Hypertensive Disorders of Pregnancy (Home Health Care) - CE

ALERT

Accurate blood pressure (BP) measurement aids early detection of hypertensive disorders that may lead to eclamptic seizures or stroke (Box 1).

Treatment is indicated for systolic BP of 160 mm Hg or greater, diastolic BP of 110 mm Hg or greater, or both, confirmed as persistent (lasting 15 minutes or more).^{undefined#ref1">1,2}

Administer antihypertensive treatment, as ordered, as soon as possible, but ideally within 60 minutes after criteria are met.^1,2

OVERVIEW

Several types of hypertensions can occur in pregnancy (Table 1):^1,2,5,7

• Gestational hypertension is characterized by hypertension diagnosed after 20 weeks’ gestation in a patient with a previously normal BP. BP levels return to normal during the postpartum period.
• Chronic hypertension is hypertension that was present before the pregnancy and does not return to normal after the postpartum period.
• Preeclampsia is new-onset hypertension diagnosed after 20 weeks’ gestation in a patient who was previously normotensive and who may have new-onset proteinuria.
• Eclampsia is characterized by new-onset tonic-clonic, focal, or multifocal seizures that cannot be attributed to other causes, such as epilepsy, cerebral ischemia and infarction, intracranial hemorrhage, or drug use.
• Chronic hypertension with superimposed preeclampsia is a diagnosis of preeclampsia in a patient who has a history of hypertension before pregnancy or before 20 weeks’ gestation.

Hypertension in pregnancy is categorized according to BP, proteinuria, the onset of symptoms related to gestation, and system involvement (Table 1).^1,2 Establishing a patient baseline and conducting regular assessments of vital signs, symptoms, and laboratory results is essential to identifying hypertensive disorders of pregnancy.²

Gestational hypertension occurs when patients have abnormal BP values after 20 weeks’ gestation.^1,2 It is considered severe when the systolic BP reaches or exceeds 160 mm Hg or the diastolic BP reaches or exceeds 110 mm Hg.^1,2 Proteinuria and other symptoms of preeclampsia are absent in gestational hypertension; however, it is common for gestational hypertension to progress to preeclampsia.²

Preeclampsia affects 2% to 8% of patients who are pregnant and is a major cause of perinatal morbidity and mortality worldwide.² When hypertension progresses to preeclampsia, patients are at risk for seizures.² Patients who are pregnant with chronic hypertension or preeclampsia have an increased risk of stroke or cerebral complications during pregnancy, even without excessive elevations in BP.¹

Risk factors for developing preeclampsia include (Box 2):²

• Nulliparity
• Preeclampsia in a previous pregnancy
• Multifetal gestations
• Gestational diabetes
• Preexisting medical conditions

Relying on patient symptoms can be problematic when diagnosing preeclampsia because symptoms can be nonspecific in nature and are not clearly indicative of hypertensive disorders of pregnancy. Preeclampsia can result in short- and long-term complications for patients who are pregnant or postpartum. Complications of preeclampsia include:²

• Coagulopathy
• Retinal injury
• Renal failure
• Acute respiratory distress syndrome
• Stroke
• Myocardial infarction
• Pulmonary edema

Generalized pitting edema (Figure 1), once a diagnostic criterion for preeclampsia, is now a nonspecific sign.² Pitting edema may be absent in some patients who develop preeclampsia and may be severe in other pregnant patients who do not have preeclampsia.⁶ Headaches are unreliable and nonspecific as a diagnosis criterion.²

A severe form of preeclampsia is hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. HELLP syndrome has been associated with higher rates of patient morbidity and mortality and is mostly seen during the third trimester but can also present for the first time or progress during the postpartum period (Table 1).^1,2 The main presenting symptoms in HELLP syndrome include right upper quadrant pain, generalized malaise, nausea, and vomiting.²

