Hypertensive Disorders in Pregnancy

Gestational hypertension
- is a condition in which vasospasm occurs in both small and large arteries during pregnancy, causing
increased blood pressure.
Preeclampsia
- is a pregnancy-related disease process evidenced by increased blood pressure and proteinuria.
- An older term for preeclampsia was toxemia of pregnancy because researchers pictured the
symptoms as being caused by women producing a toxin of some kind in response to the foreign
protein of the growing fetus. The condition occurs in 5% to 7% of pregnancies.
- The cause of the disorder is unknown, although women with antiphospholipid syndrome (APS) or
the presence of antiphospholipid antibodies in maternal blood are much more likely to develop
preeclampsia
- The condition tends to occur most frequently in women of color; those with a multiple pregnancy;
primiparas younger than 20 years or older than 40 years of age; women from low socioeconomic
backgrounds (perhaps because of poor nutrition); those who have had five or more pregnancies;
those who have polyhydramnios (i.e., overproduction of amniotic fluid; refer to later discussion); or
whose who have an underlying disease such as heart disease, diabetes with vessel or renal
involvement, and essential hypertension.

PATHOPHYSIOLOGIC EVENTS
- The symptoms of preeclampsia affect almost all organs.
- Usually during pregnancy, blood vessels are resistant to the effects of pressor substances such as
angiotensin and norepinephrine, so even with the increased blood supply, blood pressure remains
normal during pregnancy.
- With gestational hypertension, this reduced responsiveness to blood pressure changes appears to
be lost because of the prostaglandin release. Vasoconstriction occurs, and blood pressure increases
dramatically.
- Beginning about the 20th week of pregnancy, almost all body systems begin to be affected. The
cardiac system, for example, can easily become overwhelmed because the heart is forced to pump
against rising peripheral resistance. This causes a reduced blood supply to organs, most markedly
the kidney, pancreas, liver, brain, and placenta. Poor placental perfusion reduces the fetal nutrient
and oxygen supply
- Vasospasm in the kidney increases blood flow resistance. Degenerative changes then develop in the
kidney glomeruli because of back pressure. This leads to increased permeability of the glomerular
membrane, allowing the serum proteins albumin and globulin to escape into the urine (i.e.,
proteinuria)
- Edema is further increased because, as more protein is lost, the osmotic pressure of the circulating
blood falls and fluid diffuses from the circulatory system into the denser interstitial spaces to
equalize the pressure
- Extreme edema can lead to maternal cerebral and pulmonary edema and seizures(eclampsia).
 ASSESSMENT
- Although women may have additional symptoms such as vision changes, typically hypertension,
proteinuria, and edema are considered the classic signs of preeclampsia. Of the three, hypertension
and proteinuria are the most significant because extensive edema occurs only after the other two
are present.
PICTURE INSERT
- Preeclampsia is classified as preeclampsia without severe features, preeclampsia with severe
features, and eclampsia, depending on how far development of the syndrome has advanced (Table
21.6). Any woman with a high risk of preeclampsia should be observed carefully for symptoms at
prenatal visits. She needs instructions about what symptoms to watch for so she can alert her
healthcare provider if symptoms begin to occur between visits.
SYMPTOMS OF GESTATIONAL HYPERTENSION
Hypertension Symptoms
Type
Gestational Blood pressure is 140/90 mmHg or systolic pressure
Hypertension elevated 30 mmHg or diastolic pressure elevated 15
mmHg above prepregnancy level; no proteinuria or
edema; blood pressure returns to normal after birth
Preeclampsia without severe features Blood pressure is 140/90 mmHg or systolic pressure
elevated 30 mmHg or diastolic pressure elevated 15
mmHg above prepregnancy level; proteinuria of 1+
to 2+ on a random sample;weight gain over 2
lb/week in second trimester and 1 lb/week in third
trimester; mild edema in upper extremities or face
Preeclampsia with severe features Blood pressure is 160/110 mmHg; proteinuria 3+ to
4+ on a random sample and 5 g on a 24-hour
sample; oliguria (500 ml or less in 24 hours or
altered renal function tests; elevated serum
creatinine more than 1.2 mg/dl); cerebral or visual
disturbances (headache,blurred vision); pulmonary
or cardiac involvement; extensiveperipheral edema;
hepatic dysfunction; thrombocytopenia;epigastric
pain
Eclampsia Either seizure or coma accompanied by signs and
symptoms of preeclampsia are present.

