What are the guidelines for the emergency treatment of acute-onset severe hypertension (high blood pressure) during pregnancy?

Updated: Feb 22, 2019
  • Author: Matthew R Alexander, MD, PhD; Chief Editor: Eric H Yang, MD  more...
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There is consensus across guidelines (JNC 7, ESH/ESC, ACOG, SOGC) for the need to acutely manage severe hypertension, defined as systolic BP ≥160 mm Hg or diastolic BP ≥110 mm Hg or both, with the goal of preventing maternal stroke and avoiding intrauterine growth restriction (IUGR). [5, 126, 138, 142]

In 2015, the American College of Obstetricians and Gynecologists Committee on Obstetric Practice issued updated guidelines regarding the emergency treatment of acute-onset severe hypertension during pregnancy, including the following [143] :

  • Acute-onset, severe hypertension that is accurately measured using standard techniques and is persistent for 15 minutes or longer is considered a hypertensive emergency
  • Intravenous (IV) labetalol and hydralazine have long been considered first-line medications for the management of acute-onset, severe hypertension in pregnant and post-partum women; available evidence suggests that oral nifedipine also may be considered as a first-line therapy
  • Parenteral labetalol should be avoided in women with asthma, heart disease, or congestive heart failure
  • When urgent treatment is needed before the establishment of IV access, the oral nifedipine algorithm can be initiated as IV access is being obtained, or a 200-mg dose of labetalol can be administered orally; the latter can be repeated in 30 minutes if appropriate improvement is not observed
  • Magnesium sulfate is not recommended as an antihypertensive agent, but it remains the drug of choice for seizure prophylaxis in severe preeclampsia and for controlling seizures in eclampsia
  • Sodium nitroprusside should be reserved for extreme emergencies and used for the shortest amount of time possible because of concerns about cyanide and thiocyanate toxicity in the mother and fetus or newborn, and increased intracranial pressure with potential worsening of cerebral edema in the mother
  • Adoption of standardized, evidence-based clinical guidelines for managing patients with preeclampsia is needed; individuals and institutions should have mechanisms in place for prompt initiation of medication when a patient presents with a hypertensive emergency

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