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    Hypertensive Disorders of Pregnancy

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    Mar.31.2022

    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 (Box 1)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#ref2">2

    OVERVIEW

    Several types of hypertension can occur in pregnancy (Table 1)Table 1:

    • Gestational hypertension is characterized by hypertension diagnosed after 20 weeks’ gestation2,8 in a patient with a previously normal BP; proteinuria and severe features of preeclampsia are absent. 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.1,5
    • Preeclampsia is new-onset hypertension diagnosed after 20 weeks’ gestation2,8 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.2,8
    • Chronic hypertension with superimposed preeclampsia is a diagnosis of preeclampsia in a pregnant patient who has a history of hypertension before pregnancy or before 20 weeks’ gestation.1,8

    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.1,3

    Risk factors for developing preeclampsia include (Box 2)Box 2:2,6

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

    Generalized pitting edema (Figure 1)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. Pitting edema may be absent in some pregnant patients who develop preeclampsia and may be severe in other pregnant patients who do not have preeclampsia.9

    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)Table 1. HELLP syndrome may present for the first time or progress in the postpartum period. The main presenting symptoms in HELLP syndrome include right upper quadrant pain, generalized malaise, nausea, and vomiting.2

    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.9

    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
      • Eclampsia
      • Chronic hypertension
      • Gestational hypertension
    • For a patient with preeclampsia, explain that the condition can compromise placental blood flow and instruct the patient and support person regarding proper positioning.
      • Assume a side-lying position, if possible, to decrease BP and increase perfusion to the uterus and kidneys.
      • 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.7
      • Change positions frequently with assistance.
      • Keep the knees slightly bent.
    • For a patient with preeclampsia or eclampsia, explain that the risk for seizure remains high during postpartum,2,9 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, fetal heart rate (FHR), and contraction assessment.
    • Instruct the patient and support person on the signs and symptoms of impending seizure (e.g., headache, mental confusion or drowsiness, visual disturbances) and provide instructions on when to seek additional care.
    • Explain to the patient and support person that excessive stimulation may precipitate seizure activity.9
    • Reduce central nervous system (CNS) irritability using:
      • Environmental control (i.e., quiet, low lighting, reduced stimulation)
      • Bedrest in the lateral position
    • Instruct the patient and support person on the steps to take during a seizure.
      • Guide the mother 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 mother to the side with the head tilted slightly forward.
      • Do not restrain the mother or attempt to insert anything into the mouth during a seizure.
      • Call for emergency assistance.
    • If the patient must be transferred to an acute care facility for a higher level of care, teach the patient and support person about the use of magnesium sulfate, a CNS depressant, to prevent seizures.
    • 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. Don appropriate 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 mother and support person.
    3. Verify the correct patient using two identifiers.
    4. Explain the procedure to the mother and support person and ensure that the patient agrees to treatment.
    5. Verify the practitioner’s order and assess the patient for pain.
    6. Assess pertinent baseline laboratory history, such as proteinuria; complete blood count results; blood urea nitrogen, creatinine, and electrolyte levels; liver function studies; coagulation screen; and serum medication levels.
    7. Record the date of the patient’s last menstrual period and estimated date of delivery or date of delivery if postpartum.
    8. Assess the patient for signs and symptoms of an impending seizure.
      1. Change in vital signs, sometimes subtle
      2. Hyperreflexia, sometimes accompanied by ankle clonus (Figure 2)Figure 2
      3. Continuous headache, drowsiness, or mental confusion
      4. Visual disturbances, such as blurred vision or double vision
        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.9 Visual disturbances, such as blurred vision or double vision, indicate retinal edema and arterial spasms.9
    9. Assess the patient for 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.9
    10. Prepare an area in a clean, convenient location and assemble the necessary supplies.
    11. Perform hand hygiene and don gloves.
    12. Assist the patient with removing clothes as needed, ensuring privacy.
    13. Obtain the patient’s vital signs, check deep tendon reflexes (DTRs), and assess for clonus.
      Rationale: Baseline data are used to evaluate treatment effectiveness.9
    14. 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.9 Pulmonary edema can occur with preeclampsia with severe features.
    15. Assess the fundus and lochia if the patient is postpartum.
    16. 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.9
    17. 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 Category II characteristics are noted.4
    18. Notify the practitioner of any abnormal findings.
      1. If the patient’s BP is in the range of preeclampsia with severe features, signs of impending seizure are noted, or both are present, prepare the patient for emergent transportation to an acute care facility.
      2. If Category II FHR is auscultated, prepare the patient for emergent transportation to an acute care facility.
    19. Assess pain, treat if necessary, and reassess.
    20. Provide support and education to the patient and support person and opportunities for them to ask questions or state concerns.
    21. Discard or store supplies, remove PPE, and perform hand hygiene.
    22. Document the procedure in the patient’s record.

    EXPECTED OUTCOMES

    • BP remains within acceptable parameters
    • No seizure activity
    • Category I auscultated FHR

    UNEXPECTED OUTCOMES

    • BP does not remain within acceptable parameters
    • Seizure activity
    • Category II auscultated FHR
    • Maternal death
    • Fetal death

    DOCUMENTATION

    • Ongoing physical assessment
      • Vital signs
      • Reflexes
      • Clonus
      • Visual disturbances
      • Epigastric discomfort
      • Nausea
      • Vomiting
      • Edema
      • Headache
    • 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 and associated FHR category
    • Seizure safety precautions
    • Any seizure activity and interventions and patient 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). ACOG practice bulletin no. 222: Gestational hypertension and preeclampsia. Obstetrics & Gynecology, 135(6), e237-e260. doi:10.1097/AOG.0000000000003891 (Level I)
    3. Bernstein, P.S. and others. (2017). Consensus bundle on severe hypertension during pregnancy and the postpartum period. JOGNN: Journal of Obstetric, Gynecologic, and Neonatal Nursing, 46(5), 776-787. doi:10.1016/j.jogn.2017.05.003 (Level VII)
    4. Cypher, B. (2019). Chapter 9: Assessing the fetus. In S.S. Murray and others (Eds.), Foundations of maternal-newborn and women’s health nursing (7th ed., pp. 178-199). St. Louis: Elsevier.
    5. Dix, D. (2020). Chapter 27: Hypertensive disorders. In D.L. Lowdermilk and others (Eds.), Maternity & women’s health care (12th ed., pp. 583-597). St. Louis: Elsevier.
    6. Lai, C., Coulter, S.A., Woodruff, A. (2017). Hypertension and pregnancy. Texas Heart Institute Journal, 44(5), 350-351. doi:10.14503/THIJ-17-6359 (Level VII)
    7. Piacenza, D. (2019). Chapter 6: Maternal adaptations to pregnancy. In S.S. Murray and others (Eds.), Foundations of maternal-newborn and women’s health nursing (7th ed., pp. 100-126). St. Louis: Elsevier.
    8. Preeclampsia Foundation. (2019). Preeclampsia and future cardiovascular disease in women: What do we know and what can we do? Preeclampsia Foundation position paper. Retrieved February 10, 2022, from https://www.preeclampsia.org/public/frontend/assets/img/gallery/pages/FINAL_PE_CVD_POSITION-PAPER.pdf
    9. Scheffer, K.L. and others. (2019). Chapter 10: Complications of pregnancy. In S.S. Murray and others (Eds.), Foundations of maternal-newborn and women’s health nursing (7th ed., pp. 200-270). 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

    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. (2021). Heart disease & stroke. Retrieved February 10, 2022, 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

    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

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