SE M I N A R S I N P E R I N A T O L O G Y 40 (2016) 112–118

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Seminars in Perinatology

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Management of severe hypertension in pregnancy

Leslie A. Moroz, MDa,n, Lynn L. Simpson, MDa, and Burton Rochelson, MDb
a
Department of Obstetrics and Gynecology, Columbia University Medical Center, PH 16-66 622 W 168th St,
New York, NY 10032
b
Division of Maternal-Fetal Medicine, North Shore-LIJ Health System, Manhasset, NY

article info abstract

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.
& 2016 Elsevier Inc. All rights reserved.

Introduction in Pregnancy in 2010 as one of the factors in achieving this

Hypertensive disorders of pregnancy account for approxi-
mately 17% of maternal mortality in the United States.1
Maternal mortality reporting is not federally mandated, which
limits the accuracy of national mortality statistics. However,
the trends in mortality statistics have highlighted the need to
address the issue (Figs. 1 and 2). Some states have established
reporting systems that have highlighted the significant con-
tribution of hypertensive disorders to maternal mortality. The
California Pregnancy Associated Mortality Review found that
the overall mortality rate for preeclampsia among deaths
included in the registry was 1.6/100,000 live births for the
period 2002–2004.2 In the most recent Confidential Enquiries
report from the United Kingdom, reflecting the time period
from 2009 to 2012, the maternal mortality rate associated with
preeclampsia and eclampsia was 0.38 per 100,000 maternities
for 2010–2012, the lowest rate ever recorded, having decreased
significantly since the last report from 2006 to 2008.3 The
authors cite the introduction of the National Institute for
Heath and Care Excellence (NICE) guidance on Hypertension
reduction in mortality. The NICE guidelines outline evidence-
based recommendations for the diagnosis and management
of women with hypertensive disorders of pregnancy.4
Indeed, the opportunity to decrease morbidity and improve
outcomes for women with hypertensive disorders during
pregnancy lies in timely and appropriate response to severe
hypertension. The ability to mount an effective response to
any critical situation depends largely on preparedness, guide-
lines, and communication. A well-delineated algorithm for
escalating response can improve communication among
members of a care team and expedite delivery of care.
Protocols should delineate triggers that might signal a change
in clinical status and identify key personnel to be notified for
further evaluation. Standard protocols such as the modified
early obstetric warning system (MEOWS), introduced in the
United Kingdom following the 2003–2005 Confidential Enquiry
into Maternal and Child Health report, reliably predict mater-
nal morbidity and mortality and reduce adverse outcomes.3–5
Clear and consistent diagnostic criteria should ensure that
providers know when treatment is indicated and which

n
Corresponding author.
E-mail address: lm3000@cumc.columbia.edu (L.A. Moroz).

