Policy

Clinical Guideline
Hydralazine Infusion Regimen

Policy developed by: SA Maternal & Neonatal Community of Practice

Approved SA Health Safety & Quality Strategic Governance Committee on:
19 April 2016
Next review due: 19 April 2019

Summary Clinical practice guideline on the use of intravenous Hydralazine

for the treatment of severe hypertension in the peripartum period

Keywords hydralazine, hypertension, preeclampsia, systolic, diastolic,

peripheral vasodilator, apresoline, facial flushing, headache,
severe hypertension, anti-hypertensive, infusion, regimen, blood
pressure, clinical guideline

Policy history Is this a new policy? N

Does this policy amend or update an existing policy? Y v 3.0
Does this policy replace an existing policy? N
If so, which policies?

Applies to All SA Health Portfolio

Staff impact All Staff, Management, Admin, Students, Volunteers

All Clinical, Medical, Nursing, Allied Health, Emergency, Dental,
Mental Health, Pathology

PDS reference CG250

Version control and change history

Version Date from Date to Amendment

1.0 08 Dec 2004 21 Oct 2008 Original version
2.0 21 Oct 2008 22 Nov 2011 Reviewed
3.0 22 Nov 2011 19 April 2016 Reviewed
4.0 19 April 2016 Current
© Department for Health and Ageing, Government of South Australia. All rights reserved.
 South Australian Perinatal Practice Guidelines

Hydralazine infusion regimen

© Department of Health, Government of South Australia. All rights reserved.
Note

This guideline provides advice of a general nature. This statewide guideline has been prepared to promote and facilitate
standardisation and consistency of practice, using a multidisciplinary approach. The guideline is based on a review of
published evidence and expert opinion.
Information in this statewide guideline is current at the time of publication.
SA Health does not accept responsibility for the quality or accuracy of material on websites linked from this site and does not
sponsor, approve or endorse materials on such links.
Health practitioners in the South Australian public health sector are expected to review specific details of each patient and
professionally assess the applicability of the relevant guideline to that clinical situation.
If for good clinical reasons, a decision is made to depart from the guideline, the responsible clinician must document in the
patient’s medical record, the decision made, by whom, and detailed reasons for the departure from the guideline.
This statewide guideline does not address all the elements of clinical practice and assumes that the individual clinicians are
responsible for discussing care with consumers in an environment that is culturally appropriate and which enables respectful
confidential discussion. This includes:
• The use of interpreter services where necessary,
• Advising consumers of their choice and ensuring informed consent is obtained,
• Providing care within scope of practice, meeting all legislative requirements and maintaining standards of
professional conduct, and
• Documenting all care in accordance with mandatory and local requirements

Explanation of the aboriginal artwork:

The aboriginal artwork used symbolises the connection to country and the circle shape shows the strong relationships amongst families and the aboriginal culture. The horse shoe shape
design shown in front of the generic statement symbolises a woman and those enclosing a smaller horse shoe shape depicts a pregnant women. The smaller horse shoe shape in this
instance represents the unborn child. The artwork shown before the specific statements within the document symbolises a footprint and demonstrates the need to move forward together in
unison.

Australian Aboriginal Culture is the oldest living culture in the world yet
Aboriginal people continue to experience the poorest health outcomes when
compared to non-Aboriginal Australians. In South Australia, Aboriginal women are
2-5 times more likely to die in childbirth and their babies are 2-3 times more likely to
be of low birth weight. The accumulative effects of stress, low socio economic
status, exposure to violence, historical trauma, culturally unsafe and discriminatory
health services and health systems are all major contributors to the disparities in
Aboriginal maternal and birthing outcomes. Despite these unacceptable statistics
the birth of an Aboriginal baby is a celebration of life and an important cultural
event bringing family together in celebration, obligation and responsibility. The
diversity between Aboriginal cultures, language and practices differ greatly and so
it is imperative that Perinatal services prepare to respectively manage Aboriginal
protocol and provide a culturally positive health care experience for Aboriginal
people to ensure the best maternal, neonatal and child health outcomes.

