]

HTAs (Health Technology Assessments)

No new HTAs since 1 January 2025.

Economic appraisals

No new economic appraisals relevant to England since 1 September 2019.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 January 2025.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 January 2025.

New policies

No new national policies or guidelines since 1 January 2025.

New safety alerts

No new safety alerts since 1 January 2025.

Changes in product availability

No changes in product availability since 1 January 2025.

How do I manage a woman at high risk of, or exhibiting clinical features of pre-eclampsia?

• Note: The National Institute of Health and Care Excellence (NICE) defines pre-eclampsia as new onset of hypertension (over 140 mmHg systolic or over 90 mmHg diastolic) after 20 weeks of pregnancy and the coexistence of 1 or more of the following new-onset conditions:
  • Proteinuria, or
  • Other maternal organ dysfunction:
    • Renal insufficiency (creatinine 90 micromol/litre or more, 1.02 mg/100 ml or more).
    • Liver involvement (elevated transaminases [alanine aminotransferase or aspartate aminotransferase over 40 IU/litre] with or without right upper quadrant or epigastric abdominal pain).
    • Neurological complications such as eclampsia, altered mental status, blindness, stroke, clonus, severe headaches, or persistent visual scotomata.
    • Haematological complications such as thrombocytopenia (platelet count below 150,000 per microlitre), disseminated intravascular coagulation or haemolysis.
    • Uteroplacental dysfunction such as fetal growth restriction, abnormal umbilical artery Doppler waveform analysis, or stillbirth.
• Be aware that women are considered to be at high risk of pre-eclampsia if they have:
  • One of the following high-risk factors:
    • A history of hypertensive disease during a previous pregnancy.
    • Chronic kidney disease.
    • Autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome.
    • Type 1 or type 2 diabetes.
    • Chronic hypertension.
  • Two or more of the following moderate risk factors:
    • First pregnancy.
    • Aged 40 years or older.
    • Pregnancy interval of more than 10 years.
    • Body mass index (BMI) of 35 kg/m² or greater at the first visit.
    • Family history of pre-eclampsia.
    • Multiple pregnancy.
• For women assessed to be at high risk of pre-eclampsia:
  • Refer for consultant-led care at booking for specialist input to assess and manage the obstetric risk.
  • Ensure that aspirin 75 mg to 150 mg daily is prescribed from 12 weeks gestation until birth. This is usually arranged in secondary care, but should be initiated in primary care if the woman will not be seen by a specialist until after 12 weeks.
    • Seek specialist advice before prescribing aspirin to girls younger than 16 years of age, and in those with thrombophilia or uncontrolled blood pressure. There is no evidence that use of low-dose aspirin in pregnancy is associated with an increased risk of congenital abnormalities or other fetal complications.
  • Offer advice about healthy lifestyle (including rest, work, exercise, and weight) as recommended for all pregnant women. For more information, see the CKS topic on Antenatal care - uncomplicated pregnancy.
• For all pregnant women, dipstick the urine for protein and measure blood pressure at each antenatal visit. 
  • If dipstick screening is positive [1+ or more], use albumin:creatinine ratio or protein:creatinine ratio to quantify proteinuria in pregnant women.
    • If using protein:creatinine ratio, use 30 mg/mmol as a threshold for significant proteinuria.
    • If using albumin:creatinine ratio, use 8 mg/mmol as a diagnostic threshold.
    • Do not use first morning urine void to quantify proteinuria in pregnant women.
    • Note: it is recommended that proteinuria measurements in pregnant women are interpreted in the context of an assessment of symptoms, signs and other investigations for pre-eclampsia. If significant proteinuria is detected but there is still uncertainty about the diagnosis of pre-eclampsia, consider re‑testing on a new sample, in conjunctions with clinical assessment. Seek specialist advice where there is uncertainty.
• Advise all pregnant women to seek immediate medical review if they experience symptoms of pre-eclampsia (including during the first 4 weeks postpartum), such as:
  • Severe headache.
  • Problems with vision, such as blurring or flashing before the eyes.
  • Severe pain just below the ribs.
  • Vomiting.
  • Sudden swelling of the face, hands, or feet.
• Arrange emergency secondary care assessment for any woman in whom pre-eclampsia is suspected. Advise women with severe hypertension (blood pressure of 160/110 mmHg or more) that they will be offered hospital admission for ongoing monitoring of their condition and of their baby's wellbeing.
  • Women with less severe hypertension may be offered admission depending upon whether there are clinical concerns for the wellbeing of the woman or baby or if they are considered to be at high risk of adverse events. If there are no such concerns, the woman will be offered ongoing specialist management on an outpatient basis.

