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    Mar.04.2021

    Hypertensive Disorders in Pregnancy (Obstetrics Inpatient)

    Clinical Description

    • Care of the hospitalized perinatal patient experiencing gestational hypertension, preeclampsia, preeclampsia with severe effects, HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome, eclampsia, chronic hypertension or chronic hypertension with superimposed preeclampsia.

    Key Information

    • The sudden onset of severe hypertension that has been accurately measured, using the appropriately-sized cuff, and lasts for 15 minutes or longer is considered a hypertensive emergency. This requires immediate treatment to avoid neurologic complications.
    • Although proteinuria has historically been believed to be key in the diagnosis of preeclampsia, it is not always present. Other signs and symptoms, such as thrombocytopenia, renal and liver dysfunction or pulmonary edema, may assist with diagnosis in the absence of proteinuria.
    • If eclampsia occurs, maternal stabilization is the priority, followed by emergent delivery.
    • HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome may lead to DIC (disseminated intravascular coagulation).
    • Rupture of a subcapsular hematoma is considered a life-threatening emergency. It can be preceded by epigastric pain or pain in the right upper quadrant.
    • Women who are at increased risk for development of preeclampsia or have chronic hypertension are recommended to start a low-dose aspirin regimen, optimally before 16 weeks gestation, to be continued until delivery.
    • ACE (angiotensin-converting enzyme) inhibitor, ARB (angiotensin receptor blocker) or direct renin inhibitor are contraindicated in pregnancy. Although antihypertensive therapy is not a contraindication to breastfeeding, the medication is found in breast milk. Potential infant effects should be taken into consideration.

    Clinical Goals

    By transition of care

    A. The patient will achieve the following goals:
    • Maternal-Fetal Stabilization

    B. Patient, family or significant other will teach back or demonstrate education topics and points:
    • Education: Overview
    • Education: Self Management
    • Education: When to Seek Medical Attention

    Correlate Health Status

    • Correlate health status to:

      • history, comorbidity
      • age, developmental level
      • sex, gender identity
      • baseline assessment data
      • physiologic status
      • pregnancy status (e.g., complications, weeks of gestation, uterine activity, fetal wellbeing)
      • response to medication and interventions
      • psychosocial status, social determinants of health
      • barriers to accessing care and services
      • health literacy
      • cultural and spiritual preferences
      • safety risks
      • family interaction
      • plan for transition of care

    Hypertensive Disorders in Pregnancy

    Signs/Symptoms/Presentation

    • edema
    • epigastric/right upper quadrant pain
    • headache
    • malaise
    • nausea
    • seizure activity (eclampsia)
    • visual disturbance
    • vomiting

    Vital Signs: Preeclampsia

    • diastolic blood pressure persistently 90 mmHg or higher
    • systolic blood pressure persistently 140 mmHg or higher

    Vital Signs: Preeclampsia with Severe Features

    • diastolic blood pressure persistently 110 mmHg or higher
    • systolic blood pressure persistently 160 mmHg or higher

    Laboratory Values

    • 24-hour urine positive for elevated protein
    • BUN (blood urea nitrogen) increased
    • coagulation studies abnormal
    • GFR (glomerular filtration rate) decreased
    • liver enzymes elevated
    • platelet count decreased
    • serum creatinine increased
    • urine protein to creatinine ratio elevated
    • serum uric acid increased

    Laboratory Values: HELLP Syndrome

    • liver enzymes elevated
    • platelet count decreased
    • RBC (red blood cell) hemolysis

    Diagnostic Results

    • Doppler cord studies abnormal
    • fetal growth abnormal per ultrasound
    • fetal surveillance testing abnormal

    Problem Intervention

    Optimize Blood Pressure and Fluid Status

    • Limit activity and promote rest in lateral recumbent position. Raise siderails for safety if on magnesium sulfate.
    • Assess level of consciousness, deep tendon reflexes and presence of clonus.
    • Evaluate presence and degree of proteinuria.
    • Anticipate need to continue low-dose aspirin regimen until delivery.
    • Prepare for administration of antihypertensive medication for blood pressure elevation; once stabilized, prepare for maintenance therapy.
    • Maintain accurate intake and output record.
    • Closely monitor edema presence, location and degree.
    • Anticipate ongoing fetal surveillance, such as ultrasound, Doppler velocimetry, amniotic fluid volume assessment and nonstress testing.
    • Anticipate need to administer antenatal corticosteroid therapy as prescribed and gestationally-appropriate.

