What are the guidelines for managing eclampsia and hypertension in a mother undergoing vaginal delivery for labor?

From the Guidelines

For a mother with eclampsia and hypertension going into labor for vaginal delivery, immediate management should include administration of magnesium sulfate for seizure prophylaxis and blood pressure control with antihypertensive medications if systolic BP exceeds 160 mmHg or diastolic BP exceeds 110 mmHg. The management of eclampsia and hypertension in a mother undergoing vaginal delivery for labor is crucial to prevent maternal and fetal morbidity and mortality.

• Key considerations include:
  • Administration of magnesium sulfate for seizure prophylaxis with a loading dose of 4-6g IV over 20-30 minutes, followed by a maintenance infusion of 1-2g/hour 1
  • Blood pressure control with antihypertensive medications, such as labetalol or nifedipine, if systolic BP exceeds 160 mmHg or diastolic BP exceeds 110 mmHg 1
  • Continuous maternal and fetal monitoring during labor
  • Fluid balance monitoring to prevent pulmonary edema, with input and output measurements and restriction to 80-100 mL/hour 1 The most recent and highest quality study, published in 2020, recommends labetalol and nifedipine as first-line treatment for hypertensive emergencies during pregnancy 1.
• Other important considerations include:
  • Early diagnosis and adequate treatment of hypertensive disorders in the peripartum period to prevent maternal and fetal morbidity and mortality 1
  • Hospitalization and close monitoring of pre-eclamptic women in obstetric care centers with adequate maternal and neonatal intensive care resources 1
  • Induction of labor after 37 weeks of gestation 1
  • Magnesium sulfate should not be given concomitantly with calcium channel blockers due to the risk of hypotension 1

From the Research

Guidelines for Managing Eclampsia and Hypertension

• The management of severe hypertension in pregnancy involves treating blood pressures greater than 170/110 with urgency, aiming to maintain the blood pressure at less than 170/110 but not lower than 130/90 2.
• Parenteral hydralazine and labetalol (intravenously or orally) are effective and safe therapies for managing severe hypertension in pregnancy 2, 3, 4.
• Delivery of the fetus is usually the definitive management of severe hypertension in pregnancy, but this action may not reduce the blood pressure immediately 2, 3.
• In addition to anti-hypertensive agents, close attention should be given to regular clinical examination, assessment of fluid balance, neurologic status, and monitoring of other vital signs 3.
• Magnesium sulphate should be considered early to prevent seizures in patients with severe pre-eclampsia 3.

Treatment of Hypertensive Crisis

• Initial management of hypertensive emergency generally includes the rapid reduction of blood pressure through the use of intravenous antihypertensive medications, with a goal systolic blood pressure between 140 mmHg and 150 mmHg and diastolic pressure between 90 mmHg and 100 mmHg 4.
• First-line intravenous drugs include labetalol and hydralazine, but other agents may be used, including esmolol, nicardipine, nifedipine, and, as a last resort, sodium nitroprusside 4.
• Among patients with hypertensive urgency, slower blood pressure reduction can be provided with oral agents, such as labetalol, nifedipine, and methyldopa 3, 4, 5.

Protocol Adherence

• Institutions should review protocol compliance to improve care, as potential factors affecting protocol compliance include shift changes, communication issues, and conflicting protocols 6.
• A protocol to ensure prompt treatment with antihypertensive medication (intravenous labetalol) can significantly reduce poor outcomes in patients with preeclampsia with severe hypertension 6.