A 28-year-old primigravida at 34 weeks of gestation presents with blood pressure of 160/110 mmHg, proteinuria of 2+ on dipstick, and epigastric pain. She has no prior history of hypertension. What is the drug of choice for immediate blood pressure control in this patient?

Explanation

## Acute Hypertensive Management in Pregnancy **Key Point:** Immediate-release nifedipine is the first-line agent for acute hypertensive crises in pregnancy, particularly in preeclampsia with severe features. ### Mechanism of Action Nifedipine is a dihydropyridine calcium channel blocker that causes rapid, predictable vasodilation without reflex tachycardia or adverse fetal effects. ### Why Nifedipine in Preeclampsia? | Feature | Nifedipine | ACE-I | Beta-blockers | Thiazides | |---------|-----------|-------|---------------|----------| | **Onset** | 10–20 min (sublingual) | Slow, unpredictable | Slow | Slow | | **Fetal safety** | Excellent | Contraindicated (2nd/3rd trimester) | Relative caution | Caution | | **Placental perfusion** | Preserved | May decrease | May decrease | May decrease | | **Hypertensive crisis** | Gold standard | No | No | No | **High-Yield:** Nifedipine 10–20 mg sublingual (or 30 mg immediate-release orally) achieves target BP reduction (160/110 → ~150/100) within 15–30 minutes in acute preeclampsia. ### Clinical Pearl The patient's presentation (BP 160/110 + proteinuria + epigastric pain) meets criteria for preeclampsia with severe features. Immediate-release nifedipine is preferred over sustained-release formulations in acute settings because onset is faster and dose titration is easier. **Warning:** Sublingual nifedipine carries a small risk of unpredictable absorption and overshoot hypotension; immediate-release oral formulation (swallowed whole, not chewed) is now preferred by many guidelines. [cite:Williams Obstetrics 26e Ch 34]