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Course: Maternity Nursing�Topic: Hypertension and Pregnancy

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Module Goals

The learner will be able to:

Explain diagnosis of hypertension in pregnancy
Differentiate between pre-existing and gestational hypertension
List possible complications of hypertension in pregnancy
Identify the management of hypertension and preeclampsia
Identify teaching points for managing hypertension in pregnancy

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Normal Blood Pressure in Pregnancy

Normal blood pressure (BP) in pregnancy:

Systolic <140 mmHg
Diastolic < 90 mmHg

In normal pregnancy the systolic and diastolic BP both usually decrease during the second trimester and slightly increase during the third trimester.

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Hypertension During Pregnancy

Proteinuria in Pregnancy

Hypertension during pregnancy is defined as a diastolic BP of 90 mmHg or systolic BP of 140 mmHg or more.
An abnormally high BP during pregnancy is often accompanied by proteinuria.

Normally urine contains no protein or only a trace of protein
Proteinuria (excessive amount of protein in the urine)

0.3 g or more of protein in a 24-hour urine specimen
1+ or more protein as measured with a reagent strip (e.g. Uristix, Multistix, Lenstrip, etc.

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Classification of Hypertension in Pregnancy

The classification of hypertension during pregnancy depends on:

Time of onset of the hypertension
The presence or absence of proteinuria

Types of hypertension in pregnancy

Gestational hypertension
Chronic hypertension
Preeclampsia
Chronic hypertension with superimposed preeclampsia
Eclampsia

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Gestational Hypertension vs Chronic Hypertension

Gestational hypertension

Diastolic BP is 90 to 95 mmHg
Develops after 20 weeks gestation in the absence of proteinuria

Chronic hypertension

Elevated BP develops before 20 weeks of gestation, or patient is known to have had hypertension before the start of pregnancy

Chronic hypertension with superimposed preeclampsia

Develops before 20 weeks gestation and is complicated by appearance of proteinuria after 20 weeks gestation

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Management of Gestational Hypertension

Patient may stay at home under the following conditions:

She is informed about the symptoms of imminent eclampsia (seizure) and understands that she needs to seek immediate care should any of these occur
She is seen weekly at a high-risk antenatal clinic and between visits to check BP and urine protein
Umbilical artery doppler is done at 26 weeks to assess placental function
Alpha methyldopa is prescribed to control BP > 150/100 Initial dosage of alpha methyldopa is 500 mg 8 hourly.

(WHO, 2011)

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Management of Gestational Hypertension

Fetal assessment: Patient records fetal movements twice daily for an hour each time
Diastolic BP of 100 mmHg and/or systolic BP of 150 mmHg or higher must be admitted to the hospital and prescribed alpha methyldopa
Pregnancy may be allowed to continue until 40 weeks if:

BP remains well-controlled
No proteinuria develops
Fetal condition remains good

Labour should be induced at 40 weeks if not delivered by that time

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Management of Chronic Hypertension

Patients with chronic hypertension may be managed at home if:

Renal function is normal (normal serum creatinine concentration)
Pre-eclampsia is not superimposed
Diastolic BP is 80-90 mmHg and/or systolic BP is 120-140 mmHg

Patients with chronic hypertension should be referred to hospital if:

Renal function is abnormal (Serum creatinine > 120 mmol/l)
Proteinuria is present
Diastolic BP 110 mmHg and/or systolic BP 160 mmHg or higher
Intrauterine growth restriction is present
More than 1 medication is required to control BP

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Management of Chronic Hypertension

Antihypertensive drugs must be changed to alpha methyldopa after pregnancy
Special care:

Careful observation for rise in BP or development of proteinuria
Umbilical artery doppler should be done to assess placental function
Postpartum sterilization should be discussed with the patient, and especially for multi gravidas who are at higher risk in future pregnancies

Management for delivery of the patient is same as that for gestational hypertension

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Case study:

A 34-year-old pregnant woman arrives for her first antenatal visit at 8 weeks gestation. In her health history, she states that she takes medication for high blood pressure. Her BP is 130/85 mmHg and no protein found in her urine.

