Gestational and Chronic Hypertension Disorders

• ACOG & National High Blood Pressure Education Program collaborated to create criteria for HTN with pregnancy
• There are currently 2 categories of hypertensive disorders.

Gestational Hypertensive Disorders

• Gestational hypertension
• Preeclampsia
• Eclampsia

Chronic Hypertension Disorders

• Chronic hypertension
• Superimposed preeclampsia

Gestational Hypertension (GHTN)

• New onset of hypertension in a normotensive woman
• Develops after gestational week 20
• Diagnosed with a systolic blood pressure of > 140 or diastolic >90 X 2 > 4 hours apart
• Root cause is spiral artery malformation in the placenta
• Progressive disease process
• It is cured with delivery of the placenta
• There is no protein in the urine
• B/P returns to baseline by 12 weeks PP., sometimes taking up to 12 months
• Up to 50% women are diagnosed with chronic HTN after GHTN
• Occurs in 5-10% of all pregnancies
• 25-30% of GHTN progress to preeclampsia

Preeclampsia (PreE)

• Defined as the onset of hypertension after 20 weeks gestation, with or without proteinuria, and/ or with other systemic findings in a woman with normotensive
• Blood pressure is the same as gestational HTN
• Proteinuria is >300mg in 24 hr urine or 2+ on dipstick
• Or, in the absence of proteinuria:
  • Thrombocytopenia (<100,000)
  • Impaired liver function (x2 LDH/AST)
  • New-onset renal insufficiency (>1.1 creatinine, increased BUN, plasma uric acid elevation (>5.9%))
  • Pulmonary edema
  • New onset HA or visual disturbances
• Peripheral edema is not indicative of Pre-E

Severe PreEclampsia

• Maternal signs are B/P >160/110
• Proteinuria >3+ on dipstick
• Oliguria
• Cerebral or visual disturbances
• Hyperreflexia with possible ankle clonus
• Pulmonary edema
• Cardiac dysfunction
• Extensive peripheral edema (hands, face, ankles)
• Abnormal kidney function study results
  • BUN, serum creatinine (>1.1)
• Elevated liver enzymes
  • ALT, AST, PT, BILI
• Epigastric pain, RUQ pain
• Plasma uric acid elevation (>5.9%)
• Thrombocytopenia (<100,000)

Eclampsia

• Severe PreE manifestations with the onset of seizures or coma
• Usually preceded with HA, severe epigastric pain or RUQ pain, hyperreflexia, and hemoconcentration
• It can occur before, during, or after delivery
  • Occurs in 50% of women with PreE before delivery, and 30% of women with PreE after delivery

HELLP Syndrome

• A laboratory diagnosis of a severe variant of preeclampsia
  • May or MAY NOT have high B/P or S/S of Pre-E with severe features!
  • Many women have slightly higher than normal BP, and no protein in their urine
• H = Hemolysis (breaking down of RBCs)
• EL = Elevated liver enzymes
• LP = Low platelets
• It is #1 reason for preterm delivery
• Highest risk is Caucasian women
• Perinatal mortality rate is 7-34%
• Maternal mortality rate is 1%
• Signs and symptoms:
  • Begins in the antepartum period
  • Malaise
  • Flu-like symptoms
  • Nausea/vomiting
  • Statement of, “I just don't feel right" or "Something is wrong"
  • Epigastric or RUQ pain Abnormal bleeding (gums, around IV site, petechiae)
• The treatment is delivery with PP medication

Gestational Hypertension (GHTN) Risk Factors

• No one factor can identify a woman at risk
  • <19 or >40 years old
  • First pregnancy (nulliparity)
  • Chronic renal DX
  • Multi-fetal pregnancy
  • H/O Pre-E
  • Chronic HTN
  • Diabetes (GDM and Type 1)
  • Autoimmune disorders (RA, Lupus)
  • Obesity (BMI >30) H/O obstructive sleep apnea

Gestational Hypertension (GHTN) Expected Findings

• Severe, continuous HA
• Nausea
• Blurred vision
• Flashes of light or dots before the eyes
• HTN
• Proteinuria
• Edema - face, hands, periorbital
• Pitting edema of dependent extremities
• Vomiting
• Oliguria
• Hyperreflexia
• Scotoma (visual changes)
• Epigastric pain
• RUQ pain
• Dyspnea
• Decreased breath sounds
• Seizures
• Jaundice
• Worsening labs
• Progression of disease: worsening of liver and kidney labs, worsening HTN, cerebral involvement (HA, hyperreflexia, onset of seizures)

Gestational Hypertension (GHTN) Diagnostic Testing

• Dipstick urine (protein)
• 24-hour urine (protein, creatine clearance)
• NST/CST/BPP/US
• Daily kick counts
• Doppler flow studies