Introduction
> Parenteral hydralazine, labetalol and oral nifedipine are the most common drugs used to
control acute, severe hypertension in women with preeclampsia
> A systematic review of hydralazine and labetalol revealed that hydralazine was associated
with more maternal side effects and worse maternal and perinatal outcomes as compared
1
to labetalol . However, due to the broad experience in the use of hydralazine, it is used in
2
many units
> According to SOMANZ, the most important consideration in choice of antihypertensive
3
agent is that the unit has experience and familiarity with that agent

Hydralazine
> Hydralazine is a direct peripheral arteriolar vasodilator with a slow onset of action (10-20
3
minutes) and peaks approximately 20 minutes after administration
> Initially treatment is commenced as intermittent boluses. Subsequently, bolus
ISBN number: 978-1-74243-289-2
Endorsed by: South Australian Maternal & Neonatal Community of Practice
Last Revised: 19/4/2016
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 South Australian Perinatal Practice Guidelines

Hydralazine infusion regimen

administration may be followed by an infusion
> Hydralazine is known to cross the placenta following IV administration and has been
4
associated with fetal distress and fetal cardiac arrhythmia in the last trimester
3
> Continuous electronic fetal monitoring is required

Presentation
®
> Hydralazine (Apresoline )
> In powdered form in 1 mL ampoules containing 20 mg
> Dilute with sodium chloride 0.9 %

Indication
> Intravenous hydralazine is used for the acute control of blood pressure in preeclampsia
(blood pressure ≥ 160/110) and eclampsia
> The decision to administer intravenous hydralazine is made by the medical officer

Contraindications
> Known hypersensitivity to hydralazine or dihydralazine
> Idiopathic systemic lupus erythematosus (SLE)
> Severe tachycardia and heart failure with a high cardiac output (e.g. thyrotoxicosis)
> Myocardial insufficiency due to mechanical obstruction (e.g. aortic or mitral stenosis or
constrictive pericarditis)
> Isolated right ventricular heart failure due to pulmonary hypertension (cor pulmonale)
> Dissecting aortic aneurysm

Precautions
5
> Avoid use before the third trimester due to possible teratogenic effects

Intermittent bolus administration

> When administering hydralazine, intravenous treatment with crystalloid solution is required
(see ‘fluid management and monitoring in severe pre-eclampsia’ in the A to Z index at
www.sahealth.sa.gov.au/perinatal)
> It is possible that a precipitous fall in blood pressure after intravenous hydralazine may
impair placental perfusion rarely resulting in fetal distress
> If there is a risk of hypovolaemia, give intravenous fluid preload of 250 mL of
3
either sodium chloride 0.9 % or Hartmann’s immediately before use
> Continuous CTG monitoring throughout
> May be administered by a midwife under the supervision of a medical officer
> Reconstitute the hydralazine 20 mg vial with 1 mL of water for injection to
make a 20 mg / mL solution
> Dilute hydralazine 1 mL (20 mg) up to 20 mL with sodium chloride 0.9 %.
Label: hydralazine 1 mg per mL
> The initial dose is 5-10 mg as ordered, given by slow intravenous injection
8
over 3 to 10 minutes
> Blood pressure is taken at 5 minute intervals for at least 20 minutes following
each bolus
9
> An initial response should occur within 5-15 minutes

> After 15 minutes, depending upon response, a second dose of 5 mg may be

given. Note that the maximal effect occurs 15-20 minutes after each
ISBN number: 978-1-74243-289-2
Endorsed by: South Australian Maternal & Neonatal Community of Practice
Last Revised: 19/4/2016
Page 3 of 6
 South Australian Perinatal Practice Guidelines

