You’re working the night shift in a rural critical access hospital in the Midwest when a 36-year-old, 31-week primigravida patient with no known prior medical history presents with a mild headache. Initial vitals show a blood pressure (BP) of 170/115 mm Hg, which remains elevated 15 minutes later. You follow the recommended emergency department (ED) lab workup for hypertensive disorders of pregnancy, including urine protein/creatinine ratio, serum creatinine, platelet count, complete blood count, and renal liver function tests.

Fetal monitoring reveals normal fetal heart rate assessment. The physical exam is unrevealing, with no focal neurologic deficits or abdominal tenderness. A urine test reveals protein/creatinine ratio of less than 0.3; lab tests show no signs of end-organ dysfunction. Aiming to start treatment within the goal of the first 30 to 60 minutes of confirmed severe hypertension, you initiate an oral antihypertensive with immediate release oral nifedipine 10 mg and acetaminophen for her mild headache while the nurse works on intravenous (IV) access.

Once an IV is established, you first administer labetalol 20 mg IV because antihypertensive treatment is the priority, followed by magnesium sulfate 6 g IV over 20 minutes. Her headache abates after the acetaminophen. You advise the nurse to recheck the BP every 10 minutes with a target BP of 130-150/ 80-100 mm Hg and a plan to increase labetalol doses based on rechecks.

You call the nearest hospital, but because they don’t have a neonatal intensive care unit (NICU), they advise you to call another one. You speak with the OB/GYN team at that hospital, and they recommend steroids for fetal lung maturation because the pregnancy is less than 34 weeks gestation. After a few more rounds of IV labetalol, BP is stabilized, and the patient, now diagnosed with severe gestational hypertension, is flown via air ambulance to the nearest hospital with a NICU.

Acute Hypertension in Pregnancy

Hypertensive disorders of pregnancy are the second leading cause of maternal morbidity and mortality and can also result in fetal complications. Maternal complications of this medical emergency include stroke, eclampsia, and HELLP—hemolysis, elevated liver enzymes, low platelet count—syndrome. Timely treatment can reduce these risks.

The consideration of delivery in severe gestational hypertension must balance risks for maternal and fetal complications, as immediate delivery can reduce maternal complications but can increase the risk for neonatal respiratory distress syndrome, particularly when performed before 37 weeks of gestation. Importantly, these conditions can appear up to six weeks postpartum, which is why it is essential for ED screening to include the question for reproductive age women: Are you pregnant or have you been pregnant in the last six weeks?