1. Hypertensive Disorders
Chapter 27
Hypertensive Disorders
Copyright © 2016 by Elsevier Inc. All rights reserved.

2. Learning Objectives
Differentiate among gestational hypertension, preeclampsia, and chronic hypertension.
Describe etiologic theories and pathophysiology of preeclampsia.
Compare care management of women with mild or severe gestational hypertension and preeclampsia with or without severe features.

3. Learning Objectives (Cont.)
Describe appropriate nursing actions during and after an eclamptic seizure.
Discuss the preconception, antepartum, intrapartum, and postpartum management of the woman with chronic hypertension.

4. Significance and Incidence
Common medical complication of pregnancy
Hypertensive disorders are a major cause of perinatal morbidity and mortality worldwide due to the following:
Uteroplacental insufficiency
Premature birth
Of maternal deaths worldwide, 10% to 15% can be attributed to preeclampsia and eclampsia.
Preeclampsia accounts for more than 50,000 maternal deaths each year.

5. Morbidity and Mortality
Renal failure
Coagulopathy
Cardiac or liver failure
Placental abruption
Seizures
Stroke
Mortality
Pregnancy-related hypertension accounts for 10% to 15% of maternal deaths worldwide.

6. Classification of Hypertensive Disorders
Gestational hypertension
Onset of hypertension without proteinuria or other systemic findings diagnostic for preeclampsia after week 20 of pregnancy
Systolic BP >140, diastolic BP >90

7. Classification of Hypertensive Disorders (Cont.)
Preeclampsia
Pregnancy-specific condition in which hypertension and proteinuria develop after 20 weeks of gestation in a previously normotensive woman
In the absence of proteinuria, preeclampsia may be defined as hypertension along with the following:
Thrombocytopenia
Impaired liver function
New development of renal insufficiency
Pulmonary edema
New-onset cerebral or visual disturbances

8. Classification of Hypertensive Disorders (Cont.)
Eclampsia
Onset of seizure activity or coma in a woman with preeclampsia
No history of preexisting pathology
50% of eclamptic women develop the condition while pregnant
Women can develop eclampsia in the immediate postpartum period

9. Classification of Hypertensive Disorders (Cont.)
Chronic hypertension
Hypertension present before pregnancy or diagnosed before week 20 of gestation
Chronic hypertension with superimposed preeclampsia
Women with chronic hypertension may acquire preeclampsia or eclampsia
Can be difficult to diagnose

10. Preeclampsia (Cont.) Etiology A condition unique to human pregnancy
Common risk factors
Primigravidity in woman <19 or >40 years of age
First pregnancy with a new partner
History of preeclampsia
Pregnancy-onset snoring
The cause of preeclampsia is unknown.
Many theories

11. Preeclampsia (Cont.) Pathophysiology
Progressive disorder with placenta as the root cause
Begins to resolve after the placenta has been expelled
Spiral arteries in the uterus normally become larger and thicker to handle increased blood volume.
This vascular remodeling does not occur or only partially develops in women with preeclampsia and decreased placental perfusion and hypoxia result.

12. Preeclampsia (Cont.)

13. Preeclampsia (Cont.) Pathophysiology
Placental ischemia → endothelial cell dysfunction
Generalized vasospasm → poor tissue perfusion in all organ systems
Increased peripheral resistance and blood pressure (BP)
Increased endothelial cell permeability
Reduced kidney perfusion
Plasma colloid osmotic pressure decreases.
Decreased liver perfusion
Neurologic complications

14. Preeclampsia (Cont.)

15. Preeclampsia (Cont.) HELLP syndrome
Laboratory diagnosis for a variant of severe preeclampsia that involves hepatic dysfunction
Hemolysis (H)
Elevated liver enzymes (EL)
Low platelets (LP)
HELLP syndrome occurs in 0.5% to 0.9% of all pregnancies.
10% to 20% of women who have preeclampsia with severe features develop it.

16. Preeclampsia (Cont.) HELLP syndrome (Cont.)
Result of arteriolar vasospasm, endothelial cell dysfunction with fibrin deposits, and adherence of platelets in blood vessels
The clinical presentation is often nonspecific; most women with the disorder report the following:
History of malaise
Influenza-like symptoms
Epigastric or right upper quadrant abdominal pain
Symptoms worsen at night and improve during the daytime.

