Case Challenge: Woman Presents to Emergency Department With Headache and Hypertension

Lisa M. Hollier, MD, MPH; Carolyn K. Holland, MD, Med; Brittany R. Behm, MPH; Eliza C. Miller, MD, MS; Jenna M. B. White, MD; Christopher M. Zahn, MD; Nicole D. Ford, PhD, MPH; Deborah Burch, DNP, RN; Bethany Scalise, BSN; Amy St. Pierre, MBA


September 23, 2022

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Medscape &

Postpartum Preeclampsia Treatment

First-line antihypertensive treatment of postpartum preeclampsia includes short-acting antihypertensive medications (IV labetalol, IV hydralazine, oral nifedipine). Blood pressure > 160/110 mm Hg should be treated with a goal blood pressure of 140-150/90-100 mm Hg. Antihypertensive treatment should be initiated expeditiously for acute-onset severe hypertension (ie, systolic blood pressure of 160 mm Hg or more or diastolic blood pressure of 110 mm Hg or more, or both) that is confirmed as persistent (15 minutes or more).

The available literature suggests that antihypertensive agents should be administered within 30-60 minutes. However, it is recommended to administer antihypertensive therapy as soon as reasonably possible after the criteria for acute-onset severe hypertension are me.[3]

Common dosing regimens include:

  • Labetalol: 10-20 mg IV, then 20-80 mg every 10-30 minutes to a maximum cumulative dose of 300 mg; or constant infusion 1-2 mg/min IV.

  • Hydralazine 5 mg IV or IM, then 5-10 mg IV every 20-40 minutes to a maximum cumulative dose of 20 mg in the first hour; or constant infusion of 0.5-10 mg/hour.

Another first-line medication option is immediate-release nifedipine, particularly if intravenous access has not been established or if there are contraindications or relative contraindications to either labetalol (asthma, congestive heart failure) or hydralazine (tachycardia).

Although morphine would provide symptomatic treatment of the patient's headache, to prevent complications such as stroke, it is important to reduce her blood pressure. Use of diuretics such as furosemide should be guided by clinical assessment of volume status. She had no clinical signs of volume overload. It is not an ideal medication for the rapid lowering of blood pressure.