Key Points

1. Stabilize and Transfer if necessary
2. Blood pressure ranges greater than or equal to 140-159 systolic OR 90-109 diastolic are considered abnormal in pregnancy and postpartum.
3. Severe blood pressure ranges greater than or equal to 160 systolic or 110 diastolic require immediate intervention.
4. Signs of severe features include:
1. unrelenting headache,
2. visual disturbances like scotomata,
3. right upper quadrant pain,
4. thrombocytopenia (<100k),
5. elevated transaminases,
6. elevated creatinine above 1.1,
7. and pulmonary edema
5. Eclampsia is usually self-limiting. Magnesium sulfate is started to prevent recurring seizures.
6. Controlling blood pressure ranges is key to preventing stroke and other end-organ damage.

Synopsis

Hypertensive disorders of pregnancy are one of the leading causes of maternal morbidity and mortality. It is a spectrum of disorders divided into the following categories: Gestational Hypertension (GHTN), Preeclampsia (with and without severe features), Eclampsia, and Chronic Hypertension with Superimposed Preeclampsia. The distinguishing feature between GHTN and preeclampsia is the lack of proteinuria with GHTN. Proteinuria is defined as a protein/creatinine ratio of 0.3 or greater, a 24-hour urine protein of 300mg/dl or greater, or a urinalysis protein value of 1+ or more if a quantitative option is unavailable. When the blood pressure is in the severe range, greater than or equal to 160 systolic or 110 diastolic, preeclampsia with severe features is diagnosed if one or more of the following are present:

1. unrelenting headache,
2. visual disturbances like scotomata,
3. right upper quadrant pain,
4. thrombocytopenia (<100k),
5. elevated transaminases,
6. elevated creatinine above 1.1,
7. and pulmonary edema

Initial management includes antihypertensive medications which can be oral medications, if the values are in the mild range, or intravenous if the values are in the severe range. Common antihypertensive medications utilized include Labetalol, Hydralazine, and Nifedipine, which are compatible with breastfeeding. Seizure prophylaxis with magnesium sulfate is started when the blood pressure range is severe, or if the range is mild plus a severe sign/symptom.

Management

1. Antihypertensives for severe range BPs

   	Initial dose	Onset	Repeat if needed	Maximum dose	Side effects
   Labetalol IV	20mg	1-2 minutes	Q10 minutes (40, 80)	300mg	Avoid with asthma, bradycardia, heart block
   Hydralazine IV or IM	5-10mg	10-20 minutes	10mg	20mg	Hypotension, headache
   Nifedipine PO immediate release	10-20mg	5-10 minutes	Q20 min	180mg	Tachycardia, headache

   For mild ranges or longer-term therapy, start Labetalol PO or Nifedipine XL
2. Magnesium sulfate for seizure prophylaxis:
Severe range BPs or severe features 4-gram loading dose, followed by 2g maintenance dose per hour
3. Admission and observation of BP control