Which classification of hypertension does she have?

How would she be managed?

How should she be advised?

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Preeclampsia

Characterized by presence of both hypertension and proteinuria
Develops in the second half of the pregnancy
Also called gestational (pregnancy-induced) proteinuric hypertension
May present during pregnancy, labour, or the puerperium
One can have preeclampsia without symptoms. It is vital to have regular antenatal checks for BP and urine protein

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Preeclampsia- Risk Factors

Patients with at an increased risk of preeclampsia:

Primigravida
Chronic hypertension
Over 34 years of age
Multiple pregnancy (e.g twins, triplets)
Diabetic
Past history of complications due to preeclampsia, especially if they developed during late 2nd or early 3rd trimester

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Preeclampsia- Severity Grading

Preeclampsia: Proteinuria with

diastolic BP of 90-109 mmHg, and/or systolic BP of 140-159 mmHg

Pre-eclampsia with signs of severe disease:

diastolic BP ≥ 110 mmHg and/or systolic BP ≥ 160 mmHg on two occasions, 4 hours apart, or
diastolic BP ≥ 120 mmHg and/or systolic BP ≥ 170 mmHg on one occasion

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Preeclampsia- Severity Grading

Continued…..

Preeclampsia with abnormal laboratory results indicating severe disease:

A serum creatinine of 90 mmol/l or more indicating abnormal renal function
An alanine aminotransferase and/or aspartate aminotransferase of 40 iu/l or more indicate liver disease
A platelet count < 100000/microliter

Eclampsia: Any grade of preeclampsia with seizures

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Preeclampsia- Signs and Symptoms

Early signs/symptoms:

Sudden rise in BP and proteinuria

Progressive signs/symptoms:

Fluid retention (edema)- swelling of the feet, ankles, face and hands

Preeclampsia with severe features:

Symptoms: Severe headaches; visual disturbances or flashes of light seen in front of the eyes; blindness; dyspnea; altered mental status; upper abdominal pain in the epigastrium and/or over liver
Signs: Tenderness over the liver; increased deep tendon reflexes, e.g knee reflexes and clonus; pulmonary edema; ascites

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Preeclampsia- Maternal and Fetal Complications

Complications from preeclampsia is one of the main causes of maternal death. (WHO Maternal Mortality- Key Facts, 2019)
Major complications are intracerebral hemorrhage, pulmonary edema and eclampsia
Less common complications are HELLP (Hemolysis, Elevated Liver Enzyme, and a Low Platelet count) syndrome. May persist following delivery.
Rare complications are rupture of the liver, renal failure, adult respiratory distress syndrome, and a generalized disorder of blood coagulation

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Preeclampsia- Maternal and Fetal Complications

Risk for intracerebral hemorrhage is high if

diastolic BP ≥ 110 mmHg
Systolic BP ≥ 160 mmHg

Eclampsia can occur at a much lower blood pressure, especially in young patients
Fetal complications of preeclampsia:

Intrauterine growth restriction (decreased placental flow)
Abruptio placentae
Fetal distress
Preterm delivery
Intrauterine death

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Patient Education

Report warning signs to healthcare provider:

Visual disturbances, double vision or trouble seeing
Abdominal pain and indigestion in the upper right abdomen
Headache, dizziness
Swelling in hands and face, especially when waking in the morning

Do fetal movement checks:

Monitor fetal movements twice a day

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Management of Patient at Risk for Preeclampsia

Educate patient and family about the symptoms of severe disease, and advise to contact hospital immediately if they appear
Second half of pregnancy must be carefully monitored for:

Rise in diastolic and/or systolic BP
Proteinuria
Symptoms and signs of imminent eclampsia

Patients with obstetric history of preeclampsia and chronic hypertension:

low dose aspirin of 75 mg initiated before 20 weeks of pregnancy
Calcium 1.5-2 gram elemental calcium/day

WHO recommends calcium for all pregnant women in areas with low dietary calcium intake.

