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Hypertension
in Pregnancy
TE NM
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TSG 2016

WHY DO WE CARE ABOUT

HYPERTENSION IN PREGNANCY?
Most common pregnancy disorder
Racial disparities
Spectrum of disorders
Status can deteriorate rapidly

TSG 2016

T
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TSG 2016

DEFINITION HYPERTENSION
Normal Blood Pressure
Pre-hypertension
Stage 1 Hypertension
Stage 2 Hypertension

TSG 2016

REVIEW TAKING A BLOOD PRESSURE

Manual cuf
Seated, after 10
min. rest
Arm at heart level
Cuf size 1.5x
circumference of
upper arm

TSG 2016

DEFINITION CHRONIC HYPERTENSION

Chronic hypertension is the presence
of persistent hypertension.

TSG 2016

CHRONIC HYPERTENSION
Associated Maternal Risks
Associated Fetal/Neonatal Risks
Contiuum of disease process

TSG 2016

DEFINITION GESTATIONAL
HYPERTENSION
Mild hypertension developing in
previously normotensive woman
after 20 weeks of gestation. No
proteinuria or end organ
involvement. Diagnosis is only
accurate 6-12 weeks after birth
when woman is again
normotensive.*

TSG 2016

DEFINITION PRE ECLAMPSIA

A Multisystem, vasospastic disease process causing
reduced organ perfusion and occurring only during
pregnancy.
Characterized by hypertension, and proteinuria
>.3g/L in 24 hours OR end organ dysfunction.
Onset after 20 weeks gestation
May be subdivided into mild or severe form of the
disease based on blood pressure, proteinuria or
symptomatology

TSG 2016

INCIDENCE HYPERTENSIVE DISORDERS

Hypertensive Disorder

Percentage

Chronic hypertension

5% all pregnancies

Gestational hypertension

10-15% of primigravidas;
2-5% multiparas

Pre-eclampsia (PEC)

4.5-11% all pregnancies.

25% of women with chronic hypertension get

superimposed PEC

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10

TERMINOLOGY: HYPERTENSION IN
Term PREGNANCY
Presentation

Proteinuria
> .3 g/L
protein in a
24-hour urine
collection

Chronic
hypertension

Present at registration or noted prior to 20

weeks; continuing after 6-12 weeks
Postpartum.

No

Gestational
hypertension

BP 140/90 1st noted after 20 weeks; 2

measurements 4 hours apart within 1 week.
No end organ involvement. Resolves <6-12
weeks Postpartum*

No

Preeclampsia/
Eclampsia
(PEC)

BP 140/90 1st noted after 20 weeks 2

measurements 4 hours apart . May be end
organ involvement

Yes

Superimposed
PEC on
chronic
hypertension

Present at registration or noted prior to 20

weeks; Rising pressures with end organ
involvement or new onset proteinuria.

Yes

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11

WHEN IS IT PRE ECLAMPSIA?

TSG 2016

12

CONTINUUM OF GESTATIONAL
HYPERTENSION

TSG 2016

13

CONTINUUM OF CHRONIC
HYPERTENSION

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14

PREDISPOSING FACTORS PRE ECLAMPSIA

Pre-existing diseases
History of Pre-eclampsia
Factors in current
pregnancy affecting
placenta

:
Obesity

TSG 2016

15

ETIOLOGY OF PRE-ECLAMPSIA
Unknown.
Theories:
Placental factors- incidence with molar pregnancy, twins, diabetes.
MOA possibly abnormal prostacyclin synthesis, affecting trophoblast
invasion *

Immunologic factors incidence with Barrier contraception, new

partner

Genetic predisposition incidence with maternal or paternal FH

Oxidative stress-Thromboxane activity in pre eclamptic placentas

TSG 2016

16

REVIEW NORMAL PREGNANCY

PHYSIOLOGY
blood volume

cardiac output
renal blood flow & GFR

Vascular remodelingspiral arteries

in uterus expand to accommodate
greater blood flow =
systemic vascular resistance vasodilated
state

