Extended Release Nifedipine Intrapartum For Severe HTN

Summary

Dr. Chapa’s Clinical Pearls — Episode Summary

Episode Title:

Extended Release Nifedipine Intrapartum For Severe HTN
Date: October 14, 2025
Host: Dr. Chapa

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Episode Overview

This episode addresses a nuanced clinical question: Is there evidence and support for using extended release (ER) nifedipine during labor (intrapartum) to manage severe hypertension in preeclampsia? Dr. Chapa breaks down the data, evidence quality, existing guidelines, and practical considerations, responding to a listener's query inspired by the Society of Academic Specialists in General Obstetrics and Gynecology's (SASGOG) "Pearls of Excellence." The episode aims to clarify when and how ER nifedipine can be used, reviewing recent trials and distinguishing between guideline-sanctioned urgent therapy and maintenance approaches for blood pressure control.

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Key Discussion Points & Insights

1. Media Portrayal of OB Emergencies & Real-Life Relevance

• Dr. Chapa recounts a scene from Grey's Anatomy depicting preeclampsia with hepatic injury, expressing relief when TV brings attention to obstetric emergencies but cautioning about medical inaccuracies.

  • Quote:
    "I always cringe a little bit...when I see some OB issue portrayed in a movie or television show. On the one hand, I'm so thankful that attention is being given...but...shows do things that are completely off." (03:00)

• Uses this as a segue to highlight the clinical importance and topicality of preeclampsia management.

2. Listener’s Clinical Question

• A podcast listener asks about a statement found in "Pearls of Excellence" that endorsed ER nifedipine as an adjunct or maintenance therapy for severe hypertension intrapartum after acute IV therapy.
  • The clinical challenge: Is ER nifedipine evidence-based and practically supported for this use?

3. Guideline Foundation: Standards of Care

• ACOG and SOGC Recommendations:
  • First-line, urgent management of severe hypertension (≥160/110 mmHg) in pregnancy uses:
    • IV hydralazine
    • IV labetalol
    • Immediate release oral nifedipine
      (see Practice Bulletin 222 and Committee Opinion 692)
  • Maintenance therapy or prophylaxis is not detailed in these guidelines.
  • Quote:
    "The gold standard, the first line, the typical, is IV hydralazine, IV Labetalol or PO Nifedipine. Those are the standards." (09:40)
  • Urgent therapy is about rapid BP control; maintenance therapy focuses on preventing recurrent severe hypertension.

4. Pearls of Excellence & Extended Use

• The 2018 SASGOG "Pearls of Excellence" summary highlights that, following acute IV antihypertensive therapy, it is "often prudent to initiate oral labetalol or extended release nifedipine to maintain blood pressure below the severe range" (08:10).

  • Quotes:
    "It is often prudent to initiate oral labetalol or extended release nifedipine to maintain blood pressure below the severe range." (09:00) "Notice those words. Maintain...you are initiating action to keep blood pressure down rather than reaction by waiting for her to become hypertensive in the severe range." (09:50)
  • Context: These are academic society recommendations, not universal standards.

• Clinical application:

  • ER nifedipine or oral labetalol can be given to maintain or prevent rebound severe hypertension, typical dosages:
    • Oral labetalol: 200 mg, BID or TID
    • ER nifedipine: 30 mg once daily
  • Decision to start after how many episodes of urgent therapy can be clinician-dependent.
    • "If we give...two or more IV doses, it's something that we have done. It's not our standard protocol, but we have considered..." (12:05)

5. Recent Evidence: The Ohio State Trial (2022/2023)

• Trial Summary:

  • Triple-blind, placebo-controlled
  • Pregnant women with preeclampsia/severe features undergoing induction (22–42 weeks)
    • Randomized: ER nifedipine 30mg daily vs. placebo
  • Primary outcome: Need for >1 dose of acute therapy for BP ≥160/110 for >10 min

• Results:

  • Needing acute therapy: 34% (nifedipine) vs. 55% (placebo)
  • Relative risk: 0.62; ~40% reduction in need for urgent therapy
  • Number needed to treat: 5
  • Fewer cesarean deliveries (not statistically robust)
  • NICU admission lower in nifedipine group
  • No increase in adverse neonatal outcomes

