What is the best course of action for a 38-week pregnant patient undergoing labor induction with pitocin (oxytocin), presenting with rebound headache and persistent hypertension?

Immediate Delivery is Indicated for This Patient

This patient requires immediate evaluation for preeclampsia with severe features and expeditious delivery, as the combination of persistent hypertension and rebound headache in the setting of labor at 38 weeks represents a hypertensive emergency requiring urgent treatment and delivery regardless of labor progress. 1

Critical Assessment Required Now

Evaluate for preeclampsia with severe features immediately:

• Check blood pressure every 15 minutes - if ≥160/110 mmHg sustained for >15 minutes, this is a hypertensive emergency requiring treatment within 30-60 minutes 1, 2
• In the presence of hypertension, a new headache should be considered part of preeclampsia until proven otherwise - this is the safe clinical approach 1
• Obtain stat labs: complete blood count (platelets), liver transaminases, creatinine, and uric acid to assess for HELLP syndrome or other organ dysfunction 1
• Assess for other severe features: visual disturbances, epigastric/right upper quadrant pain, altered mental status, pulmonary edema 1

Immediate Blood Pressure Management

If BP ≥160/110 mmHg for >15 minutes:

• Administer IV labetalol 20 mg bolus immediately, then 40 mg after 10 minutes, then 80 mg every 10 minutes until controlled (maximum cumulative dose 300 mg) 1, 2
• Alternative: IV hydralazine 5 mg initially, then 5-10 mg every 30 minutes as needed 1
• Alternative: Oral immediate-release nifedipine 10-20 mg, repeat every 20 minutes to maximum 30 mg 1, 2
• Target BP: reduce mean arterial pressure by 15-25%, aiming for systolic 140-150 mmHg and diastolic 90-100 mmHg 1, 2
• Continuous BP monitoring every 15 minutes during acute treatment 2

Seizure Prophylaxis

Administer magnesium sulfate immediately:

• All women with preeclampsia presenting with hypertension and neurological signs or symptoms (headache) should receive MgSO4 for convulsion prophylaxis 1
• Loading dose: 4 g IV or 10 g IM 1
• Maintenance: 5 g IM every 4 hours or 1 g/hour IV infusion until delivery and for at least 24 hours postpartum 1

Delivery Decision

Proceed with delivery regardless of labor progress:

• Delivery should be strongly considered when there are signs of maternal problems including severe hypertension, visual disturbance, headache, or epigastric pain, regardless of gestational age 1
• At 38 weeks gestation with severe features, delivery is indicated - there is no benefit to expectant management 1
• Vaginal delivery is preferable to cesarean to avoid the added stress of surgery 1
• Continue pitocin augmentation if labor is progressing, but do not delay delivery for slow progress - consider cesarean if vaginal delivery is not imminent 1

Critical Pitfalls to Avoid

Do not continue expectant management:

• Preeclampsia rarely remits spontaneously and in most cases worsens with time 1
• Treatment does not alter the underlying pathophysiology - only delivery resolves the disease 1
• Headache is absent in 30-50% of women before eclampsia onset, but when present with hypertension, it mandates aggressive management 3

Do not dismiss the headache as benign:

• While headaches are common in pregnancy (39% incidence), in the presence of hypertension this symptom indicates potential cerebral involvement and increased risk of stroke 1, 3
• The combination of persistent hypertension and headache represents a constellation requiring immediate intervention 1

Fetal Monitoring During Treatment

• Continuous electronic fetal heart rate monitoring throughout acute BP management 4
• Monitor for fetal distress related to maternal hypotension or uteroplacental insufficiency 1, 4
• If fetal distress develops, administer oxygen to mother in lateral position and prepare for expedited delivery 4

Postpartum Considerations

Close monitoring remains critical after delivery:

• BP monitoring at least every 4-6 hours for minimum 3 days postpartum, as this is when BP peaks and majority of hypertension-related maternal deaths occur 2
• Continue magnesium sulfate for at least 24 hours postpartum 1
• Transition to oral antihypertensives: nifedipine extended-release 30-60 mg daily or labetalol 200-800 mg twice daily 2
• Avoid NSAIDs for postpartum analgesia as they worsen hypertension 2