What are the criteria for recommending a cesarean section (CS) in a pregnant patient with uncontrolled hypertension (HTN) and potential preeclampsia or eclampsia?

Criteria for Cesarean Section in Uncontrolled Hypertension

Cesarean section is NOT automatically indicated for uncontrolled hypertension alone—vaginal delivery should be pursued unless standard obstetric indications for cesarean exist or there is maternal/fetal deterioration requiring rapid delivery. 1

Primary Management Principle

The presence of severe or uncontrolled hypertension does not itself mandate cesarean delivery. The mode of delivery depends on gestational age, maternal stability, fetal status, and standard obstetric indications—not blood pressure levels alone. 1

Absolute Indications for Delivery (Any Mode)

Women with preeclampsia must be delivered if any of the following criteria are met:

• ≥37 weeks gestation (delivery indicated regardless of other factors) 2
• Inability to control BP despite ≥3 classes of antihypertensives in appropriate doses 2, 1
• Progressive thrombocytopenia 2
• Progressively abnormal renal or liver function tests 2, 1
• Pulmonary edema 2
• Maternal pulse oximetry <90% 2, 1
• Abnormal neurological features: severe intractable headache, repeated visual scotomata, or eclamptic convulsions 2, 1
• Nonreassuring fetal status 2
• Placental abruption 2, 1
• Reversed end-diastolic flow on umbilical artery Doppler 2, 1

Specific Indications for Cesarean Section

Cesarean delivery is indicated only when:

• Standard obstetric indications exist (malpresentation, prior classical cesarean, placenta previa, etc.) 1
• Rapid delivery is needed due to maternal or fetal deterioration and vaginal delivery cannot be accomplished expeditiously 1
• Evidence of placental insufficiency with fetal compromise requiring immediate delivery 1

Management by Gestational Age

At ≥37 Weeks

• Delivery should proceed once maternal BP is controlled 2, 1
• Vaginal delivery is preferred unless cesarean indicated for standard obstetric reasons 1

Between 34-37 Weeks

• Expectant conservative management is appropriate if maternal and fetal status remain stable 2
• Delivery indicated only if maternal/fetal deterioration occurs 2

At <34 Weeks

• Conservative expectant management at a center with Maternal-Fetal Medicine expertise 2
• Corticosteroids for fetal lung maturity should be administered 1
• Delivery only for maternal/fetal indications listed above 2

Critical Pre-Delivery Management

Before any delivery (vaginal or cesarean):

• Severe hypertension (≥160/110 mmHg) requires urgent treatment within 30-60 minutes with IV labetalol, IV hydralazine, or oral nifedipine 2
• Target BP: systolic <160 mmHg and diastolic ~85 mmHg 1
• Magnesium sulfate for seizure prophylaxis if severe hypertension with neurological signs/symptoms or proteinuria 2, 1
• BP must be controlled before, during, and after cesarean section to keep SBP <160 mmHg and DBP <110 mmHg 1

Common Pitfalls to Avoid

• Do not perform cesarean section solely because BP is difficult to control—this is an indication for delivery, not specifically for cesarean delivery 2
• Do not use proteinuria level or serum uric acid as indications for delivery 2
• Do not delay treatment of severe hypertension—96% of preeclampsia-related strokes were preceded by SBP >160 mmHg 2
• Do not assume all preeclampsia cases are "mild"—all cases may become emergencies rapidly 2
• The level of BP itself is not a reliable way to stratify immediate risk, as serious organ dysfunction can occur at relatively mild BP levels 2