Clinical Guideline (L&D):

Emergent Therapy for Acute-onset, Severe Hypertension

Background: Preeclampsia, gestational hypertension, or chronic hypertension with superimposed preeclampsia occurs in
approximately 10% of pregnancies. Severe hypertension is associated with an increased risk for maternal death or morbidity by its
association with stroke. The degree of systolic hypertension may be the most important predictor of cerebral injury and infarction.

Definition: Severe hypertension (SBP > 160 and/or DBP > 110) that persists for > 15 minutes
Severe hypertension that persists for > 15 minutes is a hypertensive emergency
Goal:

reduce blood pressure to 140-150/ 90-100 within 1 hour

Treatment: First line therapy includes IV labetalol, IV hydralazine, or oral nifedipine

Treatment algorithm: See next page

SBP > 160 and/or DBP > 110

Notify provider and repeat BP in 15 minutes (institute fetal monitoring, if fetus is viable)

SBP > 160 and/or DBP > 110

SBP < 160 and DBP < 110

Labetalol protocol

Hydralazine protocol

Nifedipine* protocol

20 mg labetalol IV

5-10 mg hydralazine IV

10 mg nifedipine oral

Repeat BP in 10 minutes

Repeat BP in 20 minutes

Repeat BP in 20 minutes

SBP > 160 and/or DBP > 110

SBP > 160 and/or DBP > 110

SBP > 160 and/or DBP > 110

40 mg labetalol IV

10 mg hydralazine IV

20 mg nifedipine oral

Repeat BP in 10 minutes

Repeat BP in 20 minutes

Repeat BP in 20 minutes

SBP > 160 and/or DBP > 110

SBP > 160 and/or DBP > 110

SBP > 160 and/or DBP > 110

80 mg labetalol IV

20 mg labetalol IV

20 mg nifedipine oral

Repeat BP in 10 minutes

Repeat BP in 10 minutes

Repeat BP in 20 minutes

SBP > 160 and/or DBP > 110

SBP > 160 and/or DBP > 110

SBP > 160 and/or DBP > 110

Hydralazine 10 mg IV

40 mg labetalol IV

40 mg labetalol IV

Repeat BP in 20 minutes

Repeat BP in 10 minutes

Repeat BP in 10 minutes

SBP > 160 and/or DBP > 110

SBP > 160 and/or DBP > 110

SBP > 160 and/or DBP > 110

Antihypertensive therapy not needed

Continue monitoring

MFM, Medicine or anesthesia consultation

Labor patients:
Antepartum/postpartum:

Once BP goal is reached, repeat BP every 10 minutes for 1 hour and then every 15 minutes until delivery
Once BP goal is reached, repeat BP every 10 minutes for 1 hour, then every 15 minutes for 1 hour,
then every 30 minutes for 1 hour, then every 4 hours

If BP goal is met and acute hypertension returns later, restart protocol from beginning
*nifedipine = short acting capsules; not XL; do not break capsule or give sublingually
labetalol contraindications: asthma, heart disease, congestive heart failure
Reference:
Emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period. American College of Obstetricians and Gynecologists
Committee Opinion No. 623. February 2015.