• Quote:
  "Initiation of extended release nifedipine is effective in reducing intrapartum acute hypertensive therapy among women with preeclampsia with severe features." (25:25)

  • Dr. Chapa: "It does make sense...it is helpful. Now if you do give the oral extended release nifedipine...probably don't give a 10 milligram of oral immediate release...for the acute." (26:20)

• Cautions:

  • This is single, well-conducted trial.
    • "The not so good news is that's kind of it. But it was enough to make it into the 2018 Society... Now remember I said that was 2018. This publication came out later because they updated..." (28:10)
  • Still not established as first-line by major guidelines.

6. Practical Pearls & Clinical Discretion

• When to use ER nifedipine?

  • Not after a single episode of severe hypertension
  • Consider if two or more rounds of acute antihypertensive therapy are required
  • Ensure patient can tolerate oral medication (no vomiting, delayed gastric emptying, etc.)
  • Avoid stacking (if using ER nifedipine for maintenance, opt for different IV agent for acute rescue, and vice versa)
    • "If I give a patient a medication, a 200mg oral labetalol intrapartum, I'm probably not going to chase her with IV labetalol because I don't want it to have a stacking effect." (27:10)

• Selection considerations:

  • Use “rule of 55”: difference between systolic and diastolic guides agent choice
    • Delta >55: consider beta blocker
    • Delta <55: peripheral vasodilator like nifedipine
  • Quote:
    "Tailor it to what's happening in the patient's profile. Okay? If you haven't heard of the rule of 55...you can go back and search for it." (14:28)

• Policy & Protocols:

  • Use in accordance with institutional policy; if none exists, get approval/documentation
  • Not explicitly covered in ACOG Practice Bulletin 222 or Committee Opinion 692 (29:30)

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Notable Quotes & Memorable Moments

• On episode inspiration:
  “We get ideas for the show not just from real world encounters, but from questions that come in through our social media channels.” (04:20)
• Pearls of Excellence on ER nifedipine:
  “Once IV acute treatment is given, it is often prudent to initiate oral labetalol or extended release nifedipine to … maintain blood pressure below the severe range.” (10:50)
• On evidence quality:
  “Is there data? Absolutely. Is there a lot of data? Nope. Nope.” (05:50)
• Evidence-based yet not first line:
  “Can you do extended release after the patient has received IV urgent hypertension? Of course. Is it standard therapy now? No, it is not.” (06:30)
• Take-home summary:
  “So is it reasonable to do that? Absolutely. Is there data? Yes, but we definitely need more. And unfortunately, the first line treatment is one that I don't like, which is just chasing her with a PRN medication.” (28:40)

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Key Timestamps

| Timestamp | Segment / Topic | |------------|--------------------------------------------------------------------------------------------------| | 03:00 | Dr. Chapa discusses medical media depictions, segues to real-life preeclampsia | | 04:20 | Introducing the listener’s question about ER nifedipine | | 08:06 | Direct quote from SASGOG’s “Pearls of Excellence” | | 09:40 | Gold standard/urgent therapy in ACOG guidelines clarified | | 12:05 | When Dr. Chapa’s team considers ER nifedipine or oral labetalol for maintenance | | 14:28 | The “rule of 55” and agent selection explained | | 22:36 | ER nifedipine trial introduction, methodology explained | | 24:53 | Trial results: efficacy and safety outcomes summarized | | 26:20 | Importance of not stacking agents, practical best-practices | | 28:10 | Single-study evidence caveat and Pearls of Excellence timeline | | 29:30 | Emphasis on policy adherence and practical summary |

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Practical Summary / Clinical Pearl

Extended release nifedipine can be reasonably considered as an adjunct to maintain blood pressure below severe range in intrapartum patients with preeclampsia who require multiple urgent antihypertensive treatments. While not a first-line or guideline-sanctioned standard, a well-conducted RCT supports its safety and efficacy for this use. Selection between ER nifedipine and oral labetalol (and their timing) should be individualized, guided by patient characteristics and institutional protocols.

