What are the ACOG guidelines for the emergency treatment of acute onset severe hypotension during pregnancy?

Updated: Jun 12, 2018
  • Author: Michael P Carson, MD; Chief Editor: Edward H Springel, MD, FACOG  more...
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In 2015 and 2017, the American College of Obstetricians and Gynecologists Committee on Obstetric Practice issued updated guidelines regarding the emergency treatment of acute onset severe hypertension during pregnancy, including the following [4, 5, 6] :

  • Acute-onset, severe hypertension that is accurately measured using standard techniques and is persistent for 15 minutes or longer is considered a hypertensive emergency.

  • Intravenous (IV) labetalol and hydralazine have long been considered first-line medications for the management of acute-onset, severe hypertension in pregnant women and women in the postpartum period. Available evidence suggests that oral nifedipine also may be considered as a first-line therapy.

  • Parenteral labetalol should be avoided in women with asthma, heart disease, or congestive heart failure.

  • When urgent treatment is needed before the establishment of IV access, the oral nifedipine algorithm can be initiated as IV access is being obtained, or a 200-mg dose of labetalol can be administered orally. The latter can be repeated in 30 minutes if appropriate improvement is not observed.

  • Magnesium sulfate is not recommended as an antihypertensive agent, but magnesium sulfate remains the drug of choice for seizure prophylaxis in severe preeclampsia and for controlling seizures in eclampsia.

  • Sodium nitroprusside should be reserved for extreme emergencies and used for the shortest amount of time possible because of concerns about cyanide and thiocyanate toxicity in the mother and fetus or newborn, and increased intracranial pressure with potential worsening of cerebral edema in the mother.

  • There is a need for adoption of standardized, evidence-based clinical guidelines for managing patients with preeclampsia. Individuals and institutions should have mechanisms in place to initiate the prompt administration of medication when a patient presents with a hypertensive emergency.

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