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Introduction   

When hearing the phrase hypertension in pregnancy, what comes to mind? If you’re an advanced practice registered nurse (APRN) with prescriptive authority, you’ve heard of hypertension and pregnancy before. Even as a nurse or maybe before nursing school, conversations about prescription drug use, hypertension, and pregnancy existed every so often.

Presently, patients seek guidance and information on various health topics from APRNs, including medication management before, during, and after pregnancy. The information in this course will serve as a valuable resource for APRNs with prescriptive authority of all specialties, education levels, and backgrounds to learn more about medications used to manage hypertension in pregnancy.

Defining Hypertension During Pregnancy

Pregnancy is a state where a fetus develops inside someone’s uterus. If a pregnancy is developing outside of the uterus, such as in the fallopian tube, that is considered a medical emergency known as an ectopic pregnancy (1).

Hypertension is often defined as blood pressure readings as systolic greater than 140 mmHg and diastolic greater than 80 mmHg (2). Hypertension in pregnancy also follows similar blood pressure readings. Because of the complex physiological and psychological changes occurring in pregnancy, hypertension can also be a possible health complication either emerging or worsening in pregnancy (2).

Some people have hypertension before pregnancy, whereas other people can develop hypertension during pregnancy and postpartum. Presently, it is estimated that hypertensive conditions influence 5-10% of all pregnancies, making hypertension in pregnancy a serious maternal and fetal complication with implications for prenatal and postpartum care (2).

Clinical guidelines for hypertension in pregnancy can be obtained and reviewed from the American College of Obstetrics and Gynecology (ACOG), the American Health Association (AHA), and the American College of Cardiology (ACC) (2).

What Is Chronic Hypertension in Pregnancy?

Chronic hypertension in pregnancy occurs when a patient has an in-office reading of a blood pressure >140/>80 at any time occurring within the first 20 weeks of pregnancy. Blood pressure can also be monitored at home or in the clinic (2). Because many people also have late entry into prenatal care, lack access to primary care services, or have co-existing health conditions before pregnancy, chronic hypertension can be undiagnosed before pregnancy (2).

What Is Gestational Hypertension?

Per ACOG guidelines, gestational hypertension is defined as a blood pressure reading >140/>80 on two separate occasions at least four hours apart after 20 weeks of pregnancy when prior blood pressure readings were normotensive (2).

What Is Pre-eclampsia?

Pre-eclampsia is a serious complication of pregnancy that affects 2-8% of pregnancies globally. Because of the complex etiology and clinical presentation of pre-eclampsia, pre-eclampsia is now defined and recognized as new-onset hypertension in pregnancy. Typically, pre-eclampsia is defined as a blood pressure reading >140/>80 on at least two separate occasions at least four hours apart after 20 weeks of pregnancy (2). Clinical presentation of pre-eclampsia can also include protein in urine, blurry vision, headaches, decreased platelets, liver dysfunction, and possible seizures (also known as eclampsia) (3). In many cases, the only way to treat pre-eclampsia is to deliver the baby and placenta (3).

What If Hypertension in Pregnancy Is Left Untreated?

If hypertension in any form is left untreated or unmanaged in pregnancy, severe maternal and fetal complications can arise, such as fetal malformation, maternal stroke, maternal cardiovascular damage, maternal ocular damage, postpartum hypertension, maternal death, and fetal death. Given the importance of normotensive blood pressure outside of pregnancy and the complex physiologic changes occurring in pregnancy, there are several ways to manage hypertension in pregnancy to avoid and reduce hypertensive complications (1,2,3).

Defining Anti-Hypertensive Medications

What Are Anti-Hypertensive Medication Options for Pregnancy?

Several anti-hypertensive medication options can be used in pregnancy, such as beta blockers, calcium channel blockers, vasodilators, and diuretics. Specific anti-hypertensive medication drug classes, such as angiotensin receptor blockers (ARBs), angiotensin-converting enzyme (ACE) inhibitors, nitroprusside, and mineralocorticoid receptor antagonists are considered teratogenic and advised to not be used in pregnancy.

A low-dose aspirin medication, such as an 81mg baby aspirin, is also considered to be a possible medication option to help prevent hypertension in pregnancy but is not a first-line option to manage hypertension in pregnancy by itself (2).

How and Where Are Anti-Hypertensive Medications Used?

