Hypertensive emergency
ICD-10 I16.1 · ICD-11 BA03.1

Hypertensive Emergency in Pre-Eclampsia or Eclampsia: What to Do in an Acute Crisis

When a hypertensive crisis occurs in the setting of pre-eclampsia or eclampsia, both mother and fetus face immediate risk. This is a time-critical obstetric emergency requiring structured, rapid intervention.

Clinical scenario

This protocol applies to patients with pre-eclampsia or eclampsia who develop a hypertensive crisis. The co-existence of severely elevated blood pressure with the systemic or neurological features of these conditions defines a high-acuity situation where immediate, protocol-driven management is essential.

Treatment targets

The immediate goal is to reduce systolic BP to below 160 mmHg and diastolic BP to below 105 mmHg, with this reduction achieved within 150–180 minutes of presentation.

Approach to treatment

Management involves intravenous antihypertensive therapy for rapid BP reduction, combined with a neuroprotective agent — with specific additional agents considered when pulmonary oedema is present. The complete evidence-based regimen is in the full protocol.

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1093/eurheartj/ehae178

  • In pre-eclampsia or eclampsia with hypertensive crisis, drug treatment with i.v. labetalol or nicardipine and magnesium is recommended.
  • In pre-eclampsia or eclampsia associated with pulmonary oedema, nitroglycerin given as an i.v. infusion is recommended.
  • In women with pre-eclampsia and severe hypertension, immediately reducing systolic BP to <160 mmHg and diastolic BP to <105 mmHg using i.v. labetalol or nicardipine (with administration of magnesium sulfate if appropriate and consideration of delivery if appropriate) was recommended in the 2018 ESC/ESH Guidelines on the management of arterial hypertension and the 2022 ESC Guidelines for management of cardiovascular disease in pregnancy.
  • Magnesium sulfate [4 g i.v. over 5 min, then 1 g/h i.v.; or 5 g intramuscularly (i.m.) into each buttock, then 5 g i.m. every 4 h] is recommended for eclampsia treatment but also for women with pre-eclampsia who have severe hypertension and proteinuria or hypertension and neurological symptoms or signs.
  • The objective of treatment is to lower BP within 150–180 min.
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