How should I manage a woman with chronic hypertension?

• Offer advice about:
  • Healthy lifestyle (including work, rest, exercise, healthy diet, and weight) as recommended for all pregnant women. For more information, see the CKS topic on Antenatal care - uncomplicated pregnancy.
  • Restriction of dietary salt. For more information, see the CKS topic on Hypertension.
• Be aware that women with chronic hypertension are at high risk of pre-eclampsia and should be referred for consultant-led care at booking for specialist input to assess and manage the obstetric risk. 
• While the woman is waiting to see a specialist, if she is taking:
  • An angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB) for hypertension, stop this immediately and prescribe an alternative antihypertensive if necessary.
    • Explain that there is an increased risk of adverse fetal outcomes if these drugs are taken during pregnancy, particularly during the second and third trimesters.
    • Advise women who have continued to take ACE inhibitors or ARBs during the first trimester that there is no strong evidence that this is associated with increased risk to the fetus.
  • An ACE inhibitor or ARB for another condition such as renal disease, treatment should also be stopped — seek specialist advice on alternative treatment.
  • A thiazide or thiazide-like diuretic — prescribe an alternative antihypertensive if necessary or seek specialist advice on alternative treatment if being used for another indication.
  • Any other antihypertensive — consider continuing existing treatment if necessary. Advise the woman that the limited evidence available has not shown an increased risk of congenital malformation with such treatments.
• Be aware that pregnant women previously diagnosed with chronic hypertension may exhibit blood pressure within the normal range due to the physiological drop in blood pressure that occurs in early pregnancy. Continued antihypertensive treatment is not necessary if either:
  • Sustained systolic blood pressure is less than 110 mmHg.
  • Sustained diastolic blood pressure is less than 70 mmHg.
  • The woman has symptomatic hypotension. 
• If an alternative antihypertensive treatment is required during pregnancy:
  • First-line treatment is usually labetalol if not contraindicated. 
  • Consider nifedipine for women in whom labetalol is not suitable.
  • Consider methyldopa if both labetalol and nifedipine are not suitable.
  • Base the choice on any pre-existing treatment, side-effect profiles, risks (including fetal effects) and the woman's preference. 
    • For more information, including recommended doses, see the relevant sections in Prescribing information.
• If a woman with chronic hypertension is not already taking antihypertensive treatment, while she is waiting to see a specialist, offer drug treatment if there is either:
  • Sustained systolic blood pressure of 140 mmHg or higher.
  • Sustained diastolic blood pressure of 90 mmHg or higher.
• Target blood pressure following antihypertensive treatment in pregnancy is 135/85 mmHg.
• Ensure that aspirin 75 mg to 150 mg daily is prescribed from 12 weeks gestation until birth.
  • This is usually arranged in secondary care, but should be initiated in primary care if the woman will not be seen by a specialist until after 12 weeks.
    • Specialist advice should always be sought before prescribing aspirin to girls younger than 16 years of age, and in those with thrombophilia or uncontrolled blood pressure.
• Assess for symptoms of pre-eclampsia at each antenatal visit. Advise the woman that she should seek immediate medical review if she develops any symptoms (including during the first four weeks postpartum).
• Dipstick the urine for protein and measure blood pressure at each antenatal visit. 
  • If dipstick screening is positive [1+ or more], use albumin:creatinine ratio or protein:creatinine ratio to quantify proteinuria in pregnant women.
    • If using protein:creatinine ratio, use 30 mg/mmol as a threshold for significant proteinuria.
    • If using albumin:creatinine ratio, use 8 mg/mmol as a diagnostic threshold.
    • Do not use first morning urine void to quantify proteinuria in pregnant women.
• Arrange emergency secondary care assessment for any woman in whom pre-eclampsia is suspected.

