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Jan.28.2021

Hypertensive Disorders of Pregnancy (Maternal-Newborn) - CE

ALERT

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)Box 1.

OVERVIEW

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)Box 2:2,9

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

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

  • Gestational hypertension is characterized by hypertension diagnosed after 20 weeks’ gestation2 in a patient with 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 or before 20 weeks’ gestation and does not return to normal after the postpartum period.1,7
  • Preeclampsia is new-onset hypertension diagnosed after 20 weeks’ gestation2 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.2
  • 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

Hypertension in pregnancy is categorized according to BP, proteinuria, the onset of symptoms related to gestation, and system involvement (Table 1)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

  • A systolic BP of 140 mm Hg or more or a diastolic BP of 90 mm Hg or more, on two occasions, at least 4 hours apart, AND
  • After 20 weeks’ gestation in a previously normotensive patient, AND
  • 300 mg or more of protein in a 24-hour urine specimen, OR
  • A protein to creatinine ratio of 0.3 or more, OR
  • A dipstick reading of 2+ (only if other quantitative methods are not available)

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. 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

  • A systolic BP of 160 mm Hg or more or a diastolic BP of 110 mm Hg or more on two occasions, at least 4 hours apart (unless antihypertensive therapy is initiated before this time)
  • Thrombocytopenia (platelet count less than 100 × 109/L)
  • Impaired liver function (blood levels of liver enzymes elevated to more than twice the upper limit of normal concentrations) and not a symptom of an alternative diagnosis or severe persistent right upper quadrant or epigastric pain unresponsive to medication
  • Renal insufficiency (elevated serum creatinine greater than 1.1 mg/dl or doubling of serum creatinine concentration in the absence of other renal disease)
  • Pulmonary edema
  • New-onset headache unresponsive to medication and unexplained by alternative diagnoses
  • Visual disturbances

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

  • Lorazepam 4 mg is given intravenously over 2 to 5 minutes. The dose can be repeated in 5 to 15 minutes. The maximum cumulative dose is 8 mg in 12 hours.5
  • Diazepam 5 to 10 mg is given intravenously slowly. The dose can be repeated every 15 minutes up to 30 mg.5
  • Midazolam 1 to 2 mg is given intravenously. The dose can be repeated in 5 to 10 minutes.
  • Phenytoin 1000 mg is given intravenously over 20 minutes.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

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.
  • Instruct the patient and support person about the need to reduce central nervous system (CNS) irritability, to decrease the risk of seizure, using:
    • Environment control (quiet, low lighting, reduced stimulation)
    • Bedrest in the lateral position
  • Teach the patient and support person about the use of magnesium sulfate, a CNS depressant, to prevent seizures during the inpatient stay.
  • Teach the patient and support person the possible adverse effects of magnesium sulfate, if it is ordered.5,7
    • Flushing
    • Sedation, lethargy
    • Sensations of heat or burning
    • Decreased urine output
  • Teach the patient and support person the signs and symptoms of magnesium sulfate toxicity to report, if magnesium sulfate is ordered.5,7
    • Hypotension
    • Nausea
    • Vomiting
    • Oliguria
    • Muscle weakness
    • Slurred speech
    • Decreased or absent reflexes
    • Shortness of breath
    • Chest pains
    • Respiratory depression or respiratory arrest
  • Teach the patient and support person about additional medications, if they are ordered.
    • Antihypertensives
    • Anticonvulsants
  • Explain the appropriate disease processes applicable to the patient’s condition.
    • Preeclampsia
    • Gestational hypertension
    • Chronic hypertension
    • Chronic hypertension with superimposed preeclampsia
    • Preeclampsia with severe features
    • Eclampsia
    • HELLP syndrome
  • Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

  1. Perform hand hygiene before patient contact.
  2. Introduce yourself to the mother and support person
  3. Verify the correct patient using two identifiers.
  4. Obtain the patient’s vital signs, check DTRs, and assess for clonus.
  5. Record the date of the patient’s last menstrual period and estimated date of delivery.
  6. Assess the patient for seizure risk factors.
  7. Assess the patient for vaginal bleeding.
  8. Assess any report of contractions, vaginal drainage, or abdominal pain.
  9. 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.
  10. Monitor fetal heart rate (FHR) and contractions continually.

Preparation

  1. Obtain the practitioner’s order for the administration of the magnesium sulfate loading dose and maintenance dose, if applicable.
  2. Obtain the practitioner’s orders for laboratory studies, activity levels, diet, and medications.
  3. Gather supplies.

