RETIRING - Hypertensive Disorders of Pregnancy (Maternal-Newborn) - CE/NCPD

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):^1,2,4,8

• Gestational hypertension is characterized by hypertension diagnosed after 20 weeks’ gestation in a patient with previously normal BP. BP levels return to normal during the postpartum period.
• Chronic hypertension is hypertension that was present before the pregnancy or before 20 weeks’ gestation 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 cerebral ischemia and infarction, intracranial hemorrhage, epilepsy, 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.⁷ 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 maternal 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 Obstetric Hypertensive Crisis

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 Antihypertensive treatment should be the first priority, immediately followed by magnesium sulfate for seizure prevention.³ 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 maternal 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.⁷

Magnesium sulfate is the drug of choice for preventing seizures in patients with preeclampsia with severe features, HELLP syndrome, and hypertensive crisis during the pregnant and postpartum periods.² Although magnesium is used for seizure prevention, it is not given to stop a seizure, but to prevent the recurrence.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.⁴ Toxic levels of magnesium sulfate (greater than 9 mg/dl) can cause loss of deep tendon reflexes (DTRs), respiratory depression, and cardiac arrest.² Magnesium toxicity is treated with calcium gluconate.

Timing of Delivery

To prevent adverse maternal and fetal outcomes, delivery of the fetus is recommended after the mother is stabilized, when gestational hypertension or preeclampsia with severe features is diagnosed at 34 0/7 weeks gestation or beyond, 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.
• Instruct the patient regarding proper positioning.
  • Assume a side-lying position if possible.
  • Avoid lying on the back or if lying on the back, place a pillow or wedge under the right or left hip.
  • Change positions frequently with assistance.
  • Keep the knees slightly bent.
• Instruct the patient and support person regarding electronic fetal monitoring.
• Explain the appropriate disease processes applicable to the patient’s condition.
  • Preeclampsia
  • Gestational hypertension
  • Chronic hypertension
  • Eclampsia
  • HELLP syndrome
• Suggest methods to reduce central nervous system (CNS) irritability using:
  • Environment control (e.g., quiet, low lighting, reduced stimulation)
  • Bedrest in the side-lying position
• Explain to the patient and support person the importance of managing medication information to identify and resolve discrepancies.⁶
• 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.
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

1. Perform hand hygiene before patient contact. 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 patient and support person.
3. Verify the correct patient using two identifiers.
4. Obtain the patient’s vital signs (including BP [Box 1], pulse, respirations, SpO₂), check 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

5. Note the date of the patient’s last menstrual period and estimated date of delivery, or date of delivery, if postpartum.
6. 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, which 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.⁷

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

      Rationale: Visual disturbances, such as blurred vision or double vision, indicate retinal edema and arterial spasms.⁷

7. Assess pertinent laboratory results, such as urinalysis, complete blood count results, blood urea nitrogen, creatinine, electrolyte levels, liver function studies, and coagulation screening.

Preparation

1. Review the practitioner’s order for the administration of antihypertensive medications and magnesium sulfate, if applicable.

   If concurrent administration is not possible, make antihypertensive treatment the first priority.³

2. Gather supplies.

PROCEDURE

1. Perform hand hygiene and don gloves. Don additional PPE based on patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Verify the correct patient using two identifiers.
3. Explain the procedure and ensure that the patient agrees to treatment.
4. Assess any report of contractions, vaginal bleeding or drainage, and abdominal pain.
5. Palpate the uterus and note contractions and abdominal tenderness.

   Rationale: Abdominal tenderness could indicate placental abruption in a patient with preeclampsia.⁷

6. Apply the fetal monitor and evaluate fetal well-being and uterine activity. Notify the practitioner of abnormal findings.
7. After meeting hypertensive BP criteria or stabilization, assist the patient into a side-lying position and instruct the patient regarding activity restrictions, if ordered.

   Rationale: Preeclampsia can compromise placental blood flow. Patients with preeclampsia are encouraged to maintain the side-lying position to decrease BP and increase perfusion to the uterus and kidneys. Displacing the weight of the uterus from the descending vena cava prevents supine hypotension.⁹

8. Assess and monitor the patient for signs of fluid volume excess.
   1. Increased edema
   2. Decreased urine output
   3. Elevated serum creatinine level
   4. Weight gain
   5. Dyspnea
   6. Crackles

      Rationale: Decreased urinary output is caused by poor renal perfusion and may precede acute renal failure.⁷

9. Monitor the patient for signs of impaired gas exchange, such as increased respiration and dyspnea.
10. Establish IV access line(s), initiate antihypertensive treatment and magnesium, as ordered.

    Administer antihypertensive treatment, as ordered, as soon as possible, but ideally within 60 minutes after criteria are met.^1,2 If concurrent administration is not possible, make antihypertensive treatment the first priority.³

11. Discard supplies, remove gloves, and perform hand hygiene.
12. Establish a calm, quiet environment.

    Rationale: Stimuli may precipitate seizure activity.⁷

    1. Provide a private room and restrict the number of visitors.
    2. Lower the lights and decrease the volume on maternal and fetal monitors.
    3. Encourage the patient to minimize or mute the volumes on the telephone and television.
    4. Cluster nursing care and interventions.
13. Provide safety measures for potential seizures.