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At present, national guidelines for foetal surveillance in preeclamptic pregnancies are inconsistent, due to a lack of evidence detailing the most appropriate assessment modalities as well as the timing and frequency at which assessments should be conducted

Bettercare/Primary Maternal Care/3. Hypertensive disorders of pregnancy:

Calcium tablets need to be taken 4 hours apart from the iron tablets as calcium reduces the absorption of iron.
If the patient develops generalized oedema, but remains normotensive (normal BP) and does not have proteinuria then she should:

· Rest as much as possible

· Contact the clinic or hospital immediately if she has any symptoms of imminent eclampsia

· Be followed up weekly at the antenatal clinic and carefully checked for the development of hypertension and proteinuria

· Carefully monitor fetal movements

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Case study:

A 21-year-old primigravida patient is attending the antenatal clinic. Her pregnancy progresses normally to 33 weeks. At her next visit at 35 weeks, the patient complains that her hands and feet have started to swell over the past week. On examination, you notice that slight facial edema is present. Her blood pressure is 120/80, which is the same as her previous visit, and she has no proteinuria. She reports that her fetus moves frequently.

Why is this patient at high risk of developing pre-eclampsia?
How should this patient be managed further?
What advice should this patient be given?
One week later she has diastolic BP of 90 mmHg without proteinuria. How would she be managed further?

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Why is this patient at high risk of developing pre-eclampsia?

Because she is primigravida and has developed generalized oedema over the past week.

How should this patient be managed further?

She should rest a lot.
She should be seen at the antenatal clinic again in a week when she must be carefully examined for a rise in blood pressure or the presence of proteinuria.

What advice should this patient be given?

She should be told about the symptoms of imminent eclampsia (preeclampsia with severe features)

-Severe headaches

- Visual disturbances or flashes of light seen in front of the eyes

-Blindness

- Dyspnoea

- Altered mental status

- Upper abdominal pain in the epigastrium and/or over the liver

She should be asked to count and record fetal movements twice a day for one hour each.
She should be advised to contact the hospital immediately if she experiences the above symptoms or if fetal movements decrease.

One week later she has diastolic BP of 90 mmHg without proteinuria. How would she be managed further?

she has pregnancy-induced hypertension.
If home conditions are satisfactory she can be managed with bed rest at home.
Hypertension must be controlled with alpha methyldopa.
She must be seen twice a week and carefully be monitored to detect a rise in her BP and the possible development of proteinuria.
if her BP rises and/or proteinuria develops, she must be admitted to the hospital.
if home conditions are poor, she must be admitted to the hospital for bed rest.

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Preeclampsia- Management

Timely identification and diagnosis of preeclampsia during antenatal visits
Preeclampsia cases can be managed outside of hospital depending on the severity
Methyldopa is prescribed to control the BP
Careful monitoring of fetal wellbeing

Patient should count and record fetal movements twice a day

Labor induction at 36 weeks, or earlier if necessary
The only definitive cure for preeclampsia is delivery of the infant

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Preeclampsia- Additional Assessments

Urinary tract infections (UTI) should be excluded in all patients with proteinuria with culture of midstream urine (MSU)
Obtain platelet count

Platelet count of less than 100,000 is an indication for referral

Serum creatinine to assess renal function
Ultrasound examination to assess gestational age and fetal weight
Umbilical artery doppler to assess placental function

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Management of Preeclampsia with Severe Disease (Severe Features)

Goal of Management:

Magnesium sulfate to prevent eclampsia (seizure)
Lower blood pressure to prevent intracerebral hemorrhage (parenteral dihydralazine or oral nifedipine capsules
Slow administration of intravenous fluids (not more than 80 ml per hour) to prevent pulmonary edema

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(Bettercare/Primary Maternal Care/3. Hypertensive disorders of pregnancy):

The initial management of preeclampsia with severe features is aimed at prevention of eclampsia, intracerebral haemorrhage, and pulmonary oedema.

