Management of Severe Hypertension in Pregnancy
Management of Severe Hypertension in Pregnancy
Management of Severe Hypertension in Pregnancy
Seminars in Perinatology
www.seminperinat.com
Keywords: While hemorrhage is the leading cause of maternal death in most of the world, hyper-
Severe hypertension tensive disorders of pregnancy are the leading cause of maternal mortality in the United
postpartum hypertension States. The opportunity to improve outcomes lies in timely and appropriate response to
preeclapsia severe hypertension. The purpose of this article is to review the diagnostic criteria for
antihypertensive therapy severe hypertension, choice of antihypertensive agents, and recommended algorithms for
evaluation and management of acute changes in clinical status. Adhering to standard
practices ensures that care teams can timely and appropriate care to these high risk
patients. With heightened surveillance and prompt evaluation of signs and symptoms of
worsening hypertension, maternal morbidity and mortality can be decreased.
& 2015 Elsevier Inc. All rights reserved.
n
Corresponding author.
E-mail address: [email protected] (L.A. Moroz).
http://dx.doi.org/10.1053/j.semperi.2015.11.017
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Table 1 – Severe features of preeclampsia. be checked in 10 min. If SBP remains Z160 mmHg or DBP Z
110 mmHg, 40 mg labetalol should be administered IV over
Blood pressure Systolic Z160 mmHg
2 min, and blood pressure should be checked after 10 min.
Diastolic Z110 mmHg
On two occasions at least 4 h apart Dosing of labetalol is repeated in increasing increments of
20 mg to a maximum dose of 80 mg until goal blood pressure is
Thrombocytopenia Platelets o100,000/ml
achieved. If a goal blood pressure is not achieved with a dose of
Impaired liver AST and/or ALT Z twice upper limit of 80 mg of labetalol, treatment with hydralazine is recom-
function reference range mended. Dosing of hydralazine is initiated at 10 mg adminis-
Severe persistent right upper quadrant or tered over 2 min. Blood pressure should be checked at 10 min
epigastric pain unrelieved by
and 20 min after dosing. If SBP remains Z160 mmHg or DBP Z
medication
110 mmHg 20 min after the dose is administered, consultation
Renal insufficiency Serum creatinine Z1.1 mg/dl or doubling with maternal–fetal medicine, internal medicine, anesthesiol-
Pulmonary edema
ogy, critical care or emergency medicine is recommended.
Cerebral New-onset headache Hydralazine can also be chosen as the first-line manage-
disturbance ment for severe hypertension, as outlined in Figure 4. When
Visual New-onset scotomata treatment is initiated with hydralazine, a 5 mg IV dose should
disturbances be administered over 2 min. Blood pressure should be
checked at 10 min and 20 min after dosing. Some patients
may be very sensitive to hydralazine, and therefore starting
at a low dose is recommended. Patients who are not already
Choice of antihypertensive agents in the treatment taking beta blockers may also experience a reflex tachycardia
of severe hypertension following hydralazine administration. If SBP remains Z160
mmHg or DBP Z 110 mmHg 20 min after the dose is admin-
The standard first-line medications for the management of istered, 10 mg IV hydralazine should be administered and
hypertensive emergency in pregnant and postpartum women blood pressures repeated at 10 and 20 min. If blood pressure
are intravenous labetalol and intravenous hydralazine. For remains above goal, treatment with 20 mg IV labetalol is
patients with a maternal heart rate o60 bpm, hydralazine is recommended. If target blood pressure is not achieved after
the preferred antihypertensive. Labetalol should be avoided 20 min, 40 mg IV labetalol should be administered and spe-
in patients with asthma and heart failure. The data regarding cialty consultation is recommended.
whether labetalol produces severe symptoms of β-adrenergic For patients without IV access, 10 mg oral nifedipine may
effect in neonates are inconclusive. Some studies report an be given as an initial measure prior to establishing IV access.
