Cardiac monitor if severe range BP or cardiopulmonary symptoms
Two IV lines if severe features or concern for hemorrhage
Left lateral positioning if hypotension concern
Seizure precautions if neuro symptoms
Severe range BP pathway
If persistent severe range BP 15 minutes or more, IV or PO rapid acting antihypertensive
Target BP range
Systolic 140 to 150 mmHg
Diastolic 90 to 100 mmHg
Avoid rapid overcorrection
Uteroplacental perfusion risk
Maternal cerebral perfusion risk
Antihypertensive treatment
Rapid BP control options
Labetalol IV
Initial 20 mg IV
Repeat 40 mg IV after 10 minutes if needed
Repeat 80 mg IV after 10 minutes if needed
Maximum cumulative dose per local protocol
Hydralazine IV
Initial 5 mg IV
Repeat 5 to 10 mg IV after 20 minutes if needed
Maternal tachycardia monitoring
Nifedipine immediate release PO
Initial 10 mg PO
Repeat 10 to 20 mg PO after 20 minutes if needed
Avoid sublingual administration
Maintenance control options
Labetalol PO
Typical starting dose per local protocol
Dose titration schedule per local protocol
Nifedipine extended release PO
Typical starting dose per local protocol
Dose titration schedule per local protocol
Seizure prophylaxis and treatment
Magnesium sulfate indications
Preeclampsia with severe features
Eclampsia
HELLP syndrome with severe features
Magnesium sulfate dosing
Loading dose
4 g IV over 20 to 30 minutes
Alternative 6 g IV per local protocol
Maintenance dose
1 g per hour IV infusion
Alternative 2 g per hour IV infusion per local protocol
Duration
Continue 24 hours postpartum
Continue 24 hours after last seizure
Magnesium toxicity monitoring
Deep tendon reflexes
Respiratory rate
Urine output
Serum magnesium if renal impairment
Magnesium antidote
Calcium gluconate
1 g IV over 3 minutes
Repeat if persistent toxicity signs
Delivery and obstetric management
Obstetrics consultation triggers
Any severe range BP
Any severe feature symptom
Any lab severe feature
Suspected abruption
Nonreassuring fetal status
Delivery timing principles
Preeclampsia with severe features
Delivery recommended at 34 weeks or later unless maternal or fetal instability earlier
Earlier delivery for uncontrolled severe hypertension or worsening end organ dysfunction
Preeclampsia without severe features
Delivery at 37 weeks or later
Earlier for deterioration
Gestational hypertension
Delivery at 37 weeks or later
Earlier for severe range BP or symptoms
Corticosteroids for fetal lung maturity
Betamethasone regimen per local protocol
Use when preterm delivery expected and time allows
Monitoring and reassessment loop
Reassessment cadence
BP every 10 to 20 minutes during acute control
Neuro symptom reassessment hourly if severe features
Strict intake and output
Escalation triggers
Recurrent severe range BP despite therapy
New hypoxia
Rising creatinine
Falling platelets
Worsening transaminases
New chest pain
Seizure
Disposition
Level of care criteria
ICU or high acuity indications
Eclampsia
Pulmonary edema
Hypertensive emergency with end organ injury
Continuous IV antihypertensive infusion requirement
Persistent altered mental status
Inpatient obstetric admission indications
Preeclampsia with severe features
HELLP syndrome
Worsening labs
Nonreassuring fetal status
Need for magnesium infusion
Observation pathway considerations
Mild range hypertension without severe features
Normal labs
Reliable follow up and home BP monitoring
Discharge criteria
Maternal stability
No severe range BP after observation period
No severe feature symptoms
Labs stable
Clear outpatient plan
Follow up plan
BP recheck within 72 hours postpartum or after ED visit
BP recheck within 7 to 10 days
Obstetric follow up timing per local protocol
Discharge Instructions
Copy discharge instructions
Diagnosis summary
You were evaluated for high blood pressure in pregnancy or after delivery
Your tests today did not show severe complications at this time
Medications
Take your blood pressure medicine exactly as prescribed
Do not start new over the counter medicines without checking first
Home monitoring
Check blood pressure at home as instructed
Record readings and bring them to follow up
Return to emergency care now for
Severe headache that does not go away
Vision changes
Chest pain
Trouble breathing
Seizure
Severe upper belly pain
Heavy vaginal bleeding
Decreased fetal movement
Follow up
Follow up with obstetrics within the timeframe provided
Arrange blood pressure recheck within the next few days
References
Guidelines and key sources
ACOG Practice Bulletin
Gestational Hypertension and Preeclampsia
2020
ACOG Practice Bulletin
Chronic Hypertension in Pregnancy
2019
Society for Maternal Fetal Medicine guidance
Severe hypertension treatment bundle
Year local protocol dependent
NICE guideline
Hypertension in pregnancy
2019
International Society for the Study of Hypertension in Pregnancy guideline
Hypertensive disorders of pregnancy
2021
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.