Hydralazine infusion regimen

bolus

> Consider infusion if the total intermittent bolus dosage is 20 mg or more

Hydralazine infusion
> Reconstitute each hydralazine 20 mg vial with 1 mL of water for injection to make a
20 mg / mL solution
> Mix 2 ampoules (40 mg) of hydralazine up to a volume of 40 mL with sodium chloride 0.9 %
(to obtain 1 mg per mL in a 50 mL syringe)
> Administer via syringe pump
> May be piggybacked into the main line
> Commence infusion at the rate of 2 to 10 mg per hour depending on blood pressure
> Monitor blood pressure and pulse every 15 - 30 minutes as required
> Blood pressure should not be lowered below 140 / 85 mm Hg

Side effects
> Facial flushing and headache
> Tachycardia (if pulse rate exceeds 120 beats per minute and the blood pressure is still high,
alternative antihypertensives should be considered)
> Nausea, vomiting, dizziness, anxiety and tremor

ISBN number: 978-1-74243-289-2

Endorsed by: South Australian Maternal & Neonatal Community of Practice
Last Revised: 19/4/2016
Page 4 of 6
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Hydralazine infusion regimen

References
1. Magee LA, Cham C, Waterman EJ, Ohlsson A, von Dadelszen P. Hydralazine for
treatment of severe hypertension in pregnancy: meta-analysis. BMJ 2003; 327:955-
60.
2. Paterson-Brown, Howell C, editors. Managing Obstetric Emergencies and Trauma.
Chapter 24 Pre-eclampsia and eclampsia. The MOET Course Manual. 3rd edition.
New York: Cambridge University Press; 2014.
3. Lowe SA, Bowyer L, Lust K, McMahon LP, Morton MR, North RA et al. Guideline for
the management of hypertensive disorders of pregnancy 2014. Society of Obstetric
Medicine of Australia and New Zealand (SOMANZ); 2014. Available from URL:
https://somanz.org/guidelines.asp
4. Australian Medicines Handbook (AMH). Hydralazine. July 2015.
5. MIMS Online. Apresoline. CMPmedica; Sydney. Australia; 2014.
6. Duley L, Meher S, Jones L. Drugs for treatment of very high blood pressure during
pregnancy. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.:
CD001449. DOI: 10.1002/14651858.CD001449.pub3. Available from URL:
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001449.pub3/pdf/standard
7. World Health Organisation (WHO). Managing complications in pregnancy and
childbirth. A guide for midwives and doctors, Geneva; 2003. WHO/RHR/00.7
8. Australian Injectable Drugs Handbook (AIDH). Hydralazine. Society of Hospital
Pharmacists of Australia, 6th ed. Collingwood, Victoria: Society of Hospital
Pharmacists of Australia; 2014.
9. DRUGDEX System (Micromedex 2.0). Hydralazine. Greenwood Village, CO: Truven
Health Analytics; c1974-2015 [cited 2015 Sept 18]. Available from URL:
http://www.micromedexsolutions.com

ISBN number: 978-1-74243-289-2

Endorsed by: South Australian Maternal & Neonatal Community of Practice
Last Revised: 19/4/2016
Page 5 of 6
 South Australian Perinatal Practice Guidelines

Hydralazine infusion regimen

Abbreviations

APPG Australian Prescription Products Guide

IV Intravenous
mg Milligram(s)
mL Millilitre(s)
mm Hg Millimetres of mercury
 Registered trademark
SLE Systemic lupus erythematosus
SOMANZ Society of Obstetric Medicine of Australia and New Zealand
WHO World Health Organisation

Version control and change history

PDS reference: OCE use only

Version Date from Date to Amendment

1.0 08 Dec 2004 21 Oct 2008 Original version
2.0 21 Oct 2008 22 Nov 2011 Reviewed
3.0 22 Nov 2011 19 April 2016 Reviewed
4.0 19 April 2016 Current

ISBN number: 978-1-74243-289-2

Endorsed by: South Australian Maternal & Neonatal Community of Practice
Last Revised: 19/4/2016
Page 6 of 6