Cardiovascular alterations in severe pregnancy-induced hypertension: effects of intravenous nitroglycerin coupled with blood volume expansion

Anaesthetic management of a pregnant patient with Takayasu's disease undergoing abdominal aortic aneurysm repair

We report the successful anaesthetic management of repair of an abdominal aortic aneurysm in a patient with Takayasu's disease at 14 weeks' gestation. Anaesthesia was managed with combined epidural and general anaesthesia. During the intraoperative period haemodynamic parameters were well maintained. There were no episodes of haemodynamic fluctuations, oxygen desaturation or metabolic acidosis. Aortic cross-clamp time was 105 min, blood loss around 1200 mL, and central venous pressure maintained between 8 and 10 cm H2O. There were no sudden changes in cardiac parameters, base deficit or urine output before or after cross clamping. The patient later delivered a full term, normal fetus.

The Effect of Glyceryl Trinitrate on Hypertension in Women with Severe Preeclampsia, HELLP Syndrome, and Eclampsia

OBJECTIVE

The goal of this study is to evaluate the effect of glyceryl trinitrate (GTN) in the management of hypertension in women with preeclampsia, eclampsia, and HELLP syndrome.

STUDY DESIGN

Fifty five women with preeclampsia, eclampsia, and HELLP syndrome administered GTN infusion for the management of hypertension were studied. Demographic, clinical, and perinatal outcome findings were collected for analyses. We recorded initial and maintenance doses of GTN, and duration of its use in prepartum and postpartum periods. We collected systolic and diastolic blood pressures (BPs) at admission and before the administration of GTN infusion. During the GTN infusion, we calculated average diastolic and systolic blood pressures 6 hours apart on the first day, 12 hours apart on the second day, and 24 hours apart on the third day.

RESULTS

Of 55 women, 24 with severe preeclampsia, 16 with HELLP syndrome, and 15 with eclampsia were included in this study. In severe preeclampsia group, GTN infusion significantly reduced systolic and diastolic BPs beginning from the second quarter and third quarter, respectively, of first day (p < 0.05). In the HELLP syndrome group, GTN infusion significantly decreased systolic and diastolic blood pressures beginning from the third quarter and second quarter, respectively, of the first day (p < 0.05). In the eclampsia group, GTN infusion significantly reduced systolic and diastolic blood pressures beginning from the third quarter and first quarter, respectively, of the first day (p < 0.05).

CONCLUSION

In women with severe preeclampsia, eclampsia, and HELLP syndrome, infusion of GTN can be used as an alternative agent to well-known drugs and causes no significant adverse effect to the mother and fetus.

Common problems in critically ill obstetric patients, with an emphasis on pharmacotherapy

Pharmacological treatment of critically ill obstetric patients can be especially challenging due to the complexity of caring for 2 patients, with a paucity of research to support practice. This review will provide practitioners with primary recommendations for management of the critical illnesses most commonly encountered in pregnancy and will discuss the scientific and clinical merit of these recommendations.

Síndrome coronario agudo con elevación de ST durante el embarazo: descripción de un caso y revisión de las opciones terapéuticas

ST segment elevation acute coronary syndrome is a clinical condition that is rarely observed in pregnant women. However, its manifestation is a situation of high maternal-fetal risk. Pharmacotherapeutical management of these patients is difficult and requires individualized care by a multidisciplinary team since many of the standard treatments are included within the categories of teratogencity C or D of the Food and Drug Administration and experience with techniques such as coronary angioplasty with stent placement is scarce. The case of a 32-year woman who was 11 weeks pregnant and diagnosed of acute coronary syndrome with ST segment and its therapeutic approach are described. Furthermore, the information available on epidemiology, etiology and pathophysiology of acute coronary syndrome with ST segment during pregnancy and the specific role of the currently available treatment options are reviewed.

Cardiovascular Pharmacotherapeutic Considerations During Pregnancy and Lactation

Table 2 summarizes the recommendations regarding the use of cardiovascular drugs during pregnancy and lactation.

Pre-eclampsia: fluids, drugs, and anesthetic management

Severe pre-eclampsia is a complex disease, which taxes the expertise of even the most experienced obstetric anesthesiologist. The treatment should focus on stabilization of blood pressure, optimization of fluid status, and prevention of convulsions. Neuraxial blocks for labor and delivery offer many benefits to the mother and her infant. For cesarean section, there is unequivocal evidence of superiority of neuraxial anesthesia over general anesthesia. If general anesthesia is needed, careful preanesthetic preparation and meticulous airway management is essential. The successful and safe peripartum management of the pre-eclamptic patient and her infant is a team effort among the anesthesiologist, obstetrician, and neonatologist.

