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Hypertension in Pregnancy
Created & Presented by:
Jacquelyn Svoboda, MSN, RN, WHNP-C Assistant Professor/ Nurse Practitioner
UTMB School of NursingOB/GYN Department
Galveston, Texas
https://www.whattoexpect.com/pregnancy/high-blood-pressure/
Copyright 2019 University of Texas Medical Branch, School of Nursing
Hypertension in Pregnancy• Ranks 5th as contributor to maternal and perinatal morbidity and mortality• Texas ranks 43rd for Maternal Mortality- Black women died 2.3 x greater rate• Hypertensive disorders of pregnancy are the most common medical
complication reported during pregnancy• Patients who receive Nurse-Family Partnership services have 35% less cases
of Preeclampsia
Significance
• Chronic Hypertension in pregnancy- 5% of all pregnancies• Hypertension in Pregnancy (including Preeclampsia) complicates up to
10% of all pregnancies• Rate of Preeclampsia in the US has increased 25% in the last two decades
Incidence
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Hypertension in Pregnancy
Hypertensive Disorders in Pregnancy Classification
Chronic hypertension (CHTN)
Chronic hypertension with superimposed PreeclampsiaGestational hypertension (GHTN)
Preeclampsia (mild features & severe features) Eclampsia
HELLP Syndrome
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ConsiderationsEquipment• Ideal- Mercury manual cuff– Inflate >30mmHg high after radial pulse• Cuff size- assure appropriate site- cuff to cover 2/3 arm 80%
Considerations Position• Rest x 5-10min prior to taking BP• Patient should be seated supine or left lateral recumbent
ConsiderationsPatient • No smoking prior to BP• No caffeine prior to BP
Nursing Considerations Regarding Blood Pressure Monitoring
Image: https://pocatellowomensclinic.com/wp-content/uploads/2017/05/preeclampsia.jpg
Copyright 2019 University of Texas Medical Branch, School of Nursing
Classification:Chronic Hypertension Criteria
Chronic Hypertension
◦ Present BEFORE the pregnancy or diagnosed BEFORE week 20 of gestation
◦ Stage 1 hypertension: Systolic between 130–139 or diastolic between 80–
89 mm Hg
◦ Stage 2 hypertension: Systolic at least 140 or diastolic at least 90 mm Hg
◦ Blood pressures (BPs) persistently above 160/105 should be treated to goals between 120/80 and 160/105.
Copyright 2019 University of Texas Medical Branch, School of Nursing
Classification:Chronic Hypertension Criteria
Chronic Hypertension w/ Superimposed Preeclampsia
◦ Present BEFORE the pregnancy or diagnosed BEFORE week 20 of gestation AND
◦ Signs & Symptoms present for Preeclampsia or eclampsia (appear AFTER 20 weeks)
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Classification:Chronic Hypertension
https://www.hopkinsmedicine.org/sebin/p/d/pregnant-belly-640-440_4_pyramid.jpg
• Superimposed preeclampsia• Cesarean section• PPH, GDM, Placental
abruption• Increased perinatal mortality-
stroke• Fetal effects: Growth
restriction- Preterm birth, stillbirth, congenital defect
Associated with
increased incidence
Copyright 2019 University of Texas Medical Branch, School of Nursing
Management:Chronic Hypertension
• Recommendations:
https://www.info-on-high-blood-pressure.com
For systolic blood pressures ≥160 mm Hg or diastolic pressures ≥105 mm Hg:
Labetalol, Nifedipine, or Methyldopa Low dose ASA 81mg daily starting between 12-28wksSerial BP monitoring- Check home monitor for accuracyLab assessments-protein, creatinine
Delivery timing (depending on control- 37-39wks) Fetal Surveillance: Kick Count, NST
Copyright 2019 University of Texas Medical Branch, School of Nursing
• Gestational Hypertension
• Onset of hypertension without proteinuria after the 20th week of pregnancy
• Previously normotensive
• BP S >/= 140/ OR D >/= 90mmHg- persistent for 4 hrs
• Asymptomatic
Classification:Gestational Hypertension Criteria
Copyright 2019 University of Texas Medical Branch, School of Nursing
Education on signs and symptoms of pre-eclampsia and eclampsia
BP at least once weekly with proteinuria assessment in the office
Twice weekly measurement of BP at home or in the office is suggested.