TSG 2016

17

PATHOPHYSIOLOGY OF PRE ECLAMPSIA

BP

Ateriolar

Liver
Kidney
Brain
Placenta

TSG 2016

18

INADEQUATE VASCULAR REMODELING

TSG 2016

19

Efect>

Mild Pre-eclampsia

Severe Pre-eclampsia

BP

>140/ >90

>160/ >110 mm

Proteinuria

0.3 g/L in a 24 hr specimen or >0.1

g/L in a random specimen on > 2
occasions 6 hr apart with dipstick,
values from 1+ to 2 + or > 0.3
protein:creatinine ratio

>0.5 g/L in 24 hr or
3-4+ protein on dipstick.
>4.6 protein:creatinine ratio*

Reflexes

Usually normal

Hyper-reflexive, possibly clonus

Subjective
symptoms

None

Headaches, RUQ PAIN, n/v,

Visual disturbances, Oliguria (<400500 mL/day)

Edema

Peripheral

Central: face, pulmonary,ascites

Thrombocytope
nia

Usually absent

Present

Transaminases

Normal

Markedly elevated

Pre-eclampsia signs and symptoms20

TSG 2016

CLINICAL APPLICATION
35 y.o. G4 P3 at 14
weeks gestation.
Her BP = 148/94
today; 140/96 at
her initial prenatal
exam last week
What does she
have?

17 y.o. G1 P0 at 38
weeks gestation. BP =
148/94 today, 126/70
last week. 2+
proteinuria on dip and
has gained 4 pounds
since last week.
What does she have?

TSG 2016

21

CLINICAL APPLICATION
24 y.o. G3 P1 at 36
weeks . Her BP =
140/92 today. Normal
previously. Trace
proteinuria on dip and
1+ pedal edema .
Denies visual changes,
N/V, H/A, epigastric pain

Two days later her

BP is 142/90 and
she has trace
proteinuria again.
What does she
have? What is she
at risk for
developing?

TSG 2016

22

NURSES ROLE PRENATALLY

initial prenatal visit: Ongoing screening for signs and
symptoms of developing disease:
Symptoms: Headaches, dizziness, visual disturbances, RUQ
pain, oliguria, shortness of breath
Signs: Central edema, rising BP, excessive unexplained
weight gain, proteinuria, brisk reflexes, crackles, diminished
breath sounds, lag in fundal height
Coordination of lab tests and fetal assessment:

Fetal Status ! FF
TSG 2016

23

CLINICAL APPLICATION. WHOS AT RISK?

A. 16 y.o. G1P0
B. 20 y.o. G2P1 having a baby with a new
boyfriend
C. 24 y.o. G3/2002 with gestational
diabetes
D. 30 y.o. 6/0314 drug abuser with chronic
hypertension
E. 39 y.o. G1P0 who is pregnant with twins
Who is at risk for developing Preeclampsia?

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24

NORMAL PREGNANCY

PEC

HELLP

Hemoglobin/hematocrit

9.5 -15 gm/dl/ 28% to 40%

May

Platelets

150,000 to 400,000/mm3

Unchanged to

PT/PTT

12 -14 sec/60 to 70 sec

Unchanged

Unchanged

Fibrinogen

150 to 400 mg/dl

300 to 600 mg/dl

Fibrin split products (FSP)

Absent

Absent or present

Present

Blood urea nitrogen (BUN)

8-10 mg/dl

May be >10 mg/dl

Serum Creatinine

0.3 to .9 mg/dl

>1 mg/dl

Lactate dehydrogenase (LDH)

45 to 90 U/L

Unchanged

(>600)

Aspartate aminotransferase
(AST)

4 to 20 U/L

Unchanged to

Alanine aminotransferase (ALT)

3 to 21 U/L

Unchanged to

Creatinine clearance

80 to 125 ml/min

130 to 180 ml/min

Burr cells/schistocytes

Absent

Absent

Present

Uric acid

3.1- to 6.3 mg/dl

>5.9 mg/dl

>10 mg/dl

Bilirubin (total)

0.1 to 1 mg/dl

Unchanged or

(>1.2 mg/dL)

Laboratory Values

<100,000/mm3

TSG 2016

25

CONSERVATIVE MANAGEMENT MILD PRE

ECLAMPSIA
Rest
Kick counts
Fetal Assessment 2-3 X/wk
Maternal Assessment 2-3 X/wk
Follow labs
Delivery near term if stable

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26

INTRAPARTUM MANAGEMENT PREECLAMPSIA

1)
Seizure prophylaxis: Magnesium
sulfate,

Magpie Trial, Lancet 2002 supports

Magnesium sulfate as the most
efficacious drug for seizure prevention
with pre eclampsia. Reduces seizure
risk >75%.