Haemodynamic, invasive and echocardiographic monitoring in the hypertensive parturient

AIM

To determine the clinical usefulness of invasive and non-invasive haemodynamic assessment in pre-eclampsia.

METHOD

A systematic review of the literature was undertaken, using a MEDLINE electronic search using a combination of MESH headings and textwords. Over 1500 abstracts were perused; we obtained 156 full papers that were related to the subject matter. Of the full papers, 55 yielded relevant information. Hand-searching the reference lists of the retrieved papers completed the search.

RESULTS

There are no data from randomized controlled clinical trials illustrating the clinical usefulness of pulmonary artery catheters or echocardiographic techniques in hypertensive pregnancy. There are a wealth of data illustrating the haemodynamic profiles of both untreated and treated pre-eclamptic women. Data are also available comparing right heart and left heart filling pressures, demonstrating a relatively poor correlation between the two values. The clinical impact of either measurement is unclear. Data are available illustrating the correlation between echocardiographic techniques and pulmonary artery catheterization.

Management and monitoring of severe preeclampsia

Preeclampsia is associated with increased maternal and perinatal morbidity and mortality. Preeclampsia is more than pregnancy-induced hypertension. The hypertension is only one manifestation of an underlying multifactorial, multisystem disorder, initiated early in pregnancy. In established severe disease there is volume contraction, reduced cardiac output, enhanced vascular reactivity, increased vascular permeability and platelet consumption. Medical treatment of severe hypertension in pregnancy is required. The more controversial issues are the role of pharmacological treatment in conservative management of severe preeclampsia aiming at prolongation of pregnancy, the ability of such therapy to modify the course of the underlying systemic disorder and the effects on fetal and maternal outcome. This paper presents an overview concerning the current developments in management and monitoring of severe preeclampsia. Controversial topics such as the role of plasma volume expansion in preeclampsia, expectant versus aggressive management of severe preeclampsia remote from term, and pharmacological interventions in the management of eclampsia and the HELLP syndrome are addressed.

Pharmacological treatment of severe hypertension in pregnancy and the role of serotonin(2)-receptor blockers

Hypertensive disorders of pregnancy are the leading cause of maternal and perinatal mortality and morbidity in developing and developed countries. The etiology of preeclampsia is still unknown. Delivering the baby is the only definite treatment. The benefits of acute pharmacological control of severe hypertension prior to and/or post-delivery are generally accepted. Most drugs commonly used in the management of severe hypertension in pregnancy have significant maternal and/or neonatal adverse side effects. Furthermore, some are not effective to acutely lower the blood pressure in patients with a hypertensive crisis. Until recently not one of the commonly used antihypertensive drugs has been tailored to the pathophysiology of severe preeclampsia, being a clinical syndrome characterized by endothelial cell dysfunction, vasospasm and platelet aggregation. Ketanserin, a serotonin(2)-receptor blocker, is a drug that appears to be tailored for treating this pregnancy-associated enthothelial cell dysfunction. The results of several prospective trials show that there is a definite place for serotonin(2)-receptor blockers in the treatment of pregnancy-induced hypertensive disorders. This review provides a summary on the more established drugs as well as on some of the newer antihypertensive drugs used in pregnancy with emphasis on the existing experience with ketanserin.

Anesthetic management of preeclampsia/eclampsia

Preeclampsia/eclampsia affects only a small proportion of all pregnancies, yet accounts for much of the obstetric morbidity and mortality seen in the USA and UK. A full understanding of preeclampsia/eclampsia, its variable presentation and complex pathophysiology allows the consulting anesthesiologist to optimize a plan for anesthetic management of the afflicted patient.

Crack-cocaine-associated aortic dissection in early pregnancy--a case report

Even though uncommon in pregnancy, aortic dissection is a potentially catastrophic vascular complication, occurring mainly in the late stages of pregnancy. Vascular events, including aortic dissection are recognized complications of crack-cocaine use. The authors report a case of aortic dissection in early pregnancy related to crack-cocaine use. They believe that the combined effects of pregnancy and crack cocaine on the vasculature create the requisite milieu potentiating such catastrophic events as aortic dissection. This paper reviews the possible underlying pathophysiologic mechanisms and the available diagnostic, therapeutic, and management options.

