HYPERTENSIVE

DISORDERS IN
PREGNANCY
 • is a condition in which vasospasm occurs in both small
GESTATIONAL and large arteries during pregnancy, causing increased
HYPERTENSION blood pressure.
 • 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
PRE-ECLAMPS response to the foreign protein of the growing fetus.
IA 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
PATHOPHYS
IOLOGIC
EVENTS
ASSESSMENT

• Although women may have additional symptoms such as vision changes, typically
hypertension, proteinuria, and edema are considered the classic signs of preeclampsia. Of
the three, hypertension and proteinuria are the most significant because extensive
edema occurs only after the other two are present
ASSESSING THE
WOMAN WITH
GESTATIONAL
HYPERTENSION
 SYMPTOMS OF GESTATIONAL HYPERTENSION

Hypertension Symptoms Type

Gestational hypertension
Blood pressure is 140/90 mmHg or systolic pressure elevated 30 mmHg or diastolic pressure elevated 15 mmHg above pre-pregnancy
level; no proteinuria or edema; blood pressure returns to normal after birth

Preeclampsia without severe features

Blood pressure is 140/90 mmHg or systolic pressure elevated 30 mmHg or diastolic pressure elevated 15 mmHg above prepregnancy
level; 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

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

Eclampsia
Either seizure or coma accompanied by signs and symptoms of preeclampsia are present.
GESTATIONAL HYPERTENSION

• A woman is said to have gestational hypertension when she develops an elevated blood
pressure (140/90 mmHg) but has no proteinuria or edema. Perinatal mortality is not
increased with simple gestational hypertension, so careful observation but no drug
therapy is necessary.
PREECLAMPSIA WITHOUT SEVERE FEATURES

• If a seizure from preeclampsia occurs, a woman now has eclampsia, but any status above
gestational hypertension and below a point of seizures is preeclampsia. A woman is said
to be preeclamptic without severe features when she has proteinuria (1+ on a urine dip
or 300 mg in a 24-hour urine protein collection or 0.3 or higher on a urine
protein–creatinine ratio) and a blood pressure rise to 140/90 mmHg, taken on two
occasions at least 6 hours apart.
• A second criterion for evaluating blood pressure is a systolic blood pressure greater than
30 mmHg and a diastolic pressure greater than 15 mmHg above pre-pregnancy values.
PREECLAMPSIA WITH
SEVERE FEATURES

• A woman has passed to preeclampsia with

severe features when her blood pressure
rises to 160 mmHg systolic and 110
mmHg diastolic or above on at least two
occasions 6 hours apart at bed rest (the
position in which blood pressure is
lowest) or her diastolic pressure is 30
mmHg above her pre-pregnancy level.
Marked proteinuria, 3+ or 4+ on a
random urine sample or more than 5 g in
a 24-hour sample
ECLAMPSIA

• Is the most severe classification of pregnancy-related

hypertensive disorders. A woman has passed into this stage
when cerebral edema is so acute a grand mal (tonic– clonic)
seizure or coma has occurred. With eclampsia, the maternal
mortality can be as high as 20% from causes such as cerebral
hemorrhage, circulatory collapse, or renal failure
NURSING DIAGNOSES AND RELATED
INTERVENTIONS

• The nursing diagnoses used with gestational hypertensive disorders are numerous
because the disease process has such wide-ranging effects. Some possible nursing
diagnoses include:
• Ineffective tissue perfusion related to vasoconstriction of blood vessels
• Deficient fluid volume related to fluid loss
• Risk for fetal injury related to reduced placental perfusion secondary to vasospasm
• Social isolation related to prescribed bed rest
NURSING INTERVENTIONS FOR A WOMAN WITH
PREECLAMPSIA WITHOUT SEVERE FEATURES

