임신부에서 중증 고혈압, Severe hypertension in pregnancy

원인에 상관 없이 만성 고혈압이든, 임신성 고혈압이든, 전자간증이든

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중증 산모 고혈압 (수축기 160 이상, 이완기 110 이상)는 시기 적절하게 약물 치료를 시작해야 하는데

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이것을 하는 이유는 뇌혈관, 심장, 신장 사건과 사망을 줄이기 때문이며

의학 가이드라인마다 일치하는 내용입니다.

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이 권고사항에 대한 증거는 비임신 성인 중증 고혈압과 전자간증 처치에 대한 연구에서 추론된 것이며 만성 고혈압 임신부에서는 거의 연구가 없습니다.

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어떠한 약제를 선택할 것인지는 급성으로 낮추어야 하는지 만성적으로 낮추어야 하는지와 안정성에 따라 다릅니다.

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급성으로 혈압을 낮추어야 하는 경우 IV labetalol, IV hydralazine 또는 경구 니페디핀을 사용합니다. 어떠한 약제를 선택할 것인가는 이용 가능성, 임상의의 선호, 이상반응에 따라 다릅니다.

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Antihypertensive agents used for urgent blood pressure control in pregnancy

Drug	Initial dose	Follow-up
Labetalol	20 mg IV gradually over 2 minutes.	Repeat BP measurement at 10-minute intervals: If BP remains above target level at 10 minutes, give 40 mg IV over 2 minutes. If BP remains above target level at 20 minutes, give 80 mg IV over 2 minutes. If BP remains above target level at 30 minutes, give 80 mg IV over 2 minutes. If BP remains above target level at 40 minutes, give 80 mg IV over 2 minutes. Cumulative maximum dose is 300 mg. If target BP is not achieved, switch to another class of agent.
	A continuous IV infusion of 1 to 2 mg/minute can be used instead of intermittent therapy or started after 20 mg IV dose. Requires use of programmable infusion pump and continuous noninvasive monitoring of blood pressure and heart rate.	Adjust dose within this range to achieve target blood pressure. Cumulative maximum dose is 300 mg. If target BP is not achieved, switch to another class of agent.
Hydralazine	5 mg IV gradually over 1 to 2 minutes.* Adequate reduction of blood pressure is less predictable than with IV labetalol.	Repeat BP measurement at 20-minute intervals: If BP remains above target level at 20 minutes, give 5 or 10 mg IV over 2 minutes, depending on the initial response. If BP remains above target level at 40 minutes, give 10 mg IV over 2 minutes, depending on the previous response. Cumulative maximum dose is 30 mg. If target BP is not achieved, switch to another class of agent.
Nifedipine extended release	30 mg orally.	If target BP is not achieved in 1 to 2 hours, another dose can be administered. If target BP is not achieved, switch to another class of agent.
Nicardipine (parenteral)	The initial dose is 5 mg/hour IV by infusion pump and can be increased to a maximum of 15 mg/hour. Onset of action is delayed by 5 to 15 minutes; in general, rapid titration is avoided to minimize risk of overshooting dose. Requires use of a programmable infusion pump and continuous noninvasive monitoring of blood pressure and heart rate.	Adjust dose within this range to achieve target BP.
Nifedipine immediate release*	10 mg orally. May be associated with precipitous drops in BP in some women, with associated FHR decelerations for which emergency cesarean delivery may be indicated. As such, this regimen is not typically used as a first-line option and is usually reserved only for women without IV access. If used, FHR should be monitored while administering short-acting nifedipine.	Repeat BP measurement at 20-minute intervals: If BP remains above target at 20 minutes, give 10 or 20 mg orally, depending on the initial response. If BP remains above target at 40 minutes, give 10 or 20 mg orally, depending on the previous response. If target BP is not achieved, switch to another class of agent.

Labetalol and hydralazine are the preferred drugs.

IV: intravenous; BP: blood pressure; FHR: fetal heart rate.

* We caution against use of immediate-release oral nifedipine, although some obstetric guidelines have endorsed its use as a first-line option for emergency treatment of acute, severe hypertension in pregnancy or postpartum (other options were labetalol and hydralazine), particularly when IV access is not in place. In most cases, use of immediate-release oral nifedipine will be safe and well tolerated; however, there is a risk of an acute, precipitous fall in blood pressure, which may result in a reduction in uteroplacental perfusion. The immediate-release preparations are also associated with a higher incidence of headache and tachycardia. In nonpregnant adults, the package insert states that "nifedipine capsules should not be used for the acute reduction of blood pressure."

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REF. UpToDate 2021.05.08