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Accurate blood pressure (BP) measurement aids early detection of hypertensive disorders that may lead to eclamptic seizures (Box 1).
Timely treatment of a systolic BP of 160 mm Hg or greater, a diastolic BP of 110 mm Hg or greater, or both, confirmed as persistent (lasting 15 minutes or more), is necessary to decrease the risk of stroke.undefined#ref3">3,4,7,9
Several types of hypertension can occur in pregnancy (Table 1):
Preeclampsia affects 2% to 8%2 of pregnant patients and is a major cause of perinatal morbidity and mortality worldwide. When hypertension progresses to preeclampsia, patients are at risk for seizures. Pregnant patients with chronic hypertension or preeclampsia have an increased risk of stroke or cerebral complications during pregnancy, even without excessive elevations in BP.1,4
Risk factors for developing preeclampsia include (Box 2):2,8
Generalized pitting edema (Figure 1), once a diagnostic criterion for preeclampsia, is now a nonspecific sign because it occurs in many pregnancies uncomplicated by hypertension and may have many different causes.
Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is one of the more severe forms of preeclampsia that has been associated with higher rates of maternal morbidity and mortality (Table 1). HELLP syndrome may present for the first time or progress in the postpartum period.
Preeclampsia with severe features can result in short- and long-term complications for the patient and newborn. Maternal complications include coagulopathy, retinal injury, renal failure, acute respiratory distress syndrome, stroke, myocardial infarction, and pulmonary edema.2 To prevent adverse outcomes to the patient and fetus, delivery of the fetus should be recommended when gestational hypertension or preeclampsia with severe features is diagnosed at or beyond 34 0/7 weeks gestation,2 after stabilization of the mother or with labor or prelabor rupture of membranes.
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 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.12
Rationale: Seizure activity may occur without warning signs or symptoms in some patients.
2 Hyperreflexia, clonus, continuous headache, drowsiness, or mental confusion are signs of poor cerebral perfusion and may foreshadow seizure activity.
12 Visual disturbances, such as blurred vision or double vision, indicate retinal edema and arterial spasms.
Rationale: Epigastric pain, nausea, or vomiting may indicate liver capsule distention and increase the chance of liver rupture associated with severe preeclampsia.
Rationale: Baseline data are used to evaluate treatment effectiveness.
Rationale: Decreased urinary output is caused by poor renal perfusion and may precede acute renal failure.
12 Pulmonary edema can occur with preeclampsia with severe features.
Rationale: Abdominal tenderness could indicate placental abruption in a patient with preeclampsia.
FHR is assessed for evidence of adequate uteroplacental oxygenation. Fetal compromise may be identified during auscultation if Category II characteristics are noted.
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Kilpatrick, S.J. and others. (2016). Severe maternal morbidity in a large cohort of women with acute severe intrapartum hypertension. American Journal of Obstetrics and Gynecology, 215(1), 91.e1-7. doi:10.1016/j.ajog.2016.01.176
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(10), 7-10. doi:10.1002/uog.22115
Mikami, Y. and others. (2017). Provisional criteria for the diagnosis of hypertension in pregnancy using home blood pressure measurements. Hypertension Research, 40(7), 679-684. doi:10.1038/hr.2017.6
Monsen, K.A. and others. (2017). Social determinants and health disparities associated with outcomes of women of childbearing age who receive public health nurse home visiting services. JOGNN: Journal of Obstetric, Gynecologic, and Neonatal Nursing, 46(2), 292-303. doi:10.1016/j.jogn.2016.10.004
Perry, H. and others. (2018). Home blood-pressure monitoring in a hypertensive pregnant population. Ultrasound in Obstetrics & Gynecology, 51(4), 524-530. doi:10.1002/uog.19023
Preeclampsia Foundation. (2020). Heart disease & stroke. Retrieved November 23, 2020, from https://www.preeclampsia.org/health-information/heart-disease-stroke
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
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