GESTATIONAL HYPERTENSION
- A woman is said to have gestational hypertension when she develops an elevated blood pressure
(140/90 mmHg) but has no proteinuria or edema. Perinatal mortality is not increased with simple
gestational hypertension, so careful observation but no drug therapy is necessary.
PREECLAMPSIA WITHOUT SEVERE FEATURES
- If a seizure from preeclampsia occurs, a woman now has eclampsia, but any status above
gestational hypertension and below a point of seizures is preeclampsia.
- A woman is said to be preeclamptic without severe features when she has proteinuria (1+ on a
urine dip or 300 mg in a 24-hour urine protein collection or 0.3 or higher on a urine protein–
creatinine ratio) and a blood pressure rise to 140/90 mmHg, taken on two occasions at least 6
hours apart.
- According to Average blood pressures in American women, a woman younger than 20 years could
have a blood pressure of 98/61 mmHg and still be within normal limits. If her blood pressure was
elevated 30 mmHg systolic and 15 mmHg diastolic, it would be only 128/76 mmHg. This is well
beneath the traditional warning point of 140/90 mmHg but would represent hypertension for her.
 - Many women show a trace of protein during pregnancy. Actual proteinuria is said to exist when it
registers as 1+ or more (this represents a loss of 1 g/L). A woman with preeclampsia will begin to
show proteinuria of 1+ or 2+ on a reagent test strip on a random sample
- Occasionally, women have orthostatic proteinuria (i.e., on long periods of standing, they excrete
protein; on bed rest, they do not). If proteinuria is present without other signs of gestational
hypertension (no hypertension and no edema), check to see when the specimen was obtained. Ask
her to bring in a first morning urine sample next time as that may reveal that orthostatic
proteinuria, not preeclampsia, is the cause of protein in her urine.
- Edema develops, as mentioned, because of the protein loss, sodium retention, and lowered glomerular
filtration rate. The edema can be separated from the typical ankle edema of pregnancy because it
begins to accumulate in the upper part of the body as well.

PREECLAMPSIA WITH SEVERE FEATURES

- A woman has passed to preeclampsia with severe features when her blood pressure rises to 160
mmHg systolic and 110 mmHg diastolic or above on at least two occasions 6 hours apart at bed rest
(the position in which blood pressure is lowest) or her diastolic pressure is 30 mmHg above her
prepregnancy level. Marked proteinuria, 3+ or 4+ on a random urine sample or more than 5 g in a
24-hour sample.
- With preeclampsia with severe features, extreme edema is most readily palpated over bony
surfaces, such as over the tibia on the anterior leg, the ulnar surface of the forearm, and the
cheekbones, where the sponginess of fluid-filled tissue can be palpated against bone. If there is
swelling or puffiness at these points to a palpating finger but the swelling cannot be indented with
finger pressure, the edema is described as nonpitting.
- If the tissue can be indented slightly, this is 1+ pitting edema; moderate indentation is 2+; deep
indentation is 3+; and indentation so deep it remains after removal of the finger is 4+ pitting
edema. This accumulating edema will reduce a woman’s urine output to approximately 400 to 600
ml per 24 hours.
- It’s helpful to further assess edema by asking a woman if she has noticed any swelling anywhere in
her body. Women commonly report upper extremity edema as “My rings are so tight I can’t get
them off” and facial edema as “When I wake in the morning, my eyes are swollen shut” or “My
tongue is so swollen I can’t talk until I walk around awhile.”
- Some women report severe epigastric pain and nausea or vomiting, possibly because abdominal
edema or ischemia to the pancreas and liver has occurred. If pulmonary edema has developed, a
woman may report feeling short of breath. If cerebral edema has occurred, reports of visual
disturbances such as blurred vision or seeing spots before the eyes may be reported.
- Cerebral edema also produces symptoms of severe headache and marked hyperreflexia and
perhaps ankle clonus (i.e., a pulsed motion of the foot after flexion)
INSERT PICTURE

ECLAMPSIA
- the most severe classification of pregnancy-related hypertensive disorders. A woman has passed
into this stage when cerebral edema is so acute a grand mal (tonic–clonic) seizure or coma has
occurred. With eclampsia, the maternal mortality can be as high as 20% from causes such as
cerebral hemorrhage, circulatory collapse, or renal failure
- The fetal prognosis with eclampsia is also poor because of hypoxia, possibly caused by the seizure,
with consequent fetal acidosis. If premature separation of the placenta from extreme vasospasm
occurs, the fetal prognosis becomes even graver. If a fetus must be born before term, all the risks of
immaturity will be faced.

