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:
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
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.
- 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.
- Medication Review/Management
- Seizure Precautions
Education
Overview
description
signs/symptoms
Self Management
perinatal care
VTE prevention
When to Seek Medical Attention
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
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]
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.