Launceston General Hospital Clinical Guideline

P2010/0510-001

2.29/10WACS Title: Replaces: Description: Target Audience: Key Words: Policy Supported: Hydralazine for Severe Hypertension in Pregnancy Intravenous Hydralazine for Severe Hypertension in Pregnancy WACSClinProc2.29/06 Management of severe hypertension in pregnancy Midwifery and Medical Staff, Queen Victoria Maternity Unit Hydralazine, hypertension
P2010/0509-001 Management of Eclampsia

Purpose: Severe hypertension is an obstetric emergency which requires immediate multidisciplinary management. Antihypertensives should be used to lower blood pressure to prevent maternal intracerebral haemorrhage. Lowering blood pressure does not solve the underlying problems of this multi-system disease. Consideration should be given to seizure prophylaxis prior to blood pressure management if the woman is assessed to be at risk of eclampsia. Abrupt hypotension may precipitate a seizure. Definition: Severe hypertension is described as either systolic greater than or equal to 170 mmHg and/or diastolic greater than or equal to 110 mmHg. Indications for intravenous antihypertensives in pregnancy: If diastolic greater than or equal to 110 mmHg for two readings or systolic greater than or equal to 170mmHg for two readings. Eclampsia At lower levels of blood pressure than above but where there are persistent symptoms and/or failed oral antihypertensive therapy. In situations where prompt reduction of BP is required In situations where oral administration of medication is impossible or unreliable, such as in labour or the unconscious state. Hydralazine IV Push Reconstitute 20mg of hydralazine in 20 ml of normal saline to make a solution of 1mg per 1ml. Administer the initial dose as prescribed by slow intravenous injection ie 5mg (5ml) over 5 minutes If desired BP is not achieved the dose may be repeated at 20 minute intervals to a maximum of three doses. Hydralazine Infusion If hypertension is persistent despite 3 boluses of IV hydralazine then hydralazine infusion may be commenced: Load 50mg of IV hydralazine into 50ml of normal saline. Run the infusion through an infusion pump at a rate of 10ml/hr Increase rate by 5ml/hr every 15 minutes until blood pressure is controlled.
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Maternal Observations Continuous CTG throughout administration of hydralazine and until BP is stable (30 minutes after last dose). Record BP and pulse every 5 minutes after each bolus dose Continue 5 minute BP and pulse until BP stable, then measure hourly Record BP every 15 minutes for first hour of a continuous infusion, then hourly if stable. Side Effects of Hydralazine Tachycardia, headache, nausea and vomiting

Attachments
Attachment 1 Attachment 2 IV Hydralazine Principles and methods of administration References

Performance Indicators: Evaluation of compliance with guideline to be achieved through medical record audit annually by clinical Quality improvement Midwife WACS Review Date: Annually verified for currency or as changes occur, and reviewed every 3 years. Midwives and medical staff WACS Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Stakeholders: Developed by:

Dr A Dennis Co-Director (Medical) Womens & Childrens Services

Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Date: 14/01/10

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APPENDIX 1 IV Hydralazine Principles and Method of Administration AIM: to achieve a gradual reduction in blood pressure to safe levels (90mmHg diastolic), rather than a precipitate drop. NOTE: the risk of sudden hypotension can be greater in women with a contracted plasma volume. Trade name: Apresoline Presentation: 20mg ampoule Incompatibilities aminophylline, ampicillin, hydrocortisone, sulphadiazine, dextrose diluents Dose: Hydralazine 5 mg as an intravenous bolus Reconstitute 20mg of hydralazine in 20ml of normal saline to make a solution of 1mg per ml. Administer by slow IV push at a rate of 5mg (5ml) over 5 minutes. Repeat if necessary at 20 minute intervals up to a maximum of 3 doses. Concomitant Continue existing oral antihypertensive therapy and review Antihypertensive Therapy: dose regimen OR If conscious commence oral antihypertensive therapy (such as clonidine, labetalol or oxprenolol) in addition to the intravenous hydralazine Persistent hypertension despite 3 boluses of IV hydralazine 5mg may be due to a compensatory reflex tachycardia: If heart rate <125 bpm Commence hydralazine infusion of 10mg/hr Load 50 mg of IV hydralazine into 50 ml of normal saline (not a glucose containing solution) Run the infusion through an infusion pump at a rate of 10ml/hr Increase rate by 5ml/hr every 15 minutes until blood pressure is controlled. If heart rate >125 bpm Give oral clonidine, labetalol or oxprenolol in addition to hydralazine infusion Maternal and fetal Continuous CTG throughout administration of hydralazine observation and and until BP is stable (30 minutes after the last dose) monitoring Record BP (mercury sphygmomanometer) and pulse every 5 minutes are after each bolus Continue 5 minutely BP and pulse until stable, then measure hourly Record BP every 15 minutes for the first hour of a continuous infusion, then measure hourly if stable. NSW Department of Health Circular 2002/29 Protocol for administration of intravenous hydralazine for severe hypertension in pregnancy.

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APPENDIX 2 REFERENCES American Academy of Family Physicians 2000 Advanced life support in obstetrics (ALSO) course syllabus (4th edn). American Academy of Family Physicians, Kansas Duley L, Henderson-Smart DJ, Meher S. Drugs for treatment of very high blood pressure during pregnancy. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD001449. DOI 10.1002/14651858.CD001449.pub2. Enkin M, Keirse J, Neilsen J et al 2000 A guide to effective care in pregnancy and childbirth. Oxford University Press, London NSW Department of Health Circular 2002/29 Protocol for administration of intravenous hydralazine for severe hypertension in pregnancy. Online: http://www.health.nsw.gov.au/policies/PD/2005/PD2005_241.html Pairman S, Pincombe J, Thorogood C, Tracy S, Midwifery preparation for practice 2006 Elsevier Australia Royal College of Obstetricians and Gynaecologist 2006 Clinical Green Top Guidelines: Eclampsia. Online: http://www.rcog.org.uk/index.asp?PageID=1542 Society of Obstetric Medicine of Australia and New Zealand 2008 Guidelines for the Management of Hypertensive Disorders of Pregnancy 2008, Online: http://www.somanz.org/

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