http://dx.doi.org/10.1053/j.semperi.2015.11.017
0146-0005/& 2016 Elsevier Inc. All rights reserved.
 S E M I N A R S I N
Fig. 1 – Proportion of maternal deaths from hemorrhage,
hypertensive disorders, and infection or sepsis in different
regions throughout the world. (Data adapted with
permission from Khan et al.20)
agents are first line. An adequate plan for monitoring should
be in place that enables providers to reliably assess and
document changes in clinical status. In the United States,
recognition of the need to reduce maternal morbidity and
mortality has led to the formation of the National Partnership
for Maternal Safety. Unit-improvement bundles for obstetric
services have been created as a part of this initiative, includ-
ing (1) a system for detecting early warning signs, (2) a
structured process for internal reviews to identify opportu-
nities for improvement, and (3) support tools for patients,
families, and staff who experience adverse outcomes. Man-
agement of severe hypertension was one of three bundles
(including obstetric hemorrhage and venous thromboembo-
lism) that were prioritized to address common and prevent-
able causes of maternal morbidity and mortality.6 In New
York State, ACOG District II has developed the Safe Mother-
hood Initiative to promote the implementation of these
bundles and to continue to develop standard approaches for
handling obstetric emergencies.7
Care teams in obstetrics and in other disciplines such as
emergency medicine, critical care and internal medicine
Fig. 2 – U.S. maternal mortality ratio per 100,000 live births
from 1990 through 2013 and percent change in maternal
deaths per 100,000 live births during the same period. (Data
adapted with permission from Kassebaum et al.21)
P E R I N A T O L O G Y 40 (2016) 112–118 113
often need to be reminded that vigilance for such changes
needs to be maintained in the postpartum period as well.
In a study of maternal mortality, 75% of maternal
deaths associated with preeclampsia occurred in the post-
partum period, 41% of which were more than 2 days post-
partum.8 Many of these women present to non-obstetricians
who may be less familiar with the entity of postpartum
preeclampsia.
Diagnostic criteria for severe hypertension in
pregnancy
The American College of Obstetrics and Gynecology (ACOG)
Task Force of Hypertension in Pregnancy recently articulated
new definitions of the four types of hypertension during
pregnancy: (1) gestational hypertension, (2) preeclampsia-
eclampsia, (3) chronic hypertension, and (4) chronic hyper-
tension with superimposed preeclampsia. The blood pressure
criteria diagnosis remained the same: systolic blood pressure
(SBP) Z 140 mmHg or a diastolic blood pressure (DBP) Z
90 mmHg recorded on two occasions at least 4 h apart. Anti-
hypertensive therapy should not be initiated for blood pres-
sures less than 160 mmHg systolic or 110 mmHg diastolic.9
In the Task Force’s updated summary of recommendations,
proteinuria was removed as a necessary feature of the
diagnostic criteria for preeclampsia, placing emphasis on
the multi-organ system involvement seen in patients with
this diagnosis. When proteinuria is not present, preeclampsia
can be diagnosed when hypertension is found in the presence
of new-onset thrombocytopenia, renal insufficiency, oliguria,
impaired liver function, pulmonary edema, or cerebral or
visual disturbances. Proteinuria of at least 300 mg in a 24-h
urine collection, or a timed collection that is extrapolated to
this value or results in a protein/creatinine ratio of at least
0.3 mg/dl, is considered the cut-off for proteinuria.9
Severe features of preeclampsia are listed in Table 1. Severe
hypertension is defined as a SBP Z 160 mmHg or a diastolic
blood pressure Z 110 mmHg recorded at least 4 h apart.
Severe hypertension can occur during the antepartum, intra-
partum, or postpartum period. SBP Z 160 mmHg or DBP Z
110 mmHg that persists for 15 min or more is considered a
hypertensive emergency. Prompt treatment is indicated for
all pregnant or postpartum patients who meet these diag-
nostic criteria.10
There is evidence in the general medical literature to
suggest that the degree of systolic hypertension may be more
closely associated with significant morbidity than diastolic
hypertension.11 This is true in pregnancy as well. In a series
of 28 patients with severe preeclampsia and stroke, 27 had
severe systolic hypertension as compared with 4 who had
severe diastolic hypertension preceding stroke.12 When
hypertension becomes severe in the pregnant patient, sys-
tems should be in place for notifying providers immediately
to facilitate timely bedside evaluation of the patient and
appropriate treatment. Fetal surveillance should be initiated
if indicated by the circumstances. Administration of ante-
natal corticosteroids should be considered if the fetus is o34
weeks gestation due to the increased risk for indicated
preterm delivery.
114 SE M I N A R S I N P E R I N A T O L O G Y 40 (2016) 112–118

