Hypertensive Urgency in Pregnancy

Hypertensive urgency in pregnancy is severe hypertension (160/110 mmHg or more) without symptoms or signs of acute organ injury. It is most often preeclampsia, gestational hypertension or chronic hypertension with poor control. It matters because untreated severe hypertension is itself an indication for urgent treatment, and the line to hypertensive emergency can be crossed quickly.

• Treat within 30 to 60 minutes of confirmation.
• Oral drugs are suitable when the woman is well.
• Admission is advised until blood pressure is controlled and preeclampsia is excluded.

Women are usually well, with no headache, visual change, chest pain or abdominal pain, and a high reading found on routine measurement. Examination shows no focal signs.

• Blood pressure 160/110 mmHg or more on two readings 15 minutes apart.
• Normal reflexes and no pulmonary signs.
• Differential diagnosis: preeclampsia, gestational hypertension, chronic hypertension, white coat effect, anxiety, pain, drug withdrawal, phaeochromocytoma.
• Complications: progression to hypertensive emergency, eclampsia, stroke, abruption, fetal growth restriction, preterm birth, stillbirth.

The diagnosis needs confirmed severe readings and exclusion of organ injury.

• Repeat blood pressure after 15 minutes of rest with a correct cuff; confirm on both arms.
• Urine dipstick and urine protein to creatinine ratio; full blood count, creatinine, liver enzymes, lactate dehydrogenase, uric acid.
• Fundal examination, reflexes, chest examination.
• Ultrasound for growth and Doppler; cardiotocography.

The principle is oral blood pressure lowering with observation, and magnesium sulphate if preeclampsia with severe features appears.

• Supportive: admit for at least 24 hours; rest; blood pressure every 15 minutes until below 160/110 mmHg, then hourly for 4 hours, then 4-hourly; total fluids not restricted unless severe preeclampsia develops; fetal movement counts.
• Pharmacological: nifedipine immediate release 10 mg oral, repeated once after 30 minutes if blood pressure remains 160/110 mmHg or more, then 10 to 20 mg every 4 to 6 hours (maximum 120 mg daily); or labetalol 200 mg oral every 8 to 12 hours (maximum 2.4 g daily), starting with 200 mg and repeated once after 1 hour; or methyldopa 250 to 500 mg oral 8-hourly (maximum 3 g daily) for maintenance; IV labetalol 20 mg over 2 minutes then 40 mg, 80 mg and 80 mg at 10 minute intervals (maximum 220 mg) or hydralazine 5 mg IV then 5 to 10 mg every 20 to 30 minutes (maximum 20 mg) if oral drugs fail; magnesium sulphate 4 g IV over 20 minutes then 1 g per hour for 24 hours if preeclampsia with severe features appears; aspirin 150 mg oral at night from 12 weeks to 36 weeks; betamethasone 12 mg IM twice, 24 hours apart, before 34 weeks if delivery is expected.
• Procedures: delivery timed by the underlying diagnosis, at 37 weeks for preeclampsia without severe features and at 34 weeks or sooner for severe features.
• Special groups: asthma uses nifedipine instead of labetalol; chronic hypertension on ACE inhibitor is changed to nifedipine modified release 30 to 60 mg oral once daily or labetalol.
• Red flags: headache, visual change, epigastric pain, breathlessness, blood pressure 160/110 mmHg or more after 2 doses, seizure, reduced fetal movements.
• Follow-up: review within 24 to 48 hours of discharge; blood pressure twice weekly; repeat blood tests weekly; postnatal blood pressure at 6 hours, daily for 5 days, then at 2 and 6 weeks.