Management of Hypertension During Labor
Immediate treatment with intravenous labetalol or oral nifedipine is essential for blood pressure ≥160/110 mmHg lasting >15 minutes during labor to prevent severe maternal complications such as stroke and eclampsia. 1
Assessment and Monitoring
- Hypertensive disorders in pregnancy complicate 5-10% of pregnancies and are a major cause of maternal, fetal, and neonatal morbidity and mortality 1
- All pre-eclamptic women should be hospitalized and closely monitored in obstetric care centers with adequate maternal and neonatal intensive care resources 1
- Monitor for early maternal warning signs including SBP >160 mmHg, tachycardia, and oliguria, which should trigger proper diagnostic workup and treatment 1
- Evaluate for signs of end-organ damage: headache, visual disturbances, chest pain, dyspnea, neurological symptoms, abdominal pain, and altered mental status 2
- Check for brisk reflexes, papilledema, hepatic tenderness, and signs of pulmonary edema 2
Immediate Management of Severe Hypertension
- Blood pressure ≥160/110 mmHg lasting >15 minutes warrants immediate drug treatment regardless of delivery plans 1, 3
- The immediate goal is to decrease mean blood pressure by 15-25% with a target systolic blood pressure of 140-150 mmHg and diastolic blood pressure of 90-100 mmHg 2
- First-line treatments include:
- Labetalol IV: Start with 20 mg IV bolus, followed by additional doses of 40-80 mg every 10 minutes until desired effect or maximum cumulative dose of 300 mg 2, 3
- Oral nifedipine: Immediate-release formulation 1, 3
- Hydralazine IV: Alternative option, starting with 5 mg IV initially, then 5-10 mg IV every 30 minutes as needed 2, 4
- Methyldopa should not be used primarily for urgent BP reduction 1
- Continuous blood pressure monitoring is recommended during acute treatment 2
Special Considerations During Labor
- Antihypertensive treatment should be continued during labor and delivery 3
- Magnesium sulfate is recommended for the prevention of eclampsia and treatment of seizures 1
- Caution: Magnesium sulfate should not be given concomitantly with calcium channel blockers due to risk of hypotension from potential synergism 1
- Vaginal delivery should be considered unless cesarean delivery is required for standard obstetric indications 3
- Monitor for maternal hypotension during treatment, which can lead to fetal distress 2
Medication Considerations
- When using labetalol IV, avoid co-administration with alkaline drugs like furosemide in the same infusion line due to potential white precipitate formation 5
- Patients with a history of severe anaphylactic reactions may be more reactive to repeated challenge while taking beta-blockers 5
- Labetalol has been associated with neonatal hypotension, bradycardia, hypoglycemia, and respiratory depression when used during pregnancy 5
Postpartum Management
- Ten percent of maternal deaths due to hypertensive disorders in pregnancy occur in the postpartum period 1
- Continue monitoring blood pressure closely after delivery 3
- Transition to oral antihypertensive medications compatible with breastfeeding once blood pressure is controlled 2
- Safe options for breastfeeding mothers include labetalol, nifedipine, enalapril, and metoprolol 1
- All women with hypertension in pregnancy should have blood pressure and urine checked at 6 weeks postpartum 2
- Women with persisting hypertension or proteinuria at 6 weeks should be referred to a specialist 2, 3
Long-term Considerations
- Women with pregnancy-related hypertensive disorders are at increased risk of developing hypertension, stroke, ischemic heart disease, and thromboembolic disease later in life 2
- Cardiovascular risk assessment and lifestyle modifications are recommended for all women with a pregnancy-related hypertensive disorder 2