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ACOG Guidance: Emergency Treatment for Severe Hypertension in Pregnancy

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Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Restate the BP values that ACOG defines as severe hypertension
2. Identify the first line therapies used to treat severe hypertension

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Genoox, Inc., and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Dec 31 2019, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Designated for 0.1 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

Read Disclaimer & Fine Print

Summary:

ACOG has released guidance on the management of sudden onset severe hypertension, including in the setting of preeclampsia.  This can be a life-threatening event during pregnancy and requires special vigilance in the postpartum period, particularly following hospital discharge.

When to Treat:

Urgently treat any of the following in pregnancy or postpartum period:

  • BP ≥ 160/110 mm Hg persisting for 15 minutes
  • Systolic pressure ≥ 160 mm Hg persisting for 15 minutes
    • systolic BP a predictor of maternal morbidity/mortality
  • Severe diastolic hypertension:  ≥ 110 mm Hg persisting for 15 minutes

Target BP:

  • Do not aim to normalize BP
  • Target range:
    • Systolic: 140-150 mm Hg
    • Diastolic: 90-100 mm Hg

First Line Therapy:

Nifedipine

Hydralazine

Labetalol

Immediate Release Oral Nifedipine:

  • Administer 10 mg immediate release nifedipine capsules orally
  • Repeat BP in 20 minutes and record results
    • If either BP threshold still elevated, administer immediate release nifedipine 20 mg capsules orally
    • If BP below threshold, continue with close monitoring
  • Repeat BP in 20 minutes and record results
    • If either BP threshold still elevated, administer immediate release nifedipine 20 mg capsules orally
    • If BP below threshold, continue with close monitoring
  • Repeat BP in 20 minutes and record results
    • If either BP threshold still elevated, administer labetalol 20 mg IV for more than 2 minutes
    • Obtain emergency consultation (MFM, internal medicine, anesthesia or critical care)
    • Give additional medications per specific order
  • Once thresholds met
    • repeat BP every 10 minutes for 1 hour, then
    • every 15 minutes for 1 hour, then
    • every 30 minutes for 1 hour and then
    • every hour for 4 hours
  • Give additional BP meds as per specific order

Medication risks for nifedipine

  • Maternal tachycardia
  • Maternal hypotension (systolic ≤ 90 mm Hg)
    • Do not use sublingually

Immediate release oral nifedipine is first line treatment If IV access not available or not yet initiated

  • If nifedipine unavailable:
    • Administer 200 mg does oral labetalol
    • Repeat labetalol dose in 30 minutes if no improvement

IV Hydralazine

  • Administer hydralazine 5 – 10 mg IV for > than 2 minutes
  • Repeat BP in 20 minutes and record results
    • If either BP threshold still elevated, administer hydralazine 10 mg IV for > 2 minutes
    • If BP below threshold, continue with close monitoring
  • Repeat BP in 20 minutes and record results
    • If either BP threshold still elevated, administer labetalol 20 mg IV for > 2 minutes
    • If BP below threshold, continue with close monitoring
  • Repeat BP in 10 minutes and record results
    • If either BP threshold still elevated, administer labetalol 40 mg IV for > 2 minutes
    • Obtain emergency consultation (MFM, internal medicine, anesthesia or critical care)
    • Give additional medications per specific order
  • Once thresholds met:
    • repeat BP every 10 minutes for 1 hour, then
    • every 15 minutes for 1 hour, then
    • every 30 minutes for 1 hour and then
    • every hour for 4 hours
  • Give additional BP meds as per specific order

Medication risks for hydralazine

  • Maternal hypotension (systolic ≤ 90 mm Hg)

IV Labetalol

  • Administer labetalol 20 mg IV for > than 2 minutes
  • Repeat BP in 10 minutes and record results
    • If either BP threshold still elevated, administer labetalol 40 mg IV for > 2 minutes
    • If BP below threshold, continue with close monitoring
  • Repeat BP in 10 minutes and record results
    • If either BP threshold still elevated, administer labetalol 80 mg IV for > 2 minutes
    • If BP below threshold, continue with close monitoring
  • Repeat BP in 10 minutes and record results
    • If either BP threshold still elevated, administer hydralazine 10 mg IV for > 2 minutes
    • If BP below threshold, continue with close monitoring
  • Repeat BP in 20 minutes and record results
    • If BP still elevated, obtain emergency consultation (MFM, internal medicine, anesthesia or critical care)
    • Give additional medications per specific order
  • Once thresholds met:
    • repeat BP every 10 minutes for 1 hour, then
    • every 15 minutes for 1 hour, then
    • every 30 minutes for 1 hour and then
    • every hour for 4 hours
  • Give additional BP meds as per specific order

Medication risks for IV labetalol

  • May cause neonatal bradycardia
  • Avoid in women with asthma, heart disease, congestive heart failure

Magnesium Sulfate

  • Magnesium Sulfate should not be used to reduce blood pressure
  • Remains drug of choice for seizure prophylaxis
  • Administer and do not delay in the setting of
    • Gestational hypertension with severe features
    • Preeclampsia with severe features
    • Eclampsia

Learn More – Primary Sources:

ACOG Committee Opinion 767: Emergent Therapy for Acute-Onset, Severe Hypertension During Pregnancy and the Postpartum Period

ACOG II Severe Hypertension in Pregnancy Bundle 

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Related ObG Topics:

Diagnosing Preeclampsia – Key Definitions and ACOG Guidelines
Aspirin Treatment for Women at Risk for Preeclampsia – ACOG and USPSTF Recommendations  
Does Enoxaparin Prevent Preeclampsia?
ASPRE Trial: A Combined Risk Algorithm and Use of Aspirin to Prevent Preterm Preeclampsia
Eclampsia and Role of Magnesium Sulfate

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