What is the management of a hypertensive emergency during Lower Segment Caesarean Section (LSCS)?

Management of Hypertensive Emergency During LSCS

In a hypertensive emergency during Lower Segment Caesarean Section (LSCS), immediate treatment with intravenous labetalol or nicardipine is recommended to reduce blood pressure to <160/105 mmHg to prevent maternal complications while monitoring fetal heart rate. 1, 2

Definition and Assessment

• Hypertensive emergency during LSCS is defined as severe blood pressure elevation (typically >180/120 mmHg) with evidence of acute end-organ damage requiring immediate intervention 1, 3
• Assessment should focus on identifying signs of end-organ damage including:
  • Cardiac: pulmonary edema, heart failure
  • Neurological: encephalopathy, visual disturbances
  • Renal: acute kidney injury
  • Retinal: advanced hypertensive retinopathy 3, 4

First-Line Management

• Intravenous labetalol is the first-line treatment for hypertensive emergency during LSCS:

  • Initial dose: 20 mg IV over 2 minutes
  • Can repeat 20-80 mg every 10 minutes up to a total dose of 300 mg
  • Do not exceed cumulative dose of 800 mg/24h to prevent fetal bradycardia 1, 5, 2

• Intravenous nicardipine is an effective alternative:

  • Initial dose: 5 mg/h
  • Increase by 2.5 mg/h every 5 minutes to maximum 15 mg/h
  • Administer via slow continuous infusion through a central line or large peripheral vein 1, 6

Blood Pressure Targets

• Target blood pressure should be <160/105 mmHg to prevent acute hypertensive complications in the mother 1, 2
• Avoid excessive blood pressure reduction (>25% in first hour) as it may lead to placental hypoperfusion 1, 4
• Once target BP is achieved, maintain with continuous infusion until oral therapy can be initiated 1, 3

Monitoring and Precautions

• Continuous maternal blood pressure monitoring is essential during treatment 1, 3
• Fetal heart rate monitoring is mandatory, especially when using labetalol, to detect fetal bradycardia 1, 2
• Avoid sodium nitroprusside as it carries risk of fetal cyanide toxicity 1, 2
• Avoid hydralazine as it has been associated with adverse perinatal outcomes 1

Adjunctive Measures

• Consider magnesium sulfate for seizure prophylaxis in cases of severe pre-eclampsia or eclampsia 1, 2
• Timely institution of oral antihypertensive therapy (e.g., methyldopa or long-acting nifedipine) should be considered once BP is stabilized 1
• Consider delivery timing after maternal condition has stabilized 1, 2

Post-Crisis Management

• After initial stabilization, transition to oral antihypertensive medications 1, 4
• Close monitoring should continue for at least 24-48 hours post-delivery 4
• Follow-up should include frequent visits (at least monthly) until target BP is reached and hypertension-mediated organ damage has regressed 1

Important Considerations

• The speed and magnitude of BP reduction should be carefully controlled to prevent maternal hypotension and compromised placental perfusion 1, 4
• If using labetalol, monitor for fetal bradycardia, especially when cumulative dose approaches 800 mg/24h 1
• Change infusion site every 12 hours if nicardipine is administered via peripheral vein 6