How should I manage a woman with new hypertension after 20 weeks' gestation?

• Arrange secondary care assessment within 24 hours by a healthcare professional trained in the management of hypertensive disorders of pregnancy for all women with new onset of hypertension (over 140 mmHg systolic or over 90 mmHg diastolic) after 20 weeks of pregnancy.
• Be aware of the signs and symptoms of, and risk factors for pre-eclampsia.
• Advise women with new-onset severe hypertension (blood pressure of 160/110 mmHg or more) that they are likely to be admitted to hospital for ongoing monitoring of their condition and of their baby's wellbeing.
  • Women with less severe hypertension may not be routinely admitted and will instead be offered additional maternal and fetal monitoring on an outpatient basis.

How should I manage a woman with proteinuria and no hypertension after 20 weeks' gestation?

If the woman is over 20 weeks gestation and has new proteinuria on dipstick testing but no hypertension:

• Be aware that this can be a symptom of impending pre-eclampsia —if there are other symptoms of pre-eclampsia, arrange a same-day obstetric assessment.
• If there are no other symptoms of pre-eclampsia, consider possible urinary tract infection (UTI):
  • If there is [1+] protein on dipstick testing and the woman has symptoms of a UTI, consider a working diagnosis of UTI.
    • Send a midstream specimen of urine (MSU) for culture and sensitivity and manage appropriately.
    • For detailed information on the diagnosis and management of UTI, see the CKS topic on Urinary tract infection (lower) - women.
  • For women who are asymptomatic but assessed as being at intermediate or high risk for preterm delivery, or are at risk of developing pyelonephritis or other complications due to UTI, consider a working diagnosis of asymptomatic bacteriuria.
    • Send a midstream specimen of urine (MSU) for culture and sensitivity and manage appropriately.
    • For detailed information on the diagnosis and management of UTI, see the CKS topic on Urinary tract infection (lower) - women.
  • Women who are assessed as having a low-risk pregnancy should be advised to seek urgent medical review if any symptoms of UTI develop.
• If there is [2+] protein or more on dipstick testing, arrange urgent secondary care assessment, even if there is evidence of a possible UTI.
• For women with [1+] protein on dipstick testing and no other symptoms of pre-eclampsia:
  • Measure the blood pressure, and use albumin:creatinine ratio or protein:creatinine ratio to quantify the proteinuria.
  • Arrange a follow-up appointment in primary care and reassess in 1 week.
  • Advise the woman to seek immediate medical attention if she develops symptoms of pre-eclampsia in the intervening period.
  • At the follow-up appointment, dipstick the urine, measure the blood pressure, and use albumin:creatinine ratio or protein:creatinine ratio to quantify any persistent ([1+] on dipstick) proteinuria.
  • Seek specialist obstetric advice if proteinuria is significant (protein:creatinine ratio of at least 30 mg/mmol, or albumin:creatinine ratio of at least 8 mg/mmol), or if there are any other concerns or uncertainty.

How should I follow up a woman with confirmed pre-eclampsia postpartum?