NURSING INTERVENTIONS FOR A WOMAN WITH PREECLAMPSIA WITHOUT SEVERE FEATURES

- Patients with preeclampsia without severe features prior to full term can be managed at home with
frequent follow-up care and fetal testing.
 1. Monitor Antiplatelet Therapy - Because of the increased tendency for platelets to cluster along
arterial walls, a mild antiplatelet agent, such as low-dose aspirin, may prevent or delay the
development of preeclampsia. Because aspirin is such a common over-the counter drug, be certain
women appreciate that this is not something to be taken lightly but a serious drug prescription for
them. Be certain they purchase low-dose aspirin (81 mg, sold as baby aspirin) as excessive salicylic
levels can cause maternal bleeding at the time of birth.
2. Promote Bed Rest - When the body is in a recumbent position, sodium tends to be excreted at a
faster rate than during activity. Bed rest, therefore, is the best method of aiding increased
evacuation of sodium and encouraging diuresis of edema fluid. Be certain women know to rest in a
lateral recumbent position to avoid uterine pressure on the vena cava and prevent supine
hypotension syndrome.
3. Promote Good Nutrition - A woman needs to continue her usual pregnancy nutrition while on bed
rest. At one time, stringent restriction of salt was advised in order to reduce edema. This is no
longer true because stringent sodium restriction may activate the renin–angiotensin– aldosterone
system and actually result in increased blood pressure, thus compounding the problem Assess if a
woman has someone to help her prepare food, or either bed rest or nutrition may be
compromised.
4. Provide Emotional Support - It is difficult for a woman with preeclampsia to appreciate the
potential seriousness of symptoms because they are so vague; neither high blood pressure nor
protein in urine is something she can see or feel. She is aware edema is present, but it seems
unrelated to the pregnancy; after all, it is in her hands and face, not a body area near her growing
child.

NURSING INTERVENTIONS FOR A WOMAN WITH PREECLAMPSIA WITH SEVERE FEATURES

- If a woman’s preeclampsia is severe (systolic blood pressure of more than 160 mmHg, diastolic
blood pressure of more than 110 mmHg after a woman has been on bed rest; extensive edema;
marked proteinuria [3+ to 4+]; cerebral or visual disturbances; marked hyperreflexia; or oliguria
[500 ml per 24 hours or less]), a woman may be admitted to a healthcare facility for care. If the
pregnancy is greater than 37 weeks, labor can be induced or a cesarean birth performed to end the
pregnancy at that point. If the pregnancy is less than 37 weeks, interventions will be instituted to
attempt to alleviate the severe symptoms and allow the fetus to come to term. However, if the
symptoms persist or worsen, or if the fetal testing shows a compromised fetus, vaginal or
caesarean delivery will be necessary even if the pregnancy is preterm.
1. Support Bed Rest - With preeclampsia with severe features, most women are hospitalized so that
bed rest can be enforced and a woman can be observed more closely than she can be on home
care. Getting up to use the bathroom is not contraindicated in women with preeclampsia. Visitors
are usually restricted to support people such as a partner, father of the child, mother, or older
children. Because a loud noise such as a crying baby or a dropped tray of equipment can be
sufficient to trigger a seizure that initiates eclampsia, a woman with preeclampsia with severe
features is admitted to a private room so she can rest as undisturbed as possible. Raise side rails to
help prevent injury if a seizure should occur.
2. Monitor Maternal Well-Being - device to detect any increase, which is a warning that a woman’s
condition is worsening. Obtain blood studies such as a complete blood count, platelet count, liver
function, blood urea nitrogen, and creatine and fibrin degradation products as ordered by the
obstetric team to assess renal and liver function and the development of DIC, which often
accompanies severe vasospasm, as well as plasma estriol levels (a test of placenta function), and
electrolyte levels. Because a woman is at high risk for premature separation of the placenta and
resulting hemorrhage, a blood sample for type and crossmatch is usually also obtained.
3. Monitor Fetal Well-Being - Generally, single Doppler auscultation at approximately 4-hour intervals
is sufficient at this stage of management. A woman may have a nonstress test or biophysical profile
done daily to assess uteroplacental sufficiency, If fetal bradycardia occurs, oxygen administration to
the mother may be necessary to maintain adequate fetal oxygenation.
4. Support a Nutritious Intake - A woman needs a diet moderate to high in protein and moderate in
sodium to compensate for the protein she is losing in urine. An intravenous fluid line is usually
initiated and maintained to serve as an emergency route for drug administration as well as to
administer fluid to reduce hemoconcentration and hypovolemia.
5. Administer Medications to Prevent Eclampsia - A hypotensive drug such as hydralazine
(Apresoline), labetalol (Normodyne), or nifedipine may be prescribed to reduce hypertension.
These drugs act to lower blood pressure by peripheral dilatation and thus do not interfere with
placental circulation. They can, however, cause maternal tachycardia, so assess pulse and blood
pressure before and after administration. Diastolic pressure should not be lowered below 80 to 90
mmHg or inadequate placental perfusion could occur. Even with these new drugs, magnesium
sulfate still remains the drug of choice to prevent eclampsia. This drug, classified as a cathartic,
reduces edema by causing a shift in fluid from the extracellular spaces into the intestine. It also has
a central nervous system depressant action (it blocks peripheral neuromuscular transmissions),
which lessens the possibility of seizures. To achieve an immediate reduction of blood pressure,
magnesium sulfate may first be given intravenously in a loading or bolus dose. The drug begins to
act almost immediately; unfortunately, the effect lasts only 30 to 60 minutes, so administration
must be continuous.

