Antihypertensive Pregnancy: C — neonatal bradycardia and growth restriction risk

Propranolol (Portal Hypertension)

Brand names: Inderal, Angilol

Adult dose

Dose: Primary prophylaxis varices: 40–80mg BD (titrate to reduce HR by 25% or to HR 55–60 bpm)

Route: Oral

Frequency: Twice daily

Max: 320mg/day

Portal hypertension: non-selective beta-blocker reduces portal pressure by reducing cardiac output and splanchnic vasodilation. Titrate to resting HR 55–60 bpm or 25% reduction from baseline. Check endoscopy results — carvedilol (6.25mg BD) has better portal pressure reduction.

Dose adjustments

Renal

No adjustment required.

Hepatic

Reduce dose — reduced hepatic metabolism in cirrhosis. Increased bioavailability and risk of accumulation.

Clinical pearls

Non-selective beta-blockers (propranolol, nadolol, carvedilol) reduce portal hypertension via reduction of cardiac output AND splanchnic vasoconstriction (β₂ block).
BAVENO VII recommendations: carvedilol 6.25mg BD preferred over propranolol — superior reduction in HVPG (hepatic venous pressure gradient).
Prophylaxis of first variceal bleed: propranolol or band ligation (EVL). Combination not superior.
Spontaneous bacterial peritonitis: propranolol may paradoxically worsen outcomes in advanced cirrhosis with refractory ascites — reassess risk/benefit.

Contraindications

Asthma (non-selective beta-blockade — bronchospasm)
Second or third degree AV block
Peripheral vascular disease (severe — worsens limb ischaemia)
Porphyria

Side effects

Bradycardia, hypotension
Cold extremities
Fatigue, nightmares (CNS penetration)
Bronchospasm (non-selective — contraindicated in asthma)
Masking of hypoglycaemia in diabetes

Interactions

Verapamil / diltiazem: severe bradycardia and AV block
Adrenaline: paradoxical hypertension then severe bradycardia
Hypoglycaemic agents: masks hypoglycaemia symptoms

Monitoring

Resting HR (target 55–60 bpm)
BP
signs of HF or bronchospasm
compliance

Reference: BAVENO VII Consensus 2022; BSG Portal Hypertension Guidelines; NICE BNF 84. Verify against your local formulary and the latest BNF before prescribing.

Curated clinical cross-links plus same-class fallbacks.

Calculators

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Pathways