• Patients with preeclampsia without severe features prior to full term can be managed at
home with frequent follow-up care and fetal testing.
• 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 (Leaf & Connors, 2015). Because aspirin is such a common over-the-
counter drug, be certain women appreciate that this is not something to be taken lightly
but a serious drug prescription for them. Be certain they purchase low-dose aspirin (81
mg, sold as baby aspirin) as excessive salicylic levels can cause maternal bleeding at the
time of birth.
• 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. Be certain women know
to rest in a lateral recumbent position to avoid uterine pressure on the vena cava and
prevent supine hypotension syndrome.
• 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. This is no longer
true because stringent sodium restriction may activate the renin–angiotensin–
aldosterone system and actually result in increased blood pressure, thus compounding
the problem.
• Assess if a woman has someone to help her prepare food, or either bed rest or nutrition
may be compromised.
• Provide Emotional Support
• Almost 90% of women of childbearing age work outside their home at least part time
today. In addition, most working women make major financial contributions to the
running of their households. If a woman is unmarried, her income is probably her sole
support. This makes it seem difficult to leave work on the basis of a few vague
symptoms—a little swelling or a little headache—unless the woman receives clear
information that, if these early symptoms are ignored, they could worsen to the point
that they interfere with both her health and that of her fetus.
NURSING INTERVENTIONS FOR A WOMAN WITH
PREECLAMPSIA WITH SEVERE FEATURES
• If a woman’s preeclampsia is severe (systolic blood pressure of more than 160 mmHg, diastolic
blood pressure of more than 110 mmHg after a woman has been on bed rest; extensive edema;
marked proteinuria [3+ to 4+]; cerebral or visual disturbances; marked hyperreflexia; or oliguria
[500 ml per 24 hours or less]), a woman may be admitted to a healthcare facility for care. If the
pregnancy is greater than 37 weeks, labor can be induced or a cesarean birth performed to end
the pregnancy at that point. If the pregnancy is less than 37 weeks, interventions will be
instituted to attempt to alleviate the severe symptoms and allow the fetus to come to term.
However, if the symptoms persist or worsen, or if the fetal testing shows a compromised fetus,
vaginal or cesarean delivery will be necessary even if the pregnancy is preterm.
• Support Bed Rest
• With preeclampsia with severe features, 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,
a woman with preeclampsia with severe features is admitted to a private room so she can rest as
undisturbed as possible. Raise side rails to help prevent injury if a seizure should occur.
• Darken the room if possible because a bright light can also trigger seizures. However, the room should
not be so dark that caregivers need to use a flashlight to make assessments. Shining a flashlight beam into
a woman’s eyes is the kind of sudden stimulation to be avoided.
• 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. Allow her opportunities to express
her feelings about what is happening or how bewildered she is because the few simple
symptoms she noticed 2 weeks ago (e.g., increase in weight, increasing edema) have now
developed into a syndrome that may be lethal to her baby and possibly to herself.
• Monitor Maternal Well-Being

• Take blood pressure frequently (at least every 4 hours) or with a continuous monitoring device
to detect any increase, which is a warning that a woman’s condition is worsening. 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, which often accompanies severe vasospasm, as well
as plasma estriol levels (a test of placenta function), and electrolyte levels. Because a woman is
at high risk for premature separation of the placenta and resulting hemorrhage, a blood sample
for type and cross- match is usually also obtained.
• Monitor Fetal Well-Being
• Generally, single Doppler auscultation at approximately 4-hour intervals is sufficient at
this stage of management. A woman may have a nonstress test or biophysical profile
done daily to assess uteroplacental sufficiency. If fetal bradycardia occurs, oxygen
administration to the mother may be necessary to maintain adequate fetal oxygenation.
• Support a Nutritious Intake
• A woman needs a diet moderate to high in protein and moderate in sodium to
compensate for the protein she is losing in urine. An intravenous fluid line is usually
initiated and maintained to serve as an emergency route for drug administration as well
as to administer fluid to reduce hemoconcentration and hypovolemia.
• Administer Medications to Prevent Eclampsia
• A hypotensive drug such as hydralazine (Apresoline), labetalol (Normodyne), or
nifedipine may be prescribed to reduce hypertension. These drugs act to lower blood
pressure by peripheral dilatation and thus do not interfere with placental circulation.
They can, however, cause maternal tachycardia, so assess pulse and blood pressure
before and after administration. Diastolic pressure should not be lowered below 80 to
90 mmHg or inadequate placental perfusion could occur. Even with these new drugs,
magnesium sulfate still remains the drug of choice to prevent eclampsia
• 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. Make these assessments every hour if a
continuous intravenous infusion is being used.
NURSING INTERVENTIONS FOR A WOMAN WITH
ECLAMPSIA
• Degeneration of a woman’s condition from preeclampsia with severe features to eclampsia
occurs when cerebral irritation from increasing cerebral edema becomes so acute that a seizure
occurs. This usually happens late in pregnancy but can happen up to 48 hours after childbirth.
Immediately before a seizure, a woman’s blood pressure rises suddenly from additional
vasospasm. The increased cerebral pressure causes her temperature to rise sharply to 103° to
104°F (39.4° to 40°C). She notices blurring of vision or severe headache (from the increased
cerebral edema), and her reflexes become hyperactive. She may experience a premonition or
aura that “something is happening.” Vascular congestion of the liver or pancreas can lead to
severe epigastric pain and nausea or vomiting. Urinary output may decrease abruptly to less
than 30 ml/hr. However, eclampsia has actually occurred, by definition, only when a woman
experiences a seizure.
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 post birth, are essential to detect this residual hypertension