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)
 S E M I N A R S I N P E R I N A T O L O G Y
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
DBP o 160 mmHg and o110 mmHg, respectively. Lowering
blood pressures to “normal” ranges (i.e., SBP o 140 mmHg or
DBP o 90 mmHg) does not confer additional benefit and may
be harmful.10 Once target goal blood pressures are achieved,
blood pressure monitoring should occur at 10 min intervals
for 1 h, 15 min intervals the next hour, 30 min intervals for
the following hour, and every hour for 4 h. The following
baseline labs should be obtained: CBC, lactate dehydrogen-
ase, liver function tests, electrolytes, BUN, creatinine, and an
assessment of urine protein (protein:creatinine ratio, urine
dipstick for protein, and/or 24 h urine protein collection).
The maximum cumulative dose of IV labetalol should
not exceed 300 mg over a 24 h period. Cumulative doses
of hydralazine that exceed 25 mg in 24 h are not
recommended.
Magnesium sulfate for seizure prophylaxis
Magnesium sulfate remains the drug of choice for seizure
prophylaxis in preeclamptic patients and for controlling
seizures in eclampsia. Unless magnesium sulfate is contra-
indicated in a particular patient (i.e., myasthenia gravis,
pulmonary edema, and renal failure), it should be given while
managing a hypertensive crisis. However, providers should
be reminded that it is not an antihypertensive agent. The use
of magnesium sulfate in patients with preeclampsia is
recommended when severe features are present, but not
mandatory when absent.9
Standard regimens for seizure prophylaxis include an IV
bolus of 4–6 g of magnesium sulfate in 100 ml of normal
saline administered over 20 min followed by an IV infusion of
1–2 g per hour. For patients without IV access, a loading dose
of 10 g of magnesium sulfate in 50% solution can be admin-
istered intramuscularly (IM): 5 g in each buttock usually
mixed with 1–2 ml lidocaine for injection. Magnesium sulfate
may be continued antepartum during assessment of disease
status, during induction of labor or preoperatively, and for
24 h postpartum following delivery.
For recurrent seizures, or when magnesium sulfate is
contraindicated, alternative anticonvulsants can be given.
40 (2016) 112–118 115
Benzodiazepines, such as lorazepam (Ativans) and diazepam
(Valiums), phenytoin (Dilantins), and levetiracetam (Kepp-
ras) are dosed as outlined in Table 2.
Providers should routinely assess patients for signs of
magnesium toxicity including nausea, headache, lethargy,
loss of deep tendon reflexes, hypotension, and bradycardia.
At higher serum levels of magnesium, somnolence, muscle
paralysis, respiratory failure, and heart block may result. If
there is clinical concern for magnesium toxicity, the magne-
sium sulfate infusion should be discontinued, and the serum
magnesium level should be checked. For treatment of acute
symptomatic hypermagnesemia, calcium gluconate can be
administered intravenously at a dose of 1 g as 10 ml of 10%
solution given over 1–2 min. Monitoring of magnesium levels
with serial labs should be considered for patients with
evidence of renal insufficiency.
Severe hypertension as a change in disease status
Following the stabilization of a pregnant patient with severe
hypertension, a full assessment of the status of the patient
should be performed. During this time, magnesium sulfate
should be given for seizure prophylaxis if not already ini-
tiated. When the gestational age is less than 34 weeks,
expectant management, at least through administration of
antenatal corticosteroids, may be an acceptable goal when
there is no evidence of deterioration in maternal or fetal
status. Contraindications to a delay in delivery for the benefit
of corticosteroids include uncontrolled hypertension, eclamp-
sia, pulmonary edema, placental abruption, disseminated
intravascular coagulation, non-reassuring fetal status, or
intrauterine fetal demise.
For gestational ages of 34 weeks and greater, or for women
with a contraindication to expectant management, a plan for
the timing and mode of delivery should be made. Vaginal
delivery is preferred if delivery can be achieved in a reason-
able amount of time in most cases of HELLP syndrome, severe
preeclampsia, and chronic hypertension with superimposed
preeclampsia. However, for patients remote from delivery
with an unripe cervix or prior cesarean, expeditious delivery
by cesarean should be considered.
116 SE M I N A R S I N P E R I N A T O L O G Y 40 (2016) 112–118

Table 2 – Alternative anticonvulsants.

Anticonvulsant Dose Schedule

Lorazepam 2–4 mg IV Once, can repeat once after 10–15 min

Diazepam 5–10 mg IV Every 5–10 min (maximum dose 30 mg)
Phenytoina 15–20 mg/kg IV Once, can repeat 10 mg/kg IV after 20 min
Levetiracetamb 500 mg IV or PO Once, can repeat in 12 h
a
Phenytoin should be avoided in patients with hypotension and may cause arrhythmias.
b
Levetiracetam should be renally dosed in patients with renal insufficiency.