    Rationale: Advanced preparation reduces the time between seizure activity and interventions to reduce the risk of further complications.

    1. Pad side rails.
    2. Ensure that the code cart is readily available with medications (magnesium sulfate, calcium gluconate, anticonvulsants, and antihypertensives) and standard resuscitation supplies (e.g., oxygen, suction, and advanced airway equipment).^5,7

       Rationale: Calcium gluconate reverses magnesium toxicity and prevents respiratory arrest.⁷

    3. Place the bed in the low position.
14. Monitor the patient for signs and symptoms of an impending seizure.

    There are no signs and symptoms that predict imminent seizure activity; however, be aware of subtle changes in the patient’s vital signs and general condition and be prepared to intervene if seizures occur in a patient diagnosed with preeclampsia.⁷

    1. Change in vital signs, sometimes subtle
    2. Hyperreflexia, sometimes accompanied by ankle clonus (Figure 2)

       Rationale: Hyperreflexia and clonus are signs of poor cerebral perfusion and may foreshadow seizure activity.⁷

    3. Continuous headache, drowsiness, or mental confusion

       Rationale: Continuous headache, drowsiness, or mental confusion are signs of poor cerebral perfusion and may foreshadow seizure activity.⁷

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

       Rationale: Visual disturbances, such as blurred vision or double vision, indicate retinal edema and arterial spasms.⁷

    5. 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.⁷

15. Discard supplies, remove PPE, and perform hand hygiene.
16. Document the procedure in the patient’s record.

Patients Experiencing a Seizure

1. If seizure activity occurs, stay with the patient and call for assistance.
2. Note the onset time of the seizure.
3. Follow the organization’s practice for notification of an obstetric emergency.
4. Ask a health care team member to notify the anesthesia provider immediately to assist with airway management.
5. Ask a health care team member to bring the emergency cart to the patient’s bedside.
6. Perform hand hygiene and don gloves. Don additional PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
7. Provide for patient safety during the seizure (Box 3).
8. Assess the patient for presence of labor, rupture of membranes, and signs of placental abruption.⁷

   Rationale: During a seizure, breathing is affected and the blood oxygen level decreases. FHR deceleration is common during a maternal seizure; fetal bradycardia may occur. Uterine contractility and baseline tone may increase.

   Do not leave a patient unattended after a seizure because of the risk of recurring seizures, disorientation, or coma in this postictal state. Delivery of the fetus may be necessary once the patient is stabilized.^2,7

9. Alert the practitioner to any abnormal findings.
10. Continue seizure precautions after the patient returns to the previous cognitive level.
11. Discard supplies, remove PPE, and perform hand hygiene.
12. Document the procedure in the patient’s record.

MONITORING AND CARE

1. Monitor the patient’s vital signs and check DTRs and for clonus.
2. Monitor and assess any report of contractions, vaginal bleeding or drainage, and abdominal pain or tenderness.
3. Continue to monitor FHR and contraction pattern as ordered.
4. Monitor the patient for signs of fluid volume excess.
5. Monitor the patient for signs of impaired gas exchange.
6. Monitor the patient for signs and symptoms of an impending seizure.
7. Maintain seizure precautions throughout the patient’s stay.

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

8. Report any significant changes in the patient’s status to the practitioner.
9. Assess, treat, and reassess pain.
10. Provide support for the patient and support person as well as opportunities for them to ask questions or state concerns.
11. Provide post seizure care as needed.
    1. Explain to the support person that the patient may be unconscious for a time and then will be drowsy.
    2. After the patient regains consciousness, provide support and answer any questions to help address the patient’s and support person’s concerns.⁷

EXPECTED OUTCOMES

• No abnormal findings
• 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

• Abnormal findings
• Seizure activity
• Adverse patient outcomes related to hypertension or seizure activity
• Adverse fetal outcomes related to hypertension or seizure activity
• Patient death
• Fetal death
• Magnesium toxicity

DOCUMENTATION

• Vital signs
• Patient history and estimated date of delivery
• Neurologic assessment
• Patient’s report of contractions and associated pain level
• Contraction frequency, duration, intensity, and resting tone
• FHR assessment and associated category
• Seizure safety precautions
• Ongoing physical assessment
• Assessment of pain, treatment if necessary, and reassessment
• Seizure activity details, interventions, and patient responses
• Medication administered
• Report of patient status to practitioner and practitioner’s response
• Education
• Unexpected outcomes and related interventions

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. 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.
5. Joint Commission, The. (2019). R³ report: Provision of care, treatment, and services standards for maternal safety. Retrieved August 18, 2023, from https://www.jointcommission.org/-/media/tjc/documents/standards/r3-reports/r3-issue-24-maternal-12-7-2021.pdf (Level VII)
6. Joint Commission, The. (2023). National Patient Safety Goals for the hospital program. Retrieved August 18, 2023, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2023/npsg_chapter_hap_jan2023.pdf (Level VII)
7. 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.
8. 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)
9. 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

Preeclampsia Foundation. (2022). Heart disease & stroke. Retrieved August 18, 2023, from https://www.preeclampsia.org/health-information/heart-disease-stroke

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.

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