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Risk reduction and successful, safe clinical outcomes forwomen with preeclampsia or eclampsia require avoidanceand management of severe systolic and severe diastolic

hypertension. How to integrate standardized order setsinto everyday safe practice in the United States is a chal-lenge. Increasing evidence indicates that standardizationof care improves patient outcomes (1). Introducing intoobstetric practice standardized, evidence-based clini-cal guidelines for the management of patients withpreeclampsia and eclampsia has been demonstrated toreduce the incidence of adverse maternal outcomes (2, 3).With the advent of pregnancy hypertension guidelinesin the United Kingdom, care of maternity patients withpreeclampsia or eclampsia improved significantly, andmaternal mortality rates decreased because of a reductionin cerebral and respiratory complications (4, 5).

Acute-onset, severe systolic (greater than or equal to160 mm Hg) or severe diastolic (greater than or equal to110 mm Hg) hypertension or both can occur in pregnantor postpartum women with any hypertensive disordersduring pregnancy. Acute-onset, severe hypertension thatis accurately measured using standard techniques andis persistent for 15 minutes or more is considered ahypertensive emergency. This occurs in the second halfof gestation in patients not known to have chronic hyper-tension who develop sudden, severe hypertension (ie,with preeclampsia, gestational hypertension, or HELLP

[hemolysis, elevated liver enzymes, low platelets] syn-drome) or, less frequently, in patients with chronic hyper-tension who are developing superimposed preeclampsia

with acutely worsening, difficult to control, severe hyper-tension. It is well known that severe hypertension can causecentral nervous system injury. Two thirds of the maternaldeaths in the most recent Confidential Inquiries reportfrom the United Kingdom for 2003–2005 resulted fromeither cerebral hemorrhage or infarction (4). The degreeof systolic hypertension (as opposed to the level of dia-stolic hypertension or relative increase or rate of increaseof mean arterial pressure from baseline levels) may be themost important predictor of cerebral injury and infarction.In a recent case series of 28 women with severe preeclamp-sia and stroke, all but 1 woman had severe systolic hyper-tension (greater than or equal to 160 mm Hg) just before

a hemorrhagic stroke, and 54% died, whereas only 13%had severe diastolic hypertension (greater than or equalto 110 mm Hg) in the hours preceding stroke (6). A simi-lar relationship between severe systolic hypertension andrisk of hemorrhagic stroke has been observed in nonpreg-nant adults (7). Thus, systolic BP of 160 mm Hg or greateris widely adopted as the definition of severe hypertensionin pregnant or postpartum women (8, 9).

Pregnant or postpartum women with acute-onset,severe systolic or severe diastolic hypertension or bothrequire antihypertensive therapy. The goal is not to nor-

Emergent Therapy for Acute-Onset, Severe

Hypertension With Preeclampsia or Eclampsia

ABSTRACT: Acute-onset, persistent (lasting 15 minutes or more), severe systolic (greater than or equal to

160 mm Hg) or severe diastolic hypertension (greater than or equal to 110 mm Hg) or both in pregnant or postpar-

tum women with preeclampsia or eclampsia constitutes a hypertensive emergency. Severe systolic hypertensionmay be the most important predictor of cerebral hemorrhage and infarction in these patients and if not treated

expeditiously can result in maternal death. Intravenous labetalol and hydralazine are both considered first-line drugs

for the management of acute, severe hypertension in this clinical setting. Close maternal and fetal monitoring by

the physician and nursing staff are advised. Order sets for the use of labetalol and hydralazine for the initial man-

agement of acute, severe hypertension in pregnant or postpartum women with preeclampsia or eclampsia have

been developed.

Committee on Obstetric PracticeThis document reflects emerging clinical and scientific advances as of the date issued and is

subject to change. The information should not be construed as dictating an exclusive course of

treatment or procedure to be followed.

