What is the further management for a 30-year-old postpartum female with uncontrolled hypertension (blood pressure 160/100) and symptoms of severe headache and blurred vision, currently on Adalat (Nifedipine) 30 mg once daily and Labetalol 200 mg oral twice daily (BID), after a course of Magnesium sulphate?

Management of Severe Postpartum Hypertension with Neurological Symptoms

This patient requires immediate IV antihypertensive therapy and magnesium sulfate administration due to severe postpartum pre-eclampsia with neurological symptoms.

Immediate Management

• The patient's current blood pressure of 160/100 mmHg with severe headache and blurred vision indicates severe postpartum pre-eclampsia with impending eclampsia requiring urgent intervention 1, 2
• Administer magnesium sulfate immediately: 4g IV over 5 minutes, followed by 1g/hour IV infusion to prevent eclampsia 1, 2
• Switch from oral medications to intravenous labetalol or nicardipine as first-line treatment for this hypertensive emergency 1
  • IV labetalol: Start with 20 mg IV bolus, then 20-80 mg every 10-30 minutes or continuous infusion 1, 2
  • IV nicardipine: 5 mg/h, increasing by 2.5 mg/h every 5-15 minutes to maximum 15 mg/h 1

Target Blood Pressure

• The goal is to lower blood pressure to <160/105 mmHg within 60 minutes to prevent complications such as stroke 1, 2
• Do not lower blood pressure too rapidly or excessively; aim for a 20-25% reduction in mean arterial pressure initially 1

If IV Access Is Difficult

• If IV access cannot be established immediately, increase oral medication dosing 2:
  • Increase nifedipine to 20 mg orally (current dose is inadequate at 30 mg once daily) 3, 4
  • Increase labetalol to 300 mg orally (current dose is 200 mg BID) 5
• Note: Avoid concomitant administration of high-dose nifedipine with magnesium sulfate due to risk of hypotension 2

Monitoring

• Continuous monitoring of blood pressure every 10-15 minutes until stabilized 1, 2
• Monitor for signs of magnesium toxicity: respiratory depression, loss of deep tendon reflexes, altered mental status 1
• Monitor for signs of end-organ damage: worsening neurological symptoms, oliguria, pulmonary edema 2
• If BP control is not achieved within 60 minutes with first-line treatment, add a second agent 1, 2

Further Management

• Once stabilized, transition back to oral medications with adequate dosing 1, 2:
  • Labetalol 200-400 mg orally three times daily
  • Nifedipine extended-release 30-90 mg once daily
• Continue antihypertensive therapy postpartum; do not cease abruptly 2
• Avoid NSAIDs for postpartum analgesia to prevent renal complications 2

Follow-up

• Monitor blood pressure and clinical condition at least every 4 hours while awake for at least 3 days postpartum 2
• Review at 3 months postpartum to ensure blood pressure, urinalysis, and laboratory abnormalities have normalized 2
• Annual medical review is advised lifelong due to increased future cardiovascular risk 2

Important Considerations

• The combination of severe headache and blurred vision with elevated blood pressure indicates impending eclampsia requiring immediate intervention 1
• Oral nifedipine has been shown to cause a significant decrease in cerebral perfusion pressure compared to labetalol, which may be relevant in this patient with neurological symptoms 6
• If blood pressure control is not achieved despite two medications at adequate doses within 6 hours, consider ICU admission 2