Fetal Surveillance: Kick Count, NST as indicated
Management :Gestational Hypertension
Copyright 2019 University of Texas Medical Branch, School of Nursing
• Preeclampsia (Previous termed Pregnancy Induced Hypertension PIH)
• Pregnancy-specific syndrome• Hypertension develops AFTER 20 weeks of gestation in previously
normotensive women• A vasospastic systemic disorder categorized as Mild or Severe Feature
Classification: Preeclampsia
Copyright 2019 University of Texas Medical Branch, School of Nursing
Classification: Preeclampsia (mild & severe features)
• Signs & symptoms develop only during pregnancy and disappear after birth** Rare-Postpartum Preeclampsia does occur
Etiology:• Family history• Multifetal pregnancy (twins, triplets or >)• African-American race• Obesity• <19 and </=40 years old • Pre-existing medical or genetic conditions• Smokers, Maternal Infection, Lower Socioeconomic
Status, New partner
Who is at risk?
Copyright 2019 University of Texas Medical Branch, School of Nursing
Pathophysiology:Preeclampsia
• Potential to progress along a continuum from mild to severe
• Multiple theories of etiology• Caused by disruptions in placental
perfusion and endothelial cell dysfunction• Placental itching• Generalized vasospasm• Reduced kidney perfusion
perfusion and endothelial cell dysfunction
http://epomedicine.com/medical-students/hypertensive-disorders-in-pregnancy-basics/Copyright 2019 University of Texas Medical Branch, School of Nursing
Classification-Pre Eclampsia (Mild Features) Criteria
Pre Eclampsia Mild Feature Criteria: Systolic & diastolic blood pressures ≥140 OR ≥90
mm Hg, (respectively, occurring twice, 4 hours apart, after 20 weeks) WITH: Proteinuria (ie, ≥300 mg per 24 hours, protein to
creatinine ratio ≥0.3 day or 1+ urinary protein dipstick reading) OR:
◦ OR in the Absence of Proteinuria- any of the following findings (next slide)
Copyright 2019 University of Texas Medical Branch, School of Nursing
Or, in the absence of proteinuria but with any of the following:
Classification-Pre Eclampsia (Mild Features) Criteria (Con’t)
Affected System Evidence
Blood Pressure (x2, 4 hrs apart) ≥140 OR ≥90 mm Hg
Platelets Platelet counts <100,000 µLLiver Function Elevated liver enzymes (twice normal)Renal Function Renal Insufficiency- elevated creatinine clearance,
proteinuriaCerebral Function Cerebral disturbances- headache/ blurred visionPulmonary Function Pulmonary edema
Copyright 2019 University of Texas Medical Branch, School of Nursing
Identify:Pre- Eclampsia (Mild Features)
Signs & Symptoms:
Blurred vision• Headache• Epigastric pain
Exam Findings
Dependent edema
• Pitting edema
• Deep tendon reflexes
• Clonus
Lab Findings
• ALT, AST, Creatinine, Uric Acid, LDH, Platelets, UA
https://www.rd.com
Copyright 2019 University of Texas Medical Branch, School of Nursing
Management:Preeclampsia (mild feature)
Serial maternal assessment Serial BP (twice weekly)
Lab: Platelet counts, kidney function & liver enzymes (weekly).