TSG 2016

27

2)Continuous fetal monitoring

3) Maternal monitoring:
4) Laboratory and fetal assessment
studies
5) Steroids to mature fetal lungs if <34
weeks gestation
6) Delivery decision based on maternal &
fetal risks/benefits: gestational age,
stability, fetal compromise

Collaborative care
cont.
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28

CLINICAL APPLICATION
37 year old primigravida at 33 weeks gestation
is admitted to the hospital with a blood
pressure of 150/98 and 425 mg proteinuria in
24 hours.
Does she have mild or severe preeclampsia?
Twenty four hours later, she has a blood
pressure of 160/112, her protein:creatinine
ratio is 5 and she has a headache and right
upper quadrant pain..
Does she have mild or severe pre-eclampsia?

TSG 2016

29

CLINICAL APPLICATION
What categories of medications
would you expect the physician to
have ordered on admission of the
patient to the hospital?
Twenty fours after admission what
other medication would the
physician order?

TSG 2016

30

Definition
Incidence
Priorities during seizure.
Complications

ECLAMPSIA
TSG 2016

31

ANTIHYPERTENSIVE MEDICATIONS
Medication

Action

Maternal SE

Fetal SE

Hydralazine
(Apresoline)

Arterial dilator. Acute

therapy

HA, flushing,
palpitations,
tachycardia,N/V

Tachycardi
a, fetal
distress if
DBP <90

Labetalol

A- & B-blocker,
vasodilation. Acute
and maintenance
therapy

Minimal: flushing,
tremulousness,
orthostatic hypotension
Contraind: asthma

May blunt
FHT accels

Methyldopa
(Aldomet)

Maintenance
therapy, decreased
peripheral vascular
resistance

Sleepiness, postural
hypotension,
constipation

+Coombs
after 4
mos.

Nifedipine
(Procardia)

Calcium channel
blocker, reduces
vascular resistance by
relaxation arterial
smooth muscles

HA, flushing,
potentiates CNS effects
w/ Mag, may interfere
w/ labor

TSG 2016

32

PRE ECLAMPSIA VS HELLP

HELLP= hemolysis (H),

elevated liver enzymes (EL), and
low platelets (LP)

TSG 2016

33

Screening and assessment

Supportive care:
Monitor for DIC:
Coordinate and review laboratory studies
Counseling for future pregnancies:

Collaborative management of
HELLP

TSG 2016

34

CLINICAL APPLICATION
You have orders to start Magnesium sulfate on a pre-eclamptic
patient. who is 37 weeks gestation . The order is written:
Administer a 4 Gm loading dose over 15 minutes then maintain
at 2 Gm/hr.
The medication comes as 40 Gm Magnesium sulfate in 1000 mL.
LR.
Calculate the setting for the pump in mL/ hr. for the loading dose.
_______________ mL/hr.
After the loading dose, what will be the pump setting be for the
maintenance dose?
_______________mL/hr.

TSG 2016

35

CLINICAL APPLICATION
16 years old, G1P0 at 37 weeks. She
presents to the labor unit with
contractions and says she has had
a bad headache all day. While she
is in triage, she begins to seize.
What do you do?

TSG 2016

36

SUMMARY
PEC is unique to human pregnancy
Most common in Nulliparas and extremes of
reproductive age
Continuum from gestational hypertension to mild to
severe, less often to HELLP or Eclampsia
Etiology unknown
Pathology is endothelial cell dysfunction and vasospasm
Cure is delivery of the baby and placenta but may take
72 hours for symptoms to resolve

TSG 2016

37