Chronic Hypertension in Pregnancy

• Definition:Hypertension present before pregnancy or that initially manifests before 20 weeks of pregnancy
  • SBP ≥ 140 mm Hg and/or DBP ≥ 90 mm Hg on two occasions at least 4 hours apart (same as GHTN)
• Maternal and fetal outcomes of pregnancy better when the client has good B/P control at time of conception
• Prenatal counseling of hypertensive women is important
• Assess B/P medication client is taking and insure it is safe for pregnancy
  • ACE inhibitors or angiotensin II receptors not safe in pregnancy

Chronic Hypertension with Superimposed Preeclampsia

• Definition:
  • Development of preeclampsia (with or without severe features) in women with chronic hypertension
• S/S include:
  • HA, visual changes, proteinuria, seizures, epigastric pain, laboratory findings reflecting elevation in PLT, liver studies, creatinine
• POC includes Mag, corticosteroids, delivery

Medical Management for Gestational hypertension and Preeclampsia (without severe features)

• Antepartum Management
  • Promoting safety is the first priority!
  • Stabilize B/P and systemic changes
  • Frequent lab testing for identification of severe features/progression of gestational hypertension to preeclampsia
  • Expectant management at home before 37 weeks gestation with PO medication
    • May or may not be on modified bedrest
  • Twice weekly prenatal visits and prenatal testing beginning at 32 weeks gestation NST
    • BPP
  • Education about subjective and objective signs/symptoms of worsening preeclampsia
  • When to notify HCP of findings
  • Goal to get to 37 weeks gestation
  • Corticosteroid administration to promote fetal surfactant development
  • In-patient care: daily weights, strict I&O, modified bedrest

Medication for GHTN

• Aspirin
  • 81 mg daily
• Antihypertensive
  • Methyldopa
  • Nifedipine
  • Hydralazine
  • Labetalol
• Betamethasone
  • Celestone
  • Dexamethasone
• Anticonvulsant/neuroprotectant
  • Magnesium sulfate

Magnesium Sulfate

• Indicated to prevent seizure activity in the pregnant client and for neuroprotection of the fetus
• Initiate seizure precautions:
  • Side rails up, padded
    • Intubation supplies ready
    • O2 & suction ready
  • Calm environment
• Dosing:
  • Load with 4-6g over 15-30 mins
    • Maintenance with 1-2g/hr
    • Therapeutic levels: 4-7 mEq/L
• Antidote : CALCIUM GLUCONATE (1g)

Nursing Management of Client Having Eclamptic Seizure

• Record: Note time of onset and ending of seizure
• Turn: Turn client to her side
• Call: For help from the bedside Administer
• Administer: supplemental oxygen at 10 L/min with nonrebreather
• Remove anything from the bed that could be a safety hazard
• Do not place anything in the mouth during the seizure.
• After convulsion ceases: - Clear airway with suction if needed - Continue to administer 10 L oxygen per face mask - Apply pulse oximeter - Start IV if not already in place - Start magnesium sulfate if not already infusing - Insert foley
  • Pregnant client
    • Apply EFM (electronic fetal monitor)
    • Assess cervix
    • Prepare for C/S
  • Vital signs per protocol
• Provide and explain situation to the family
• Once the client is alert and oriented, explain the situation and provide emotional support.

Managing Gestational Hypertension and Preeclampsia (Discharge Instructions)

• Bedrest, side-lying position several times a day
• Perform diversional activities
• Avoid foods high in sodium
• Avoid ETOH and tobacco, limit caffeine
• Increase H2O intake to at least 8 glasses/day
• Maintain a quiet, calm environment
• Maintain airway in the event of a seizure
• Know S/S of worsening condition
• Take antihypertensives as prescribed
• Keep HCP appointments (anticipate weekly HCP/OB visits until B/P stable or delivery)

Managing Postpartum Gestational hypertension and Preeclampsia

• Continue administration of magnesium sulfate for 24-48 hours postpartum
• Close follow-up after hospital discharge - Earlier and more frequent postpartum visits to - Anticipate 1st PP OB visit in the first week after D/C - Offer Home health nursing care
• Educate family on:
  • Preeclampsia in future pregnancies
  • Hypertension (increased risk by of 4-fold)
  • Ischemic heart disease, venous thromboembolism, CVA (2-fold risk)
  • HTN may persist for up to 1 year after delivery

Careplanning: Potential Nursing Diagnoses

• Risk for injury (woman and fetus) risk factor: biochemical dysfunction AEB CNS irritability identified through 4+ DTRs with 1 beat clonus bilaterally - Goal: Client will demonstrate diminished signs of CNS irritability (DTRs ≤ 3+ [on 0-4 scale] with no clonus; absence of seizure activity)
• Ineffective peripheral tissue perfusion (placental) r/t arterial vasospasm 2° preeclampsia AEB BP of 160/110 and 1+ peripheral pulses in all 4 extremities - Goal: Client will demonstrate signs of adequate tissue perfusion (U.O. > 30 ml/hour) and reassuring FHR tracing