Chapter 9: Hypertensive Emergency

BACKGROUND

Hypertensive disorders of pregnancy complicate nearly 10% of all pregnancies^1-3 and contribute significantly to maternal morbidity and mortality in the United States, most notably in the week following delivery.⁴

Approximately 1% to 2% of all pregnant women will experience a hypertensive emergency during pregnancy or postpartum,² defined as acute onset blood pressure value ≥160/110 persisting for 15 minutes or more.⁵ Appropriate and prompt management of hypertension can improve perinatal outcomes and save lives.

COMPLICATIONS

Maternal

Neonatal

GOALS

• Initiate antihypertensive therapy within 30 to 60 minutes.

• Decrease mean arterial pressure by 20% to 25%.

• Achieve a range of blood pressure (BP) 140-150/90-100 mm Hg.

The overarching goal is maternal stabilization before delivery to avoid maternal end-organ damage. Simultaneous assess for delivery of fetus is also necessary.

CLINICAL MANAGEMENT

Treatment starts with intravenous labetalol or hydralazine, or immediate release oral nifedipine if intravenous (IV) access is not available. Choice is based on physician experience and knowledge of adverse effects.⁶

All algorithms (in tables) start with initial treatment (Tables 9-1 to 9-3), followed by rechecking BP after 10 minutes. If BP control has reached the goal, the treatment may stop bolus medications and initiate a maintenance regimen. If timely relief does not occur, the dose is escalated and emergent consultation with an anesthesiologist, maternal-fetal medicine subspecialist, or critical care subspecialist is recommended.⁵ Medications for treating hypertensive crisis are listed in Tables 9-4 and 9-5.