DRUGS USED IN PREECLAMPSIA

Drug Indication Dosage Comments
Magnesium sulfate Muscle relaxant; Loading dose 4–6 g - Infuse loading dose
(pregnancy risk prevents seizures Maintenance dose 1–2 slowly over 15–30
category B) g/hr IV minutes.
- Always administer as
a piggyback infusion.
- Assess respiratory
rate, urine output,
deep tendon reflexes,
and clonus every hour.
- Urine output should
be over 30 ml/hr and
respiratory rate over
reaths/min. Serum
Magnesium level
should remain below
7.5 mEq/l.
-Observe for central
nervous system (CNS)
depression and
hypotonia in infant at
birth and calcium
deficit in the mother.
Hydralazine Antihypertensive 5–10 mg IV Administer slowly to
(Apresoline) (peripheral avoid sudden fall in
(pregnancy vasodilator); blood pressure.
Risk category C) used to decrease Maintain diastolic
hypertension pressure over
90 mmHg to ensure
adequate
placental filling.
Diazepam (Valium) Halt seizures 5–10 mg IV - Administer slowly.
(pregnancy risk Dose may be
 category D) repeated q 5–10
minutes (up
to 30 mg/hr).
-Observe for
respiratory
depression or
hypotension in
mother and respiratory
depression and
hypotonia in
infant at birth
Calcium gluconate Antidote for 1 g IV (10 ml of a 10% Have prepared at
(pregnancy risk magnesium solution) bedside as the
category C) Intoxication antidote when
administering
magnesium sulfate.
Administer at 5
ml/min.

- The importance of different serum levels of magnesium sulfate is shown in Box Below. For the drug to
act as an anticonvulsant, blood serum levels must be maintained at 5 to 8 mg per 100 ml. If the blood
serum level rises above this, respiratory depression, cardiac arrhythmias, and cardiac arrest can occur.

Nursing Care Planning Based on Responsibility for Pharmacology

MAGNESIUM SULFATE
Action: Magnesium sulfate is a central nervous system depressant that acts to block
neuromuscular transmission of acetylcholine to halt convulsions.
Pregnancy Risk Category: A
Dosage: Initially, 2–6 g IV administered in a 250-ml solution over a 20-minute
period, followed by individually calculated IV infusion at a rate to maintain
designated serum levels
• Therapeutic range: 5–8 mg/100 ml
• Patellar reflex disappears: 8–10 mg/100 ml
• Respiratory depression occurs: 15–20 mg/100 ml
• Cardiac conduction defects occur: more than 20 mg/100 ml
Possible Adverse Effects: Flushing, thirst; with toxicity, absence of deep tendon
reflexes, respiratory depression, cardiac arrhythmias, cardiac arrest, and decreased
urine output
Nursing Implications
• Administer continuous infusion piggybacked into a main IV line so it can be
discontinued immediately without interfering with fluid administration.
• Always use an infusion control device to maintain a regular flow rate.
• Assess maternal blood pressure and fetal heart rate continuously with bolus IV
administration.
• Assess deep tendon reflexes every 1–4 hours during continuous infusion. Use the
patellar reflex. If patient has received epidural anesthesia, use the biceps reflex.
• Monitor intake and output every hour during continuous infusion. Urine output
should be 30 ml/hr or greater.
• Assess patient’s level of consciousness, including ability to respond to questions,
every hour.
• Obtain serum magnesium levels as indicated, usually every 6–8 hours.
 • Keep calcium gluconate, the antidote for toxicity, readily available at the bedside.
• Maintain serum blood levels (for anticonvulsant use) at 5–8 mg/100 ml. If blood
serum levels rise above this, respiratory depression, cardiac arrhythmias, and
cardiac arrest can occur.
• Do not administer additional doses and stop infusion if deep tendon reflexes are
absent or if respiratory rate is less than 12–14 breaths/min or urine output is less
than 30 ml/hr.
• This drug may cause respiratory depression in the newborn if administered close
to birth. Alert neonatal care personnel about this possibility.
• Magnesium sulfate may cause osteoporosis in the mother if given over a long
time.