COMMITTEE OPINIONNumber 514 • December 2011

The American College of Obstetricians and Gynecologists

Women’s Health Care Physicians



2 Committee Opinion No. 514

malize BP, but to achieve a range of 140–160/90–100mmHg in order to prevent repeated, prolonged expo-sure of the patient to severe systolic hypertension, withsubsequent loss of cerebral vasculature autoregulation.When this happens, maternal stabilization should occurbefore delivery, even in urgent circumstances (10). Whenacute-onset, severe hypertension is diagnosed in the office

setting, the patient should be sent to the hospital expedi-tiously for treatment. Also, if transfer to a tertiary center islikely (eg, for preterm severe preeclampsia), BP should bestabilized and other measures instituted as appropriate,such as magnesium sulfate before transfer. Another risk forsevere hypertension is endotracheal intubation, an inter-vention that is well known to increase BP sometimes tosevere levels that require emergent therapeutic interven-tion (10). Induction of general anesthesia and intubationshould never be undertaken without first taking steps toeliminate or minimize the hypertensive response to intu-bation. Close maternal and fetal monitoring by the physi-cian and nursing staff are advised during the treatment

of acute-onset, severe hypertension, and judicious fluidadministration is recommended even in the case of oligu-ria. After initial stabilization, the team should monitor BPclosely and institute maintenance therapy as needed.

Recommendations

First-Line Therapy

Intravenous labetalol and hydralazine are both consid-ered first-line medications for the management of acute-onset, severe hypertension in pregnant and postpartumwomen; less information currently exists for the use ofcalcium channel blockers for this clinical indication.

Patients may respond to one drug and not the other.Magnesium sulfate is not recommended as an antihyper-tensive agent, but magnesium sulfate remains the drug ofchoice for seizure prophylaxis in severe preeclampsia andfor controlling seizures in eclampsia. Box 1 and Box 2outline order sets for the use of labetalol and hydralazinefor the initial management of acute-onset, severe hyper-tension in pregnant or postpartum women with pre-eclampsia or eclampsia (11). Although both medicationsare appropriately used for the treatment of hypertensiveemergencies in pregnancy, each agent can be associatedwith adverse effects. Parenteral hydralazine may increase

the risk of maternal hypotension (systolic BP 90 mm Hgor less) (11). Parenteral labetalol may cause neonatalbradycardia and should be avoided in women withasthma or heart failure (12, 13). No significant changesin umbilical blood flow have been observed with the useof either labetalol or hydralazine (14), and maternal andperinatal outcomes are similar for both drugs (15). Ifintravenous access is not yet obtained and treatment foracute-onset, severe hypertension is urgently needed, a200 mg-dose of labetalol can be administered orally andrepeated in 30 minutes if an appropriate improvement isnot observed (5).

Second-Line Therapy

In the rare circumstance that intravenous bolus labetalolor hydralazine or both fail to relieve acute-onset, severehypertension and are given in successive appropriatedoses such as those outlined in the order sets (see Box 1and Box 2), emergent consultation with an anesthesiolo-gist, maternal–fetal medicine subspecialist, or critical care

specialist to discuss second-line intervention is recom-mended. Second line alternatives to consider includelabetalol or nicardipine by infusion pump (16–18).

Box 1. Order Set for Severe Intrapartumor Postpartum Hypertension Initial

First-Line Management With Labetalol*

1. Notify physician if systolic BP measurement is greater than or equal to 160 mm Hg or if diastolic BP mea-surement is greater than or equal to 110 mm Hg.

2. Institute fetal surveillance if undelivered and fetus isviable.

3. Administer labetalol (20 mg IV over 2 minutes).

4. Repeat BP measurement in 10 minutes and recordresults.

5. If either BP threshold is still exceeded, administerlabetalol (40 mg IV over 2 minutes). If BP is below threshold, continue to monitor BP closely.




9. If either BP threshold is still exceeded, administerhydralazine (10 mg IV over 2 minutes). If BP is below threshold, continue to monitor BP closely.


11. If either BP threshold is still exceeded, obtain emer-gency consultation from maternal–fetal medicine,internal medicine, anesthesia, or critical care spe-cialists.

