Pharmacotherapy for Hypertensive Disorders of Pregnancy: A Systematic Review and Narrative Synthesis of Clinical Practice Guidelines

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.