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Final Clinical Pearl:
“Is there data for extended released nifedipine intrapartum? Yes...Not a problem to do either, although it is not mentioned in ACOG's original guidance on this…which uses either IV or immediate acting for faster and tighter control.” (29:35)

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This episode provided a focused, evidence-based, and pragmatic exploration of managing intrapartum hypertension in preeclampsia, clarifying the place of extended release nifedipine as a maintenance (not acute) therapy in select cases.

Transcript

[Podcast Host]

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[Nurse or Medical Staff]

Lauren is she. She lost a lot of blood but she is stable and we are taking her to the icu. Turns out her indigestion wasn't indigestion. Her pain was worsening. Preeclampsia caused her liver to fail. But your baby is healthy and we are doing everything they can for Lauren.

[Concerned Family Member]

Preeclampsia?

[Nurse or Medical Staff]

I don't understand.

[Concerned Family Member]

Should someone have seen this? Maybe we were just at her OB.

[Nurse or Medical Staff]

We were here for two hours before.

[Concerned Family Member]

She went into labor.

[Nurse or Medical Staff]

Mr. Ferguson.

[Concerned Family Member]

Oh, he done his plan.

[Nurse or Medical Staff]

Since the day.

[Dr. Chapa]

I always cringe a little bit, just a little bit when I see some OB issue portrayed in either a movie or in a television show. On the one hand, I'm so thankful that attention is being given to these obstetrical emergencies, whether it's a shoulder dystocia, which is handled in a weird way or like in this clip of Grey's Anatomy, not a sponsor where the patient developed preeclampsia with severe features leading to hepatic injury. So I'm all for giving attention to things except when shows do things that are completely off as is typical, like when they grab the paddles for a cardio vers to shock something like asystole. Hello, you don't shock asystole. EPI and chest compressions. EPI and chest compressions. But that doesn't look as good on TV as like charge poof. And then giving the paddles. So you just got to put things in perspective. And I tell my wife all the time now, she's like, I know, I know. Can't I just watch the show? Because I say it every time. You don't give a charge. You don't shock for asystole. Oh my goodness. We're not talking about asystole, but we are talking about preeclampsia as the clip in our just little moments ago our intro highlighted so and again, as I've said many times before, we get ideas from the for the show, not just from real world encounters, but from questions that come in through our social media channels. Well, one of our podcast Family members said, you know, I was reading something called the Pearls of Excellence, not to be confused with Dr. Chapa's clinical pearls, now called the no Spin podcast, but there is something called the Pearls of Excellence. I'll let you know what society puts those out. And our podcast family members said, hey, they said for intrapartum preeclampsia with severe features, in addition to giving, you know, acute IV therapy for hypertension to bring it down so the patient is no longer in the urgent range of 160 over 110. The pearls of Excellence stated that you could give extended release nifedipine. In other words, extended release ProCardia versus the immediate release. Is this a thing. Where did this come from? And is this valid? So, so clinically applicable? I said, you know what, let's do this as a mini episode. We're going to knock this out because. Great question. We have done this just as all disclosure. We have given in patients who are getting or require several rounds of IV medication. We give them in addition to what we have used as immediate release nifedipine in the typical protocol of 10, 20 and 20 milligrams. We'll talk about that in just a minute. We've given the extended spectrum. Extended spectrum, the extended release option of about 30 milligrams. But where does this come from? So it's very bimodal here. The answer. Okay, because. Is there data? Yeah, there's actually Pretty nice Level 1 data done by a then MFM fellow out of the Ohio State University. We're going to talk about that, but that's pretty much it now. There's a lot of anecdotal reports and, you know, small, you know, case series that people have put out. But. But in terms of level one evidence, there's really only this one publication actually made a lot of the media circuits in 2022 when it was released ahead of print. It actually just came out two years ago officially in print in the journal hypertension in 2023. And we use this, I think we use this in our journal club back then now. So is there data? Absolutely. Is there a lot of data? Nope. Nope. Now we're going to relate this back to standard guidance, which is ACOG's committee opinion. We're going to talk about that and what the guidance currently says about immediate versus extended release, because that's all in committee opinion number six, nine two. Severe hypertension during pregnancy and the postpartum interval. We're gonna talk about that and we're gonna talk about this trial. So is there Data for this? Yes, there's level one data, but it's kind of the only trial now. It was very well done. It was actually triple blind. It's very nice. But that's the one piece of information. So it all goes to this. Can you do extended release after the patient has received IV urgent hypertension? Of course. Is it standard therapy now? No, it is not. And I want to be very clear. The first line therapy is the immediate release because it's much more actionable and easier to control, which is the 10 and then escalated to 20 and 20 separated in time, but per dose every 20 minutes. We're gonna get into this in this episode. So in response to our question from our podcast family member, we're gonna cover extended release nifedipine intrapartum for severe hypertension. What does the data say? What does this trial say? And is this a good idea? Well, the answer is, well, it depends on who you read. But yes, we have done this because the data says that you can. But. But we definitely need other data to collaborate that 2022 slash 2023 publication. I think I've set it up enough. Now that we've done all that. Let's get out of the intro and we will be right back. Foreign this is Dr. Choppa's OB GYN no Spin podcast.