    Associated Documentation

    • Fetal Wellbeing Promotion
    • Fluid/Electrolyte Management

    Problem Intervention

    Monitor and Manage Symptom Progression

    • Note behavioral changes (e.g., restlessness).
    • Monitor for report of headache not relieved by pharmacologic therapy or visual disturbance.
    • Implement seizure precautions.
    • Evaluate any complaint of epigastric or abdominal pain.
    • Anticipate initiation and titration of magnesium sulfate infusion for seizure prevention. Note: Magnesium sulfate has also been identified to provide neuroprotection with gestations of less than 32 weeks.
    • Assess for signs of bleeding (vaginal or other sites, such as intravenous site, gums).
    • Evaluate for presence of respiratory compromise by regularly auscultating breath sounds and monitoring pulse oximetry (continuous if on magnesium sulfate); report presence of chest pain, decreased oxygen saturation, cough and shortness of breath.
    • Provide calm, reassuring presence; offer clear explanation of events.
    • Prepare for delivery, planned or emergent, based on change in maternal-fetal status.

    Associated Documentation

    • Medication Review/Management
    • Seizure Precautions

    Education

    CPG-Specific Education Topics

    Overview

    • description

    • signs/symptoms

    Self Management

    • perinatal care

    • VTE prevention

    When to Seek Medical Attention

    • unresolved/worsening symptoms

    General Education Topics

    General Education

    • admission, transition of care

    • orientation to care setting, routine

    • advance care planning

    • diagnostic tests/procedures

    • diet modification

    • opioid medication management

    • oral health

    • medication management

    • pain assessment process

    • safe medication disposal

    • tobacco use, smoke exposure

    • treatment plan

    Safety Education

    • call light use

    • equipment/home supplies

    • fall prevention

    • harm prevention

    • infection prevention

    • MDRO (multidrug-resistant organism) care

    • personal health information

    • resources for support

    References

    • (2021). Rice Simpson, K.; Creehan, P. A.; O'Brien-Abel, N.; Roth, C. K.; Rohan, A. J. (Eds.), AWHONN's Perinatal Nursing. Philadelphia: Wolters Kluwer. [Core Curriculum]
    • Additional Information: Table_Hypertensive Disorders in Pregnancy_2021. PDF. Download[]
    • Al-Rubaie, Z.; Askie, L. M.; Hudson, H. M.; Ray, J. G.; Jenkins, G.; Lord, S. J.. Assessment of NICE and USPSTF guidelines for identifying women at high risk of pre-eclampsia for tailoring aspirin prophylaxis in pregnancy: An individual participant data meta-analysis. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2018;, 159-166. doi:10.1016/j.ejogrb.2018.08.587 [Meta-analysis]
    • Al-Rubaie, Z.; Askie, L. M.; Hudson, H. M.; Ray, J. G.; Jenkins, G.; Lord, S. J.. Assessment of NICE and USPSTF guidelines for identifying women at high risk of pre-eclampsia for tailoring aspirin prophylaxis in pregnancy: An individual participant data meta-analysis. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2018;, 159-166. doi:10.1016/j.ejogrb.2018.08.587 [Meta-analysis]
    • American College of Obstetricians and Gynecologists' Committee on Practice Bulletins-Obstetrics; Espinoza, J.; Vidaeff, A.; Pettker, C. M.; Simhan, H. ACOG Practice Bulletin Number 222: Gestational Hypertension and Preeclampsia (Interim Update) . Obstetrics & Gynecology. 2020;135(6), e237-e260. doi:10.1097/AOG.0000000000003891 [Expert/Committee Opinion,Core Curriculum]