Randomised trial of nitric oxide donor versus prostaglandin for cervical ripening before first-trimester termination of pregnancy

BACKGROUND

Vaginal administration of the nitric oxide donor isosorbide mononitrate can induce effective ripening of the human cervix. We investigated whether this drug is associated with fewer side-effects than prostaglandins when used to ripen the cervix before first-trimester surgical termination of pregnancy, and assessed whether the extent of cervical ripening it induces is clinically sufficient.

METHODS

66 primigravid women scheduled for surgical termination were assigned to receive before surgery, per vaginam, isosorbide mononitrate 40 mg or 80 mg, or the prostaglandin analogue gemeprost 1 mg. The primary measured outcome was onset of new symptoms before termination of pregnancy.

FINDINGS

More women remained symptom-free after isosorbide mononitrate than after gemeprost (28/44 [64%] vs 3/22 [14%], p<0.005). Pretreatment with gemeprost resulted in abdominal pain in 73% of women and vaginal bleeding in 32% compared with 3% and 0%, respectively, after isosorbide mononitrate, whereas, more women developed headache after isosorbide mononitrate (27%) than after gemeprost (0%). Cervical resistance and measured intraoperative blood loss were lowest after pretreatment with gemeprost. The measured cervical resistance and intraoperative blood loss with either dose of isosorbide mononitrate did not differ from those in a comparison group of 22 parous women not in the randomised trial.

INTERPRETATION

Pretreatment with isosorbide mononitrate to ripen the cervix before first-trimester termination of pregnancy is associated with fewer side-effects than gemeprost treatment and adequately decreases cervical resistance. Isosorbide mononitrate could be used as an alternative to gemeprost for this indication.

Use of nitroglycerin for uterine relaxation

Data from human and experimental animal research indicate that nitric oxide (NO), a novel messenger, formed during the nitric oxide synthase-catalyzed oxidation of L-arginine to L-citrulline, is involved in maintaining normal uterine tone during gestation. There are demonstrated and potential benefits of manipulating the L-arginine-NO system during pregnancy. Several recent case reports and case series have described the effective use of nitroglycerin (GTN), a NO donor compound, antenatally, intrapartum, and postpartum for acute uterine relaxation. Therapeutic indications for GTN range from facilitating external cephalic version, difficult vaginal or cesarean section delivery, and manual exploration of the uterus, to its use as a tocolytic. The intravenous regimen of GTN required to obtain the desired degree of uterine relaxation is extremely variable; intravenous bolus doses of 50 micrograms to 500 micrograms GTN with up to three repeated injections of 50 micrograms to 250 micrograms have been reported. Other methods of GTN administration include transdermal patches and sublingual spray. GTN, when used in low doses, may provide safe and effective uterine relaxation with no clinically apparent fetal or maternal adverse effects. However, clinical trials with use of objective methods of evaluating uterine tone and comparing GTN to other tocolytic agents are required before widespread use in advocated.

Cerebrovascular disorders complicating pregnancy--beyond eclampsia

OBJECTIVE

Our purpose was to investigate the problems encountered in the diagnosis and management of cerebrovascular disorders associated with pregnancy and the puerperium.

STUDY DESIGN

Pregnancies complicated by cerebrovascular disorders were identified by retrospective chart review (1985 to 1995). Events associated with trauma, neoplasm, drug ingestion, and infection were excluded.

RESULTS

The study population comprised 24 women with a variety of cerebrovascular disorders: 14 with infarction (5 arterial, 9 venous), 6 with intracranial hemorrhage (3 anatomic malformation, 3 unknown etiology), 3 with hypertensive encephalopathy, and 1 with an unruptured aneurysm. Blood pressure reflected physical condition at presentation and did not predict diagnosis or outcome except in the 3 women with hypertensive encephalopathy. Only 4 of 14 women with infarction and 1 of 6 with intracranial hemorrhage had a diastolic blood pressure > or = 110 mm Hg. Presumption of eclampsia delayed the diagnosis in 10 women (41.7%). In addition, patient delay in seeking medical attention complicated 10 cases. After review, none of the adverse maternal outcomes were deemed preventable by earlier physician intervention. Seven maternal deaths occurred (29.2%). Neonatal outcome was related to the gestational age and the maternal condition at presentation.