Magnesium sulphate is given as primary and secondary prophylaxis of seizures in women with preeclampsia regardless of gestation and is also recommended in planned or expected preterm delivery for its neuroprotective effects in the offspring.

The steps in the management of patients with preeclampsia with severe features are:

Step 1: An intravenous infusion is started (plasmalyte B or Ringer’s lactate) and magnesium sulfate is administered as follows:

1. Give 4 g slowly intravenously over 10 minutes. Prepare the 4g by adding 8 ml 50% magnesium sulfate (i.e 2 ampoules) to 12 ml sterile water.

2. Then give 5 g (i.e 10 ml 50% magnesium sulfate) by deep intramuscular injection into each buttock.

3. 200 ml of the intravenous infusion is given rapidly over half an hour. Thereafter, the infusion is given slowly, at a rate of 80 ml per hour.

A total of 14 g of magnesium sulfate is given.

Step 2: After the magnesium sulfate has been administered, a Foley catheter is inserted into the patient’s bladder to monitor the urinary output.

Step 3: After giving the magnesium sulfate, the blood pressure must be measured again. If the diastolic blood pressure is still 110 mmHg or more and/or systolic BP is 160 mmHg or more, oral nifedipine or dihydralazine is given as follows:

Give 10 mg (1 capsule) nifedipine orally or 5 mg dihydralazine slowly intravenously.
the patient’s BP is taken every 5 minutes for the next 30 minutes.
If the BP drops too much, intravenous Balsol or Ringer’s lactate is administered rapidly, until the BP returns to normal.
if the diastolic BP remains 110 mmHg and/or the systolic BP 160 mmHg or more after 30 minutes, patients who received 10 mg nifedipine orally can be given a second dose of 10 mg nifedipine orally. If necessary, 10 mg of nifedipine can be repeated half-hourly up to a maximum dose of 50 mg.
Nifedipine 10mg capsules always be given orally and not given sublingually (under the tongue). The 10 mg capsules should not be confused with XL tablets which are slowly dissolved and not suitable for rapidly lowering blood pressure.

Or

if dihydralazine was used, an ampoule of dihydralazine (25 mg) should be mixed with 10 ml of sterile water. Bolus doses of 2 ml (5 mg) are given slowly intravenously, at 30-minute intervals, until the diastolic BP drops to below 110 mmHg and/or systolic BP below 160 mmHg. a total of 3 doses of 5 mg each can be given.

If dihydralazine is not available, labetalol 20 mg is given intravenously. If a decline in BP does not occur after 10 minutes a further 40 mg is given intravenously.

Step 4: When the BP is controlled, the patient is transferred to a level 2 or 3 hospitals.

Patients with pre-eclampsia and features of severe disease must always be stabilized before they are transferred, or until further management is decided upon.

The only definitive cure for preeclampsia is delivery of the infant

Conservative management of Pre-eclampsia with severe features (severe diseases):

1. Magnesium sulfate must be stopped.

2. The patient must be hospitalized for bed rest in a level 2 or 3 hospitals.

3. the fetal movement must be monitored daily.

4. If possible antenatal cardiotocography (CTG) must be done twice or more daily.

5. Urinary tract infections must be excluded.

6. A platelet count and renal function tests (urea and creatinine) must be done twice a week. if the platelet count is < 100000, liver function tests should be done. Poor renal failure raised liver enzymes or a platelet count that falls further are indications for delivery.

7. Ultrasound examination to assess fetal weight, fetal viability. Fetal growth must be monitored.

8. Because of the danger of hyaline membrane disease in a newborn infant who, though viable, has a gestational age of less than 34 weeks, steroids (Betamethasone 12 mg) must be given intramuscularly to the patient, to enhance fetal lung maturity. The second dose must be repeated 24 hrs later.

