ABC | Volume 114, Nº5, May 2020

Statement Brazilian Cardiology Society Statement for Management of Pregnancy and Family Planning in Women with Heart Disease – 2020 Arq Bras Cardiol. 2020; 114(5):849-942 Endotracheal intubation is another risk in hypertensive emergencies. Induction of general anesthesia and intubation should never be performed without first taking measures to eliminate or minimize the hypertensive response to intubation. Maternal-fetal monitoring must be strict by the medical and nursing staff during treatment. After initial stabilization, the team should monitor BP closely and institute maintenance therapy as needed. The Ame r i c an Co l l ege o f Ob s t e t r i c i an s and Gynecologists 268,269,280 makes the following recommendations and conclusions: • Treatment with first-line agents should be immediate or occur as soon as possible within 30 to 60 minutes after confirmed severe hypertension (blood pressure greater than 160/110 mmHg and persistent for 15 minutes) to reduce the risk of maternal stroke . The patient must be positioned in a sitting or semi-reclining position, with the back supported, they must not be repositioned to be reclined or to stand on their side to obtain low blood pressure, as it will provide a false reading of the pressure measurement; 292 • Maternal and fetal monitoring by a doctor and nursing staff is recommended during the treatment of severe acute onset hypertension; • After initial stabilization, the team should monitor blood pressure closely and institute maintenance therapy as needed; • Intravenous labetalol and hydralazine (IV) are considered first-line drugs for the treatment of severe acute onset hypertension in pregnant women and women in the postpartum period; • Immediate-release oral nifedipine can also be considered as first-line therapy, especially when IV access is not available; • The use of labetalol IV, hydralazine IV or oral nifedipine of immediate release for the treatment of severe acute onset hypertension in pregnant or postpartum patients does not require cardiac monitoring; • In the rare circumstances in which immediate release oral labetalol, hydralazine or nifedipine boluses fail to relieve acute onset, severe hypertension and are administered in appropriate successive doses, emergent consultation with an anesthetist, subspecialist in maternal-fetal medicine or subspecialist in intensive care to discuss second-line intervention is recommended; • Magnesium sulfate is not recommended as an antihypertensive agent, but magnesium sulfate remains the drug of choice for the prophylaxis of seizures in women with severe acute onset hypertension during pregnancy and the postpartum period. The onset of magnesium should not be delayed in the setting of acute severe hypertension; it is recommended regardless of whether the patient has severe gestational hypertension, pre-eclampsia with severe features or eclampsia. 4.5. Practice for Hypertensive Emergency in Preeclampsia (PA ≥ 160/110 mmHg) In the hypertensive emergency, the most effective drugs are nifedipine, hydralazine and labetalol. There may be subtle differences in your security profiles. The evidence is inadequate for other drugs. Medicines for intravenous use are hydralazine and intravenous labetalol (not available in Brazil). Oral nifedipine is now accepted as first-rate. A recent systematic review by Cochrane found no significant differences between these three drugs in the treatment of hypertensive crisis in terms of efficacy or safety between hydralazine and labetalol or between hydralazine and BCC. 277,295-297 • Nifedipine: initial dose of 10-20 mg orally. The onset time of action of oral nifedipine is 5-10 minutes. The dose should be repeated in 20 minutes, if necessary (if blood pressure is> 155/105 mmHg). Maintaining 10-20 mg every 2-6 hours with the maximum daily dose is 120 mg. Repeat medication if blood pressure is> 155/105 mmHg and administer a maximum of three doses. After 20 min of the third dose and the persistence of arterial hypertension, administer a drug of second choice. It should be noted that the tablets should not be chewed and the formulations should not be used sublingually; • Hydralazine: Initial dose of 5 mg intravenously (maximum dose of 45 mg) in bolus, slowly, over 1 to 2 min, repeat, if necessary, 5 mg every 20 minutes (note: The hydralazine ampoule contains 1 ml, in concentration of 20 mg / ml, dilute an ampoule (1 ml) in 19 ml of distilled water, thus obtaining a concentration of 1 mg / ml). The action starts within 10 to 30 minutes and lasts 2 to 4 hours. Parenteral hydralazine may increase the risk of maternal hypotension (systolic BP, 90 mmHg or less); 271 • In the rare circumstances in which the bolus of labetalol (not available in Brazil), hydralazine or oral nifedipine (retard) administered in appropriate and successive doses does not control blood pressure levels, it is recommended to discuss intervention with drugs considered to be second line; 267 • Nitroglycerin is considered a medication of choice for preeclampsia associated with acute pulmonary edema (intravenous infusion of 5 mg/min, gradually increasing every 3 to 5 min to a maximum dose of 100 mg/min); • Sodium nitroprusside should be considered as a preferential option for controlling arterial pressure in exceptional situations, such as refractory hypertension of severe hypertension with risk of death. Prolonged treatment with sodium nitroprusside is associated with fetal risk sodium nitroprusside is associated with the fetal risk of intoxication by cyanide, a metabolic product of sodium nitroprusside;for this reason, it should be initiated at 0.25 μg/kg/min up to a maximum of 4 μg/kg/min, for no longer than 4 hours of continuous infusion. 275 899