• Women with pre-eclampsia who have given birth should be transferred to primary care only if:
  • There are no symptoms of pre-eclampsia.
  • Blood pressure with or without treatment is 150/100 mmHg or lower.
  • Blood test results are stable or improving.
• Women should be given an individual care plan on hospital discharge that includes:
  • Who will provide follow-up care, including medical review if needed.
  • Frequency of blood pressure monitoring.
  • Thresholds for reducing or stopping treatment.
  • Indications for referral to primary care for blood pressure review
  • Advice on self-monitoring for symptoms of pre-eclampsia.
• All women with pre-eclampsia:
  • Should be assessed for symptoms of pre-eclampsia (particularly severe headache and epigastric pain) at each consultation.
  • Who are discharged to primary care with abnormal blood results should have repeat blood tests to measure platelet count, transaminases, and serum creatinine as clinically indicated, until results return to normal.
• Women with pre-eclampsia who did not take antihypertensive treatment:
  • Should have their blood pressure measured at least once between days 3–5 after birth. If blood pressure is abnormal, it should then be measured on alternate days until it normalizes.
  • Target blood pressure is lower than 140/90 mmHg.
  • Antihypertensive treatment should be started if blood pressure is 150/100 mmHg or higher.
• Women with pre-eclampsia who took antihypertensive treatment:
  • Should continue receiving antihypertensive treatment.
  • Should have their blood pressure measured every 1–2 days for up to 2 weeks after transfer to community, care until treatment is no longer required and there is no hypertension.
    • If blood pressure falls below 140/90 mmHg — a reduction in treatment can be considered.
    • If blood pressure falls below 130/80 mmHg — treatment can be reduced.
• If antihypertensive treatment is required in the postnatal period, be aware that:
  • Methyldopa taken during pregnancy should ideally be stopped within 2 days of birth, and an alternative antihypertensive provided, as postnatal methyldopa use may increase the risk of depression.
  • Antihypertensives that are taken once daily should be used wherever possible.
• For women who are not breastfeeding or planning to breastfeed, hypertension should be managed as for a member of the general population. For further information, see the CKS topic on Hypertension.
• If the woman wishes to breastfeed, advise that their treatment can be adapted to accommodate breastfeeding, and that using antihypertensive medication is not a contraindication to breastfeeding.
  • Enalapril should be offered first-line, with appropriate monitoring of maternal renal function and serum potassium.
  • If the woman is of black African or Caribbean family origin, first-line treatment with nifedipine (or amlodipine if the woman has previously used this successfully) should be considered.
  • Where possible, use of diuretics or angiotensin receptor blockers should be avoided in women who are breastfeeding or expressing milk.
  • If blood pressure is not controlled with a single medicine, a combination of nifedipine (or amlodipine) and enalapril can be considered. If this combination is not tolerated or is ineffective, it may be appropriate to either add atenolol or labetalol to the combination treatment or swap one of the medicines being used for atenolol or labetalol. Seek specialist advice where there is uncertainty.
  • As antihypertensives can pass (in small quantities) into breastmilk, women who are breastfeeding should be advised to monitor their babies for symptoms of hypotension, such as drowsiness, lethargy, pallor, cold peripheries, or poor feeding.
• Women remaining on antihypertensive treatment should be offered a medical review in primary care or with a specialist 2 weeks after transfer to community care.
• A postnatal review 6–8 weeks after birth should be carried out in primary care or by a specialist:
  • All women who have had pre-eclampsia should undergo medical review of their hypertension.
  • A urinary reagent-strip test should be carried out. Women with [1+] proteinuria should be offered a further review in primary care or by a specialist three months after delivery to assess kidney function.
    • If this review takes place in primary care, consider referring women with abnormal kidney function at three months postpartum for specialist kidney assessment. Note: the requirement for this will depend largely upon the urinary albumin:creatinine ratio.  For further information, see the CKS topic on Chronic kidney disease.

How should I follow up a woman with chronic hypertension postpartum?