9. The fetus must be delivered if the clinical assessment or ultrasound size suggests a pregnancy of 34 weeks.

10.If there is no fetal distress and the presentation is cephalic, medical or surgical induction of labour must be done at 34 weeks gestation.

11.If fetal distress is present, or the presentation is abnormal, a caesarean section must be done.

12.A well-stabilized patient must be placed on an oral antihypertensives drug. Alpha methyldopa is the drug of choice. A high dosage (500 mg 8 hourly that can be increased to 750 mg 8 hourly) must be used. If the diastolic BP remains at 110 mmHg and/or the systolic BP 160 mmHg or higher, a second or even a third antihypertensive drug is added.

Note:

Long-acting nifedipine is the drug of choice if a second antihypertensive drug is required. Labetalol may be added if a third drug is required. This form of management must take place in a level 3 hospital.
When managing the patient conservatively, the danger of prematurity (if the fetus is delivered) must continually be weighed against the danger of fetal distress or abruptio placentae (which could result in intrauterine death.)

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Management of Preeclampsia with Severe Disease (Severe Features)

Maintenance doses of magnesium Sulfate:

after initial loading dose, regular maintenance doses given until 24 hours after delivery
5g every 4 hours by deep IM injection into alternate buttocks

Prevention of overdose:

If the patellar reflex is absent or reduced, withhold next dose
Urinary output < 30 ml per hour, follow-up doses given only in definite presence of patellar reflex

Overdose causes respiratory and cardiac depression
Antidote of overdose: 10 ml of 10% Calcium Gluconate

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Management of Eclampsia

A life-threatening condition for mother and fetus
Immediate management

Step 1: Call for help and prevent aspiration of the stomach contents

Step 2: Stop convulsion and prevent further convulsions (Lorazepam or Diazepam IV may be given initially

Step 3: After magnesium Sulfate has been given, insert indwelling bladder catheter to monitor urinary output

Step 4: Reduce diastolic BP < 110 mmHg, and/or systolic BP < 160 mmHg

Step 5: Transfer to level 2 or 3 hospital

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Bettercare/Primary Maternal Care/3. Hypertensive disorders of pregnancy:

Eclampsia is a life-threatening condition that needs to be immediately managed as follows:

Step 1: Call for help and prevent aspiration of the stomach contents by:

Turning the patient immediately onto her side.
Keeping the airway open by suctioning (if necessary)
Administering oxygen

Step 2: Stop convulsion and prevent further convulsions by putting up an intravenous infusion of Balso or Ringer’s lactate and giving magnesium sulfate as follows:

1. Give 4 g slowly intravenously over 10 minutes. Prepare the 4 g by adding 8 ml 50% magnesium Sulfate (i.e. 2 ampoules) to 12 ml sterile water.

2. Then give 5 g (i.e. 10 ml 50% magnesium Sulfate) by deep intramuscular injection into each buttock.

A total of 14 g of magnesium Sulfate is given.

Step 3: After magnesium Sulfate has been given, insert a Foley catheter to monitor the urinary output

Step 4: if the diastolic BP ≥ 110 mmHg and/or systolic BP ≥ 160 mmHg, dihydralazine should be administered. Oral nifedipine can be used if the patient is fully conscious after the convulsion as follows:

· Give 10 mg (1 capsule) nifedipine orally or 5 mg dihydralazine slowly intravenously.

· the patient’s BP is taken every 5 minutes for the next 30 minutes.

· If the BP drops too much, intravenous Balsol or Ringer’s lactate is administered rapidly, until the BP returns to normal.

· if the diastolic BP remains 110 mmHg and/or the systolic BP 160 mmHg or more after 30 minutes, patients who received 10 mg nifedipine orally can be given a second dose of 10 mg nifedipine orally. If necessary, 10 mg of nifedipine can be repeated half-hourly up to a maximum dose of 50 mg.