PROCEDURE

Patients with Hypertensive Disorders

  1. Perform hand hygiene.
  2. Verify the correct patient using two identifiers.
  3. Explain the procedure to the mother and support person and ensure that the mother agrees to treatment.
  4. Provide privacy and assist the patient with donning a patient gown.
  5. Maintain a quiet, darkened environment.
    Rationale: Stimuli may precipitate seizure activity. 12
  6. Assist the patient into a side-lying position and instruct the patient regarding the ordered bedrest.
    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. 11
  7. Palpate the uterus and note contractions and abdominal tenderness.
  8. Rationale: Abdominal tenderness could indicate placental abruption in a patient with preeclampsia. 12
  9. Apply the fetal monitor and perform a nonstress test. Notify the practitioner of abnormal readings.
  10. 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. 6
  11. Establish baseline data (e.g., DTRs, clonus).
  12. Rationale: Baseline data are used to evaluate treatment effectiveness. 12
  13. Monitor the FHR for baseline variability and the absence of late decelerations.
  14. Rationale: FHR is assessed for evidence of adequate uteroplacental oxygenation. 6
  15. Assess and monitor the patient for signs of fluid volume excess: increased edema, decreased urine output, elevated serum creatinine level, weight gain, dyspnea, and crackles.
    Rationale: Decreased urinary output is caused by poor renal perfusion and may precede acute renal failure. 12
  16. Monitor the patient for signs of impaired gas exchange: increased respiration and dyspnea.
  17. Perform hand hygiene and don gloves.
  18. Establish multiple IV access lines.
  19. 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
  20. Discard supplies, remove gloves, and perform hand hygiene.
  21. Establish a calm environment.
    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.
  22. Provide safety measures for potential seizures.
    1. Padded side rails
    2. Code cart readily available with medications (magnesium sulfate, calcium gluconate, anticonvulsants, and antihypertensives12) and standard resuscitation supplies (e.g., oxygen, suction, and advanced airway equipment)
    3. 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. 12
      Follow the organization’s safety practices for the administration of magnesium sulfate and monitor serum magnesium levels to detect toxicity.
  23. Monitor 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
      Rationale: Hyperreflexia and clonus are signs of poor cerebral perfusion and may foreshadow seizure activity. 12
    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. 12
    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. 12
    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. 12
      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
  24. Discard supplies and perform hand hygiene.
  25. Document the procedure in the patient’s record.

Patients Experiencing a Seizure

  1. If seizure activity occurs, call for assistance.
  2. Perform hand hygiene and don gloves.
  3. Provide patient safety during the seizure (Box 3)Box 3.
    1. Maintain a patent airway by keeping the patient in a side-lying position and providing oral suction as needed, being careful not to place the suction device between the teeth during the seizure.
    2. Notify the anesthesia provider immediately to assist with airway management.
    3. Ensure adequate padding around the patient.
    4. Notify the practitioner and administer medications as ordered.
    5. Apply a cardiac monitor and pulse oximeter to the patient.
    6. Prepare for an emergency cesarean delivery if seizure activity cannot be controlled.
    7. 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.
  4. After the seizure activity, administer oxygen via face mask and reassess uterine and fetal conditions. Assess the patient for presence of labor, rupture of membranes, and signs of placental abruption.12 Alert the practitioner to any unusual findings.
  5. 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
  6. Continue seizure precautions after the patient returns to the previous cognitive level.
  7. Discard supplies, remove gloves, and perform hand hygiene.
  8. Document the procedure in the patient’s record.

MONITORING AND CARE

  1. Maintain seizure precautions throughout the patient’s stay in the organization.
  2. Rationale: Seizure activity may occur without warning signs or symptoms in some patients. 2
  3. Report any change in patient status to the practitioner.
  4. Assess, treat, and reassess pain.
  5. Provide support for the patient and support person and opportunities for them to ask questions or state concerns. Post seizure guidelines:
    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.12
  6. Administer magnesium sulfate during the first 24 hours after delivery, if ordered.2
  7. Rationale: A magnesium sulfate infusion is continued after birth for seizure prophylaxis. 2
  8. Before discharge, provide discharge instructions and teach the patient seizure precautions to follow at home.
  9. 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.

EXPECTED OUTCOMES

  • No abnormal findings
  • Absence of seizures
  • No adverse maternal or fetal outcomes related to hypertension or seizure activity

UNEXPECTED OUTCOMES

  • Abnormal findings
  • Seizure activity
  • Compromised fetus
  • Compromised patient
  • Maternal death
  • Fetal death
  • Emergency cesarean delivery
  • Magnesium toxicity

DOCUMENTATION

  • Maternal 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
    • Vital signs
    • Reflexes
    • Visual disturbances
    • Epigastric discomfort
    • Nausea
    • Vomiting
    • Edema
    • Clonus
  • Any seizure activity and interventions and patient responses
  • Medication administered for seizure prevention
  • Medication administered for severe hypertension
  • Sedative medication administered for persistent seizure
  • Report of patient status to practitioner and practitioner’s response
  • Education
  • Unexpected outcomes and related interventions
  • 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 VII)
  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 VII)
  3. American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice. (2019). ACOG committee opinion no. 767: Emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period [Interim update]. Obstetrics & Gynecology, 133(2), e174-e180. doi:10.1097/AOG.0000000000003075
  4. Bernstein, P.S. and others. (2017). Consensus bundle on severe hypertension during pregnancy and the postpartum period. JOGNN, 46(5), 776-787. doi:10.1016/j.jogn.2017.05.003 (Level VII)
  5. California Maternal Quality Care Collaborative (CMQCC). (2014). Improving health care response to preeclampsia: A California quality improvement toolkit. Retrieved November 18, 2020, from https://www.cmqcc.org (classic reference)* (Level VII)
  6. 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.
  7. 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.
  8. Judy, A.E. and others. (2019). Systolic hypertension, preeclampsia-related mortality, and stroke in California. Obstetrics & Gynecology, 133(6), 1151-1159. doi:10.1097/AOG.0000000000003290 (Level IV)
  9. 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
  10. Magee, L.A., von Dadelszen, P. (2018). State-of-the-art diagnosis and treatment of hypertension in pregnancy. Mayo Clinic Proceedings, 93(11), 1664-1677. doi:10.1016/j.mayocp.2018.04.033
  11. 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.
  12. 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

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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  • 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