HYPERTENSIVE

DISORDERS
NCM 108
FRITZIE NECITAS A. DURAN, RN
LECTURER
 Hypertension
• Sustained, elevated, systemic, arterial blood pressure; diastolic elevation
more serious
• Pathophysiology: increased peripheral resistance leading to thickened
arterial walls and left ventricular hypertrophy
• Risk factors: use of birth control pills, overweight, smoking, stress, excessive
sodium intake or saturated fat, lack of activity
• Classifications:
1. Essential HPN
2. Secondary HPN
3. Malignant HPN
4. Labile HPN
• Assessment: early-morning headache, usually occipital, light-headedness,
tinnitus, palpitations, fatigue, insomnia, altered vision, epistaxis, shortness
of breath on slight exertion, elevated BP, cardiac, cerebral and renal changes
 Nursing Care Planning

• Provide for physical and emotional rest

• Provide for special safety needs
• Health teaching
Weight control
Diet restrictions
Lifestyle changes
 Chronic Hypertension

• Is defined as hypertension present before conception, before 20 weeks

gestation, or persisting more than 6 weeks postpartum. The primary
pathophysiology of chronic hypertension is elevated blood pressure.

• Stages of hypertension:
Prehypertension- systolic 120-139 or diastolic 80-89
Stage 1 hypertension- systolic 140-159 or diastolic 90-99
Stage 2 hypertension- systolic> 160 or diastolic > 100
 Antihypertensive Medications for Chronic
Hypertension During Pregnancy
MEDICATION DRUG CLASSIFICATION USUAL DOSAGE MAXIMUM DOSAGE

Methyldopa(Aldomet) Central-acting 250 mg orally bid or tid 2000 mg

antiadrenergic agent

Labetalol Beta-blocker Start at 100 mg orally bid 1200 mg

Increase 100 mg bid q 2 to 3
weeks

Pindolol Beta-blocker 5 mg orally bid 60 mg

Increase by 10 mg/day q 3 to 4
weeks

Nifedipine Calcium channel blocker 10 mg orally tid 180 mg

Hypertensive disorders in pregnancy includes:

1. Gestational HPN
2.Preeclampsia without
severe features
3. Preeclampsia with
severe features
4.Eclampsia
Type
Classification of Hypertensive States of Pregnancy
GESTATIONAL HYPERTENSION
PREECLAMPSIA (without severe features)
PREECLAMPSIA (with severe features)
ECLAMPSIA
Description
Development of mild hypertension during pregnancy in
previously normotensive patient without proteinuria and with
abnormal laboratory test.
Blood pressure returns to normal by 6 weeks postpartum.
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
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;
extensive peripheral edema; hepatic dysfunction;
thrombocytopenia; epigastric pain
Either seizure or coma accompanied by signs and symptoms of
preeclampsia are present.
 Preeclampsia( without severe features)
• 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. The diastolic
value of blood pressure is extremely important to document because it is this
pressure that best indicates the degree of peripheral arterial spasm present.
• A second criterion for evaluating blood pressure is a systolic blood pressure
greater than 30 mmHg and a diastolic pressure greater than 15 mmHg above
pre-pregnancy values. This rule is helpful for a woman with preexisting
hypertension, but the value of 140/90 mmHg is a more useful cutoff point
when there are no baseline data available, such as when a woman seeks
prenatal care late in pregnancy.
 Incidence
• The strongest risk factors for preeclampsia are a primigravida younger than 19 years or older than 40
years.
• Other factors associated includes:
Familial history
Connective tissue disease such a lupus or rheumatoid arthritis
Acquired or congenital thrombophilia
Limited sperm exposure such as donor insemination
Partner who fathered preeclamptic pregnancy in another woman
Woman born as SGA
Adverse outcome in a previous pregnancy such as fetal growth restriction, abruptio placenta, or fetal
death
Preexisting vascular disease such as diabetes, renal disease, chronic hypertension
Exposure to a superabundance of trophoblastic tissue , such as in multiple gestation and hydatidiform
mole
Thrombophilia disorder
Obesity
Periodontal disease
 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.
• 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).
 Eclampsia
• Eclampsia is the most severe classification of
pregnancy-related hypertensive disorders. There is an
occurrence of seizure activity and is thought to be
triggered by several cerebral vasospasm, hemorrhage,
ischemia or edema. Occasionally, encephalopathy
may trigger seizure activity. Severe, persistent
headache, visual disturbances, epigastric pain, and
restlessness can be warning signs of impending
eclampsia.
.
 Maternal effects

• Preeclampsia is a very serious disease.