Medication Treatment for Hypertension

Pregnant patients with hypertension or preeclampsia have an increased risk of stroke or cerebral complications.¹ Treatment is indicated for systolic BP of 160 mm Hg or greater, diastolic BP of 110 mm Hg or greater, or both, confirmed as persistent (lasting 15 minutes or more).^1,2 Antihypertensive treatment should be administered as soon as possible, but ideally within 60 minutes after criteria are met.^1,2 Therapeutic objectives of hypertensive treatment are to decrease the risk of congestive heart failure, myocardial ischemia, renal injury or failure, and ischemic or hemorrhagic stroke.^1,2 Antihypertensive treatment in the obstetric population may be provided with first-line agents, such as nifedipine (immediate release oral) or IV labetalol or hydralazine.^1,2 Continued medication treatment may include labetalol, nifedipine, hydralazine, or methyldopa.^1,2 Methyldopa is not used as frequently due to side effects and lesser effectiveness when compared with labetalol, nifedipine, or hydralazine.¹

Seizure Prevention and Treatment

Seizures related to hypertension that develop during pregnancy are called eclamptic seizures. Eclampsia is frequently preceded by signs of cerebral irritation, such as severe, persistent occipital and frontal headaches; blurred vision; photophobia; and altered mental status, but it can also occur without any warning signs or symptoms at all.² Most eclamptic seizures are self-limited, but can cause patient hypoxia, and prolonged fetal heart rate (FHR) abnormalities. Eclamptic seizures that occur postpartum usually occur within the first 7 days, and 50% of eclamptic seizures occur in labor or within the first 48 hours postpartum.⁶

Magnesium sulfate is the drug of choice for preventing seizures in patients with preeclampsia with severe features and potential hypertensive crisis during the pregnancy and postpartum periods.² Its mechanism of action for seizure prevention is unclear, but it may work as a central anticonvulsant, may prevent or decrease cerebral edema, or may cause vasodilation in the cerebral and peripheral circulation.⁵ Although magnesium is used for seizure prevention, it is not given to stop a seizure, but to prevent the recurrence.²

Timing of Delivery

To prevent adverse maternal and fetal outcomes, delivery of the fetus is recommended when gestational hypertension or preeclampsia with severe features is diagnosed at 34 0/7 weeks gestation or beyond, after the patient is stabilized, or with labor or pre-labor rupture of membranes.² When the late preterm period has been reached, delay of delivery to administer steroids is not recommended.² For patients with preeclampsia without severe features or with gestational hypertension, expectant management up to 37 weeks’ gestation is recommended, along with frequent maternal and fetal evaluation.²

SUPPLIES

See Supplies tab at the top of the page.

EDUCATION

• Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
• Explain the appropriate disease processes applicable to the patient’s condition.
  • Preeclampsia
  • Gestational hypertension
  • Chronic hypertension
  • Eclampsia
  • HELLP syndrome
• Instruct the patient and support person regarding activity limitations and frequent rest periods or bed rest, if prescribed.⁶
  • Reduce daily physical activity.⁶
  • Take frequent rest periods with legs elevated or resting in bed.⁶
  • Lie in a lateral position to decrease pressure on the vena cava and improve perfusion to the vital organs and placenta.⁶
  • Avoid lying on the back or if lying on the back, place a pillow or wedge under the right or left hip to displace the weight of the uterus from the descending vena cava and prevent supine hypotension.⁸
• Explain to the patient and support person that safety concerns apply in the home as well as in an acute care facility, and taking safety precautions at home may help lower the risk of injury and anxiety levels.
• Instruct the patient and support person regarding fetal movement counts and contraction assessment, if appropriate.
• Suggest methods to reduce central nervous system (CNS) irritability, using:
  • Environmental control (e.g., quiet, low lighting, reduced stimulation)
  • Bedrest in the lateral position
• Instruct the patient and support person on the signs and symptoms of worsening illness (e.g., headache, mental confusion or drowsiness, visual disturbances) and provide instructions on when to seek urgent or additional care.
• Instruct the patient and support person on the steps to take during a seizure.
  • Guide the patient to the floor (if standing or sitting) and place a pad under the head for protection.
  • Clear surrounding objects out of the way.
  • If able, turn the patient to the side with the head tilted slightly forward.
  • Do not restrain the patient or attempt to insert anything into the mouth during a seizure.
  • Call for emergency assistance.
• Teach the patient and support person about additional medications as indicated.
  • Antihypertensives
  • Anticonvulsants
  • Low dose aspirin
• Encourage questions and answer them as they arise.