Anti-hypertensive medications in pregnancy are used in a variety of clinical settings, such as hospitals, outpatient clinical settings, public health departments, correctional facilities, and more. Oral anti-hypertensive medications are prescribed and then taken by mouth. Depending on the dosage and severity of hypertension and the patient clinical presentation, some people might need IV medication to manage their hypertension during pregnancy (1,2,3).

What Are the Clinical Criteria for Prescribing Anti-Hypertensive Medication in Pregnancy?

Clinical criteria for prescribing anti-hypertensive medications are from ACOG and can be used in conjunction with other clinical guidelines from AHA and ACC. In addition, patient history, clinical presentation, and other factors can be used to determine first-line medication management for hypertension in pregnancy. In general, first-line medication options for hypertension in pregnancy include beta-blockers (such as labetalol) and calcium channel blockers (such as nifedipine) starting with the lowest dose possible and adjusting dosages depending on the patient’s response to medication therapy (2).

In addition, vasodilators (such as hydralazine) can be used in hypertensive emergencies during pregnancy or if a patient is not responding well to other pharmacologic methods (3). Depending on patient history and clinical presentation, diuretics, such as hydrochlorothiazide or furosemide, might be considered as well, especially if someone has a history of hypertension before pregnancy (2,4).

What Is the Average Cost of Anti-Hypertensive Medications?

Cost for anti-hypertensive medications can significantly vary depending on the type of medication, insurance, dosage, administration route, frequency, and other factors. Cost is among a leading reason why many patients cannot maintain their medication regime (5). If cost is a concern for your patient, consider reaching out to your local pharmacies or patient care teams to find cost-effective solutions for your patients.

Anti-Hypertensive Pharmacokinetics

Drug Class – Beta Blockers

The healthcare provider’s professional discretion and patient condition should guide therapy. Consider reviewing a patient’s medication history, clinical presentation, and health history before prescribing anti-hypertensive medications during pregnancy. Consider consulting with a cardiology specialist, maternal-fetal specialist, obstetric provider, and other relevant clinical staff regarding hypertension management in pregnancy.

Beta-blockers, also known as beta-1 receptor antagonists, are commonly prescribed medications that can be used to manage hypertension and other cardiovascular conditions, such as tachycardia and heart failure. Commonly prescribed beta blockers are known as the “lol” drugs, such as labetalol, carvedilol, propranolol, and atenolol (6). Beta-blockers can be administered as pills to be taken by mouth or given as fluid intravenously to manage hypertension in pregnancy (2,6).

Beta-blockers are extremely common as a first-line medication in pregnancy for hypertension management given their low cost, general tolerable side effect profile, and effectiveness at managing hypertension (2). It is recommended to start on the lowest dosage possible and titrate upwards or add another anti-hypertensive medication to manage hypertension in pregnancy.

Beta Blockers Method of Action

Beta-blockers, also known as beta-1 receptor antagonists, are medications that antagonize beta-1 receptors in the body. Beta 1 receptors are mostly found in the heart, fat cells, and kidneys. Beta-blockers vary in their specific affinity towards various receptors; as a result, the medication effects depend on the type of receptor(s) antagonized and blocked (6).

When someone takes a beta-blocker, blood pressure is lowered as a result of several mechanisms being triggered, such as decreased renin, decreased heart rate, and decreased cardiac output. The negative chronotropic and inotropic effects from beta blockers make beta blockers an effective first-line method for hypertensive management in pregnancy (2,6).

Beta-blockers can be generally classified as non-selective or beta-1 selective. Non-selective beta blockers bind to both beta 1 and beta 2 receptors to encourage antagonizing effects on both receptors. Non-selective beta blocker examples include labetalol, propranolol, and carvedilol. Beta 1 selective blockers, such as atenolol, metoprolol, and bisoprolol, only bind to the beta 1 receptors, making these specific beta blockers cardio selective.

Some beta-blockers, such as carvedilol, labetalol, and bucindolol, have additional alpha-1 receptor antagonizing activity in addition to their non-selective beta receptor blockage. This pharmacokinetic property is clinically relevant because beta blockers that antagonize the alpha-1 receptor additionally have a more distinct effect on managing hypertension (6).