[Concerned Family Member]

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[Dr. Chapa]

In the September 2018 Society for Academic Specialists in General Obstetrics and Gynecology's Pearl of Excellence publication, the title of which was Management of Preeclampsia at term in it does state, if hypertension management requires acute IV treatment, it is often prudent to initiate oral labetalol or extended release nifedipine to maintain blood pressure below the severe range. Intrapartum blood pressure management and consultation should not delay progress towards delivery. All right, so we get this. Now, a couple of things here because there's a lot in those few words already in 2018. This is out of the Pearls of Excellence. Now, excellence is with two X's. Why it's with two X's, I actually don't know. But Pearls of Excellence, that comes from sagogs. That is s A S G O G. Now, some of you have never heard of SAS gog, and this is worth you listening to the episode right now. There you go. Podcast is done. No, no, no, Keep listening, because we haven't even gotten to the good part, but there is SAS GoG S A S G O G. My goodness. Like the App Store, where there's an app for everything, There is a society for everything. SAS GOG stands for the Society of Academic Specialists in General Obstetrics and Gynecology. Basically, it's a form of. It's different than apco, but it's academic obgyn, basically, or those who are part of a residency or fellowship program. All right, so that I used to be part of SAS gog, and I'm like, there's so many societies that you can be in. So I, I, I. It's been years that I haven't. But saskog is a society of academic specialists in general obstetrics and gynecology. They do have nice pearls of excellence on a variety of things, which are basically little snippets of summaries. And it's fine. It's good. And in this, it does say, look, if a patient has acute urgent hypertension who needs IV treatment, then you can do oral labetalol or extended release nifedipine to maintain blood pressures below the severe range. Notice those words. Maintain now. So it's saying two things, that in those patients who are intrapartum. Yes. And it's been published. You can actually give, like, 200 milligrams of labetalol. Do that bid or tid to try to maintain blood pressures down to reduce the patient from having severe range of pressures where you're being reactive. Okay, so in other words, you are initiating action to keep blood pressure down rather than reaction by waiting for her to become hypertensive in the severe range. And you can do that with either labetalol, not IV label. I'm talking about oral labetalol, typically at a dose of 200, in addition to the IV medication to keep blood pressure down. Or you can do extended release. Nice nifedipine. So we have to clarify a couple of things. All right? First, the gold standard, the first line, the typical, is IV hydralazine, IV Labetalol or PO Nifedipine. Those are the standards. Okay? Nothing has changed there. That's the old standby. We get that. And that's very clear out of ACOG's practice bulletin, which is 222, which we've covered many times. Before that goes back to 2020. That is gestational hypertension and preeclampsia, as well as Committee Opinion 692, which is emergent therapy for acute onset severe hypertension during pregnancy and the postpartum period. The standard is IV hydralazine, IV labetalol with escalating dosages or PO Nifedipine as immediate release. But, okay, that's. We get that. That's for urgent treatment. That's the way to go. However, if you're intrapartum, there is data, not a lot of data, but there is data that you could use standard oral labetalol at a dose of 200 milligrams. And everybody has different regimens. Some do it every 12 hours, some do it every eight hours. But there is evidence that oral labetalol at 200 milligrams can help maintain blood pressure down to prevent urgent a need for antihypertensive medication, as there is also for extended release nifedipine, which is what I'm trying to get at. That's the question specifically asked by our podcast family member. So there's two things here. The urgent first line treatment, which is still po, immediate release nifedipine or IV hydralazine or IV labetalol, like we all do. But outside of that ACOG guidance, there is independent studies that have shown that oral labetalol or extended release nifedipine can help maintain, notice that word, maintain blood pressure out of the severe range to keep the patient out