• If treated early and effectively, maternal mortality rate is low. If the disease
is allowed to progress to the HELLP syndrome or eclampsia, maternal
mortality increases to as high as 24% and morbidity levels are even higher.
• The most common causes of maternal mortality or morbidity are related to
abruptio placenta, pulmonary edema, adulty respiratory distress syndrome,
stroke, renal or hepatic failure, cardiopulmonary arrest, DIC and cerebral
hemorrhage.
• Women who receive no prenatal care are 12 times as likely to die from
preeclamptic complications.
 Fetal and Neonatal effects
• Perinatal mortality related to mild eclampsia ranges
from 1% to 8%, increasing to an overall average of 12%
in severe preeclampsia.
• If the disease progress into HELLP syndrome or
eclampsia, perinatal mortality can be as high as 60%. The
majority of the perinatal losses are related to placental
insufficiency, which causes fetal growth restriction,
prematurity associated with preterm delivery,
hypoxia/acidosis, or abruptio placenta.
 Signs and symptoms
• The cardinal signs of preeclampsia are Hypertension and proteinuria.
• Subjective signs of preeclampsia suggesting end-organ involvement include the following:
Headaches
Visual changes, such as blurred vision
Rapid-onset edema of the face or abdomen or pitting edema in the feet or legs after 12 hours of
bedrest
Oliguria less than 500ml/24 hours
Hyperreflexia
Nausea and vomiting
Epigastric or right upper quadrant pain
• Signs of HELLP syndrome follows:
Right upper quadrant tenderness or epigastric pain related to obstructed hepatic blood flow
Nausea and vomiting related to hepatic stretching
Influenza-like symptoms
Jaundice
hematuria
Medical Management and Protocols for Nurse
Practitioners

• The only cure for preeclampsia is termination of the

pregnancy. However, If the pregnancy has progressed 36
weeks or more, delivery is the treatment of choice after
the condition is stabilized. If the pregnancy is fewer than
36 weeks of gestation or the fetus is immature,
interventions are instituted to attempt to arrest or
improve preeclampsia and allow time for the fetus to
mature. If HELLP syndrome develops, immediate
delivery is necessary at any gestational age.
 Expectant Management
1) Activity restriction
2) Diet
3) Fetal surveillance
4) Antihypertensive therapy
5) Corticosteroid therapy
6) Blood component replacement
7) Delivery
Vaginal delivery is preferred unless CS is indicated for other obstetric
reasons
 Nursing Management

1. Adequate nutrition
2.Adequate rest
3. Water therapy
4.Heparin therapy
 Seizure precautions
1. Assess for signs of impending eclampsia, such as epigastric or right upper
quadrant pain, nausea and vomiting, headache, jaundice and hematuria
2. Implement seizure precautions by having oxygen, suction, a padded tongue blade
and supplies to pad side rails at bedside
3. Provide a quiet, pleasant environment with limited lighting
4. Limit visitors
5. Administer magnesium sulfate or other anticonvulsant therapy as ordered
6. Assess for signs of magnesium toxicity, absence of DTRs, respirations fewer than
12/min, or a significant drop in BP.
7. Monitor urine output. Note serum magnesium levels.
8. Have the antidote of calcium gluconate at the bedside
9. Notify the physician of any worsening signs.
 During the seizure

