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

Management of Severe Hypertension (160/100) at 35+ Weeks of Pregnancy

Severe hypertension (BP 160/100) at 35+ weeks of pregnancy is not an automatic indication for cesarean section, but rather requires urgent blood pressure treatment, close monitoring, and consideration of delivery, which can be vaginal if there are no other contraindications.

Urgent Management of Severe Hypertension

• Blood pressure ≥160/110 mmHg requires urgent treatment in a monitored setting to reduce the risk of maternal cerebrovascular complications 1
• Acceptable agents for urgent BP reduction include oral nifedipine, intravenous labetalol, or intravenous hydralazine 1
• The immediate goal is to decrease mean BP by 15-25% with a target of systolic BP 140-150 mmHg and diastolic BP 90-100 mmHg 1
• Magnesium sulfate should be administered for seizure prophylaxis in women with severe hypertension, especially with neurological signs or symptoms 1

Delivery Considerations

• At 35+ weeks gestation with severe hypertension (160/100), delivery should be strongly considered rather than continued expectant management 1
• The mode of delivery (vaginal vs. cesarean) should be based on standard obstetric indications, not solely on the presence of hypertension 1
• Indications for delivery in hypertensive disorders include:
  • 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
  • Neurological features such as severe intractable headache, visual disturbances, or eclampsia 1
  • Placental abruption or non-reassuring fetal status 1

Important Clinical Considerations

• Blood pressure levels alone are not reliable indicators of immediate risk in preeclampsia; some women may develop serious organ dysfunction at relatively mild hypertension levels 1
• Close maternal monitoring should include BP checks, assessment for proteinuria, clinical evaluation including clonus, and blood tests for hemoglobin, platelet count, and liver/renal function 1
• Fetal monitoring should include initial assessment to confirm fetal well-being and ongoing surveillance as indicated 1
• After 37 weeks, delivery is recommended for women with preeclampsia regardless of severity 1

Common Pitfalls to Avoid

• Delaying treatment of severe hypertension (≥160/110 mmHg) increases risk of maternal stroke, myocardial ischemia, and mortality 1
• Excessive BP lowering may impair uteroplacental blood flow; avoid reducing BP below 130/90 mmHg 2
• Short-acting oral nifedipine can induce uncontrolled hypotension, particularly when combined with magnesium sulfate 1
• Assuming cesarean section is required based solely on hypertension diagnosis without considering other obstetric factors 1

In summary, severe hypertension at 35+ weeks requires urgent treatment and consideration of delivery, but the mode of delivery should be determined by standard obstetric indications rather than the hypertension diagnosis alone.