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Chapter 27Chapter 27Hypertensive DisordersHypertensive Disorders

in Pregnancyin Pregnancy

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Significance and IncidenceSignificance and Incidence Hypertensive disordersHypertensive disorders

5% to 10% of all pregnancies5% to 10% of all pregnancies Preeclampsia Preeclampsia

• Complicates 3% to 7% of all pregnanciesComplicates 3% to 7% of all pregnancies Predispose the woman to serious complicationsPredispose the woman to serious complications Pregnancy associated hypertension accounts for Pregnancy associated hypertension accounts for

10%-15% of maternal deaths worldwide10%-15% of maternal deaths worldwide

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ClassificationClassificationGestational Hypertensive Disorders Gestational Hypertensive Disorders

Gestational hypertension Gestational hypertension Onset of hypertension without proteinuria after Onset of hypertension without proteinuria after

week 20 of pregnancy week 20 of pregnancy PreeclampsiaPreeclampsia

Pregnancy-specific syndrome in which Pregnancy-specific syndrome in which hypertension develops after 20 weeks of gestation hypertension develops after 20 weeks of gestation in a previously normotensive womanin a previously normotensive woman

Catagorized as Mild or SevereCatagorized as Mild or Severe

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ClassificationClassificationGestational Hypertensive DisordersGestational Hypertensive Disorders

Mild PreeclampsiaMild Preeclampsia

Severe PreeclampsiaSevere Preeclampsia

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EclampsiaEclampsia Onset of seizure activity or coma in a woman Onset of seizure activity or coma in a woman

diagnosed with preeclampsiadiagnosed with preeclampsia

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ClassificationClassificationChronic Hypertensive Disorders Chronic Hypertensive Disorders

Chronic hypertensionChronic hypertension Hypertension present before pregnancy or Hypertension present before pregnancy or

diagnosed before week 20 of gestationdiagnosed before week 20 of gestation Chronic hypertension with superimposed Chronic hypertension with superimposed

preeclampsiapreeclampsia Women with chronic hypertension may acquire Women with chronic hypertension may acquire

preeclampsia or eclampsiapreeclampsia or eclampsia

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Preeclampsia Preeclampsia

EtiologyEtiology Signs and symptoms develop Signs and symptoms develop

during pregnancy and disappear after birthduring pregnancy and disappear after birth Risk factorsRisk factors

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Preeclampsia Preeclampsia

PathophysiologyPathophysiology Disruptions in placental perfusion Disruptions in placental perfusion

and endothelial cell dysfunctionand endothelial cell dysfunction Inadequate vascular remodeling in uterusInadequate vascular remodeling in uterus Placental ischemia causes cell dysfunction. This in Placental ischemia causes cell dysfunction. This in

turn causes generalized vasospasm which results turn causes generalized vasospasm which results in poor tissue perfusion in all organs, increased in poor tissue perfusion in all organs, increased resistance and B/P, and increased cell resistance and B/P, and increased cell permeability= less plasma volume permeability= less plasma volume

Reduced function in maternal organs (kidneys, Reduced function in maternal organs (kidneys, liver, brain)liver, brain)

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Preeclampsia Preeclampsia Reduced function in placenta contributes to Reduced function in placenta contributes to

iincreased incidence of placental abruption, ncreased incidence of placental abruption, premature birth, early aging of placenta, restriction premature birth, early aging of placenta, restriction of fetal growthof fetal growth

HELLP syndromeHELLP syndrome Laboratory diagnosis for a variant of severe Laboratory diagnosis for a variant of severe

preeclampsia that involves hepatic dysfunctionpreeclampsia that involves hepatic dysfunction Diagnosis associated with increased risk for Diagnosis associated with increased risk for

adverse perinatal outcomesadverse perinatal outcomes

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Care ManagementCare ManagementIdentifying and AssessingIdentifying and Assessing

Mild Preeclampsia: Assessment and home Mild Preeclampsia: Assessment and home carecare Health history for risk factorsHealth history for risk factors Monitoring B/PMonitoring B/P Dependent edema/Pitting edemaDependent edema/Pitting edema Deep tendon reflexes (DTRs)Deep tendon reflexes (DTRs) Lab tests/biophysical monitoringLab tests/biophysical monitoring Activity restrictionActivity restriction DietDiet

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Care ManagementCare ManagementHospital ManagementHospital Management

Severe Preeclampsia: Hospital CareSevere Preeclampsia: Hospital Care Bedrest, side rails up, quiet roomBedrest, side rails up, quiet room Fetal monitoringFetal monitoring Magnesium sulfate- administered IVMagnesium sulfate- administered IV Control of blood pressure-antihypertensive Control of blood pressure-antihypertensive

medicationsmedications Eclampsia- immediate care during convulsion- Eclampsia- immediate care during convulsion-

ensure a patent airway and prevent aspirationensure a patent airway and prevent aspiration

