Is a cesarean section (CS) indicated for a pregnancy at 35+ weeks with severe hypertension (blood pressure 160/100)?

Management of Severe Hypertension at 35+ Weeks of Pregnancy

Cesarean section is not automatically indicated for a pregnant woman at 35+ weeks with severe hypertension (160/100 mmHg), but immediate blood pressure control and assessment for delivery is essential. 1

Immediate Management of Severe Hypertension

• Blood pressure ≥160/110 mmHg lasting >15 minutes warrants immediate antihypertensive treatment regardless of delivery plans 1
• First-line treatments for acute severe hypertension include:
  • IV labetalol (starting with 20 mg bolus, followed by 40-80 mg doses) 1
  • Oral nifedipine (10-20 mg) 1
• Target blood pressure should be <160 mmHg systolic and diastolic around 85 mmHg 1
• Methyldopa should not be used for urgent BP reduction 1

Delivery Decision-Making

• At 35+ weeks with severe hypertension (160/100 mmHg), delivery should be considered but mode of delivery depends on several factors 1
• Vaginal delivery should be considered for women with any hypertensive disorders unless cesarean delivery is required for standard obstetric indications 1
• All women with severe pre-eclampsia should be delivered promptly, regardless of gestational age 1

Indications for Immediate Delivery (Any Mode)

• Inability to control maternal BP despite using ≥3 classes of antihypertensives in appropriate doses 1
• Progressive deterioration in liver function, creatinine, hemolysis, or platelet count 1
• Ongoing neurological features (severe headache, visual scotomata, eclampsia) 1
• Maternal pulse oximetry <90% 1
• Placental abruption 1
• Reversed end-diastolic flow in umbilical artery Doppler or non-reassuring cardiotocograph 1

Specific Considerations for Cesarean Section

• Cesarean section is indicated if:
  • There are standard obstetric indications (e.g., malpresentation, fetal distress) 1
  • Rapid delivery is needed due to maternal or fetal deterioration 1
  • There is evidence of placental insufficiency with fetal compromise 1
• Blood pressure should be controlled before, during, and after cesarean section to keep SBP <160 mmHg and DBP <110 mmHg 1

Important Considerations During Peripartum Period

• Magnesium sulfate should be considered for seizure prophylaxis in women with pre-eclampsia who have severe hypertension with neurological signs or symptoms 1
• Caution: Magnesium sulfate should not be given concomitantly with calcium channel blockers due to risk of hypotension 1
• Corticosteroids for fetal lung maturity should be considered if delivery is anticipated before 34 weeks 1
• Close maternal monitoring should include:
  • Frequent BP measurements 1
  • Assessment for proteinuria 1
  • Clinical assessment including clonus 1
  • Blood tests for hemoglobin, platelet count, liver enzymes, creatinine, and uric acid 1

Postpartum Management

• Antihypertensive treatment should be continued during labor, delivery, and postpartum 1
• Blood pressure and urine should be checked at 6 weeks postpartum 1
• Women with persisting hypertension or proteinuria at 6 weeks should be referred to a specialist 1
• Safe medications for breastfeeding mothers include labetalol, nifedipine, enalapril, and metoprolol 1

Common Pitfalls to Avoid

• Do not delay treatment of severe hypertension (≥160/110 mmHg) as it increases risk of stroke and other complications 1
• Do not rely solely on BP levels to stratify risk in pre-eclampsia, as organ dysfunction can occur at relatively mild levels of hypertension 1
• Do not use ACE inhibitors, ARBs, or direct renin inhibitors during pregnancy due to fetotoxicity 1
• Do not restrict salt intake, particularly close to delivery, as this may induce low intravascular volume 1