• Note: antihypertensive treatment in the postnatal period will usually be initiated by a specialist before the woman is discharged from hospital. Further monitoring and management may take place in primary care under the terms of a shared-care arrangement.
• Measure blood pressure (this will usually be done by the community midwife after hospital discharge).
  • Daily for the first 2 days postnatally.
  • At least once between days 3–5 postnatally.
  • As clinically indicated if the woman's antihypertensive treatment is changed postnatally.
• Continue antihypertensive treatment if required:
  • Aim to keep blood pressure lower than 140/90 mmHg.
  • Methyldopa taken during pregnancy should ideally be stopped within 2 days of birth, and an alternative antihypertensive provided, as postnatal methyldopa use may increase the risk of depression.
  • Antihypertensives that are taken once daily should be used wherever possible.
• If the woman wishes to breastfeed, advise that their treatment can be adapted to accommodate breastfeeding, and that using antihypertensive medication is not a contraindication to breastfeeding.
  • Enalapril should be offered first-line, with appropriate monitoring of maternal renal function and maternal serum potassium.
  • If the woman is of black African or Caribbean family origin, first-line treatment with nifedipine (or amlodipine if the woman has previously used this successfully) should be considered.
  • Where possible, the use of diuretics or angiotensin receptor blockers should be avoided in women who are breastfeeding or expressing milk.
  • If blood pressure is not controlled with a single medicine, consider a combination of nifedipine (or amlodipine) and enalapril. If this combination is not tolerated or is ineffective, consider either adding atenolol or labetalol to the combination treatment or swapping one of the medicines being used for atenolol or labetalol. Seek specialist advice where there is uncertainty.
  • When treating women with antihypertensive medication during the postnatal period, medicines that are taken once daily should be used wherever possible.
  • As antihypertensives can pass (in small quantities) into breastmilk, women who are breastfeeding should be advised to monitor their babies for symptoms of hypotension, such as drowsiness, lethargy, pallor, cold peripheries, or poor feeding.
  • Reduce antihypertensive treatment if blood pressure falls below 130/80 mmHg.
• Review antihypertensive treatment 2 weeks postnatally.
• Ensure that women with chronic hypertension are offered a medical review 6–8 weeks after the birth either in primary care, or with a specialist as appropriate. 

How should I follow up a woman with gestational hypertension postpartum?

• Most women with gestational hypertension will be followed up by the maternity unit after delivery until their blood pressure has returned to normal, or will be referred to a specialist if blood pressure remains elevated. Women then being transferred to community care should receive a care plan which outlines:
  • Who will provide follow-up care, including medical review if needed.
  • Frequency of blood pressure monitoring.
  • Thresholds for reducing or stopping treatment.
  • Indications for referral to primary care for blood pressure review.
• The woman's blood pressure should be measured:
  • Daily for the first 2 days postnatally.
  • At least once between days 3–5 postnatally.
  • As clinically indicated if the woman's antihypertensive treatment is changed postnatally.
• If continued antihypertensive treatment is required:
  • Target blood pressure is lower than 140/90 mmHg.
  • Methyldopa taken during pregnancy should ideally be stopped within 2 days of birth, and an alternative antihypertensive provided, as postnatal methyldopa use may increase the risk of depression.
  • Antihypertensives that are taken once daily should be used wherever possible.
• For women who are not breastfeeding or planning to breastfeed, hypertension should be managed as for a member of the general population. For further information, see the CKS topic on Hypertension.
• If the woman wishes to breastfeed, advise that their treatment can be adapted to accommodate breastfeeding, and that using antihypertensive medication is not a contraindication to breastfeeding.
  • Enalapril should be offered first-line, with appropriate monitoring of maternal renal function and maternal serum potassium.
  • If the woman is of black African or Caribbean family origin, first-line treatment with nifedipine (or amlodipine if the woman has previously used this successfully) should be considered.
  • Where possible, use of diuretics or angiotensin receptor blockers should be avoided in women who are breastfeeding or expressing milk.
  • If blood pressure is not controlled with a single medicine, consider a combination of nifedipine (or amlodipine) and enalapril. If this combination is not tolerated or is ineffective, consider either adding atenolol or labetalol to the combination treatment or swapping one of the medicines being used for atenolol or labetalol. Seek specialist advice where there is uncertainty.
  • When treating women with antihypertensive medication during the postnatal period, medicines that are taken once daily should be used wherever possible.
  • As antihypertensives can pass (in small quantities) into breastmilk, women who are breastfeeding should be advised to monitor their babies for symptoms of hypotension, such as drowsiness, lethargy, pallor, cold peripheries, or poor feeding.
  • Reduce antihypertensive treatment if blood pressure falls below 130/80 mmHg.
• For women with gestational hypertension who did not take antihypertensive treatment and have given birth, antihypertensive treatment should be started if blood pressure is 150/100 mmHg or higher.
• Women who remain on antihypertensive treatment postnatally should be offered a medical review in primary care, or with their specialist 2 weeks after transfer to community care.
• Ensure that women with gestational hypertension are offered a medical review 6–8 weeks after the birth either in primary care, or with a specialist as appropriate. 