Beta Blockers Side Effects

Every medication has the possibility of side effects, and beta blockers are no exception. Possible side effects of beta blockers include decreased heart rate (bradycardia), decreased blood pressure (hypotension), decreased cardiac output, changes in sleep, fatigue, sexual dysfunction, an increased risk of a heart block, headache, and dizziness (6). It is important to monitor patient side effects to determine if the risks outweigh the benefits and to adjust the medication regime as needed.

Beta Blockers Alternatives

Given the nature of hypertension in pregnancy, several things can be done to help with reducing blood pressure. Patients can try another pharmacological option, such as calcium channel blockers. Patients can try lifestyle modifications, such as stress reduction techniques, smoking cessation, alcohol cessation, and exercises appropriate during pregnancy. Diet, especially a low-sodium diet, can also help with lowering blood pressure as well (2,6).

Drug Class – Calcium Channel Blockers

The healthcare providers’ professional discretion and patient condition should guide therapy. Consider reviewing a patient’s medication history, clinical presentation, and health history before prescribing anti-hypertensive medications during pregnancy. Consider consulting with a cardiology specialist, maternal-fetal specialist, obstetric provider, and other relevant clinical staff regarding hypertension management in pregnancy.

Calcium channel antagonists, also known as calcium channel blockers (CCBs), have been widely used in pregnancy for hypertension management (2). CCBs are generally classified into two main drug categories, either non-dihydropyridine CCBs or dihydropyridine CCBs. Common non-dihydropyridine CCBs include verapamil and diltiazem, and common dihydropyridine CCBs are drugs that end with “pine,” such as nifedipine and amlodipine (7). Calcium channel blockers are extremely common as a first-line medication in pregnancy for hypertension management given their low cost, general tolerable side effect profile, and effectiveness at managing hypertension (2). It is recommended to start on the lowest dosage possible and titrate upwards or add another anti-hypertensive medication to manage hypertension in pregnancy.

Calcium Channel Blockers Method of Action

CCBs work to reduce blood pressure by blocking the inward movement of calcium. CCBs bind to long-acting, voltage-gated calcium channels in the heart. Non-dihydropyridine CCBs, such as verapamil and diltiazem, have what is known as inhibitory effects on the sinoatrial (SA) and atrioventricular (AV) nodes, resulting in a slowing of cardiac conduction and decreased contractility.

Non-dihydropyridine CCBs are used to manage hypertension, decrease the oxygen demand, and help to control the heart’s contractility rate. Dihydropyridine CCBs, such as nifedipine and amlodipine, have less noticeable effects on the muscular tissues of the heart, also known as myocardium. However, dihydropyridine CCBs act as peripheral vasodilators, which is why they are still clinically relevant and practical for hypertension management in pregnancy (7). Both types of CCBs can be administered by pill to take by mouth or via intravenous fluid (7).

Calcium Channel Blockers Side Effects

Every medication has the possibility of side effects, and calcium channel blockers are no exception. Non-dihydropyridine CCBs, such as verapamil and diltiazem, have possible side effects of constipation, altered cardiac output, and bradycardia. Dihydropyridine CCBs, such as nifedipine and amlodipine, have possible side effects of dizziness, flushing, headaches, bradycardia, and edema (7). It is important to monitor patient side effects to determine if risks outweigh the benefits and to adjust the medication regime as needed.

Calcium Channel Blockers Alternatives

Given the nature of hypertension in pregnancy, several things can be done to help reduce blood pressure. Patients can try another pharmacological option, such as beta-blockers. Patients can try lifestyle modifications, such as stress reduction techniques, smoking cessation, alcohol cessation, and exercises appropriate during pregnancy. Diet, especially a low-sodium diet, can also help with lowering blood pressure as well (2,7).

Drug Class – Diuretics

The healthcare provider’s professional discretion and patient condition should guide therapy. Consider reviewing a patient’s medication history, clinical presentation, and health history before prescribing anti-hypertensive medications during pregnancy. Consider consulting with a cardiology specialist, maternal-fetal specialist, obstetric provider, and other relevant clinical staff regarding hypertension management in pregnancy.

Diuretics are used in pregnancy for hypertension management (2). There are two main classes of diuretic drugs that are used in pregnancy, thiazide diuretics and loop diuretics. Common thiazide diuretics include hydrochlorothiazide (HCTZ), indapamide, and chlorthalidone (8). Common loop diuretics include furosemide, torsemide, and bumetanide (9). Commonly used diuretics in pregnancy for hypertension management include HCTZ and furosemide (2,4,8,9). Diuretics are common as an anti-hypertensive medication option in pregnancy given their low cost and effectiveness at reducing fluid overload (2). It is recommended to start on the lowest dosage possible and titrate upwards or add another anti-hypertensive medication to manage hypertension in pregnancy.

