Targeted antihypertensive therapy after hypertensive pregnancy: Lactation-safe choices, treatment thresholds, and outcomes (2015–2025)

Background

Postpartum hypertension is a leading driver of emergency visits and readmissions within 6 weeks of delivery, yet optimal therapy must balance BP control with lactation safety.

Objective

To synthesize contemporary evidence (Jan 2015–Aug 2025) on postpartum antihypertensives with emphasis on breastfeeding compatibility, treatment thresholds/targets, and maternal–infant outcomes. Data Sources: PubMed/MEDLINE, Embase, Scopus, Web of Science, Cochrane, ClinicalTrials.gov/ICTRP, and guideline repositories (AHA/ACOG/NICE), plus LactMed and UK Specialist Pharmacy Service (SPS). Eligibility: RCTs, comparative cohorts/case–control studies, and ≥10-patient case series reporting postpartum outcomes or lactation data.

Results

First-line postpartum agents compatible with breastfeeding in term, healthy infants are dihydropyridine calcium-channel blockers (nifedipine, amlodipine), ACE inhibitors (enalapril), and labetalol. Multiple large cohorts associate nifedipine (at discharge) with lower hypertension-related readmissions than labetalol. Small RCTs show signals for enalapril-related cardiac reverse remodeling and physician-optimized self-monitoring improving 9-month BP and cardiac structure. Severe BP ≥160/110 mmHg warrants urgent treatment (IV labetalol or hydralazine; oral IR nifedipine if no IV), while persistent ≥150/100 mmHg merits/continues oral therapy titrated toward ≤140/90 mmHg in clinic (≈≤135/85 mmHg at home). Early review within 3–10 days (≤72 h after severe disease) and remote/home BP programs reduce unplanned care.

Conclusions

For lactating patients, nifedipine ER/amlodipine, enalapril, and labetalol are appropriate first-line choices; real-world data favor nifedipine for lowering readmissions. Scaling home BP monitoring with early follow-up improves outcomes. Large pragmatic RCTs comparing step-care strategies and tracking infant outcomes remain a priority.