How should I follow up a woman with proteinuria and no hypertension?

• At postnatal review 6–8 weeks after birth, for all women with unexplained isolated proteinuria during pregnancy who remained normotensive.
  • A urinary reagent-strip test should be carried out. Women with [1+] proteinuria should be offered a further review in primary care or by a specialist 3 months after delivery to assess kidney function.
    • If this review takes place in primary care, assess renal function using estimated glomerular filtration rate (eGFR) and quantification of proteinuria. For further information, see the CKS topic on Chronic kidney disease.
    • Consider referring women with an abnormal renal function assessment at 3 months for specialist assessment.

How should I manage a woman with postpartum pre-eclampsia or eclampsia?

• All women with suspected postpartum pre-eclampsia or eclampsia should be admitted to hospital for immediate assessment.
• Consider the possibility of imminent pre-eclampsia or eclampsia in a woman up to 4 weeks postpartum (even if she has not had previous hypertension or pre-eclampsia) if she develops any of the following:
  • Severe headaches (increasing frequency unrelieved by regular analgesics).
  • Visual problems, such as blurred vision, flashing lights, double vision, or floating spots.
  • Persistent new epigastric pain or pain in the right upper quadrant.
  • Vomiting.
  • Hypertension.
  • Proteinuria.
  • Breathlessness due to pulmonary oedema.
  • Sudden swelling of the face, hands, or feet.
• Consider the possibility of eclampsia in any woman who has a seizure within 4 weeks of delivery.

Contraindications and cautions

• Labetalol is not specifically licensed for the treatment of hypertension in pregnancy.

Labetalol should not be prescribed to people with:

• Asthma or history of bronchospasm or chronic obstructive airways disease.
• Uncontrolled heart failure.
• Cardiogenic shock.
• Sick sinus syndrome (including sino-atrial block, second- or third-degree heart block).
• Prinzmetal's angina.
• Phaeochromocytoma.
• Metabolic acidosis.
• Marked bradycardia (less than 45-50 bpm).
• Hypotension.
• Severe peripheral circulatory disorders (Raynaud's disease and intermittent claudication).

Labetalol should be used with caution in people with:

• Poor cardiac reserve.
• Peripheral circulatory disorders (Raynaud's disease and intermittent claudication).
• Diabetes mellitus.
• Psoriasis.
• History of hypersensitivity to allergens.
• Myasthenia gravis.
• Portal hypertension — risk of deterioration in liver function.
• Renal impairment — dose reduction should be considered.
• Hepatic impairment — there have been rare reports of (usually reversible) severe hepatocellular injury with labetalol after both short and long term treatment. Liver function tests should be done at the first sign or symptom of liver dysfunction. If there is laboratory evidence of liver injury or the person is jaundiced, labetalol should be stopped and not re-started.
• Ischaemic heart disease and first degree atrioventricular (AV) block — the course of labetalol should not be interrupted or discontinued abruptly.

[BNF, 2025; EMC, 2024]

Adverse effects

Adverse effects of labetalol include:

• Neurological — tiredness, weakness, headache, confusion, and visual impairment.
• Skin — rashes, tingling scalp, nipple pain, and Raynaud's phenomenon, and rarely lichenoid rash.
• Gastrointestinal — epigastric pain, nausea, vomiting, and liver damage.
• Urological — difficulty in micturition.
• Neuropsychiatric — depressed mood and sleep disorders.
• Hepatic — Raised liver function tests.
• Other — dyspnoea, postural hypotension, nasal congestion, and sweating.

[BNF, 2025; EMC, 2024]

Drug interactions

Concomitant use of labetalol is contraindicated with:

• Calcium antagonists such as verapamil and to a lesser extent diltiazem — may reduce cardiac contractility and atrioventricular conduction.
• Digitalis glycosides — may increase cardiac atrioventricular conduction time.
• Clonidine — beta-blocker use increases the risk of rebound hypertension.
• Monoamineoxidase inhibitors (MAOIs) — except MOA-B inhibitors.

