Escalating antihypertensives in early severe pre-eclampsia: a marker of rising maternal risk

Design

Retrospective cohort, single level IV referral centre, 2016–2025

Population

396 singleton pregnancies managed expectantly for pre-eclampsia with severe features at 23+0 to 33+5 weeks

Primary outcome

Composite serious maternal morbidity or death

Effect

+4.2 percentage points per escalation (95% CI 2.0 to 6.5); aRR 4.07 (1.41–11.78) for 3 and 5.20 (1.81–14.90) for ≥4 vs none

A single US level IV referral centre reviewed 396 singleton pregnancies managed expectantly for pre-eclampsia with severe features between 23+0 and 33+5 weeks, from 2016 to 2025. The exposure was the number of times oral antihypertensive doses were increased; the outcome was a composite of abruption, intrauterine death, acute kidney injury, pulmonary oedema, myocardial infarction, HELLP, DIC, eclampsia, stroke or maternal death.

About 40% needed no escalation and 14% needed three or more. Each additional step was associated with a 4.2 percentage point absolute increase in the composite. Women escalated three times had about four times the adjusted risk of those never escalated, and those escalated four or more times about five times. Escalating every day carried the steepest gradient. Repeated intravenous pushes for severe-range pressure followed the same pattern. Neonatal outcomes did not differ across groups.

This does not suggest that escalation itself causes harm — controlling severe hypertension remains essential. It suggests the drug chart is telling you something about the disease. A woman needing a third step-up within days of admission is likely on a different trajectory from one stable on a starting dose.

In practice, count the escalations and IV doses at each review alongside the laboratory and fetal picture, and treat a rising count as a prompt to reconsider the case for continuing expectant management, particularly in units where intensive monitoring is stretched.

• Record the number of oral antihypertensive dose increases since admission at every ward review of expectant pre-eclampsia management.
• Treat three or more escalations, or a step-up most days, as a signal to reassess maternal status and timing of birth.
• Count repeated intravenous labetalol or hydralazine doses for severe-range pressure the same way — they showed the same gradient.
• Use the trajectory when counselling the woman and family about what continued expectant management involves.
• Do not withhold escalation to keep the count low; severe-range blood pressure still needs prompt control.

Why it matters

The drug chart may be an early, cheap marker of disease progression that sits alongside the bloods and the CTG.

Don't overread it

This was a retrospective single-centre association — it does not show that escalating treatment causes harm or that delivery at a given count improves outcomes.

The statistics, in plain English

The adjusted relative risks are large but their confidence intervals are wide — for three escalations the true value could plausibly be anywhere from about 1.4 to 11.8 times the risk — because few women reached those categories. The 4.2 percentage point rise per step is the more stable estimate (95% CI 2.0 to 6.5).

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