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Timely treatment of a systolic blood pressure (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), is necessary to decrease the risk of stroke.undefined#ref3">3,4,8,10
Accurate BP measurement aids early detection of hypertensive disorders that may lead to eclamptic seizures (Box 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):2,9
Several types of hypertension can occur in pregnancy (Table 1):
Hypertension in pregnancy is categorized according to BP, proteinuria, the onset of symptoms related to gestation, and system involvement (Table 1). Establishing a patient baseline and conducting regular assessments of vital signs, symptoms, and laboratory results is essential to identifying hypertensive disorders of pregnancy. A diagnosis of a hypertensive disorder of pregnancy is based on:2
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. It may be absent in some pregnant patients who develop preeclampsia and may be severe in other pregnant patients who do not have preeclampsia.12
In the absence of proteinuria, a patient may be diagnosed with new-onset preeclampsia with severe features if any of these signs or symptoms are present: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
Pregnant patients with chronic hypertension or preeclampsia, even if they do not experience severe increases in BP, have an increased risk of stroke or cerebral complications during pregnancy.1 Treatment of 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) is necessary to decrease the risk of stroke.3
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. Criteria used for making the diagnosis of HELLP syndrome include elevated lactate dehydrogenase (LDH) to 600 IU/L or more,2 aspartate aminotransferase (AST) and alanine aminotransferase (ALT) elevations of more than twice the upper limit of normal, and a platelet count of 100 × 109/L or less.2 HELLP syndrome is mostly seen during the third trimester, but it may present for the first time or progress in the postpartum period.
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
Magnesium sulfate is the drug of choice for preventing seizures in patients with severe hypertension during pregnancy and the postpartum period.3 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.7 A loading dose of 4 to 6 g is infused over 20 to 30 minutes, as ordered by a practitioner.2 A maintenance dose of 1 to 2 g/hr2 is ordered for seizure prevention. Toxic levels of magnesium sulfate (greater than 9 mg/dl) can cause loss of deep tendon reflexes (DTRs), respiratory depression, and cardiac arrest.2 Calcium gluconate should be readily available to treat magnesium toxicity, with 10 ml of a 10% solution administered intravenously over 3 minutes.2,12
If the patient has persistent seizure activity regardless of repeated loading doses of magnesium sulfate, another anticonvulsant should be administered:5
The use of other agents such as propofol is organization specific.5
To prevent adverse maternal and fetal outcomes, delivery of the fetus is recommended when gestational hypertension or preeclampsia with severe features is diagnosed at 34 0/7 weeks2 of gestation or beyond, after the mother is stabilized, or with labor or prelabor rupture of membranes. When the late preterm period has been reached, delay of delivery to administer steroids is not recommended.2 For pregnant 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
Rationale: Stimuli may precipitate seizure activity.
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.
Rationale: Abdominal tenderness could indicate placental abruption in a patient with preeclampsia.
Rationale: A nonstress test establishes a baseline and demonstrates fetal well-being.
Fetal compromise may be identified in a Category II (indeterminate) or Category III (abnormal) tracing and may be demonstrated by FHR decelerations with moderate variability or by recurrent FHR decelerations with minimal or absent variability.
Rationale: Baseline data are used to evaluate treatment effectiveness.
Rationale: FHR is assessed for evidence of adequate uteroplacental oxygenation.
Rationale: Decreased urinary output is caused by poor renal perfusion and may precede acute renal failure.
Rationale: IV magnesium sulfate, calcium gluconate, antihypertensives, and antiepileptics may be incompatible with standard IV maintenance solutions and oxytocin.
Always piggyback magnesium sulfate into a mainline infusion and administer it using an infusion pump.12
Rationale: Advanced preparation reduces the time between seizure activity and interventions to reduce the risk of further complications. Calcium gluconate reverses magnesium toxicity and prevents respiratory arrest.
Follow the organization’s safety practices for the administration of magnesium sulfate and monitor serum magnesium levels to detect toxicity.
Rationale: Hyperreflexia and clonus are signs of poor cerebral perfusion and may foreshadow seizure activity.
Rationale: Continuous headache, drowsiness, or mental confusion are signs of poor cerebral perfusion and may foreshadow seizure activity.
Rationale: 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.
None of these signs and symptoms predict imminent seizure activity, but 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.12
Rationale: Multiple team members can perform several interventions simultaneously, reducing the risk of complications and injury from the ongoing seizure activity. A patent airway is always the first priority in seizure management, but mouth and teeth damage may occur if a device is placed between the patient’s teeth.
Do not restrain a patient experiencing a seizure.
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.2,12
Rationale: Seizure activity may occur without warning signs or symptoms in some patients.
Rationale: A magnesium sulfate infusion is continued after birth for seizure prophylaxis.
Rationale: The patient with preeclampsia or eclampsia remains at risk for seizure postpartum.
2,12 Safety concerns apply in the home as well as in the organization. Education of the patient and support person regarding safety precautions at home may help lower the risk of injury and lower anxiety levels regarding the patient’s condition.
Jafar, M.F. (2015). Hypertensive disorders in pregnancy. Anaesthesia, Pain & Intensive Care, 19(1), 80-86.
Preeclampsia Foundation. (2019). Preeclampsia and future cardiovascular disease in women: What do we know and what can we do? Preeclampsia foundation position paper. Retrieved November 18, 2020, from https://www.preeclampsia.org/public/frontend/assets/img/gallery/pages/FINAL_PE_CVD_POSITION-PAPER.pdf
Preeclampsia Foundation. (2020). Heart disease & stroke. Retrieved November 18, 2020, from https://www.preeclampsia.org/health-information/heart-disease-stroke
*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.
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