PROCEDURE

1. Perform hand hygiene and don gloves. Don additional personal protective equipment (PPE) based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Introduce yourself to the patient and support person.
3. Verify the correct patient using two identifiers.
4. Explain the procedure and ensure that the patient agrees to treatment.
5. Note the date of the patient’s last menstrual period and estimated date of delivery or actual date of delivery if postpartum.
6. Obtain the patient’s vital signs (including BP [Box 1], pulse, respirations, SpO₂), check deep tendon reflexes (DTRs), and assess for clonus.

   If BP is greater than or equal to 140/90 mm Hg, repeat the BP measurement within 15 minutes.³

7. Assess the patient for signs and symptoms of worsening illness or of an impending seizure.

   Seizure activity may occur without warning signs or symptoms in some patients.²

   1. Increase in BP, may be subtle
   2. Hyperreflexia, sometimes accompanied by ankle clonus (Figure 2), continuous headache, drowsiness, or mental confusion

      Rationale: Hyperreflexia, clonus, continuous headache, drowsiness, or mental confusion are signs of poor cerebral perfusion and may foreshadow seizure activity.⁶

   3. Visual disturbances, such as blurred vision or double vision

      Rationale: Visual disturbances, such as blurred vision or double vision, may indicate retinal edema and arterial spasms.⁶

   4. Epigastric pain, nausea, or vomiting

      Rationale: Epigastric pain, nausea, or vomiting may indicate liver capsule distention and increase the chance of liver rupture associated with severe preeclampsia.⁶

8. Auscultate breath sounds and assess the patient for signs of fluid volume excess.
   1. Increased edema
   2. Decreased urine output
   3. Weight gain
   4. Dyspnea
   5. Crackles in the lungs

      Rationale: Decreased urinary output is caused by poor renal perfusion and may precede acute renal failure.⁶

9. Assess for any report of contractions, vaginal drainage or bleeding, or abdominal pain or tenderness if the patient is antepartum.

   Rationale: Abdominal tenderness could indicate placental abruption in a patient with preeclampsia.⁶

10. Assess FHR by auscultation if the patient is antepartum.

    FHR is assessed for evidence of adequate uteroplacental oxygenation. Fetal compromise may be identified during auscultation if abnormal heart tones are noted.⁴

11. Assess the fundus and lochia if the patient is postpartum.
12. Assess pertinent laboratory results, such as urinalysis, complete blood count results, elevated blood urea nitrogen, creatinine, and electrolyte levels, liver function studies, and coagulation screening.
13. Notify the practitioner of any abnormal findings.
    1. If the patient’s BP is greater than or equal to a sustained pressure of 160 mm Hg systolic or 110 mm Hg diastolic, signs of worsening illness are noted, or both are present, notify the practitioner and prepare the patient for transfer to an acute care facility. Remain with the patient until stable or transfer.
    2. If abnormal fetal heart tones are noted with auscultation, notify the practitioner and prepare the patient for transfer to an acute care facility for evaluation. Remain with the patient until stable or transfer.
14. Assess pain, treat if necessary, and reassess.
15. Provide support and education to the patient and support person and opportunities for them to ask questions or state concerns.
16. Discard or store supplies, remove PPE, and perform hand hygiene.
17. Document the procedure in the patient’s record.

EXPECTED OUTCOMES

• BP within acceptable parameters
• Absence of signs and symptoms of fluid volume excess
• Absence of seizures
• No adverse patient outcomes related to hypertension or seizure activity
• No adverse fetal outcomes related to hypertension or seizure activity

UNEXPECTED OUTCOMES

• BP not within acceptable parameters
• Worsening signs and symptoms of fluid volume excess
• Seizure activity
• Adverse patient outcomes related to hypertension or seizure activity
• Adverse fetal outcomes related to hypertension or seizure activity

DOCUMENTATION

• Physical assessment
• Patient history and estimated date of delivery
• Patient’s report of contractions and associated pain level
• Contraction frequency, duration, intensity, and resting tone
• Auscultated FHR
• Seizure safety precautions
• Any seizure activity and interventions and patient’s responses
• Unexpected outcomes and related interventions
• Report of patient status to practitioner and practitioner’s response
• Education
• Assessment of pain, treatment if necessary, and reassessment

