1. Management of severe hypertension

2.  For women with persistent chronic hypertension with SBP >160 or DBP >105, start antihypertensive therapy  Maintain blood pressures at 120-160/80- 105  Initial therapy (PO): ◦ Labetalol ◦ Nifedipine ◦ Methyldopa

3.  Challenges: ◦ How to distiguish chronic hypertension from preeclampsia ◦ When to treat blood pressures ◦ When to deliver

4. SBP >140 or DBP >90 (2 occasions, 4 hours apart, <20wks) Proteinuria (300mg/24 hours, PCR >300, +1 on dipstick) Thrombo- cytopenia <100K Creatinine 1.1 or doubled from baseline Cerebral or visual disturbances Pulmonary edema Liver transaminases >2x normal

5. New-onset proteinuria or increase in proteinuria from baseline A sudden increase in BP or escalation in need for medications Known chronic hypertension

6. SBP >160 or DBP >110 (2 occasions, 4 hours apart)Thrombocytopenia <100KCreatinine 1.1 or doubled from baselineCerebral or visual disturbancesPulmonary edemaLiver transaminases >2x normal

7.  <23 0 wks gestation: ◦ Deliver after maternal stabilization ◦ Administer magnesuim sulfate intrapartum and postpartum to prevent eclampsia ◦ Treat with antihypertensives for SBP >160 or DBP >110  ≥ 34 0 wks gestation ◦ Deliver after maternal stabilization ◦ Administer magnesuim sulfate intrapartum and postpartum to prevent eclampsia ◦ Treat with antihypertensives for SBP >160 or DBP >110

8.  Transfer to appropriate facility  Administer corticosteroids for fetal lung maturity  Manage expectantly until 34 wks  Deliver after course of corticosteroids (48 hours) if: ◦ PPROM or labor ◦ Thrombocytopen ia <100K ◦ AST/ALT persistently elevated >2x normal ◦ IUGR, oligo- hydramnios, abnormal dop ◦ New-onset or worsening renal dysfunction  Deliver soon after maternal stabilization if: ◦ Uncontrollable severe HTN  Eclampsia  Pulmonary edema  Placental abruption  DIC  Non-reassurring fetal status

9.  The mode of delivery should depend on: ◦ Gestational age ◦ Presentation ◦ Maternal and fetal status ◦ Cervix  Everyone with severe preeclampsia should get intrapartum and postpartum magnesuim sulfate to prevent eclampsia ◦ The continued intraoperative administration is recommended for cesarean delivery  Neuraxial analgesia is recommended  Invasive hemodynamic monitoring does not need to be routinely used

10. In preeclampsia or eclampsia

11.  Hypertensive emergency ◦ Severe: SBP >160 or DBP >110 ◦ Persistent: lasting more than 15 minutes ◦ Acute onset

12.  “Severe systolic hypertension may be the most important predictor of cerebral hemorrhage and infarction in these patients and, if not treated expeditiously, can result in maternal death.”  UK report 2003-2005: 2/3 of maternal deaths resulted from cerebral hemorrhage or infarction  Case series of 28 women with preeclampsia/stroke ◦ All but 1 had severe SBP ◦ 54% died

13.  Goal of treatment is to reduce pressures to 140-160/90-100  This should be accomplished before delivery, even if delivery is needed urgently

14. SBP >160 or DBP >110 Notify physician (should be an order) Apply EFM Administer labetalol 20mg IV over 2 minutes Repeat BP in 10 minutes If still elevated, labetalol 40mg IV over 2 minutes Repeat BP in 10 minutes If still elevated, labetalol 80mg IV over 2 minutes Repeat BP in 10 minutes If still elevated, hydralazine 10mg IV over 2 minutes Repeat BP in 20 minutes If still elevated, consult MFM, critical care, anesthesia If BP goal achieved, repeat BP: every 10 minutes for 1 hour, every 15 minutes for 1 hour, every 30 minutes for 1 hour, every 60 minutes for 4 hours

15. SBP >106 or DBP >110 NST Hydralazine 5-10mg IV over 2 minutes Repeat BP in 20 minutes If still elevated, hydralazine 10mg IV over 2 minutes Repeat BP in 20 minutes If still elevated, labetalol 20mg IV over 2 minutes Repeat BP in 10 minutes If still elevated, consult MFM, critical care, anesthesia If BP goal achieved, repeat BP: every 10 minutes for 1 hour, every 15 minutes for 1 hour, every 30 minutes for 1 hour, every 60 minutes for 4 hours

16.  Hydralazine can increase risk of maternal hypotension  Labetalol can cause neonatal bradycardia and should be used with caution in women with asthma, heart failure  Second line intervention: labetalol or nicardipine infusion pump  Sodium nitroprusside only for extreme emergencies ◦ Cyanide toxicity, increased maternal ICP  Once mother is stabilized, discuss plan including delivery