hypertension in pregnancy - nurse-family partnership · hypertension in pregnancy •ranks 5th as...

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

https://www.whattoexpect.com/pregnancy/high-blood-pressure/

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


https://pocatellowomensclinic.com/wp-content/uploads/2017/05/preeclampsia.jpg

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.


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)

http://images.agoramedia.com/


http://images.agoramedia.com/ugcphotoservice/100/2015/6/30/63130495/22f5cb0c-e9f0-4270-aa45-06e0ccbffe76.jpg

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


https://www.hopkinsmedicine.org/sebin/p/d/pregnant-belly-640-440_4_pyramid.jpg

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


https://www.info-on-high-blood-pressure.com/images/listofHBPMedications.jpg

• 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


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


• 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


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?


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

http://epomedicine.com/medical-students/hypertensive-disorders-in-pregnancy-basics/

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)


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


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


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


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


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


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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


https://www.medpagetoday.com/upload/2013/7/10/40379.jpg

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:


https://www.stayathomemum.com.au/wp-content/uploads/2015/10/via-www.whatthehellp.com_......-e1445837310391.jpg

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

http://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


Hypertension in Pregnancy:Fetal Considerations

Poor Fetal

Growth

Preterm birth

Infant death

Acidosis Life consequences

Whattoexpect.com


http://r.search.yahoo.com

Biophysical ProfileUltrasoundFetal Doppler


http://brooksidepress.org/ob_newborn_care_1/wp-content/uploads/2015/05/Reactive_NST_640.jpg

http://brooksidepress.org/ob_newborn_care_1/wp-content/uploads/2015/05/Reactive_NST_640.jpg

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


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


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


(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

https://youtu.be/mMW-oc014uc

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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At Risk At Risk Pregnancies


Thank you!!

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• 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


http://www.acog.org/Womens-Health/Preeclampsia

https://www.acog.org/Clinical-Guidance-and-Publications/Practice-Bulletins-List

https://www.acog.org/Clinical-Guidance-and-Publications/Practice-Bulletins-List

https://www.nursefamilypartnership.org/wp-content/uploads/2019/01/Maternal-and-Child-Mortality.pdf

https://www.preeclampsia.org/images/pdf/FINAL_PE_CVD_POSITION-PAPER.pdf

https://dshs.texas.gov/mch/pdf/MMMTFJointReport2018.pdf

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