17. Care Management Identifying and preventing preeclampsia
No reliable test or screening tool has been developed
Low-dose aspirin (60 to 80 mg) may help certain high risk women
Potential biomarkers being investigated
Tyrosine kinase (sFLt) and serum placental growth factor
Abnormal uterine artery Doppler velocimetry in the first or second trimester of pregnancy

18. Care Management (Cont.)
Assessment and nursing diagnoses
Accurate measurement of BP
Assessment of edema, although the presence of edema is no longer included in the definition of preeclampsia
Deep tendon reflexes (DTRs)
Assess for hyperactive reflexes (clonus)
Proteinuria: ideally determined by evaluation of a 24-hour urine collection
Evaluate for signs and symptoms of severe preeclampsia:
Headaches
Epigastric pain
Right upper quadrant abdominal pain
Visual disturbances

19. Interventions
Mild gestational hypertension and preeclampsia without severe features
Goals of therapy are to ensure maternal safety and deliver a healthy newborn close to term.
Home care
Maternal and fetal assessment
Activity restriction
Diet

20. Interventions (Cont.)
Severe gestational hypertension and preeclampsia with severe features
Goals of care are to ensure maternal safety and formulate a plan for delivery.
Intrapartum care
Bed rest with siderails up
Darkened environment
Magnesium sulfate therapy
Antihypertensive medications

21. Interventions (Cont.) Postpartum care
Vital signs, DTRs, level of consciousness
30% of cases of eclampsia and HELLP syndrome occur postpartum.
Unable to tolerate excessive blood loss
Future health care
Seven-fold risk of developing preeclampsia or eclampsia in a future pregnancy
Increased risk of adverse perinatal outcomes

22. Interventions (Cont.) Eclampsia Immediate care
Premonitory signs: persistent headache and blurred vision
Epigastric or right upper quadrant pain
Altered mental status
Convulsions appearing without warning
Ensuring a patent airway and client safety
Maternal stabilization

23. Interventions (Cont.) Chronic hypertension IUGR Preterm birth
Affects 4% to 5% of pregnant women
Ideally the management of chronic hypertension in pregnancy begins before conception
Associated with increased incidence of the following:
Abruptio placentae
Superimposed preeclampsia
Increased perinatal mortality
IUGR
Preterm birth

24. Chronic hypertension Interventions (Cont.) Postpartum complications
Pulmonary edema
Renal failure
Heart failure
Encephalopathy

25. Case Study
Your client, Julie, is a G3 P2002 at 39 weeks of gestation. She presented to the high risk labor and delivery triage are an hour ago. Her blood pressure has been steadily increasing for the past 3 weeks. Today her blood pressure was 160/110, and she presents to the triage area with complaints of a severe headache and “spots in my vision.” Her cervical exam is 2 cm/80%/-2 firm midposition.
What type of pregnancy hypertensive disorder do you suspect Julie may have?
What other priority information is it important for the nurse to assess and gather?
Julie most likely has preeclampsia, due to the fairly recent onset of hypertension (after 20 weeks of gestation). Also, her complaints of a worsening headache and visual disturbances point to a diagnosis of preeclampsia.
See Chapter 27 text for other symptoms of preeclampsia:
Maternal and Fetal Assessment:
Initial maternal laboratory evaluation for women with preeclampsia without severe features includes measurement of serum creatinine, platelet count, liver enzymes, and a 24-hour urine protein assessment. Thereafter, the platelet count and liver enzymes should be assessed weekly. Women are also evaluated for signs or symptoms of severe features such as severe headaches, blurred or double vision, mental confusion, right upper quadrant or epigastric pain, nausea or vomiting, shortness of breath, and decreased urinary output (ACOG, 2013; Sibai, 2012). BP should be monitored twice weekly and proteinuria assessed weekly (ACOG).
Fetal evaluation generally includes daily fetal movement counts and nonstress testing or a biophysical profile once or twice weekly until birth. (See Chapter 26 for more information on fetal assessment tests.) Ultrasound evaluation of amniotic fluid status and determination of estimated fetal weight are performed at the time preeclampsia is diagnosed and serially thereafter, depending on findings (Sibai, 2012).
(Refer to Chapters 16 and 19 if you need to review information about cervical and labor assessment.)