Magnesium Sulfate if indicated * New ACOG bulletin
Corticosteroids x 2 if preterm
Decrease activity- bed rest not recommended
Delivery when indicated
Fetal Surveillance: FKC Sheet, NST, BPP, Doppler
Copyright 2019 University of Texas Medical Branch, School of Nursing
Classification-Preeclampsia (Severe Features) Criteria
Affected System Evidence Blood Pressure (x2, 4 hrs apart) ≥160 or 110 mm Hg, after 20 weeks gestation
AND Any of the following:Platelets Platelet counts <100,000 µL- thrombocytopeniaLiver Function Unexplained right-upper-quadrant- epigastric pain
unresponsive to medications, or hepatic transaminase levels twice normal
Renal Function Progressive renal insufficiency- elevated creatine clearance (pitting edema), proteinuria
Cerebral Function New onset cerebral or visual disturbances (headache/blurred vision)
Pulmonary Function Pulmonary edema Copyright 2019 University of Texas Medical Branch, School of Nursing
Identify:Pre- Eclampsia (Severe Features)
Signs & Symptoms:
Blurred vision• Headache• Epigastric pain
(RUQ)• ** Sx more
severe
Exam Findings
Dependent edema
• Pitting edema• Deep tendon
reflexes • Clonus• Excessive weight
gain • ** Sx more
severe
Lab Findings
• ALT, AST, Creatinine, Uric Acid, LDH, Platelets, UA
https://www.rd.com
Copyright 2019 University of Texas Medical Branch, School of Nursing
Management:Preeclampsia (Severe Features)
Features)
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Mg So4- monitor toxicityDTR- assessmentBetamethasone x 2Bed rest/ NST, BPP, Dopplers
Serial Labs Antihypertensives PRN
DeliveryClonus exam
Copyright 2019 University of Texas Medical Branch, School of Nursing
Classification:Eclampsia Criteria
• Eclampsia• Seizure activity or coma in woman diagnosed
with preeclampsia • May be on continuum with preeclampsia or
may present eclamptic • No history of pre-existing pathology• Eclamptic seizures can occur before, during,
or after birthImage: https://www.medpagetoday.com/upload/2013/7/10/40379.jpg
Copyright 2019 University of Texas Medical Branch, School of Nursing
Management:Eclampsia
Immediate care- prevent injury, stabilization
Treatment- MgSO4, Diazepam, Phenytoin, O2
Nursing action during a convulsion
Prevention
Prenatal care for assessment and early
interventionsCopyright 2019 University of Texas Medical Branch, School of Nursing
Classification:HELLP Syndrome Criteria
Hemolysis (H) of red blood cells
Elevated (E)
Liver enzymes (function) (L)
Low (L)
Platelets (P)
Laboratory diagnostic variant
of severe preeclampsia
involves hepatic dysfunction,
characterized by:
Copyright 2019 University of Texas Medical Branch, School of Nursing
Signs & Symptoms
• Nausea• Vomiting• Headache• Right Upper Quadrant
pain• Chest/arm pain
Associated with
increased risk
Pulmonary edema, Sepsis,Stroke
Renal failure
Liver hemorrhage or failure,
DeathDisseminated intravascular coagulation
(DIC)
Placental abruption
Acute respiratory
distress syndrome
Identify:HELLP
Syndrome
Copyright 2019 University of Texas Medical Branch, School of Nursinghttp://dmatxi.com/wp-content/uploads/2014/02/Upper-Abdominal-Pain-during-Pregnancy.jpg
Management:HELLP Syndrome
Tertiary Care Center- transfer if indicated
Close monitoring
Lab testing at minimum every 12 hrs
Corticosteroids, Mag So4
Delivery soon after maternal stabilization
Copyright 2019 University of Texas Medical Branch, School of Nursing
Hypertension in Pregnancy:Fetal Considerations
Poor Fetal
Growth
Preterm birth
Infant death
Acidosis Life consequences
Whattoexpect.com
Copyright 2019 University of Texas Medical Branch, School of Nursing
http://r.search.yahoo.com
Biophysical ProfileUltrasoundFetal Doppler
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Antepartum Education -CHTN, GHTN, Preeclampsia, Superimposed PreE, Eclampsia, HELLP