Combinations requiring caution include:

• Class I anti-arrhythmic agents, for example disopyramide, quinidine; and the class III anti-arrhythmic drug amiodarone — may have potentiating effects on atrial conduction time and induce negative inotropic effect.
• Insulin and oral hypoglycaemic drugs — may intensify the blood-sugar lowering effect, especially of non-selective beta-blockers. Beta blockade may prevent the appearance of signs of hypoglycaemia.
• Cimetidine and hydralazine — may increase the bioavailability of labetalol.
• Dihydropyridine derivates such as nifedipine — may increase the risk of hypotension. In people with latent cardiac insufficiency, treatment with beta-blockers may lead to cardiac failure.
• Cyclo-oxygenase (COX)-inhibiting drugs — may decrease the hypotensive effect of beta-blockers.
• Sympathomimetic agents (for example dopamine) — may counteract the effect of beta-blockers.
• Tricyclic antidepressants — may increase the blood pressure lowering effect of labetalol and may increase the incidence of tremor.
• Barbiturates, phenothiazines or other antihypertensive agents — may increase the blood pressure lowering effect of labetalol.
• NSAIDs, corticosteroids, oestrogens and progesterones — may antagonize the hypotensive effects of labetalol.
• Mefloquine or quinine — may increase the risk of bradycardia.

[BNF, 2025; EMC, 2024]

Dosing information

• Start with a dose of 100 mg labetalol twice a day.
• Increase the dose at fortnightly intervals if needed and tolerated.
• Usual dose 200 mg twice daily, increased if necessary up to 800 mg daily in 2 divided doses, to be taken with food, higher doses to be given in 3 to 4 divided doses.
• The maximum recommended dose is 2400 mg daily.

[BNF, 2025]

Contraindications and cautions

• Methyldopa is not specifically licensed for the treatment of hypertension in pregnancy. The manufacturer states that there is no obvious teratogenic effect of methyldopa, but use should be reserved for those in whom the benefits of treatment outweigh the risks.

Methyldopa should not be prescribed to people with:

• Active hepatic disease, such as acute hepatitis or active cirrhosis.
• Depression.
• Phaeochromocytoma or paraganglioma.
• Acute porphyria.

Methyldopa should be used with caution in people with:

• History of hepatic disease or renal impairment.

[EMC, 2022; BNF, 2025]

Adverse effects

Adverse effects of methyldopa include:

• Cardiac — bradycardia, aggravation of angina pectoris, myocarditis, and pericarditis.
• Haematological — haemolytic anaemia, bone marrow depression, leukopenia, granulocytopenia, thrombocytopenia, and eosinophilia.
• Neurological — sedation (usually transient), headache, paraesthesia, parkinsonism, Bell's palsy, involuntary choreoathetotic movements, impaired mental acuity, dizziness, lightheadedness, symptoms of cerebrovascular insufficiency, asthenia, and weakness.
• Gastrointestinal — gastrointestinal disorders, dry mouth, sore or 'black' tongue, pancreatitis, hepatitis, and jaundice.
• Skin — rashes (including toxic epidermal necrolysis), lupus-like syndrome, angioedema, and urticaria. 
• Neuropsychiatric — nightmares, reversible mild psychoses, and depression.
• Endocrine — hyperprolactinaemia, gynaecomastia, amenorrhoea, and lactation. 
• Other — hepatic disorders, prolonged carotid sinus hypersensitivity, nasal stuffiness, arthralgia, myalgia, sialadenitis, orthostatic hypotension, oedema (and weight gain), fever, and decreased libido.