increased incidence in neonatal bradycardia and hypoten- Blood pressure should be checked in 20 min. If the SBP
sion, whereas others have not found a difference after remains Z160 mmHg or DBP Z 110 mmHg and IV access is
controlling for gestational age.13–15 A recent addition to the still unavailable, 20 mg oral nifedipine should be given. If a
acceptable first-line antihypertensives is 10 mg short-acting repeat blood pressure remains elevated 20 min later, another
nifedipine administered orally as an initial measure.10 20 mg dose of nifedipine can be given.10 A large retrospective
If labetalol is chosen for treatment of severe hypertension, review examined the risk for hypotension and neuromuscu-
the initial recommended dose is 20 mg administered IV over lar blockade with concomitant use of nifedipine and magne-
2 min. An algorithm for managing severe hypertension using sium sulfate did not show an increased risk for complications
labetalol is provided in Figure 3. A repeat blood pressure should with the combination of these medications.16
Fig. 3 – Algorithm for first-line management of severe hypertension with labetalol. (Adapted with permission from ACOG.7)
4 SE M I N A R S I N P E R I N A T O L O G Y ] (2015) ]]]–]]]
Fig. 4 – Algorithm for first-line management of severe hypertension with hydralazine. (Adapted with permission from ACOG.7)
Goals for blood pressure reduction are sustained SBP and Benzodiazepines, such as lorazepam (Ativans) and diazepam
DBP o 160 mmHg and o110 mmHg, respectively. Lowering (Valiums), phenytoin (Dilantins), and levetiracetam (Kepp-
blood pressures to “normal” ranges (i.e., SBP o 140 mmHg or ras) are dosed as outlined in Table 2.
DBP o 90 mmHg) does not confer additional benefit and may Providers should routinely assess patients for signs of
be harmful.10 Once target goal blood pressures are achieved, magnesium toxicity including nausea, headache, lethargy,
blood pressure monitoring should occur at 10 min intervals loss of deep tendon reflexes, hypotension, and bradycardia.
for 1 h, 15 min intervals the next hour, 30 min intervals for At higher serum levels of magnesium, somnolence, muscle
the following hour, and every hour for 4 h. The following paralysis, respiratory failure, and heart block may result. If
baseline labs should be obtained: CBC, lactate dehydrogen- there is clinical concern for magnesium toxicity, the magne-
ase, liver function tests, electrolytes, BUN, creatinine, and an sium sulfate infusion should be discontinued, and the serum
assessment of urine protein (protein:creatinine ratio, urine magnesium level should be checked. For treatment of acute
dipstick for protein, and/or 24 h urine protein collection). symptomatic hypermagnesemia, calcium gluconate can be
The maximum cumulative dose of IV labetalol should administered intravenously at a dose of 1 g as 10 ml of 10%
not exceed 300 mg over a 24 h period. Cumulative doses solution given over 1–2 min. Monitoring of magnesium levels
of hydralazine that exceed 25 mg in 24 h are not with serial labs should be considered for patients with
recommended. evidence of renal insufficiency.
Magnesium sulfate for seizure prophylaxis Severe hypertension as a change in disease status
Magnesium sulfate remains the drug of choice for seizure Following the stabilization of a pregnant patient with severe
prophylaxis in preeclamptic patients and for controlling hypertension, a full assessment of the status of the patient
seizures in eclampsia. Unless magnesium sulfate is contra- should be performed. During this time, magnesium sulfate
indicated in a particular patient (i.e., myasthenia gravis, should be given for seizure prophylaxis if not already ini-
pulmonary edema, and renal failure), it should be given while tiated. When the gestational age is less than 34 weeks,
managing a hypertensive crisis. However, providers should expectant management, at least through administration of
be reminded that it is not an antihypertensive agent. The use antenatal corticosteroids, may be an acceptable goal when
of magnesium sulfate in patients with preeclampsia is there is no evidence of deterioration in maternal or fetal
recommended when severe features are present, but not status. Contraindications to a delay in delivery for the benefit
mandatory when absent.9 of corticosteroids include uncontrolled hypertension, eclamp-
Standard regimens for seizure prophylaxis include an IV sia, pulmonary edema, placental abruption, disseminated
bolus of 4–6 g of magnesium sulfate in 100 ml of normal intravascular coagulation, non-reassuring fetal status, or
saline administered over 20 min followed by an IV infusion of intrauterine fetal demise.
1–2 g per hour. For patients without IV access, a loading dose For gestational ages of 34 weeks and greater, or for women
of 10 g of magnesium sulfate in 50% solution can be admin- with a contraindication to expectant management, a plan for
istered intramuscularly (IM): 5 g in each buttock usually the timing and mode of delivery should be made. Vaginal
mixed with 1–2 ml lidocaine for injection. Magnesium sulfate delivery is preferred if delivery can be achieved in a reason-
may be continued antepartum during assessment of disease able amount of time in most cases of HELLP syndrome, severe
status, during induction of labor or preoperatively, and for preeclampsia, and chronic hypertension with superimposed
24 h postpartum following delivery. preeclampsia. However, for patients remote from delivery
For recurrent seizures, or when magnesium sulfate is with an unripe cervix or prior cesarean, expeditious delivery
contraindicated, alternative anticonvulsants can be given. by cesarean should be considered.
SEM I N A R S I N P E R I N A T O L O G Y ] (2015) ]]]–]]] 5
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