Contributor: Kiersten Williams MD, Travis Barlock MD, Jeffrey Olson MS2

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Hypertensive disorders of pregnancy are one of the leading causes of maternal mortality worldwide.
Hypertension (HTN) complicates 2-8% of pregnancies
The definition of HTN in pregnancy is a systolic >140 or diastolic >90, measured 4 hours apart
There is a range of HTN disorders

Systolics above 160 mmHg
Diastolics above 110 mmHg
Headache, especially not going away with meds, or different than previous headaches
Visual changes, anything that lasts more than a few minutes
RUQ pain, which could present as heartburn
Pulmonary edema
Low platelets, if <150 perk up ears, <100 definitely look into
Renal insufficiency, creatinine 1.1 or higher or doubling of baseline
Impaired liver function
Note: Hemoconcentration and LDH >600 are not diagnostic but worth paying attention to

Start with 6 g or 4 g over 20 minutes if the patient is small or has bad kidney function
Follow with 2 g per hour or 1 g per hour
Don’t give in myasthenia gravis

Magnesium is the best drug
Can use phenytoin or benzos IV as an alternate
Diazepam is available PR which is a good option if you don’t have IV access
IM magnesium is doable but painful, mix with lidocaine and split dose between the butt cheeks

20% of women will have HTN post-partum
Most resolve by 6 weeks
If it lingers past 6 months this is chronic HTN
If the patient has severe features (see above) they desevere 24 hours on magnesium while being monitored on the L&D floor
Post-partum is the most common time for strokes
Providers can be much more aggressive with HTN treatment because the fetus is no longer being exposed
Enalapril is safe in breast feeding
Some patients might need to give up breast feeding to be on even more aggressive HTN therapy
Are NSAIDs safe while breastfeeding?

Last pearl: Put pregnant patients in left or right lateral decubitus while in ER or put a folded towel under their hip to help with venous return which can also help with nausea

References

Metoki, H., Iwama, N., Hamada, H., Satoh, M., Murakami, T., Ishikuro, M., & Obara, T. (2022). Hypertensive disorders of pregnancy: definition, management, and out-of-office blood pressure measurement. Hypertension research : official journal of the Japanese Society of Hypertension, 45(8), 1298–1309. https://doi.org/10.1038/s41440-022-00965-6
Rana, S., Lemoine, E., Granger, J. P., & Karumanchi, S. A. (2019). Preeclampsia: Pathophysiology, Challenges, and Perspectives. Circulation research, 124(7), 1094–1112. https://doi.org/10.1161/CIRCRESAHA.118.313276
Reed, B. (2020, May 2). ‘They didn’t listen to me’: Amber Rose Isaac tweeted about her death before dying in childbirth. The Guardian. https://www.theguardian.com/us-news/2020/may/02/amber-rose-isaac-new-york-childbirth-death
Reisner, S. H., Eisenberg, N. H., Stahl, B., & Hauser, G. J. (1983). Maternal medications and breast-feeding. Developmental pharmacology and therapeutics, 6(5), 285–304. https://doi.org/10.1159/000457330
Wilkerson, R. G., & Ogunbodede, A. C. (2019). Hypertensive Disorders of Pregnancy. Emergency medicine clinics of North America, 37(2), 301–316. https://doi.org/10.1016/j.emc.2019.01.008
Wu, P., Green, M., & Myers, J. E. (2023). Hypertensive disorders of pregnancy. BMJ (Clinical research ed.), 381, e071653. https://doi.org/10.1136/bmj-2022-071653

Produced by Jeffrey Olson, MS3 | Edited by Jeffrey Olson and Jorge Chalit, OMSIII

Laboring Under Pressure Episode 3: Hypertensive Disorders of Pregnancy with Dr. Kiersten Williams

Emergency Medical Minute