12. Give additional antihypertensive medication per spe-cific order.

13. Once the aforementioned BP thresholds are achieved,repeat BP measurement every 10 minutes for 1 hour, then every 15 minutes for 1 hour, then every 30 min-utes for 1 hour, and then every hour for 4 hours.

14. Institute additional BP timing per specific order.

Abbreviations: BP, blood pressure; IV, intravenously.

*See text for important adverse effects and contraindications.

Data from Report of the National High Blood Pressure EducationProgram Working Group on High Blood Pressure in Pregnancy.Am J Obstet Gynecol 2000;183:S1–S22.



Committee Opinion No. 514 3

References

1. Kirkpatrick DH, Burkman RT. Does standardization ofcare through clinical guidelines improve outcomes andreduce medical liability? Obstet Gynecol 2010;116:1022–6.

2. Menzies J, Magee LA, Li J, MacNab YC, Yin R, Stuart H,et al. Instituting surveillance guidelines and adverse out-comes in preeclampsia. Preeclampsia Integrated Estimate of

RiSk (PIERS) Study Group. Obstet Gynecol 2007;110:121–7. 3. von Dadelszen P, Sawchuck D, McMaster R, Douglas MJ,

Lee SK, Saunders S, et al. The active implementation ofpregnancy hypertension guidelines in British Columbia.Translating Evidence-Based Surveillance and TreatmentStrategies (TESS) Group. Obstet Gynecol 2010;116:659–66.

4. Saving Mothers’ Lives: reviewing maternal deaths to makemotherhood safer: 2006–08. The Eighth Report on Con-fidential Enquiries into Maternal Deaths in the United King-dom. Centre for Maternal and Child Enquiries (CMACE).BJOG 2011;118(suppl 1):1–203.

5. Tuffnell DJ, Jankowicz D, Lindow SW, Lyons G, Mason GC,Russell IF, et al. Outcomes of severe pre-eclampsia/eclamp-

sia in Yorkshire 1999/2003. Yorkshire Obstetric CriticalCare Group. BJOG 2005;112:875–80.

6. Martin JN Jr, Thigpen BD, Moore RC, Rose CH, Cushman J,May W. Stroke and severe preeclampsia and eclampsia: aparadigm shift focusing on systolic blood pressure. ObstetGynecol 2005;105:246–54.

7. Lindenstrom E, Boysen G, Nyboe J. Influence of systolicand diastolic blood pressure on stroke risk: a prospectiveobservational study. Am J Epidemiol 1995;142:1279–90.

8. Diagnosis, evaluation, and management of the hypertensivedisorders of pregnancy. SOGC Clinical Practice GuidelineNo. 206. Society of Obstetricians and Gynaecologists ofCanada. J Obstet Gynaecol Can 2008;30(suppl 1):S1–S48.

9. Confidential Enquiries into Maternal Deaths. Why moth-ers die 1997–1999. The fifth report of the ConfidentialEnquiries into Maternal Deaths in the United Kingdom.London (UK): RCOG Press; 2001.

10. Lyons G. Saving mothers’ lives: confidential enquiry intomaternal and child health 2003–5. Int J Obstet Anesth2008;17:103–5.

11. Report of the National High Blood Pressure EducationProgram Working Group on High Blood Pressure in Preg-nancy. Am J Obstet Gynecol 2000;183:S1–S22.

12. Magee LA, Cham C, Waterman EJ, Ohlsson A, vonDadelszen P. Hydralazine for treatment of severe hyper-tension in pregnancy: meta-analysis. BMJ 2003;327:955–60.

13. Magee LA, von Dadelszen P. The management of severehypertension. Semin Perinatol 2009;33:138–42.

14. Baggio MR, Martins WP, Calderon AC, Berezowski AT,Marcolin AC, Duarte G, et al. Changes in fetal and maternalDoppler parameters observed during acute severe hyper-tension treatment with hydralazine or labetalol: a random-ized controlled trial. Ultrasound Med Biol 2011;37:53–8.

