Hypertensive Disorders in Pregnancy
Gestational hypertension is a condition in which vasospasm occurs in both small and
large arteries during pregnancy, causing increased blood pressure.
Preeclampsia is a pregnancy-related disease process evidenced by increased blood
pressure and proteinuria.
An older term for preeclampsia was toxemia of pregnancy because researchers
pictured the symptoms as being caused by women producing a toxin of some kind in
response to the foreign protein of the growing fetus. The condition occurs in 5% to
7% of pregnancies. The cause of the disorder is unknown, although women with
antiphospholipid syndrome (APS) or the presence of antiphospholipid antibodies in
maternal blood are much more likely to develop preeclampsia.
Occurs most likely to women that had
 multiple pregnancy;
 primiparas younger than 20 years or
 older than 40 years of age;
 women from low socioeconomic backgrounds (perhaps because of poor
nutrition);
 Those who have had five or more pregnancies; those who have
polyhydramnios (i.e., overproduction of amniotic fluid; refer to later
discussion); or
Those who have an underlying disease such as
 heart disease,
 diabetes with vessel
 renal involvement, and
 essential hypertension
Pathophysiologic events
The vascular spasm that occurs may be caused by the increased cardiac output
required by pregnancy, which injures the endothelial cells of the arteries and reduces
the action of prostacyclin—a prostaglandin vasodilator—and excess production of
thromboxane—a prostaglandin vasoconstrictor and stimulant of platelet aggregation.
With gestational hypertension, this reduced responsiveness to blood pressure
changes appears to be lost because of the prostaglandin release. Vasoconstriction
occurs, and blood pressure increases dramatically.
Beginning about the 20th week of pregnancy, almost all body systems begin to be
affected.
 Cardiac system: causes a reduced blood supply to organs, most markedly
the kidney, pancreas, liver, brain, and placenta.
 Poor placental perfusion reduces the fetal nutrient and oxygen supply
 Ischemia in the pancreas can result in epigastric pain and an elevated
amylase–creatinine ratio
If spasm occurs in the arteries of the retina, vision changes can occur. If this results in
retinal hemorrhage, blindness can result.
 Vasospasm in the kidney increases blood flow resistance.
 Degenerative changes then develop in the kidney glomeruli because of back
pressure. This leads to increased permeability of the glomerular membrane,
allowing the serum proteins albumin and
 globulin to escape into the urine (i.e., proteinuria)
 The degenerative changes also result
 In decreased glomerular filtration, so there is lowered urine output and
clearance of creatinine. If increased kidney tubular reabsorption occurs,
retention of sodium begins.
 As sodium retains fluid, edema results.
 Edema is further increased because, as more protein is lost, the osmotic
pressure of the circulating blood falls and fluid diffuses from the circulatory
system into the denser interstitial spaces to equalize the pressure
Arterial spasm causes the bulk of the blood volume in the maternal circulation to be
pooled in the venous circulation, so on assessment, a woman has a deceptively low
arterial intravascular volume.
 thrombocytopenia or a lowered platelet count occurs as platelets cluster at
the sites of endothelial damage
 A hematocrit level above 40% suggests significant fluid loss into interstitial
spaces
Assessment
Classic Signs of preeclampsia
Hypertension, proteinuria, and edema; of the three, hypertension and proteinuria are
the most significant because extensive edema occurs only after the other two are
present.
Hypertension Type Symptoms
Blood pressure is 140/90 mmHg or
systolic pressure elevated 30
Gestational hypertension mmHg or diastolic pressure elevated 15
mmHg above
prepregnancy level; no proteinuria or
edema; blood pressure returns to normal
after birth
Blood pressure is 140/90 mmHg or
systolic pressure elevated 30
mmHg or diastolic pressure elevated 15
mmHg above prepregnancy level;
Preeclampsia without severe features proteinuria of 1+ to 2+ on a random
sample; weight gain over 2 lb/week in
second trimester and 1 lb/week in
third trimester; mild edema in upper
extremities or face
Preeclampsia with severe features
Eclampsia
Blood pressure is 160/110 mmHg;
proteinuria 3+ to 4+ on a random
sample and 5 g on a 24-hour sample;
oliguria (500 ml or less in 24
hours or altered renal function tests;
elevated serum creatinine
more than 1.2 mg/dl); cerebral or visual
disturbances (headache,
blurred vision); pulmonary or cardiac
involvement; extensive
peripheral edema; hepatic dysfunction;
thrombocytopenia;
epigastric pain;
If cerebral edema has occurred, reports
of visual disturbances such as blurred
vision or seeing spots before the eyes
may be reported.