Diuretics Method of Action

Thiazide diuretics, such as HCTZ, perform diuretic effects by blocking the sodium-chloride (Na/Cl) channel in the proximal segment of the distal convoluted tubule of the kidney nephrons. When the Na/Cl channel is blocked, lower amounts of sodium can pass through the luminal membrane, allowing for fluid shifts to occur. Thiazide diuretics are administered via pill to be taken by mouth (8).

Loop diuretics, such as furosemide, perform their diuretic effect by competing with chloride to bind to the NKCC2 cotransporter at the loop of Henle, which inhibits the reabsorption of sodium and chloride. By altering the reabsorption of sodium and chloride, there are more shifts in fluid volume, allowing for an increased amount of water excretion (4,9). Loop diuretics are administered via pill to be taken by mouth or intravenous fluid (9).

Diuretics Side Effects

Every medication has the possibility of side effects, and diuretics are no exception. Most common side effects of thiazide diuretics include several electrolyte imbalances, such as hypokalemia, hyponatremia, hypercalcemia, and metabolic alkalosis. Other possible side effects of thiazide diuretics include hyperglycemia, dizziness, fatigue, headache, hyperuricemia, hypotension, hyperlipidemia, and pancreatitis (8).

Most common side effects of loop diuretics include several electrolyte imbalances, such as hypokalemia, hypomagnesemia, hypochloremia, hyponatremia, hypercalcemia, and metabolic alkalosis. Additional possible side effects of loop diuretics include hypertriglyceridemia, headache, fatigue, hypercholesterolemia, hyperuricemia, and decreased blood pressure (9).

Diuretics Alternatives

Given the nature of hypertension in pregnancy, there are several things that can be done to help with reducing blood pressure. Patients can try another pharmacological option, such as beta blockers or diuretics. Patients can try lifestyle modifications, such as stress reduction techniques, smoking cessation, alcohol cessation, and exercises appropriate during pregnancy. Diet, especially a low-sodium diet, can also help with lowering blood pressure as well (2,8).

Drug Class – Vasodilators

The healthcare provider’s professional discretion and patient condition should guide therapy. Consider reviewing a patient’s medication history, clinical presentation, and health history before prescribing anti-hypertensive medications during pregnancy. Consider consulting with a cardiology specialist, maternal-fetal specialist, obstetric provider, and other relevant clinical staff regarding hypertension management in pregnancy.

The most commonly used vasodilator in hypertension in pregnancy management is hydralazine (2,10). While there are other vasodilator medications, hydralazine is often used in hypertensive emergencies in pregnancy or in conjunction with other anti-hypertensive medications. Hydralazine is often administered via intravenous fluid but can be administered via pill to be taken by mouth as well. It is recommended to start on the lowest dosage possible and titrate upwards or add another anti-hypertensive medication to manage hypertension in pregnancy.

Vasodilators Method of Action

Hydralazine is a direct arteriole vasodilator, meaning it is a very potent vasodilator and has profound influences on cardiac function. However, despite its frequent use in emergency settings for both pregnant and non-pregnant people, hydralazine’s method of action is not well-defined or understood (10).

Vasodilators Side Effects

Every medication has the possibility of side effects, and vasodilators are no exception. The most common side effects of hydralazine include GI upset, headaches, decreased blood pressure, increased heart rate, and chest pain. Chronic use of hydralazine can be at risk for hydralazine-related drug-induced lupus erythematosus (DILE), also known as hydralazine-induced lupus syndrome (HILS) (10).

Vasodilators Alternatives

Given the nature of hypertension in pregnancy, several things can be done to help reduce blood pressure. Patients can try another pharmacological option, such as beta-blockers or calcium channel blockers. Patients can try lifestyle modifications, such as stress reduction techniques, smoking cessation, alcohol cessation, and exercises appropriate during pregnancy. Diet, especially a low-sodium diet, can also help with lowering blood pressure as well (2,8).

Nursing Considerations

What Is the Nurses’ Role in Anti-Hypertensive Medication Patient Education and Medication Management?