1. Remain with the patient

2. Reduce the risk for aspiration and establish airway patency by lowering
and turning the head to one side to keep the airway open. Suction any
secretions
3. Observe seizure activity for time of occurrence, length of eizure and type
of seizure activity
4. Maintain adequate oxygenation by administering oxygen via face mask at
8-10 liters/minute
5. Prevent maternal injury.
 After the seizure
1. Assess airway and suction if needed
2. Start an IV line as soon as possible if not having
3. Ensure maternal oxygenation after seizure
4. Ensure fetal oxygenation after seizure
5. Provide a quiet environment
6. Establish seizure control with magnesium sulfate
7. Assess frequently for uterine contractions
8. Assess for abruptio placenta
9. Assess for signs of HELLP syndrome
10.Assess and treat severe hypertension
11.Assess for protein in urine
12.I and O hourly
13.Initiate delivery
Drugs Indication Dosage Comments

Magnesium Muscle relaxant; Loading dose Infuse loading dose slowly over
sulfate prevents seizures 4–6 g 15–30 minutes.
(pregnancy Maintenance Always administer as a
risk dose 1–2 piggyback infusion.
category B) Drugs used in Preeclampsia
g/hr IV Assess respiratory rate, urine
output, deep tendon reflexes,
and clonus every hour.
Urine output should be over 30
ml/hr and respiratory rate over
12 breaths/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 avoid
(Apresoline) (peripheral sudden fall in blood pressure.
(pregnancy vasodilator); Maintain diastolic pressure
risk used to decrease over
category C) hypertension 90 mmHg to ensure adequate
placental filling.

Diazepam Halt seizures 5–10 mg IV Administer slowly. Dose may

(Valium) be
(pregnancy repeated q 5–10 minutes (up
risk to 30 mg/hr).
category D) Observe for respiratory
depression or hypotension in
mother and respiratory
depression and hypotonia in
infant at birth.

Calcium Antidote for 1 g IV (10 ml Have prepared at bedside as

gluconate magnesium of a 10% the
(pregnancy intoxication solution) antidote when administering
risk magnesium sulfate.
category C) Administer at 5 ml/min.
 HELLP Syndrome
• Characterized by rapidly deteriorating liver function and thrombocytopenia.
• HELLP syndrome is a variation of the gestational hypertensive process named for the common symptoms
that occur:
• • Hemolysis leads to anemia
• • Elevated liver enzymes lead to epigastric pain
• • Low platelets lead to abnormal bleeding/clotting.
• It occurs in both primigravidas and multigravidas and is associated with APS or the presence of
antiphospholipid antibodies.
• In addition to proteinuria, edema, and increased blood pressure, additional symptoms of nausea, epigastric
pain, general malaise, and right upper quadrant tenderness from liver inflammation occur. Laboratory studies
reveal hemolysis of red blood cells (they appear fragmented on a peripheral blood smear), thrombocytopenia
(a platelet count <100,000/mm3), and elevated liver enzyme levels (alanine aminotransferase [ALT] and
serum aspartate aminotransferase [AST]), which are all effects of hemorrhage and necrosis of the liver.
Because of the low platelet count, women with the HELLP syndrome need extremely close observation for
bleeding, in addition to the observations necessary for preeclampsia. Complications associated with the
syndrome are subcapsular liver hematoma, hyponatremia, renal failure, and hypoglycemia from poor liver
function. Mothers are also at risk for cerebral hemorrhages, aspiration pneumonia, and hypoxic
encephalopathy. Fetal complications can include growth restriction and preterm birth .
 Critical care interventions for HELLP
Syndrome
1. Assess and stabilize maternal condition.
2. Implement the same monitoring protocol for the severe preeclamptic patient
3. Provide oxygen, 8 to 10 liters/minute via face mask
4. Prevent eclampsia with anticonvulsant therapy
5. When DIC is present, correct coagulopathy
6. Be aware that the patient is at increased risk for abruptio placenta, pulmonary
edema, acute renal failure, eclampsia and subcapsular hematoma of the liver.
7. Consider the diagnosis of acute fatty liver of pregnancy.
8. Provide continuous electronic monitoring of FHR.
9. Initiate corticosteroid therapy
10.Prepare for delivery
That in all things God may be glorified!