Cerebral edema also produces
symptoms of severe headache
and marked hyperreflexia and perhaps
ankle clonus
Either seizure or coma accompanied by
signs and symptoms of preeclampsia are
present.
The fetal prognosis with eclampsia is
also poor because of hypoxia, possibly
caused by the seizure, with consequent
fetal acidosis. If premature separation of
the placenta from extreme vasospasm
occurs, the fetal prognosis becomes
even
 Nursing interventions for a woman with preeclampsia without severe features
1. Monitor Antiplatelet Therapy
Because of the increased tendency for platelets to cluster along arterial walls, a mild
antiplatelet agent, such as low-dose aspirin, may prevent or delay the development of
preeclampsia
2. Promote Bed Rest
When the body is in a recumbent position, sodium tends to be excreted at a faster
rate than during activity. Bed rest, therefore, is the best method of aiding increased
evacuation of sodium and encouraging diuresis of edema fluid.
3. Promote Good Nutrition
 A woman needs to continue her usual pregnancy nutrition while on bed rest. At
one time, stringent restriction of salt was advised in order to reduce edema
 Assess if a woman has someone to help her prepare food, or either bed rest or
nutrition may be compromised
4. Provide Emotional Support
 Healthcare providers cannot solve financial problems, but be certain to ask
enough questions at healthcare visits so financial need, if present, can be
determined. Questions such as “What will it mean to your family if you have to
be on bed rest?” and “How long a maternity leave does your work allow?” will
bring concerns to the surface.
 Ask if a woman with small children will need to make child care arrangements
so she can get sufficient rest.
Women with beginning signs of preeclampsia will be seen approximately weekly or
more frequently for the remainder of pregnancy. Be certain a woman understands
that if symptoms worsen before her next healthcare visit, she should report them
immediately. Symptoms worsen before her next healthcare visit, she should report
them immediately.
Nursing interventions for a woman with preeclampsia with severe features
1. Support Bed Rest
 Most women are hospitalized so that bed rest can be enforced and a woman
can be observed more closely than she can be on home care. Getting up to use
the bathroom is not contraindicated in women with preeclampsia
 Visitors are usually restricted to support people such as a partner, father of the
child, mother, or older children. Because a loud noise such as a crying baby or
a dropped tray of equipment can be sufficient to trigger a seizure that initiates
eclampsia
 Darken the room if possible because a bright light can also trigger seizures.
 Stress is another stimulus capable of increasing blood pressure and evoking
seizures in a woman with severe preeclampsia – Be certain, therefore, the
woman receives clear explanations of what is happening and what is planned,
especially about the need for visitor restrictions and not to “cheat” on bed rest.
2. Monitor Maternal Well-Being
 Take blood pressure frequently (at least every 4 hours)
 Obtain blood studies such as a complete blood count, platelet count, liver
 function, blood urea nitrogen, and creatine and fibrin degradation products as
ordered by the obstetric team to assess renal and liver function and the
development of DIC
 A blood sample for type and crossmatch is usually also obtained.
 Daily hematocrit levels are used to monitor blood concentration (this level will
rise if increased fluid is leaving the bloodstream for interstitial tissue [edema]).
 Obtain daily weights at the same time each day as another evaluation of fluid
retention.
 An indwelling urinary catheter may be inserted to allow accurate recording of
output and comparison with intake. Urinary output should be more than 30
ml/hr; an output lower than this suggests oliguria.
 Urinary proteins and specific gravity are measured and recorded with voiding
or hourly if an indwelling catheter is present.
 A 24-hour urine sample, or a urine protein–creatinine ratio, may be collected
for protein and creatinine clearance determinations to evaluate kidney function.
