From the Guidelines
The best next step in management of this patient's hypertension is to initiate oral labetalol therapy. This 30-year-old pregnant woman at 24 weeks gestation has new-onset hypertension with blood pressure readings consistently above 140/90 mmHg (152/88 and 154/86 mmHg), minimal proteinuria (1+), and no other concerning symptoms, which is consistent with gestational hypertension. According to the International Society for the Study of Hypertension in Pregnancy (ISSHP) classification, diagnosis, and management recommendations for international practice 1, blood pressures consistently at or >140/90 mm Hg in clinic or office should be treated, aiming for a target diastolic BP of 85 mm Hg in the office. Labetalol is typically started at 100-200 mg orally twice daily and can be titrated up to 800 mg daily in divided doses as needed to maintain blood pressure below 150/100 mmHg.
Key Considerations
- Alternative first-line medications include nifedipine (extended-release, 30-60 mg daily) or methyldopa (250-500 mg orally two to three times daily) 1.
- Treatment is important because uncontrolled hypertension during pregnancy increases risks of preeclampsia, placental abruption, fetal growth restriction, and maternal stroke.
- The patient should also have more frequent prenatal visits (every 1-2 weeks), home blood pressure monitoring, and serial ultrasounds to assess fetal growth.
Monitoring and Follow-up
- Importantly, her normal liver enzymes, normal platelet count, and absence of symptoms like headache or visual changes indicate she does not have preeclampsia with severe features, which would require more aggressive management, including magnesium sulfate for convulsion prophylaxis and potential delivery if she has reached 37 weeks’ gestation or develops any concerning symptoms 1.
- Fetal monitoring should include an initial assessment to confirm fetal well-being, and maternal monitoring should include BP monitoring, repeated assessments for proteinuria, and twice weekly blood tests for hemoglobin, platelet count, and tests of liver and renal function 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Patient Assessment
The patient is a 30-year-old woman, gravida 1 para 0, at 24 weeks gestation with no chronic medical conditions and an uncomplicated pregnancy. Her blood pressure is 152/88 mm Hg and 154/86 mm Hg on repeat measurement.
Hypertension Management
- The patient's blood pressure is above the normal range, and according to the study by 2, first-line therapy for hypertension is lifestyle modification, including weight loss, healthy dietary pattern, physical activity, and moderation or elimination of alcohol consumption.
- However, since the patient is pregnant, the management of hypertension is different. The study by 3 compared the efficacy and safety of three oral drugs (labetalol, nifedipine retard, and methyldopa) for the management of severe hypertension in pregnancy.
- The study by 4 reviewed advances in the treatment of hypertensive emergencies and considered oral nifedipine as an alternative first-line therapy for women presenting with pre-eclampsia.
- The study by 5 compared oral nifedipine with intravenous labetalol for the treatment of severe hypertension during pregnancy and found that oral nifedipine was associated with less risk of persistent hypertension and reported maternal side effects.
- The study by 6 compared the blood pressure lowering effects of labetalol and nifedipine modified release (MR) in hypertensive pregnant women and found significant differences between the two drugs.
Next Steps
- Since the patient's blood pressure is not severely elevated, the next step would be to monitor her blood pressure closely and consider lifestyle modifications as recommended by 2.
- If the patient's blood pressure remains elevated, oral medications such as labetalol or nifedipine may be considered, as recommended by 3, 4, 5, and 6.