of harm's way. We have done it. I think it's fine. The question is, well, when do you do that? Is it after the second round of acute IV therapy? Is it after the first round? And that's what varies. And we don't have any guidance for. Right. So there is a part of physician discretion and clinical, you know, decision making, individualized care at that time. Now, we don't do it. If somebody needs urgent IV hypertension one time, we're not going to give her oral therapy. But for us, if we give. If the patient requires two or more. Okay, two or more IV doses, it's something that we have done. It's not our standard protocol, but we have considered and used both oral labetalol, intrapartum and extended release nifedipine. The catch is. The catch is that they have to hold it down. All right? So if they are in active labor and they're puking everywhere because of the parasympathetic response and delayed GI emptying, that's the issue here. But if somebody's undergoing induction and they're early on in labor and they're requiring a couple of rounds of IV urgent medication, it is reasonable to give either oral labetalol or extended release nycantipine. Let me read you that part from the Pearls of Excellence again. And then we're going to go into the study that specifically looked at extended Release ProCardia at 30 milligrams. All right, very well done. Again, came out ahead of print in 2022, but formally out two years ago in 2023 in the journal Hypertension. Now, to be very clear, you can do it. It's not standard. So adhere to whatever policy and procedures your hospital has. And if it doesn't have this as policy and procedures, do that as an addendum. It's fine to do this. There's nothing wrong with it. Just make sure that you don't freak anybody out, like, well, you know, we don't do that. Extended release has to be immediate. Yes, I understand that that is first line. But there is data that you can maintain blood pressure suppressed and controlled so that you don't punish the patient. Quote end qu by needing urgent PRN medication. So let me read you that statement again from the Pearls of Excellence. Quote. Once IV acute treatment is given, it is often prudent to initiate oral labetalol or extended release nifedipine to. Here it is, guys. Maintain blood pressure below the severe range, end quote. So, yes, that is in Sasagog's Pearls of Excellence. And there is data for this. Now, which one is superior? It's unclear, but the idea is, number one, definitely treat urgent hypertension. Number two, whether you choose to do labetalol or procardia, you know, that's up to you. Perhaps you can use the, you know, the delta we've talked about that, the rule of 55. So that if the change of systolic and diastolic, if the absolute difference is greater than 55, it suggests high output hyperdynamic hypertension. And you can give a beta blocker. If the delta of the rule of 55 is under, for example, 160 over 110, where the delta is 50, the difference, the straight difference between systolic and diastolic is less than 55, then perhaps a peripheral vasodilation with a calcium channel blocker like nifedipine would be best. So tailor it to what's happening in the patient's profile. Okay? If you haven't heard of the rule of 55, my goodness. We've covered many episodes on that. You can go back and search for it. We're not getting into that. But short of it is one is either called hyperdynamic and the other is vasoconstrictive cardiac profile of hypertension. All right, so first of all, is this evidence based? Yes, absolutely. In addition to the immediate release nifedipine, in addition to IV labetalol and hydralazine, you can do oral therapy to try to keep blood pressure down. As our podcast family member asked specifically, specifically about the extended nifedipine, and I want to call your attention to this trial that was published again ahead of print in 2022, officially in 2023 out of the Ohio State University. The title of this trial was quote, trial of intrapartum. So that's good. It's not anti. It's not postpartum. It's intrapartum. What we're talking about extended release. Yeah. So what we're talking about nifedipine to prevent severe hypertension among pregnant individuals, AKA pregnant women with preeclampsia with severe features. End quote. All right, so this is exactly what our podcast family member was asking about. We're going to do this super fast, really rapid. I think it's going to take us like, maybe three, five minutes. When we come back after the break.