  Serum magnesium
3. Monitor Fetal Well-Being level should
remain below 7.5
 Single Doppler auscultation at approximately 4-hour intervals is sufficient at this mEq/l.
stage of management. Observe for central
 A woman may have a nonstress test or biophysical profile done daily to assess nervous
uteroplacental sufficiency system (CNS)
depression and
If fetal bradycardia occurs, oxygen administration to the mother may be necessary to hypotonia in infant
maintain adequate fetal oxygenation. at birth
and calcium deficit
4. Support a Nutritious Intake in the mother.
Administer slowly
 A woman needs a diet moderate to high in protein and moderate in sodium to Hydralazine Antihypertensive to avoid sudden
compensate for the protein she is losing in urine. (Apresoline) (peripheral fall in blood
 An intravenous fluid line is usually initiated and maintained to serve as an (pregnancy vasodilator); 5–10 mg IV pressure.
emergency route for drug administration as well as to administer fluid to reduce risk used to decrease Maintain diastolic
hemoconcentration and hypovolemia category C) hypertension pressure over
90 mmHg to
5. Administer Medications to Prevent Eclampsia ensure adequate
placental filling.
Drug Indication Dosage Comments Administer slowly.
Infuse loading Dose may be
dose slowly over repeated q 5–10
15–30 minutes. minutes (up
Always administer Diazepam to 30 mg/hr).
as a piggyback (Valium) Observe for
infusion. (pregnancy Halt seizures 5–10 mg IV respiratory
Loading dose risk depression or
Magnesium 4–6 g Assess respiratory category D) hypotension in
sulfate Muscle relaxant; Maintenance rate, urine mother and
(pregnancy prevents seizures dose 1–2 output, deep respiratory
risk g/hr IV tendon reflexes, depression and
category B) and clonus every hypotonia in infant
hour. at birth.
Have prepared at
Urine output Calcium bedside as the
should be over 30 gluconate Antidote for 1 g IV (10 ml antidote when
ml/hr and (pregnancy magnesium of a 10% administering
respiratory rate risk intoxication solution) magnesium
over category C) sulfate.Administer
12 breaths/min. at 5 ml/min.
The most evident symptoms of overdose from magnesium sulfate administration
include decreased urine output, depressed respirations, reduced consciousness, and
decreased deep tendon reflexes. Because magnesium is excreted from the body
almost entirely through the urine, urine output must be monitored closely to ensure
adequate elimination. If severe, oliguria should occur (less than 100 ml in 4 hours),
excessively high serum levels of magnesium can result.
 Before you administer further magnesium sulfate, therefore, ensure that
urine output is at least 30 ml/hr, with a specific gravity of 1.010 or lower
 Respirations should be above 12 breaths/min, a woman should be able to
answer questions asked of her such as her name or address, ankle clonus
should be minimal, and deep tendon reflexes should be present
In addition to making the previous assessments when magnesium sulfate is being
given, a solution of 10 ml of a 10% calcium gluconate solution (1 g) should be kept
ready nearby for immediate intravenous administration should a woman develop
signs and symptoms of magnesium toxicity, as calcium is the specific antidote for
magnesium toxicity.
An FHR monitor during pregnancy may show loss of variability of the heartbeat
immediately after magnesium therapy; an ultrasound may reveal reduced fetal
breathing movements.
 Observe carefully for other signs of fetal effects, such as late deceleration
with labor contractions. Magnesium sulfate is continued for 12 to 24 hours
after birth to prevent eclampsia during this period.
Nursing interventions for a woman with eclampsia
1. Tonic–Clonic Seizures
An eclamptic seizure is a tonic–clonic type that occurs in stages
 Her back arches, her arms and legs stiffen, and her jaw closes so abruptly
she may bite her tongue. Respirations halt because her thoracic muscles
are held in contraction. This phase of the seizure, called the tonic phase,
lasts approximately 20 seconds. It may seem longer because a woman may
grow slightly cyanotic from the cessation of respirations.
