Management of Severe Hypertension at 35+ Weeks of Pregnancy

Immediate Management of Severe Hypertension

The European Society of Cardiology recommends that blood pressure ≥160/110 mmHg lasting >15 minutes warrants immediate antihypertensive treatment regardless of delivery plans 2, 3
First-line treatments for acute severe hypertension include IV labetalol and oral nifedipine, as recommended by the European Heart Journal 2, 3, 4
The American College of Cardiology recommends a target blood pressure of <160 mmHg systolic and diastolic around 85 mmHg 1

The European Society of Cardiology recommends that at 35+ weeks with severe hypertension, delivery should be considered but mode of delivery depends on several factors 4, 1
Vaginal delivery should be considered for women with any hypertensive disorders unless cesarean delivery is required for standard obstetric indications, as recommended by the European Heart Journal 4

The American College of Cardiology recommends immediate delivery for inability to control maternal BP despite using ≥3 classes of antihypertensives in appropriate doses 1
Immediate delivery is also recommended for progressive deterioration in liver function, creatinine, hemolysis, or platelet count, as well as ongoing neurological features, maternal pulse oximetry <90%, placental abruption, or reversed end-diastolic flow in umbilical artery Doppler 1

The European Society of Cardiology recommends that cesarean section is indicated if there are standard obstetric indications, rapid delivery is needed due to maternal or fetal deterioration, or evidence of placental insufficiency with fetal compromise 4, 1
Blood pressure should be controlled before, during, and after cesarean section to keep SBP <160 mmHg and DBP <110 mmHg, as recommended by the European Heart Journal 4

The American College of Cardiology recommends that magnesium sulfate should be considered for seizure prophylaxis in women with pre-eclampsia who have severe hypertension with neurological signs or symptoms 1
Corticosteroids for fetal lung maturity should be considered if delivery is anticipated before 34 weeks, as recommended by the European Heart Journal 4

The European Society of Cardiology recommends that antihypertensive treatment should be continued during labor, delivery, and postpartum 4
Blood pressure and urine should be checked at 6 weeks postpartum, and women with persisting hypertension or proteinuria at 6 weeks should be referred to a specialist, as recommended by the European Heart Journal 4

The European Heart Journal recommends that treatment of severe hypertension should not be delayed, as it increases risk of stroke and other complications 2, 3
The American College of Cardiology recommends that ACE inhibitors, ARBs, or direct renin inhibitors should not be used during pregnancy due to fetotoxicity 5