[Nurse or Medical Staff]

What can I get you?

[Dr. Chapa]

I'd like a large coffee.

[Podcast Host]

Okay.

[Dr. Chapa]

So hot coffee, hard coffee. Okay.

[Podcast Host]

Room for cream.

[Dr. Chapa]

Totally leave room for cream.

[Podcast Host]

Why are you talking like that?

[Dr. Chapa]

Why are you talking like that? Well, going to a coffee shop has become kind of an adventure and kind of an ordeal, hasn't it? I mean, from our beloved baristas who ask you if you want room for coffee, room for cream. Like, I can't do it to just the $10 cup of coffee, y'. All. There's a better way. So I'm thankful that the Strong Coffee Company has partnered with our podcast that is strong, as in striving to reach our natural greatness. Striving to reach our natural greatness. That is the Strong Coffee Company. And now for our podcast listeners alone, there is a 20% discount for anything that you order online, y'. All. They have Adaptogen coffee gummies. What? So in addition to the regular whole bean variety and the instant mix, from lattes to collagen to L theanine and the gummies, I, I actually, I, I love these things because right before I go into, like, a long case or something, I knew it's going to be complicated, man. They actually have nootropic. Adaptogen Coffee gummies and now you can buy that with 20 discount only via the link in our show notes. But I always get a kick out of that. Would you like room for cream? Yeah, I like room for cream. You can avoid all that by ordering your coffee online. So Strong Coffee company, thank you so much for your partnership. Our podcast community. That's the strong Coffee company with the link in our show notes.

[Nurse or Medical Staff]

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[Dr. Chapa]