During the second (clonic) stage, the woman’s bladder and bowel muscles contract
and relax; incontinence of urine and feces may occur. Although a woman begins to
breathe during this stage, the breathing is not entirely effective so she may remain
cyanotic. The clonic stage of a seizure lasts up to 1 minute. Following this, she will
enter an hour long postictal stage, during which she is unconscious
The priority care for a woman with a tonic–clonic seizure is to maintain a patent
airway. To prevent aspiration, turn her onto her side to allow secretions to drain
from her mouth
 Magnesium sulfate or diazepam (Valium) may be administered
intravenously as emergency measures. Assess oxygen saturation via a
pulse oximeter.
 Administer oxygen by face mask as needed to protect fetal oxygenation
 Apply an external fetal heart monitor if one is not already in place to assess
the FHR.
 During the postictal stage, a woman cannot be roused except by painful
stimuli for 1 to 4 hours. Extremely close observation is therefore as
important during this third stage as it was during the first two stages.
Be certain to assess for uterine contractions during this stage because if labor begins
during this period, the woman will be unable to report the sensation of contractions.
Also, the painful stimulus of contractions may initiate another seizure.
Be certain to keep the woman on her side so secretions can drain from her mouth.
Give her nothing to eat or drink
Continue to check for vaginal bleeding every 15 minutes.
2. Birth
 If the fetus has reached a point of viability, a decision about birth will be made as
soon as a woman’s condition stabilizes, usually 12 to 24 hours after the seizure
 fetal lung maturity appears to advance
 rapidly with preeclampsia, so even though the fetus is younger than 37 weeks, e
thlecithin/sphingomyelin ratio may indicate fetal lung maturity
 Cesarean birth is always more hazardous for the fetus than vaginal birth because
of the association of retained lung fluid (see Chapter 26). Furthermore, a woman
with severe high blood pressure is not a good candidate for surgery
 The preferred method for birth, therefore, is vaginal with a minimum of
anesthesia. If labor does not begin spontaneously, rupture of the membranes or
induction of labor with intravenous oxytocin may be instituted
Nursing interventions during the postpartum period
Postpartum preeclampsia may occur up to 10 to 14 days after birth, although it
usually occurs within 48 hours after birth. Therefore, monitoring blood pressure in the
postpartum period and at healthcare visits and being alert for preeclampsia, which
can occur as late as 2 weeks postbirth, are essential to detect this residual
hypertension.
Complications associated with the syndrome are subcapsular liver hematoma,
hyponatremia, renal failure, and hypoglycemia from poor liver function.
Mothers are also at risk for cerebral hemorrhages, aspiration pneumonia, and hypoxic
encephalopathy. Fetal complications can include growth restriction and preterm birth
(Barnhart, 2015).

Therapy for the condition is transfusion of fresh frozen plasma or platelets in order to
improve the platelet count.
HELLP Syndrome
If hypoglycemia is present, this is corrected by an intravenous glucose infusion.
HELLP syndrome is a variation of the gestational hypertensive process named for the
common symptoms that occur: The infant is born as soon as feasible by either vaginal or cesarean birth. Be alert that
maternal hemorrhage may occur at birth because of poor clotting ability.
• Hemolysis leads to anemia

• Elevated liver enzymes lead to epigastric pain
• Low platelets lead to abnormal bleeding/clotting.
 It occurs in both primigravidas and multigravidas and is associated with APS
or the presence of antiphospholipid antibodies
Epidural anesthesia may not be possible because of the low platelet count and the
high possibility of bleeding at the epidural site.
Laboratory results return to normal after birth, the same as preeclamptic symptoms,
but the experience of developing the HELLP syndrome is frightening. Women need
assurance afterward that symptoms were pregnancy related and so will not return.

 In addition to proteinuria, edema, and increased blood pressure, additional

symptoms of nausea, epigastric pain, general malaise, and right upper
quadrant tenderness from liver inflammation occur

Laboratory studies reveal hemolysis of red blood cells (they appear fragmented on a
peripheral blood smear), thrombocytopenia (a platelet count <100,000/mm3), and
elevated liver enzyme levels (alanine aminotransferase [ALT] and serum aspartate
aminotransferase [AST]), which are all effects of hemorrhage and necrosis of the
liver.

Because of the low platelet count, women with the HELLP syndrome need extremely
close observation for bleeding, in addition to the observations necessary for
preeclampsia.