NURSING INTERVENTIONS FOR A WOMAN WITH ECLAMPSIA

- eclampsia occurs when cerebral irritation from increasing cerebral edema becomes so acute that a
seizure occurs. This usually happens late in pregnancy but can happen up to 48 hours after
childbirth. Immediately before a seizure, a woman’s blood pressure rises suddenly from additional
vasospasm. The increased cerebral pressure causes her temperature to rise sharply to 103° to 104°F
(39.4° to 40°C). She notices blurring of vision or severe headache (from the increased cerebral
edema), and her reflexes become hyperactive. She may experience a premonition or aura that
“something is happening.” Vascular congestion of the liver or pancreas can lead to severe epigastric
pain and nausea or vomiting. Urinary output may decrease abruptly to less than 30 ml/hr. However,
eclampsia has actually occurred, by definition, only when a woman experiences a seizure.
1. Tonic–Clonic Seizures
- An eclamptic seizure is a tonic–clonic type that occurs in stages. After the preliminary signal or
aura that something is happening, all the muscles of the womans body contract. Her back arches,
her arms and legs stiffen, and her jaw closes so abruptly she may bite her tongue. Respirations halt
because her thoracic muscles are held in contraction. This phase of the seizure, called the tonic
phase, lasts approximately 20 seconds. It may seem longer because a woman may grow slightly
cyanotic from the cessation of respirations.
- During the second (clonic) stage, the woman’s bladder and bowel muscles contract and relax;
incontinence of urine and feces may occur. Although a woman begins to breathe during this stage,
the breathing is not entirely effective so she may remain cyanotic. The clonic stage of a seizure lasts
up to 1 minute. Following this, she will enter an hour long postictal stage, during which she is
unconscious.
The priority care for a woman with a tonic–clonic seizure is to maintain a patent airway. To prevent
aspiration, turn her onto her side to allow secretions to drain from her mouth. Magnesium sulfate
or diazepam (Valium) may be administered intravenously as emergency measures. Assess oxygen
saturation via a pulse oximeter. Administer oxygen by face mask as needed to protect fetal
oxygenation. Apply an external fetal heart monitor if one is not already in place to assess the FHR.
The seizure may announce the beginning of labor, so assess as well for uterine contractions. Check
for vaginal bleeding to detect placental separation, although evidence placental separation has
occurred will probably appear first on the fetal heart record; vaginal bleeding will strengthen the
presumption.
2. Birth
- If the fetus has reached a point of viability, a decision about birth will be made as soon as a
woman’s condition stabilizes, usually 12 to 24 hours after the seizure. Probably because of the
increased stress that has occurred, fetal lung maturity appears to advance rapidly with preeclampsia,
so even though the fetus is younger than 37 weeks, the lecithin/sphingomyelin ratio may indicate fetal
lung maturity.
- Cesarean birth is always more hazardous for the fetus than vaginal birth because of the
association of retained lung fluid. Furthermore, a woman with severe high blood pressure is not a good
candidate for surgery. An additional problem arises: Because her vascular system is low in volume, she may
become hypotensive with regional anesthesia, such as an epidural block. The preferred method for birth,
therefore, is vaginal with a minimum of anesthesia. If labor does not begin spontaneously, rupture of the
membranes or induction of labor with intravenous oxytocin may be instituted. If this is ineffective and the
fetus appears to be in imminent danger, cesarean birth becomes the birth method of choice.

NURSING INTERVENTIONS DURING THE POSTPARTUM PERIOD

- Postpartum preeclampsia may occur up to 10 to 14 days after birth, although it usually occurs
within 48 hours after birth. Therefore, monitoring blood pressure in the postpartum period and at
healthcare visits and being alert for preeclampsia, which can occur as late as 2 weeks postbirth, are
essential to detect this residual hypertension