15. Duley L, Henderson-Smart DJ, Meher S. Drugs for treat-ment of very high blood pressure during pregnancy.Cochrane Database of Systematic Reviews 2006, Issue 3.Art. No.: CD001449. DOI: 10.1002/14651858.CD001449.pub2.

Transplacental passage is minimal, as are changes inumbilical artery Doppler velocimetry (19).

Sodium nitroprusside should be reserved for extremeemergencies and used for the shortest amount of timepossible because of concerns about cyanide and thio-cyanate toxicity in the mother and fetus or newborn andincreased intracranial pressure with potential worseningof cerebral edema in the mother (11). Once the hyperten-sive emergency is treated, a complete and detailed evalu-ation of maternal and fetal well-being is needed with,among many issues, consideration of need for subsequentpharmacotherapy and appropriate timing of delivery.

Box 2. Order Set for Severe Intrapartumor Postpartum Hypertension Initial

First-Line Management With Hydralazine*

1. Notify physician if systolic BP is greater than orequal to 160 mm Hg or if diastolic BP is greater than

or equal to 110 mm Hg. 2. Institute fetal surveillance if undelivered and fetus is

viable.

3. Administer hydralazine (5 mg or 10 mg IV over 2minutes).


5. If either BP threshold is still exceeded, administerhydralazine (10 mg IV over 2 minutes). If BP is below threshold, continue to monitor BP closely.




9. If either BP threshold is still exceeded, administerlabetalol (40 mg IV over 2 minutes) and obtain emer-gency consultation from maternal–fetal medicine,internal medicine, anesthesia, or critical care spe-cialists.

10. Give additional antihypertensive medication perspecific order.

11. Once the aforementioned BP thresholds are achieved,

repeat BP measurement every 10 minutes for 1 hour, then every 15 minutes for 1 hour, then every 30 min-utes for 1 hour, and then every hour for 4 hours.

12. Institute additional BP timing per specific order.

Abbreviations: BP, blood pressure; IV, intravenously.

*See text for important adverse effects and contraindications.

Data from Report of the National High Blood Pressure EducationProgram Working Group on High Blood Pressure in Pregnancy.Am J Obstet Gynecol 2000;183:S1–S22.



4 Committee Opinion No. 514

16. Prometheus Laboratories Inc. Trandate® (labetalol hydro-chloride) tablets. San Diego (CA): Prometheus Labora-tories; 2010. Available at: http://www.prometheuslabs.com/Resources/PI/TrandateTab.pdf. Retrieved August 25, 2011.

17. Vadhera RB, Pacheco LD, Hankins GD. Acute antihyper-tensive therapy in pregnancy-induced hypertension: isnicardipine the answer? Am J Perinatol 2009;26:495–9.

18. Nij Bijvank SW, Duvekot JJ. Nicardipine for the treatmentof severe hypertension in pregnancy: a review of the litera-ture. Obstet Gynecol Surv 2010;65:341–7.

19. Carbonne B, Jannet D, Touboul C, Khelifati Y, Milliez J.Nicardipine treatment of hypertension during pregnancy.Obstet Gynecol 1993;81:908–14.

Copyright December 2011 by the American College of Obstetriciansand Gynecologists, 409 12th Street, SW, PO Box 96920, Washington,DC 20090-6920. All rights reserved. No part of this publication maybe reproduced, stored in a retrieval system, posted on the Internet,or transmitted, in any form or by any means, electronic, mechani-cal, photocopying, recording, or otherwise, without prior written per-mission from the publisher. Requests for authorization to makephotocopies should be directed to: Copyright Clearance Center, 222Rosewood Drive, Danvers, MA 01923, (978) 750-8400.

ISSN 1074-861X

Emergent therapy for acute-onset, severe hypertension with pre-eclampsia or eclampsia. Committee Opinion No. 514. AmericanCollege of Obstetricians and Gynecologists. Obstet Gynecol 2011;118:1465–8.

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