CONCLUSION

Cerebrovascular disorders are an uncommon and unpredictable complication of pregnancy that are associated with substantial maternal and fetal mortality. Suspected eclampsia unresponsive to magnesium sulfate therapy warrants an immediate neuroimaging study. Interestingly, in women with intracranial hemorrhage, severe hypertension was not an associated predictive factor.

Use of the pulmonary artery catheter in severe preeclampsia: a review

The use of a balloon-tipped, flow-directed pulmonary artery catheter in critically ill and surgical patients has become commonplace in the United States since its introduction into clinical medicine in 1970. The capability of acquiring continuous hemodynamic and, more recently, oxygen transport data, has led to an enhanced understanding of pathophysiologic processes in disease states and to an improved ability to guide therapeutic decision making. The purpose of this paper is to review experience with the pulmonary artery catheter in subsets of women with severe preeclampsia.

Endothelial dysfunction in preeclampsia. Part II: Reducing the adverse consequences of endothelial cell dysfunction in preeclampsia; therapeutic perspectives

Next to low-dose Aspirin there appear to be several new and promising pharmacologie approaches for reducing the adverse consequences of endothelial cell dysfunction in preeclampsia. Among these are selective thromboxane-A2 synthetase and/or thromboxane-A2 receptor antagonists, stable prostacyclin analogues, selective S(erotonin)2-receptor blockers, nitrovasodilators, glycoprotein IIb/IIIa antagonists, hirudin, and ticlopidine. Early-onset preeclampsia appears to be associated with certain disorders that are likely to provoke an arterial thrombotic process by impairing the normal endothelial cell-platelet interactions. Especially heterozygous hyperhomocysteinemia, protein S deficiency and anticardiolipin antibodies appear to be fairly common. The management of these 3 separate disease entities will be discussed.

[Indications of albumin for vascular loading during pregnancy]

Albumin infusion is used during pregnancy for volume loading in preeclampsia and/or intra-uterine growth retardation, before regional anaesthesia for Caesarean section, compensation of blood loss during haemorrhages of parturition, as well as prevention and treatment of ovarian hyperstimulation syndrome after in vitro fertilization. In preeclampsia, albumin is used for volume loading before initiating antihypertensive therapy. However it neither decreases blood pressure, nor increases uterine blood flow. Before regional anaesthesia for Caesarean section, an infusion of albumin 5% at a rate of 15 mL.kg-1 prevents hypotension in mothers (P < 0.05 versus Ringer lactate) and provides better Apgar scores in neonates (P < 0.05). Albumin is used to treat hypovolaemia in severe ovarian hyperstimulation syndrome. Recent studies have shown that in patients at high risk of ovarian hyperstimulation syndrome, 500 mL albumin 5% administered after ovocytes retrieval diminished the incidence of this syndrome (P < 0.05 versus normal saline).

The oxygen consumption/oxygen delivery curve in severe preeclampsia: evidence for a fixed oxygen extraction state

OBJECTIVE

Increased total body oxygen consumption requirements are usually met by increased oxygen delivery and increased oxygen extraction. In certain conditions (e.g., adult respiratory distress syndrome) the ability to increase oxygen extraction is lost, and any increase in oxygen consumption depends on increased oxygen delivery. The objective of this study was to investigate the oxygen delivery/oxygen consumption relationship in severe preeclampsia.

STUDY DESIGN

Thirty-two patients with severe preeclampsia (blood pressure > 160/110 mm Hg; 3 to 4+ proteinuria) were monitored with a pulmonary artery catheter. Baseline oxygen consumption and delivery in a group without volume expansion or pharmacologic vasodilatation were compared with those in a group who had received a magnesium sulfate infusion.

RESULTS

Oxygen consumption, oxygen delivery, arterial-venous-oxygen difference, and the oxygen extraction ratio were low when compared to that for normal 32 to 38 week pregnancy. The oxygen extraction ratio, defined as the ratio of oxygen consumption to oxygen delivery, was abnormally low for pregnancy, especially considering the low oxygen delivery levels in these patients. Oxygen consumption was dependent on oxygen delivery over the entire range of values seen.

CONCLUSIONS

Severe preeclampsia is associated with an abnormality of tissue oxygen extraction, as evidenced by a low and unresponsive oxygen extraction ratio. Oxygen consumption increases proportionately with increases in oxygen delivery without reaching an oxygen delivery-independent state. Even at high oxygen delivery levels the oxygen consumption in preeclamptic patients is still abnormally low for pregnancy.