· Nifedipine 10mg capsules must always be given orally and not given sublingually (under the tongue). The 10 mg capsules must not be confused with XL tablets which are slowly dissolved and not suitable for rapidly lowering blood pressure.

Or

if dihydralazine is used, an ampoule of dihydralazine (25 mg) should be mixed with 10 ml of sterile water. Bolus doses of 2 ml (5 mg) given slowly intravenously at 30-minute intervals, until the diastolic BP drops to below 110 mmHg and/or systolic BP below 160 mmHg. a total of 3 doses of 5 mg each can be given.

If dihydralazine is not available, labetalol 20 mg may be given intravenously. If a decline in BP does not occur after 10 minutes, 40 mg is given intravenously.

Step 5: Urgently transfer to level 2 or 3 hospitals.

If the patient convulses again, after the initial dose of 14 g of magnesium Sulfate, a further 2 g of magnesium Sulfate should be administered intravenously. This dose can be repeated once more in the unlikely event of the patient having another convulsion.

IV magnesium sulfate is the initial drug administered to terminate seizures. Seizures usually terminate after the loading dose of magnesium. A loading dose of 4-6 g (15-20 min) and a maintenance dose of 1-2 g per hour as a continuous IV solution should be administered. Alternatively, lorazepam (Ativan; 4 mg IV over 2-5 minutes) or diazepam (Valium; 5-10 mg IV slowly) can be used to terminate the seizure, after which magnesium sulfate is administered. While benzodiazepines can be used to treat seizures due to eclampsia magnesium remains the preferred choice.

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Case Study:

At an antenatal clinic you see a patient who is 39 weeks pregnant. Up until now she has had a normal pregnancy. On examination, you find that her diastolic blood pressure is 95 mm Hg and that she has 2+ proteinuria.

How should this patient be managed?
On examining this patient you observe that she has increased patellar reflexes i.e brisk knee jerks. How should this observation alter her management?
What are the health risks to this patient?
How should this patient be managed?

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How should this patient be managed?

She should be admitted to the hospital because she has preeclampsia evidenced by diastolic BP of 95 mmHg with proteinuria.

She should also be delivered, as she is more than 38 weeks pregnant.

On examining this patient, you observe that she has increased patellar reflexes.( i.e brisk knee jerks). How should this observation alter her management?

Increased tendon reflexes are a sign of preeclampsia with severe features. This diagnosis is made irrespective of the degree of hypertension or the amount of proteinuria.
To prevent the development of eclampsia, the patient should be given magnesium Sulfate.

What are the health risks this patient?

The patient has preeclampsia with severe features. The immediate health risk to her life is the development of eclampsia, an intracerebral haemorrhage, or pulmonary oedema.

How should this patient be managed?

Her clinical condition must first be stabilized.
An intravenous infusion should be started and a loading dose of 14 magnesium Sulfate must be given.
This should prevent the development of eclampsia.
A an indwelling urinary catheter inserted in her bladder to monitor urinary output.

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References:

Bettercare (n.d.). Maternal Care/3. Hypertensive disorders of pregnancy. https://bettercare.co.za/learn/maternal-care/text/03.html#3-hypertensive-disorders-of-pregnancy

Healthdirect Australia (n.d.). Pregnancy Birth and Baby - High blood pressure in pregnancy. Retrieved from

https://www.pregnancybirthbaby.org.au/high-blood-pressure-in-pregnancy

Klein, S. Miller, S., & Thomson, F. (2020). A Book for Midwives; Care for pregnancy, birth, and women’s health. Berkeley, California: Hesperian Health Guides.

https://en.hesperian.org/hhg/A_Book_for_Midwives:Check_the_mother%E2%80%99s_body�

WHO (2011).WHO recommendations for prevention and treatment of pre-eclampsia and eclampsia. Retrieved from: https://apps.who.int/iris/handle/10665/44703

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