be reassessed every 15 min. Laboratory assessment should

Brain imaging include the following: hemoglobin and hematocrit, platelets,
blood urea nitrogen, creatinine, glucose, sodium, potassium,
One of the most morbid complications of severe hypertension magnesium, AST, ALT, uric acid, LDH, type and screen, PT/
is the risk of hemorrhagic stroke. Providers must be aware of PTT, fibrinogen, and a urine drug screen. A Foley catheter
the symptoms and signs that raise concern for an intracranial should be inserted to facilitate recording of strict ins and
process and have a low threshold for imaging in these outs, no less frequently than every 2 h. Nursing staff should
patients. Brain imaging studies preferably via magnetic res- notify a clinician if urine output decreases to less than 30 ml/
onance imaging (MRI) are recommended if any of the findings h, and use of a urometer should be considered.
listed in Table 3 are present. A delivery plan should be made in response to an eclamptic
seizure. While delivery is the definitive treatment for an
eclamptic seizure, the timeframe for delivery should reflect
the clinical scenario. If a vaginal delivery can be achieved
Eclampsia within a reasonable period of time and seizures are con-
trolled, the morbidity of surgery can be avoided. Patients with
A hospital policy should be in place to ensure a rapid
eclamptic seizures may have evidence of coagulopathy and
response when an eclamptic seizure is diagnosed. Respond-
may be at greater risk of morbidity from cesarean delivery.
ers should include representatives from obstetrics, anesthe-
However, for the patient who is remote from delivery and
sia, nursing, and neonatology (if indicated). Checklists may be
otherwise stable for surgery, cesarean may expedite maternal
helpful for ensuring that a standard protocol is followed, even
recovery unless the patient is less than 32–34 weeks and time
in an emergency situation. An example of a checklist is
for the administration of corticosteroids for fetal lung matu-
shown in Figure 5.
ration can be undertaken.
The first-line medication for treatment of an eclamptic
Debriefing after a rapid response for an eclamptic seizure is
seizure is magnesium sulfate. For patients with IV access, a
an important part of ensuring the goals of care have been
4–6 g loading dose of 10% magnesium sulfate in 100 ml
met. Timely and thorough documentation is essential.
solution is administered intravenously over 20 min. For
patients without IV access, a loading dose of 10 g of IM
magnesium sulfate in 50% solution can be administered.
Following the initial loading dose, magnesium sulfate should
be placed on an infusion pump with appropriate labeling and
continued at a rate of 1–2 g per hour for at least 24 h. For
patients with recurrent seizure activity, the anticonvulsants
listed in Table 1 can be considered. Neuromuscular blockade
and intubation may also be considered in such cases, making
early involvement of anesthesia and critical care essential.
Treatment of SBP Z 160 or DBP Z 110 with labetalol or
hydralazine is recommended during management of an
eclamptic seizure. Blood pressures should be repeated at
least every 10 min during this time. Neurologic status should

Table 3 – Signs and symptoms warranting intracranial

imaging.

