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

ACOG states that “available evidence suggests that immediate release oral nifedipine also may be considered as a first-line therapy, particularly when intravenous access is not available”

• If nifedipine unavailable and there is no IV access
  • 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 

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