The effect of nicardipine on maternal and fetal hemodynamics and uterine blood flow in chronically instrumented pregnant goats

This study was designed to clarify the maternal and fetal hemodynamics of nicardipine (0.02 mg/kg) administered intravenously to unanesthetized, chronically instrumented pregnant goats. Nicardipine produced a significant increase in maternal heart rate and cardiac output, and a significant decrease in maternal mean arterial blood pressure and systemic vascular resistance. These changes persisted for about 30 minutes. There were no consistent changes in maternal pulmonary hemodynamics. Uterine arterial blood flow (UBF) decreased significantly (about 15%) after 5 minutes of the injection and returned to the control value within 30 minutes. A significant correlation between the decreases in UBF and maternal diastolic blood pressure was observed after 5 minutes of the injection. The fetal heart rate, blood pressure and acid-base status did not change after the injection of nicardipine. These observations of pregnant goats suggest that nicardipine might be a useful agent for the treatment of acutely hypertensive crises in pregnant patients.

Respiratory function in severe gestational proteinuric hypertension: the effects of rapid volume expansion and subsequent vasodilatation with verapamil

OBJECTIVES

(1) To define the baseline respiratory function in untreated severe gestational proteinuric hypertension (GPH) and (2) to assess the effects of volume expansion with dextran (MW = 70,000 Dalton) and subsequent vasodilatation with the calcium antagonist verapamil on the baseline respiratory function in severe GPH.

DESIGN

Prospective descriptive study.

SETTING

Reproductive Research Unit, Groote Schuur Hospital, Cape Town, South Africa.

SUBJECTS

Six women with severe GPH undergoing stabilization and delivery.

INTERVENTIONS

Baseline haemodynamic and respiratory function was assessed using invasive monitoring. Patients then underwent volume expansion to a pulmonary capillary wedge pressure of 16 mmHg with dextran-70, followed by vasodilatation with the calcium antagonist verapamil. Haemodynamic and respiratory variables were measured, before and after both the fluid load and the reduction (20%) in the mean arterial pressure.

MAIN OUTCOME MEASURES

Mean arterial pressure, heart rate, mean pulmonary arterial pressure, pulmonary capillary wedge pressure, central venous pressure, cardiac index, systemic vascular resistance, pulmonary vascular resistance, respiratory rate, blood gases, alveolar arterial oxygen difference, oxygen availability, oxygen consumption, pulmonary shunt fraction.

RESULTS

Baseline oxygen availability/delivery and oxygen consumption indices were consistent with severe tissue ischaemia. Volume loading with 400 +/- 114 ml dextran-70 normalized these variables, and subsequent vasodilatation with verapamil did not reduce these indices below the normal limits for pregnancy.

CONCLUSIONS

These data support the theory that some of the complications of severe GPH may follow organ damage due to prolonged tissue ischaemia. They also support the appropriateness of controlled volume expansion in the management of this condition. We suggest, from these data, that the combination of volume expansion and verapamil vasodilatation lowers the blood pressure without compromising the maternal respiratory function.

Nitroprusside in preeclampsia. Circulatory distress and paradoxical bradycardia

In severe preeclampsia, short-term peripartum management of hypertension with hydralazine is complicated by relatively prolonged hypotensive episodes, resulting in fetal distress. We hypothesized that nitroprusside's rapid onset and brief antihypertensive action would permit more controlled blood pressure reduction. Nitroprusside was infused into 10 invasively monitored subjects until mean arterial pressure either 1) was gradually reduced 10-20% or 2) fell abruptly. Subjects fell into two groups, defined by whether the hypotensive effect of nitroprusside was accompanied by a fall in heart rate (group A, n = 8) or a rise (group B, n = 2). Group B showed the expected sinoaortic baroreceptor reflex elevations in heart rate (+17 +/- 6 beats/min) in response to moderate falls in mean arterial pressure (-32 +/- 9 mm Hg) elicited by moderate doses (1.03 +/- 0.23 micrograms/kg/min). However in group A, steep reductions in mean arterial pressure (-75 +/- 22 mm Hg, p less than 0.0001), significantly greater than in group B (p less than 0.05), occurred at much lower doses (0.35 +/- 0.23 micrograms/kg/min; p less than 0.05) and were accompanied by falls in heart rate (-21 +/- 7 beats/min). The apparently paradoxical falls in heart rate and extreme hypotensive responses in group A indicate severe circulatory compromise, corresponding to the cardiac and vasomotor depression that characterizes severe hemorrhage and other forms of acute/severe hypovolemic hypotension. This hemodynamic pattern represents a cardiopulmonary baroreceptor reflex presumably related to the Bezold-Jarisch reflex. The appearance of this pattern in the present study probably reflects the imposition of nitroprusside's prominent venous dilator action on the relatively reduced blood volume that generally characterizes severe preeclampsia.