Sudden-onset, severe, or persistent headache

Focal findings on neurologic exam
Confusion
Lethargy
Seizures
Uncontrolled severe hypertension
Fig. 5 – Eclampsia checklist. (Adapted with permission from
ACOG.7)
 S E M I N A R S I N P E R I N A T O L O G Y
Guidelines for documentation
Thorough documentation of evaluation for signs and symp-
toms of preeclampsia is essential on initial presentation and
throughout a patient’s hospital course. Documentation at
times is resisted as a bureaucratic or regulatory obligation
unrelated to good medical care. This could not be further
from the truth. Firstly, good documentation is essential for
effective and safe communication across disciplines and
across shifts. It has become particularly important in an era
of electronic medical records, which at times may be multiple
and not interfaced. The advent of laborists and large groups
of covering obstetricians elevates the importance of good
documentation as well. In cases of severe hypertension, in
which a patient may be on several services during her stay
(e.g., emergency department, labor and delivery, postpartum,
and ICU) meaningful communication is critical for good
patient care. As part of the auditing process for the ACOG
District II Safe Motherhood Initiative, the failure to document
not treating blood pressures that met the criteria for severe
hypertension is considered a “fallout,” even if the reasons for
non-administration were medically acceptable.7 However,
the most important and little discussed value of regular and
meaningful documentation is that it forces caregivers to
explain their thought process and to develop a logical and
safe plan, which is then documented.
During an episode of severe hypertension or with a change
in disease status, documentation at least every 30 min has
been recommended until the patient has been stabilized.
A review of symptoms including headache, visual changes,
nausea, epigastric pain, vaginal bleeding, and fetal activity
should be conducted. A list of medications and any drugs,
including illicit substances and over the counter medications,
currently being used should be obtained from the patient.
Blood pressures over the course of pregnancy should be
reviewed. Current vital signs, including oxygen saturation
should be evaluated. Assessment of fetal well-being, both
past and current, including estimated weight, FHR monitor-
ing, and biophysical profile should be performed.
An assessment and plan should include whether the
diagnosis of preeclampsia has been made, and if not, what
steps are being taken to exclude the diagnosis. If antihyper-
tensive treatment has been initiated to control blood pres-
sures, this should be clearly documented with the medication
choice, dose, route, and schedule. Likewise if magnesium
sulfate administration has been started for seizure prophy-
laxis, the dose, route, and duration of therapy should be
stated. The record of the encounter should include an assess-
ment of fetal well-being and the plan for administration of
antenatal corticosteroids if the gestational age is o34 weeks.
A discussion of the timing and mode of delivery should also
be a part of the plan.
Postpartum severe hypertension
Close surveillance is essential during the postpartum period.
Blood pressure can peak anywhere from 2 to 6 days after
delivery. This becomes a unique challenge to be aware of as
40 (2016) 112–118 117
regulatory and insurance driven processes have shortened
the length of stay, as well as discouraging readmissions.
Caregivers, as well as patients, must be aware that after an
initial drop in blood pressure after delivery, the blood pres-
sure may rise after they have been discharged.
Preeclampsia and eclampsia can also develop in the post-
partum period, and, rarely, can present several weeks after
delivery. In the immediate postpartum period, blood pressure
should be monitored every 4 h until stable. As prior to
delivery, SBP Z 160 mmHg or DBP Z 110 mmHg that persists
for 15 min or more is considered a hypertensive emergency
and should be treated within 1 h as described previously and
outlined in Figures 3 and 4. If severe hypertension was not
present prior to delivery, a full assessment of the status of the
patient including laboratory studies should be performed.
During this time, magnesium sulfate should be given for
seizure prophylaxis if not already initiated. There are data to
suggest that nonsteroidal anti-inflammatory medications
(NSAIDs) may increase blood pressure in some patients. For
patients with severe hypertension caused by any of the
hypertensive disorders of pregnancy, NSAIDs should be
avoided.17,18
Maintenance antihypertensive therapy with labetalol or
nifedipine is suggested for women with persistent postpar-
tum hypertension, defined as SBP Z 150 mmHg or DBP Z
100 mmHg on at least two occasions Z4 h apart. Patients
with persistent postpartum hypertension or a history of
severe hypertension in the ante- or intrapartum periods
should be monitored for 72 h after delivery to ensure
adequate blood pressure control. The goal for discharge
should be adequate blood pressure control over the preceding
24-h period. Discharge planning should include blood pres-
sure measurements as an outpatient and education about the
signs and symptoms that should prompt further medical
evaluation. Outpatient surveillance with a visiting nurse
evaluation or a timely visit to her practitioner is optimal to
ensure adequate follow-up and is required in some institu-
tions when a patient with known preeclampsia is discharged,
especially when they are sent home on medications. Home
blood pressure monitoring with a wrist cuff should be
considered. Patient education should specifically note signs
and symptoms that should prompt a patient to present for
reevaluation. For example, SBP Z 160 mmHg, DBP Z
110 mmHg, or SBP 140–159 or DBP 90–109 accompanied by
headaches, visual disturbances, or epigastric or right upper
quadrant pain should prompt medical evaluation in the
office, the obstetrical unit at the hospital or the emergency
department. Ensuring that emergency department staff has
been educated about the entity of postpartum preeclampsia
is a critical component of this algorithm. All patients,
whether or not they have been diagnosed with preeclampsia,
should receive an information sheet describing the signs and
symptoms of preeclampsia in lay terms.
A significant number of postpartum patients may seek care
in the Emergency Department rather than with their primary
obstetric provider. In a recent review of 10,751 Emergency
Department visits within 42 days of postpartum discharge, it
was estimated that approximately 3% of women utilize the
Emergency Department for evaluation of hypertension or
preeclampsia.19 In addition to specific patient education
118 SE M I N A R S I N P E R I N A T O L O G Y
regarding hypertension, a plan for close follow-up should be
made prior to discharge. Adequate discharge planning may
help patients avoid additional visits to the Emergency Depart-
ment and improve outcomes. Outpatient office follow-up for
reassessment of blood pressure is recommended for all
patients with persistent postpartum hypertension or a his-
tory of severe hypertension in the peripartum period 7–10
days after delivery.
All patients who present with hypertension within 6 weeks
postpartum should be triaged with a full assessment for the
symptoms of preeclampsia and the Obstetric service should
be consulted. A full set of labs to assess for multi-system
involvement should be obtained, and IV access should be
established. SBP Z 160 mmHg or DBP Z 110 mmHg should be
treated as detailed above. Magnesium sulfate should be started
for seizure prophylaxis if the diagnosis of preeclampsia is
suspected and continued for 24 h or until the diagnosis of
preeclampsia has been ruled out. Patients with severe hyper-
tension or symptoms warrant readmission for observation and
may benefit from additional consultation with maternal–fetal
medicine, internal medicine, and/or critical care.
Conclusion
Timely diagnosis and appropriate management of severe
hypertension can reduce risk and improve clinical outcomes
in pregnant and postpartum patients with chronic hyper-
tension, preeclampsia, and/or eclampsia. Adhering to stand-
ard practices ensures that care teams meet the goals for
managing these high risk patients. With heightened surveil-
lance and prompt evaluation of signs and symptoms of
worsening hypertension, maternal morbidity and mortality
can be decreased.
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