Nurses remain the most trusted profession for a reason, and APRNs are often pillars of patient care in several healthcare settings. Patients turn to nurses for guidance, education, and support. While there is no specific guideline for the nurses’ role in anti-hypertensive medication in pregnancy education and management, here are some suggestions to provide quality care for patients currently taking anti-hypertensive medications in pregnancy.

1. Take a detailed health history. Oftentimes, blood pressure can be obtained in a hastily manner in health care settings. Sometimes, the blood pressure cuff is not attached correctly, the reading is not entered into the chart correctly, or the reading is not performed at all. Ask patients about their history and family history of hypertension. If a patient is complaining of symptoms that could be related to hypertension, such as chest pain, trouble breathing, or headaches, inquire more about that complaint. Ask about how long the symptoms have lasted, what treatments have been tried, if these symptoms interfere with their quality of life, and if anything alleviates any of these symptoms. If you feel like a patient’s complaint is not being taken seriously by other healthcare professionals, advocate for that patient to the best of your abilities.
2. Review medication history at every encounter. Often, in busy clinical settings, reviewing health records can be overwhelming. Millions of people take medications for various reasons, and people’s medication histories can look similar over time. Ask each patient about how they are feeling on the medication, if their symptoms are improving, and if there are any changes to the medication history.
3. Be willing to answer questions about hypertension and medication options. Many people do not know about medication side effects, risk factors to be aware of, and lifestyle changes that can influence hypertension in pregnancy. Be willing to be honest with yourself about your comfort level discussing topics and providing education on hypertension and anti-hypertensive medications in pregnancy.
4. Communicate the care plan to other staff involved for continuity of care. For several patients, especially for patients with hypertension in pregnancy, care often involves a team of nurses, specialists, pharmacies, and more. Ensure that patients’ records are up to date for ease in record sharing and continuity of care.
5. Stay up to date on continuing education related to anti-hypertensive medications and pregnancy, as evidence-based information is always evolving and changing. You can then present your new learnings and findings to other healthcare professionals and educate your patients with the latest information. You can learn more about the latest research on anti-hypertensive medications and pregnancy by following updates from evidence-based organizations, such as ACOG or AHA.

How can nurses identify if someone has hypertension in pregnancy?

Unfortunately, it is not possible to look at someone with the naked eye and determine if they have hypertension or are pregnant. While some people might have notable hypertensive symptoms or be visibly pregnant, such as chest pain or vision changes, the most common for many people with hypertension is no symptom. APRNs can identify and diagnose if someone has hypertension by checking a patient’s blood pressure in the office or providing an at-home blood pressure cuff to allow patients to self-monitor at home. APRNs can provide quality care by completing health history, listening to patients’ concerns, and offering medication and lifestyle management.

What should patients know about anti-hypertensive medication in pregnancy?

Patients should know that anyone has the possibility of hypertension in pregnancy. Patients should be aware that if they notice any changes in their vision, experience any headaches, or feel like something is a concern, they should seek medical care. For several reasons, people are hesitant to seek medical care because of fear, shame, cost, and embarrassment. However, as more research and social movements discuss hypertension in pregnancy more openly, there is more space and awareness for hypertension management in pregnancy.

Nurses should also teach patients to advocate for their health to avoid untreated or undetected hypertension and unwanted side effects of anti-hypertensive medication. Here are important tips for patient education in the inpatient or outpatient setting.

• Tell the health care provider of any existing medical conditions or concerns (need to identify risk factors)
• Tell the health care provider of any existing lifestyle concerns, such as alcohol use, other drug use, sleeping habits, diet, and stress levels (need to identify lifestyle factors that can influence anti-hypertensive medication use and hypertensive management)
• Tell the health care provider if you have any changes to your body throughout the pregnancy, such as pain with urination, pain with movement, or increased fatigue (potential systemic hypertensive symptoms)
• Tell the nurse or health care provider if you experience any pain that increasingly becomes more severe or interferes with your quality of life
• Keep track of your health, medication use, and health concerns via an app, diary, or journal (self-monitoring for any changes)
• Tell the health care provider right away if you are having thoughts of hurting yourself or others (possible increased risk of suicidality)
• Take all prescribed medications as indicated and ask questions about medications and possible other treatment options, such as non-pharmacological options or surgeries
• Tell the health care provider if you notice any changes while taking medications or on other treatments to manage hypertension (potential worsening or improving health situation)
• Track your blood pressure with an at-home blood pressure cuff, keep track of your readings, and report any changes to your health care provider (self-monitoring for any changes)

Research Findings

What Research on Anti-Hypertensive Medication Exists Presently?

