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Hypertensive Disorders of Pregnancy: Management

Matthew DeLaney, MD, FACEP, FAAEM and Matthew Zeitler, MD

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The summary below is from an episode of ERcast: Clinical Perspectives

Preeclampsia and eclampsia are time-sensitive obstetric emergencies that occur during pregnancy and in the postpartum period, with maternal stroke risk rising when severe hypertension is not treated promptly. Emergency clinicians need fast recognition, seizure prophylaxis, and early OB involvement.

Preeclampsia and Severe Hypertension

  • Postpartum disease window: Hypertensive disorders of pregnancy can first present after delivery, so new postpartum headache, visual symptoms, or severe blood pressure should trigger a preeclampsia evaluation, a miss we emphasize in the episode.
  • Severe pressure threshold: Sustained blood pressure at or above 160/110 mmHg marks severe disease and should prompt emergent OB/GYN consultation rather than watchful waiting or routine outpatient follow-up.
  • Maternal stroke timeline: First-line antihypertensive treatment should ideally begin within 30 to 60 minutes of confirmed severe hypertension because delay increases the risk of maternal intracranial catastrophe.
  • First-line antihypertensive options: Nifedipine, IV labetalol, and IV hydralazine are standard first-line agents, with oral nifedipine especially useful when IV access is delayed.
  • Agent-specific cautions: Labetalol should be avoided in asthma, heart disease, or heart failure, while hydralazine is more prone to maternal hypotension, headache, palpitations, and nausea.

Magnesium and Eclampsia Care

  • Seizure prophylaxis cornerstone: Magnesium sulfate is the first-line therapy for seizure prophylaxis in preeclampsia and also the first- and second-line agent for active eclampsia.
  • No-IV-access option: When IV access is not yet available, magnesium can be started intramuscularly with 5 grams in each gluteal muscle, a practical bridge in crashing patients.
  • Toxicity bedside clues: Loss of deep tendon reflexes, respiratory depression, bradycardia, and pulmonary edema are classic warning signs of magnesium toxicity that demand immediate reassessment.
  • Renal dosing caution: Renal insufficiency changes magnesium maintenance needs, and urine output becomes a key safety signal rather than a minor vital sign. We get into the adjustment logic in the chapter.
  • Contraindication to magnesium: Myasthenia gravis is an absolute contraindication to magnesium, an exception worth recognizing early before reflexively starting standard preeclampsia treatment.
  • Persistent seizure rescue: If eclamptic seizures continue after repeat magnesium, benzodiazepines such as midazolam or lorazepam are next rescue options, alongside airway control and oxygenation.

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References:

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