REFERENCES

1. American College of Obstetricians and Gynecologists (ACOG). (2019). ACOG practice bulletin no. 203: Chronic hypertension in pregnancy. Obstetrics & Gynecology, 133(1), e26-e50. doi:10.1097/AOG.0000000000003020 (Level I)
2. American College of Obstetricians and Gynecologists (ACOG). (2020, reaffirmed 2023). ACOG practice bulletin no. 222: Gestational hypertension and preeclampsia. (Interim update). Obstetrics & Gynecology, 135(6), e237-e260. doi:10.1097/AOG.0000000000003891 (Level I)
3. California Maternal Quality Care Collaborative (CMQCC). (2021). Improving health care response to hypertensive disorders of pregnancy toolkit. Retrieved August 18, 2023, from https://www.cmqcc.org/resources-tool-kits/toolkits/HDP (Level VII)
4. Cypher, R.L., Kujansuu, C.M. (2023). Chapter 9: Prenatal diagnosis and fetal assessment during the antepartum period. In S.S. Murray and others (Eds.), Foundations of maternal-newborn and women’s health nursing (8th ed., pp. 175-205). St. Louis: Elsevier.
5. Dix, D. (2024). Chapter 27: Hypertensive disorders. In D.L. Lowdermilk and others (Eds.), Maternity & women’s health care (13th ed., pp. 585-599). St. Louis: Elsevier.
6. Ketcham, N. and others. (2023). Chapter 10: Complications of pregnancy. In S.S. Murray and others (Eds.), Foundations of maternal-newborn and women’s health nursing (8th ed., pp. 207-268). St. Louis: Elsevier.
7. Leslie, M.S., Briggs, L.A. (2019). Preeclampsia Foundation position paper: Preeclampsia and future cardiovascular disease. Retrieved August 18, 2023, from https://www.preeclampsia.org/public/frontend/assets/img/gallery/pages/FINAL_PE_CVD_POSITION-PAPER.pdf (Level VII)
8. Piacenza, D. (2023). Chapter 6: Adaptations to pregnancy. In S.S. Murray and others (Eds.), Foundations of maternal-newborn and women’s health nursing (8th ed., pp. 95-121). St. Louis: Elsevier.

ADDITIONAL READINGS

Magee, L.A., Khalil, A., von Dadelszen, P. (2020). Pregnancy hypertension diagnosis and care in COVID-19 era and beyond. Ultrasound in Obstetrics & Gynecology, 56(1), 7-10. doi:10.1002/uog.22115

Society for Maternal-Fetal Medicine; Publications Committee. (2022). Society for Maternal-Fetal Medicine statement: Antihypertensive therapy for mild chronic hypertension in pregnancy–The chronic hypertension and pregnancy trial. American Journal of Obstetrics and Gynecology, 227(2), B24-B27. doi:10.1016/j.ajog.2022.04.011.

Society for Maternal-Fetal Medicine (SMFM) and others. (2022). Society for Maternal-Fetal Medicine special statement: A quality metric for evaluating timely treatment of severe hypertension. American Journal of Obstetrics and Gynecology, 226(2), B2-B9. doi:10.1016/j.ajog.2021.10.007.

Society for Maternal-Fetal Medicine (SMFM) and others. (2022). Society for Maternal-Fetal Medicine special statement: Quality metric for timely postpartum follow-up after severe hypertension. American Journal of Obstetrics and Gynecology, 227(3), B2-B8. doi:10.1016/j.ajog.2022.05.045.

US Preventive Services Task Force and others. (2021). Aspirin use to prevent preeclampsia and related morbidity and mortality: US Preventive Services Task Force recommendation statement. JAMA, 326(12), 1186-1191. doi:10.1001/jama.2021.14781.

Xydopoulos, G. and others. (2019). Home blood-pressure monitoring in a hypertensive pregnant population: Cost-minimization study. Ultrasound in Obstetrics & Gynecology, 53(4), 496-502. doi:10.1002/uog.19041

Elsevier Skills Levels of Evidence

• Level I - Systematic review of all relevant randomized controlled trials
• Level II - At least one well-designed randomized controlled trial
• Level III - Well-designed controlled trials without randomization
• Level IV - Well-designed case-controlled or cohort studies
• Level V - Descriptive or qualitative studies
• Level VI - Single descriptive or qualitative study
• Level VII - Authority opinion or expert committee reports

Clinical Review: Adele Clobes, JD, APRN, CNM

Published: October 2023