    • Ankumah, N. A.; Sibai, B. M. Chronic Hypertension in Pregnancy: Diagnosis, Management, and Outcomes. Clinical Obstetrics and Gynecology. 2017;60(1), 206-214. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Ankumah, N. A.; Sibai, B. M. Chronic Hypertension in Pregnancy: Diagnosis, Management, and Outcomes. Clinical Obstetrics and Gynecology. 2017;60(1), 206-214. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Bernstein, P. S.; Martin Jr., J. N.; Barton, J. R.; Shields, L. E.; Druzin, M. L.; Scavone, B. M.; Frost, J.; Morton, C. H.; Ruhl, C.; Slager, J.; Tsigas, E. Z.; Jaffer, S.; Menard, M. K. National Partnership for Maternal Safety: Consensus Bundle on Severe Hypertension During Pregnancy and the Postpartum Period. Obstetrics & Gynecology. 2017;130(2), 347-357. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Committee on Obstetric Practice, El-Sayed, Y. Y.; Borders, A. E. ACOG committee opinion number 767 (interim release): Emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period. Obstetrics & Gynecology. 2019;133(2), e174-e180. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Jackson, J. R.; Gregg, A. R. Updates on the Recognition, Prevention and Management of Hypertension in Pregnancy. Obstetrics and Gynecology Clinics of North America. 2017;44(2), 219. doi:10.1016/j.ogc.2017.02.007 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Jackson, J. R.; Gregg, A. R. Updates on the Recognition, Prevention and Management of Hypertension in Pregnancy. Obstetrics and Gynecology Clinics of North America. 2017;44(2), 219. doi:10.1016/j.ogc.2017.02.007 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Kilpatrick, S. J.; Papile, L.; Macones, G. A.; Watterberg, K. L.; American Academy of Pediatrics (AAP); American College of Obstetricians and Gynecologists. (2017). Guidelines for perinatal care. Elk Grove, IL; Washington, DC: American Academy of Pediatrics; American College of Obstetricians and Gynecologists (ACOG). [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Mattson, S.; Smith, J. (2016). Core curriculum for maternal-newborn nursing. St. Louis: Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Mattson, S.; Smith, J. (2016). Core curriculum for maternal-newborn nursing. St. Louis: Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • National Institute for Health and Care Excellence (NICE). (2019). NG133: Hypertension in Pregnancy: Diagnosis and Management. Source[Clinical Practice Guidelines]
    • Rouse, D. J.; Committee on Practice Bulletins-Obstetrics. ACOG Practice Bulletin Number 145: Antepartum Fetal Surveillance. Obstetrics & Gynecology. 2014;124(1), 182-192. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Troiano, N. H.; Witcher, P. M.; McMurtry Baird, S.. (2019). AWHONN: High-risk & critical care obstetrics. Philadelphia: Wolters Kluwer. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Troiano, N. H.; Witcher, P. M.; McMurtry Baird, S.. (2019). AWHONN: High-risk & critical care obstetrics. Philadelphia: Wolters Kluwer. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Troiano, N. H.; Witcher, P. M.; McMurtry Baird, S.. (2019). AWHONN: High-risk & critical care obstetrics. Philadelphia: Wolters Kluwer. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • U. S. Preventive Services Task Force (USPTF). Screening for Preeclampsia: US Preventive Services Task Force Recommendation Statement. JAMA - Journal of the American Medical Association. 2017;317(16), 1661-1667. [Quality Measures,Clinical Practice Guidelines]
    • Vidaeff, A.; Espinoza, J.; Simhan, H.; Pettker, C. M.; Committee on Practice Bulletins-Obstetrics. ACOG practice bulletin number 203: Chronic Hypertension in Pregnancy. Obstetrics & Gynecology. 2019;133(1), e26-e50. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Whelton, P. K.; Carey, R. M.; Aronow, W. S.; Casey, D. E.; Collins, K. J.; Dennison Himmelfarb, C.; DePalma, S. M.; Gidding, S.; Jamerson, K. A.; Jones, D. W.; MacLaughlin, E. J.; Muntner, P.; Ovbiagele, B.; Smith, S. C.; Spencer, C. C.; Stafford, R. S.; Taler, S. J.; Thomas, R. J.; Williams Sr., K. A.; Williamson, J. D.; Wright, J. T. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology. 2017; doi:https://doi.org/10.1016/j.jacc.2017.11.006 [Quality Measures,Clinical Practice Guidelines]

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