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.