Patient Teaching
How to Prevent hypertension in pregnancyHow to Assess Fetal well being- FKC SheetHow to Recognize Signs & SymptomsHow to Assess BP at home- Range/ LogWhen to Contact the providerImportance of keeping prenatal appointments
Recognizing Symptoms
Headache-Excessive weight gain Blurred vision, Scotoma RUQ Pain or Shoulder PainSudden onset Nausea & Vomiting Decreased Fetal Movement
Copyright 2019 University of Texas Medical Branch, School of Nursing
Postpartum Education & Follow Up-Gestational hypertension, pre-eclampsia, or superimposed preeclampsia
Monitor BP:Up to PPD 3 dayPPD 7 -10 dayMonitor for s/sxPreeclampsia
Preconception counseling in
future pregnancies
Encourage yearly assessments of
BP, lipids, fasting glucose, and
body-mass index-primary care
Educate All Patients on signs & symptoms of
Preeclampsia** PP Preeclampsia
Copyright 2019 University of Texas Medical Branch, School of Nursing
Now What?Prevention of Hypertension Disorders in Future
Pregnancy
PreventionLow Dose
Aspirin (baby ASA) QD begin
12-28 wks
Calcium supplementation
1.5-2 gram/day before 32 wks
Dietary salt intake
restriction-Ineffective
Decrease BMI if overweight
Incidence of Preeclampsia by 17%
1.5
Copyright 2019 University of Texas Medical Branch, School of Nursing
(Texas Health & Human Services, 2018)
Extend health services up to 12 month PP
Enhance prenatal screening
Improved patient education & advocacy
Connect patients to resources
Earlier PP access
Target health program for @ risk populations-Black women
Texas Maternal
Mortality & Morbidity
Taskforce 2018
Recommendations which May Impact Hypertension in Pregnancy
Copyright 2019 University of Texas Medical Branch, School of NursingPreeclampsia Foundation Joan's Story
Patient
Assist moms in adhering to
treatment plan
Educate moms
Referrals
Health System
Champion integrated care
models
Bridging gap in access & care
Advocacy
Your Impact
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Copyright 2019 University of Texas Medical Branch, School of Nursing
At Risk At Risk Pregnancies
Copyright 2019 University of Texas Medical Branch, School of Nursing
Thank you!!
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Copyright 2019 University of Texas Medical Branch, School of Nursing
• American College of Obstetricians and Gynecologists (ACOG) (2013).Preeclampsia and Hypertension in Pregnancy. Retrieved from http://www.acog.or g/Womens-Health/Preeclampsia
• ACOG Practice Bulletin No. 202 Summary: “Gestational Hypertension and Preeclampsia.” Obstetrics & Gynecology 133.1 (2019): 211–214. Retrieved from https://www.acog.org/Clinical-Guidance-and-Publications/Practice-Bulletins-List
• ACOG Practice Bulletin No. 203: “Chronic Hypertension in Pregnancy” Obstetrics & Gynecology 133.1 (2019): e26-e50. Retrieved from https://www.acog.org/Clinical-Guidance-and-Publications/Practice-Bulletins-List
• Nurse Family Partnership (2019) Reduces Maternal Child Mortality. Retrieved fromhttps://www.nursefamilypartnership.org/wp-content/uploads/2019/01/Maternal-and-Child-Mortality.pdf
• Perry, S.E., Hockenberry, M.J., Lowdermilk, D. L., & Wilson, D. (2018). Maternal Child Nursing Care (6th ed.). St. Louis: Mosby.
• Preeclampsia Foundation (2019) Position Paper: Preeclampsia and Future Cardiovascular Disease in Women. Retrieved from https://www.preeclampsia.org/images/pdf/FINAL_PE_CVD_POSITION-PAPER.pdf
• Texas Health & Human Services (2018) Maternal Mortality and Morbidity Task Force Report Retrieved https://dshs.texas.gov/mch/pdf/MMMTFJointReport2018.pdf
References
Copyright 2019 University of Texas Medical Branch, School of Nursing
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