Care Management Postpartum Nursing Care

Symptoms of preeclampsia or eclampsia resolve usually within 48 hours

Careful assessment of • vital signs• intake and output• DTR’s• level of consciousness• uterine tone/ lochia flow- boggy uterus and

heavy lochia flow due to magnesium sulfate

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Chronic Hypertension Chronic Hypertension Affects 4%-5% of all pregnanciesAffects 4%-5% of all pregnancies Associated with increased incidence of:Associated with increased incidence of:

Postpartum complications include:Postpartum complications include: Pulmonary edemaPulmonary edema Renal failureRenal failure Heart failureHeart failure EncephalopathyEncephalopathy

ATI QuestionATI Question A client with preeclampsia is receiving IV A client with preeclampsia is receiving IV

magnesium sulfate. Which of the following magnesium sulfate. Which of the following should the nurse include in the plan of care? should the nurse include in the plan of care? (select all that apply)(select all that apply)a.a. Keep calcium gluconate at the bedsideKeep calcium gluconate at the bedsideb.b. Maintain lights at dim settingMaintain lights at dim settingc.c. Have side rails up at all timesHave side rails up at all timesd.d. Keep a padded tongue blade at the bedsideKeep a padded tongue blade at the bedsidee.e. Encourage intake of clear fluidsEncourage intake of clear fluids

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Key Points Key Points

Hypertensive disorders during pregnancy are Hypertensive disorders during pregnancy are a leading cause of worldwide infant and a leading cause of worldwide infant and maternal morbidity and mortalitymaternal morbidity and mortality

Cause of preeclampsia unknown, and there Cause of preeclampsia unknown, and there are no known reliable tests for predicting are no known reliable tests for predicting which women are at risk for preeclampsiawhich women are at risk for preeclampsia

Preeclampsia is a multisystem disease rather Preeclampsia is a multisystem disease rather than only an increase in BPthan only an increase in BP

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Key Points Key Points

Failure of trophoblastic invasion of spiral Failure of trophoblastic invasion of spiral arterioles is proposed as triggering arterioles is proposed as triggering mechanism that leads to vasospasm and mechanism that leads to vasospasm and organ ischemiaorgan ischemia Cure is delivery of fetus and placentaCure is delivery of fetus and placenta

Pathologic changes of preeclampsia, Pathologic changes of preeclampsia, involving every organ system in the body, are involving every organ system in the body, are present long before clinical manifestations present long before clinical manifestations are evidentare evident

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Key Points Key Points

Historic risk factors are associated with a higher Historic risk factors are associated with a higher incidence of preeclampsiaincidence of preeclampsia First pregnancy or pregnancy of new genetic makeupFirst pregnancy or pregnancy of new genetic makeup History of vascular diseaseHistory of vascular disease Multiple gestationMultiple gestation

Progression of hypertensive disorders during Progression of hypertensive disorders during pregnancy is unpredictablepregnancy is unpredictable Mild hypertension must be taken seriously and Mild hypertension must be taken seriously and

managed as for preeclampsiamanaged as for preeclampsia

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Key Points Key Points

Once preeclampsia clinically evident Once preeclampsia clinically evident Therapeutic intervention is palliative: bed rest, dietTherapeutic intervention is palliative: bed rest, diet May slow progression of disease and allow May slow progression of disease and allow

pregnancy to continuepregnancy to continue

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Key Points Key Points

Home care management an option only for Home care management an option only for women women Whose condition is stableWhose condition is stable Who are able to comply with medical regimenWho are able to comply with medical regimen Reliably perform self-monitoringReliably perform self-monitoring Immediately recognize and report abnormal signs Immediately recognize and report abnormal signs

and symptomsand symptoms

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Key Points Key Points

HELLP syndrome can occur in women with HELLP syndrome can occur in women with severe preeclampsia and is considered life severe preeclampsia and is considered life threateningthreatening

Magnesium sulfate, the anticonvulsive agent Magnesium sulfate, the anticonvulsive agent of choice for preventing eclampsia, requires of choice for preventing eclampsia, requires careful monitoring of reflexes, respirations, careful monitoring of reflexes, respirations, and urinary outputand urinary output Antidote, calcium gluconate, should be available at Antidote, calcium gluconate, should be available at

bedsidebedside

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Key Points Key Points

Intent of emergency interventions for Intent of emergency interventions for eclampsia is to:eclampsia is to: Prevent self-injuryPrevent self-injury Ensure adequate oxygenationEnsure adequate oxygenation Reduce aspiration riskReduce aspiration risk Establish seizure control with magnesium sulfateEstablish seizure control with magnesium sulfate Correct maternal acidemiaCorrect maternal acidemia

Chronic hypertension in pregnancy associated Chronic hypertension in pregnancy associated with abruptio placentae and superimposed with abruptio placentae and superimposed preeclampsiapreeclampsia