26. Case Study (Cont.)
Julie is admitted to the labor and delivery unit for induction for preeclampsia. The provider orders magnesium sulfate: 4 gram IV loading dose and then 2 grams/hour maintenance dose. Julie asks, “What is this medication for?”
What is the nurse’s best reply?
See Chapter 27 for Etiology and Teaching about Preeclampsia and Magnesium Sulfate:
Magnesium sulfate is the drug of choice for preventing and treating seizure activity (eclampsia). It is almost always administered intravenously as a secondary infusion (piggyback) by a volumetric infusion pump. Per protocol or health care provider’s order, an initial loading dose of 4 to 6 g of magnesium sulfate is infused over 15 to 30 minutes. This dose is followed by a maintenance dose of magnesium sulfate that is diluted in an IV solution (e.g., 40 g of magnesium sulfate in 1000 mL of lactated Ringer’s solution [1 g = 25 mL]) and administered by an infusion pump at 2 to 3 g/hr. This dose should maintain a therapeutic serum magnesium level of 4 to 7 mEq/L. Contrary to popular belief, magnesium sulfate has little effect on maternal BP when administered in this fashion (Markham & Funai, 2014; Poole, 2014).
In plain language: “This medication prevents you from having seizures, which is something that can happen with preeclampsia, although it is rare. This medication does not lower your blood pressure or cure your preeclampsia; only delivery can do that.”

27. Case Study (Cont.)
What is important to teach Julie before starting the magnesium sulfate loading dose?
Some hints include the following:
Initial side effects
Safety precautions
Environmental precautions
Fluid intake and output
Nursing assessments to anticipate while on magnesium sulfate and why these assessments are being done
Refer to Boxes 27-3 and 27-4:
BOX 27-3
HOSPITAL PRECAUTIONARY MEASURES
Environment
Quiet
Nonstimulating
Lighting subdued
Seizure precautions
Suction equipment tested and ready to use

28. Future Health Care
Women with preeclampsia with severe features have a significantly increased risk of developing preeclampsia in a future pregnancy.
These women have an increased risk of developing chronic hypertension and cardiovascular disease later in life.
For now, women should be educated about lifestyle changes (maintaining a healthy weight, increasing physical activity, and avoiding smoking) that may decrease the risk for developing future health problems.

29. Key Points
Hypertensive disorders during pregnancy are a leading cause of maternal and perinatal morbidity and mortality worldwide.
The cause of preeclampsia is unknown, and there are no known reliable tests for predicting women at risk for developing preeclampsia.

30. Key Points (Cont.)
Preeclampsia is a multisystem disease, and the pathologic changes are present long before clinical manifestations such as hypertension become evident.
HELLP syndrome, which is usually diagnosed during the third trimester, is a variant of preeclampsia, not a separate illness.

31. Key Points (Cont.)
Magnesium sulfate, the anticonvulsant of choice for preventing or controlling eclamptic seizures, requires careful monitoring of reflexes, respirations, and renal function.
Women with preeclampsia (especially early-onset and preeclampsia with severe features) have an increased risk of developing chronic hypertension and cardiovascular disease later in life.

32. Key Points (Cont.)
The intent of emergency interventions for eclampsia is to prevent self-injury, enhance oxygenation, reduce aspiration risk, and establish control with magnesium sulfate.

33. Question
A client at 36 weeks of gestation presents to labor and delivery complaining of a constant headache for the past 2 days. She also states that her face “seems more swollen than usual.” What should be the nurse’s first action?
Obtain a urine sample.
Place the client on a fetal heart monitor.
Notify the physician of the client’s concerns.
Take the client’s blood pressure.
ANS: D
Feedback
A Incorrect: A urine sample should be obtained to determine if there is protein and albumin spillover as a result of reduced kidney perfusion. This can be done after the BP has been evaluated.
B Incorrect: Decreased placental perfusion is a complication of hypertensive disorders in pregnancy. The first action of the nurse should be to obtain the client’s BP. The client should then be placed on the fetal monitor in order to evaluate the fetus.
C Incorrect: Central nervous system irritability associated with preeclampsia often manifests itself as a headache. Once an accurate BP has been obtained, the health care provider should be notified.
D Correct: Accurate measurement of BP is essential to detect hypertensive disorders including preeclampsia. Personnel caring for pregnant women need to be consistent in taking and recording BP measurements in a standardized manner. BP readings are easily altered by the cuff size and position of the client.