The hemodynamic effects of intubation during nitroglycerin infusion in severe preeclampsia

The effectiveness of intravenous nitroglycerin infusion in lowering maternal blood pressure and in blunting the hemodynamic responses to endotracheal intubation was evaluated in six primigravid women with severe preeclampsia. Monitoring consisted of continuous electrocardiogram monitoring, arterial cannulation, and flow-directed pulmonary arterial catheterization in each patient. All patients underwent oxytocin induction of labor and crystalloid and/or colloid expansion to produce a pulmonary capillary wedge pressure of 10 to 15 mm Hg and a colloid osmotic pressure of greater than 17 mm Hg. Intravenous nitroglycerin was administered before induction of general anesthesia. The hemodynamic effects associated with endotracheal intubation revealed a change in the heart rate from 104 +/- 10 to 133 +/- 17 beats/min, an increase in mean arterial pressure from 134 +/- 12 to 164 +/- 32 mm Hg, and an increase in systemic vascular resistance from 1262 +/- 342 to 1351 +/- 259 dynes-sec-cm-5 that was accompanied by a small change in the cardiac index from 4.5 +/- 1.2 to 4.5 +/- 0.9 L.min-1.m-2.

Rapid-acting parenteral antihypertensive agents

Parenteral antihypertensive agents are useful in those clinical situations where rapid reduction of blood pressure is necessary or where treatment with oral antihypertensive medications is not feasible. Given the diverse selection of parenteral antihypertensive drugs now available, therapy can be individualized. The presence of concurrent diseases will often influence the decision-making process regarding choice of an agent. Complications of parenteral antihypertensive therapy can arise from the intrinsic properties of the various drugs or the development of severe hypotension. Gradual lowering of blood pressure, in conjunction with careful clinical evaluation, will minimize the risks of acute parenteral antihypertensive therapy. Given that parenteral antihypertensive therapy often needs to be replaced by oral therapy, those drugs that can be used both parenterally and orally may have an advantage.

Central hemodynamic assessment of normal term pregnancy

Ten carefully screened primiparous patients between 36 and 38 weeks' gestation underwent pulmonary artery catheterization, arterial line placement, and central hemodynamic assessment in the left lateral recumbent position. Studies were repeated in the same patients between 11 and 13 weeks post partum. Compared with the nonpregnant state, there was a significant fall in systemic vascular resistance, pulmonary vascular resistance, colloid oncotic pressure, and colloid oncotic pressure-pulmonary capillary wedge pressure gradient by the late phase of the third trimester (p less than 0.05). Pregnancy was associated with a significant rise in cardiac output and pulse in all patients (p less than 0.05). There was no significant change in pulmonary capillary wedge pressure, central venous pressure, left ventricular stroke work index, or mean arterial pressure. Normally the late phase of the third trimester is not associated with hyperdynamic left ventricular function as assessed by the left ventricular stroke work index/pulmonary capillary wedge pressure ratio.

Acute hypertensive crisis in pregnancy

Severe pre-eclampsia is a state of acute afterload increase where compensation may be total by use of the Frank-Starling mechanism and/or increased adrenergic drive, or may be uncompensated in a patient with limited or exhausted preload reserve. As such, we are presented with a diverse group of patients and antihypertensive therapy ideally should be individualized. In reality we are dealing with a complex situation because of the presence of the fetus raising concerns about direct effects on the fetus as well as on uteroplacental blood flow. This limits our choice of agents to those with extensive use in pregnancy except in complicated or resistant cases. For these reasons, hydralazine is the antihypertensive agent of choice for treatment of acute hypertensive emergencies in pregnancy. In the complicated case other agents such as sodium nitroprusside or nitroglycerin may be more appropriate and, in these cases, hemodynamic monitoring should be performed to allow not only greater safety, but also to tailor therapy to the individual hemodynamic profile.