[EMC, 2022; BNF, 2025]

Drug interactions

Combinations requiring caution include:

• Lithium — when methyldopa and lithium are given concomitantly the person should be monitored carefully for symptoms of lithium toxicity such as diarrhoea, abdominal pains, nausea, vomiting, dizziness, weakness, tremor, ataxia, and slurred speech.
  • If lithium toxicity is suspected, do an urgent lithium level and seek specialist advice.
• Other antihypertensives — potentiation of antihypertensive action may occur.
• Sympathomimetics (for example dopamine), monoamine oxidase inhibitors (MAOIs), and tricyclic antidepressants — may reduce the antihypertensive effect of methyldopa.
• Phenothiazines — may have additive hypotensive effects but can also reduce the antihypertensive effect of methyldopa.
• Iron — may decrease the bioavailability of methyldopa reducing its effect on blood pressure control.

[EMC, 2022; BNF, 2025]

Dosing information

• Start with a dose of 250 mg 2 to 3 times a day.
• If required and tolerated, increase the dose gradually at intervals of at least 2 days.
• Maximum dose is 3000 mg daily.

[BNF, 2025]

Contraindications and cautions

• Nifedipine is not specifically licensed for the treatment of hypertension in pregnancy.

Nifedipine should not be prescribed to people with:

• Cardiogenic shock.
• Clinically significant aortic stenosis.
• Unstable or acute angina.
• Recent history (within 4 weeks) of myocardial infarction.
• Inflammatory bowel disease.

Nifedipine should be used with caution in people with:

• Severe hypotension (systolic blood pressure less than 90 mmHg).
• Hepatic impairment.
• Poor cardiac reserve.
• Diabetes mellitus — may require adjustment of diabetes treatment as nifedipine can affect blood sugar.
• A history of gastro-intestinal obstruction, oesophageal obstruction, or any degree of decreased lumen diameter of the gastrointestinal tract.
• Significantly impaired left ventricular function (where heart failure deterioration has been observed).

[EMC, 2020; BNF, 2025]

Adverse effects

Adverse effects of nifedipine include:

• Neurological — headache, migraine, paraesthesia, tremor, asthenia, vertigo, and visual disturbance.
• Cardiac — vasodilation, hypotension, palpitations, dizziness, tachycardia, and syncope.
• Gastrointestinal — constipation and gastrointestinal disturbance.
• Respiratory — dyspnoea.
• Neuropsychiatric — anxiety, depression, and sleep disturbance.
• Urological — polyuria, dysuria, and nocturia.
• Other — oedema, lethargy, chills, nasal congestion, epistaxis, myalgia, joint swelling, sweating, rashes, and dry mouth.

[EMC, 2020; BNF, 2025]

Drug interactions

Concomitant use of nifedipine is contraindicated with:

• Rifampicin — this attenuates the effect of nifedipine.

Drugs that should be co-administered with caution include:

• Other antihypertensives — nifedipine may increase their blood pressure-lowering effect.
• Beta blockers — deterioration of heart failure has been observed in isolated cases.
• Digoxin — may lead to reduced digoxin clearance. The person should therefore be monitored for symptoms of digoxin toxicity such as confusion, nausea, anorexia, or disturbance of colour vision.
  • If digoxin toxicity is suspected, measure serum digoxin levels and seek specialist advice if necessary.
• Cytochrome P450 inhibitors including macrolide antibiotics (such as erythromycin), HIV protease inhibitors (such as ritonavir), azole antimycotics (such as ketoconazole), fluoxetine, nefazodone, quinupristin/dalfopristin, cisapride, valproic acid, cimetidine, diltiazem, and grapefruit juice — can lead to increased plasma concentration of nifedipine.
• Cytochrome P450 inducers such as phenytoin, carbamazepine, and phenobarbital — can lead to decreased plasma concentration of nifedipine.
• Quinidine — co-administration with nifedipine may lower plasma quinidine levels, and after discontinuation of nifedipine, an increase in plasma quinidine levels may be observed.
• Tacrolimus — co-administration with nifedipine may result in increased plasma tacrolimus levels.

[EMC, 2020; BNF, 2025]

Dosing information

• A modified-release preparation should be used and the same brand prescribed for the duration of treatment to ensure consistent bioavailability.
• Dosages are as recommended for non-pregnant people, and will depend on the brand used.

[BNF, 2025]