There is extensive publicly available literature on anti-hypertensive medications via the National Institutes of Health, the American Heart Association, and other evidence-based journals.

What are some ways for people who take anti-hypertensive medications to become a part of research?

If a patient is interested in participating in clinical trial research, they can seek more information on clinical trials from local universities and healthcare organizations.

Conclusion

Hypertension is a serious health condition affecting millions of people, including millions of people in their pregnancy. Several medication options can be used to help manage hypertension in pregnancy. However, clinical presentation and symptom management for hypertension in pregnancy can vary widely. Education and awareness of different medication options and different clinical presentations of hypertension can influence the lives of many people healthily.

Case Study #1

Susie is a 36-year-old Asian woman working as a teacher. She arrives at her prenatal exam at approximately 26 weeks pregnant with her second pregnancy. She reports nothing new in her pregnancy, and her chart reports no complications in her prior pregnancy. Susie says she’s been having some headaches and trouble sleeping for the past week. Sabrina said she’s never felt this way before, and she denies having any major changes in her life that could be affecting her health. You look over at her vital signs, and you see that her blood pressure for today is 150/110. You look at her previous blood pressure readings, and you see that they have been in the 120s-130s/70s-80s in her prior visits.

Case Study #1 Continued

Susie is hesitant to start any prescription medications today, as she wants to continue to see how she feels over the next few weeks. She states she feels the baby moves “just fine,” but she will consider prescription medication if needed. She said that her mom had high blood pressure when she was pregnant years ago and that she had “some blood pressure issues” in her first pregnancy. Susie denies taking any blood pressure medications before this pregnancy and in her former pregnancy. Susie states that in her first pregnancy, she took some Chinese herbs that helped her with her blood pressure and nausea, and she’s thinking about doing that in this pregnancy, too. Susie is fine after giving a urine sample and wants to return in a few weeks.

Case Study #1 Continued

Susie returns to the office two weeks later for a routine prenatal care visit at 28 weeks’ gestation. Her urine sample from the last visit showed trace protein and leukocytes. Susie states that the baby is moving just fine, but she is starting to be worried about her headaches. She tried some of her mom’s herbs that she took in the first pregnancy, but her headaches are not decreasing. Susie states that she is having headaches almost daily now, and sometimes, she is experiencing some trouble seeing far distances. She doesn’t regularly wear glasses or contacts but thinks it might be related to pregnancy. Susie reports using an at-home blood pressure cuff for the past week. When you look at the readings, you see that her readings are between 140s-160s/80s-100s daily.

Case Study #2

Beth is a 44-year-old Black woman working as a chef. She arrives at her first prenatal appointment at approximately 14 weeks pregnant. She reports that this is her first pregnancy. She reports not seeing a doctor in many years, so she has several questions. Beth states that for the past few months, she’s been having some chest pain on and off, and she has noticed that it has been increasing in the past few weeks since she found out she’s pregnant. She thinks it could be morning sickness, but she wants to know for sure. You look over at her vital signs, and you see that her blood pressure for today is 148/99.

Case Study #2 Continued

Beth states she has never taken any prescription medication long-term before, but she has some friends and family members who are on “those water pills for blood pressure.” Beth states that both her parents take blood pressure medications, and she read about high blood pressure in pregnancy online. She doesn’t regularly take her blood pressure at home, but she wants to know if it is helpful to do so now that she is pregnant. She wants to know what pills she can take and how she can monitor her health at home.

Case Study #2 Continued

Beth agrees to take labetalol 100 mg by mouth daily for the next 4 weeks. Given her risk factors and initial high blood pressure reading on the first prenatal visit, you refer her to a maternal and fetal specialist.

Two weeks later, at the maternal and fetal specialist office, she is reported to have three blood pressure readings of 201/129, 199/101, and 200/120. The specialist contacts you and informs you that they requested Beth to be transferred to the local obstetric emergency department for a hypertensive emergency.

Beth notes that she did not take labetalol for the past two weeks because of an issue with her insurance and was unable to buy an at-home blood pressure cuff because she recently lost her job.

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