So this was a randomized triple blind placebo controlled trial of women with preeclampsia with severe features who are undergoing labor induction anywhere from 22 weeks and 0 up to 41 weeks and 6 days. Okay, now this is very easy. Participants were randomized to either oral extended release nifedipine, 30 milligrams or an identical placebo every 24 hours. The primary outcome was the receipt of greater than or more than one dose of acute hypertensive therapy medication for blood pressure that was at or above 160 over 110 that was sustained for more than 10 minutes. In other words, it wasn't just a bad read, it had to be sustained, which is typical protocol even out of the California Maternal Quality Care Collaborative. So again, hey, you're here. You're diagnosed with preeclampsia with severe you're gonna get 30mg oral nepine, extended release or a placebo. And we're going to see who has one or more need for urgent hypertension because your pressure hit 160 over 110. Now, let me stop here for a minute. As a little aside, there are places and even the California Maternal quality care collaborative, CMQCC says maybe we're waiting too long to treat 160 over 110 in their bundle for urgent hypertension. They say it's reasonable to treat at 155 over 105. All right? The idea is, man, you're waiting for her to be really high pressure, which puts her at risk for, you know, cerebrovascular accident. So potentially, even though it's not ACOG's rule or SMFM, there is some other guidance and consensus opinion that says that you could offer IV antihypertensive therapy at 155 over 105. But in true form, this used the standard cutoff of severe hypertension of 160 or over 110. Now, they also had secondary outcomes, including a route of delivery, neonatal intensive care admissions, and a composite of adverse neonatal outcomes. All right, so they screened like 365 women, and they ended up with 110 total subjects. 110. So pretty much half went into the randomized nifedipine group, the other half to placebos. So n of 55 per arm. So here it is, primary outcome. Remember, that was one or more need for antihypertensive urgent medication. That happened 34% in the nifedipine group versus 55% in the placebo. That's a relative risk, guys, of zero. That's pretty good. 0.62. That's like a 40% reduction. And the confidence interval was under one. It was just under one. It was 0.39 to 0.97. But still it did not cross one. So showing that the 40% reduction. Ish. Was. Was actually true. The nice thing was that the number needed to treat to prevent an acute hypertensive treatment was really small. It was 4.7. So call it what it is. Call it 5. So you needed to treat 5 to prevent one from getting urgent hypertension. That's not bad. That's not bad. Okay, now, fewer individuals in the nifedipine group required cesarean delivery compared to placebo. That's great. Although that reduction, which was also a relative risk of 0.6, that confidence interval did cross one. So. Yeah, so not sure about that one. But the good news is that neonatal intensive care unit admissions was also lower in the nifedipine group. And the neonatal composite for adverse issues was actually similar between the two groups because the relative risk was 0.83. So that's like, you know, it's barely a 20% reduction. But again, that confidence interval did cross one. Short of it is. It didn't hurt. Okay, guys, so here's a take home answer. Yeah, it was a relative risk of 0.62. So basically a 40% reduction. 38% reduction, to be exact. And it didn't seem to hurt any. So the authors concluded, quote, initiation of extended release nifedipine is effective in reducing intrapartum acute hypertensive therapy among women with preeclampsia with severe features. All right, I like it. Not bad. But. But it's not first line. Unfortunately and I don't really like this guys. I agree with these authors and good for for this then fellow Aaron Cleary who did this out of the Ohio State University because I agree, I don't like, you know, having a quote unquote, you know, punish the patient, so to speak, by waiting to until she is severe to treat that I'd rather kind of prevent it. So it does make sense. So for our podcast family member, both oral labetalol, typically at a dose of 200 milligrams anywhere from every eight to every 12 hours to once daily. ProCardia extended 90 milligrams can maintain blood pressure down. It doesn't eliminate the need for urgent hypertension medications, but it is helpful. Now if you do give the oral extended release nifedipine, kind of a just general consensus kind of best practice, probably don't give a 10 milligram of oral immediate release nifedipine for the acute. You got to go and maintain either IV labidalol or the IV hydralazine kind of the same deal. If I give a patient a medication, a 200mg oral labetalol intrapartum, I'm probably not going to chase her with IV labetalol because I don't want it to have a stacking effect. I'm either going to go for the hydralazine or the PO Nifedipine just to to keep the two medications separate. All right. And that's just kind of considered best practice. And it makes sense. Not that it's harmful to do that to give IV labetalol if she had PO labetalol. It's just it makes it cleaner. If you say this is her IV therapy and for oral maintenance I've given the other agent. I just think it makes sense that way. Plus dual agent, you attack two different mechanisms of action versus stacking a mechanism of action by the same agent. So the good news is that yes, there is definitely data and this was a very nice publication. The not so good news is that's kind of it. But it was enough to make it into the 2018 Society of Academic Specialists in General Obstetrics and Gynecology, Sescog's Pearls of Excellence in their management of preeclampsia term. Now remember I said that was 2018. This publication came out later because that they updated it once that piece came out. All right, so. But the original Release was in 2018, which was management of preeclampsia at term with an update once this trial. Once this trial came out. All right, so that's how the numbers work. She's like, wait, how do they include that if that trial wasn't out yet? Well, just because it was an update once that data was available. So is it reasonable to do that? Absolutely. Is there data? Yes, but we definitely need more. And unfortunately, the first line treatment is one that I don't like, which is just chasing her with a PRN medication. It makes a lot of sense to keep the patient Safe, to give PO maintenance labetalol, or once daily, 30 milligrams of Procardia Extended release. And I have no problem doing that. No problem doing that. Of course, barring any kind of other contraindication that may exist for those meds. Well, I think that's it, podcast family. So we've covered it. So I hope this does the question justice. Is there data for extended released nifedipine intrapartum? Yes. Just as there is for oral labetalol intrapartum to maintain blood pressures down. Not a problem to do either, although it is not mentioned in ACOG's original guidance on this, either in 222 or in Committee Opinion 692, which uses either IV or immediate acting for faster and tighter control. All right, podcast family, I think that's it. As always, we're thankful for you. We're glad you're part of our podcast community. And now that we've done all that, let's take it home. This has been Dr. Chapa Zobi Gyn, no Spin podcast Podcast family. Thank you for your support. Thank you for listening. And as always, we'll see you on another episode of the no Spin Podcast. It.