A 22‑week pregnant woman with severe hypertension (220/120 mm Hg) despite one month of methyldopa 250 mg daily—what is the appropriate management?

Management of Severe Hypertension at 22 Weeks Gestation

This patient requires immediate hospitalization and urgent blood pressure reduction with intravenous labetalol or oral immediate-release nifedipine, as a blood pressure of 220/120 mmHg constitutes a hypertensive emergency requiring treatment within 15 minutes to prevent maternal stroke. 1

Immediate Management (First Hour)

Urgent Blood Pressure Reduction:

• Blood pressure ≥160/110 mmHg lasting >15 minutes warrants immediate drug treatment to prevent stroke, pulmonary edema, and other maternal complications 1, 2
• At 220/120 mmHg, this patient is at extreme risk and requires treatment immediately, not after 15 minutes 1

First-Line Medications for Hypertensive Emergency:

• Intravenous labetalol: 20 mg IV bolus, repeat with escalating doses (40 mg, 80 mg) every 10 minutes to maximum 300 mg 3, 2
• Oral immediate-release nifedipine: 10-20 mg orally (never sublingual), repeated every 20-30 minutes if BP remains severely elevated, maximum 30 mg in first hour 1, 3, 2
• Methyldopa should NOT be used for urgent BP reduction as it is ineffective for acute management 1

Critical Safety Consideration:

• If magnesium sulfate is administered for seizure prophylaxis, avoid concurrent use with nifedipine due to risk of precipitous hypotension from potential synergism 1, 3

Hospitalization and Monitoring

Immediate Admission Required:

• All women with BP ≥160/110 mmHg require hospitalization in obstetric care centers with adequate maternal and neonatal intensive care resources 1, 2
• Monitor for early maternal warning signs including tachycardia, oliguria, visual disturbances, headache, and right upper quadrant pain 1

Diagnostic Workup:

• Complete blood count, liver function tests, serum creatinine, electrolytes, and uric acid 3, 2
• Urinalysis with protein-to-creatinine ratio to assess for preeclampsia 3, 2
• Assess for signs of end-organ damage including visual changes, coagulation abnormalities, or fetal distress 1, 2

Maintenance Antihypertensive Therapy

Once BP is controlled, transition to maintenance therapy:

• Extended-release nifedipine: Up to 120 mg daily, preferred due to once-daily dosing and superior efficacy 3, 2, 4
• Labetalol: Starting at 100 mg twice daily, titrated up to maximum 2400 mg/day in divided doses (may require TID or QID dosing due to accelerated metabolism in pregnancy) 3, 2
• Continue or optimize methyldopa: Current dose of 250 mg once daily is subtherapeutic; can be increased, but consider switching to nifedipine or labetalol for better efficacy 3, 4, 5

Target Blood Pressure:

• Aim for 110-140 mmHg systolic and 85 mmHg diastolic 1, 2
• Avoid diastolic BP <80 mmHg to prevent compromising uteroplacental perfusion 1, 2

Assessment for Preeclampsia

This patient likely has preeclampsia given:

• Severe hypertension at 22 weeks gestation (early-onset) 1, 2
• Inadequate response to one month of methyldopa suggests worsening disease 1

Preeclampsia-Specific Management:

• Administer magnesium sulfate for seizure prophylaxis if proteinuria is present with severe hypertension or if neurological symptoms develop 2
• Close fetal monitoring for growth restriction and fetal distress 1
• Prepare for potential early delivery if maternal or fetal condition deteriorates 1

Common Pitfalls to Avoid

• Never use methyldopa for acute severe hypertension - it takes hours to work and is ineffective for emergencies 1
• Never use sublingual nifedipine - risk of uncontrolled hypotension and maternal myocardial infarction 3, 2
• Never use short-acting nifedipine for maintenance therapy - only extended-release formulations should be used for chronic management 3, 2
• Do not delay treatment - systolic BP >160 mmHg is associated with adverse maternal outcomes including stroke 1
• Avoid excessive BP reduction - rapid drops can compromise uteroplacental perfusion and cause fetal distress 3, 2

Long-Term Considerations

Delivery Planning:

• At 22 weeks, the goal is to prolong pregnancy safely while controlling BP and monitoring for maternal/fetal complications 1, 2
• If BP cannot be controlled with ≥3 antihypertensive drug classes, delivery may be necessary despite extreme prematurity 2
• Women with early-onset preeclampsia (delivery before 32 weeks) are at highest risk for future cardiovascular disease 1, 2

Postpartum Management:

• Switch methyldopa to nifedipine or labetalol postpartum due to risk of postpartum depression 1, 3, 2
• BP typically worsens between days 3-6 postpartum, requiring continued close monitoring 3, 2
• Annual cardiovascular risk assessment lifelong is recommended 2