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Oct.24.2019

Hypertensive Disorders in Pregnancy (Obstetrics Inpatient)

Clinical Description

  • Care of the hospitalized perinatal patient experiencing gestational hypertension, preeclampsia (with or without severe features), 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 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/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.

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

  • diastolic blood pressure persistently 90 mmHg or higher
  • systolic blood pressure persistently 140 mmHg or higher
  • diastolic blood pressure persistently 110 mmHg or higher (considered severe)
  • systolic blood pressure persistently 160 mmHg or higher (considered severe)

HELLP Syndrome

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

Laboratory Values

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

Diagnostic Results

  • poor fetal growth noted per ultrasound

Problem Intervention

Optimize Blood Pressure and Fluid Status

  • Limit activity and promote rest in lateral recumbent position.
  • Assess 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 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 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).
  • 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

  • American College of Obstetricians and Gynecologists; Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstetrics and Gynecology. 2013;122(5), 1122. doi:10.1097/01.AOG.0000437382.03963.88 [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]
  • Barnhart, L. HELLP Syndrome and the Effects on the Neonate. Neonatal Network. 2015;34(5), 269. doi:10.1891/0730-0832.34.5.269 [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]
  • Duley, L.; Meher, S.; Jones, L. Drugs for treatment of very high blood pressure during pregnancy. Cochrane Database of Systematic Reviews. 2013;(7) doi:10.1002/14651858.CD001449.pub3 [Metasynthesis,Meta-analysis,Systematic Review]
  • Espinoza, J.; Vidaeff, A.; Pettker, C. M.; Simhan, H.; Committee on Practice Bulletins-Obstetric. ACOG practice bulletin number 202: Gestational Hypertension and Preeclampsia. Obstetrics & Gynecology. 2019;133(1), e1-e25. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Haram, K.; Svendsen, E.; Abildgaard, U. The HELLP syndrome: Clinical issues and management. A review. BMC Pregnancy and Childbirth. 2009;9 doi:10.1186/1471-2393-9-8 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Hypertensive Disorders in Pregnancy. PDF. Download[]
  • 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]
  • Mao, M.; Chen, C. Corticosteroid therapy for management of hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome: A meta-analysis. Medical Science Monitor. 2015;21, 3777. doi:10.12659/MSM.895220 [Metasynthesis,Meta-analysis,Systematic Review]
  • 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]
  • 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]
  • 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]
  • van Vliet, E. O.; Askie, L. A.; Mol, B. W.; Oudijk, M. A. Antiplatelet Agents and the Prevention of Spontaneous Preterm Birth: A Systematic Review and Meta-analysis. Obstetrics and Gynecology. 2017;129(2), 327. doi:10.1097/AOG.0000000000001848 [Metasynthesis,Meta-analysis,Systematic Review]
  • 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]

Disclaimer

Clinical Practice Guidelines represent a consistent/standardized approach to the care of patients with specific diagnoses. Care should always be individualized by adding patient specific information to the Plan of Care.