NURS 3358 - OB Exam 3 Study Guide.
“Hypertensive Disorders in Pregnancy”
Morbidity and Mortality
• Preeclampsia and eclampsia account for 10-15% of all maternal deaths worldwide (50,000 deaths/year).
• A woman dies every 7 minutes from complications related to preeclampsia (World Health Organization).
• Hypertensive disorders are a major cause of perinatal morbidity and mortality (UPI, preterm birth).
• Hypertensive Disorders are one of the top causes of maternal morbidity and mortality in USA and Canada. Death related to:
o Renal Failure
o Coagulopathy
o Cardiac or Liver Failure
o Placental abruption
o Eclampsia (seizures) and Stroke
Classifications of Hypertensive Disorders During Pregnancy
• Gestational Hypertensive Disorders
o Gestational HTN
▪ Onset of hypertension after 20 weeks gestation and no proteinuria
▪ BP > 140/90 (only one pressure needs elevation; systolic OR diastolic)
▪ Need two elevated measures at least 4 hours apart
▪ BP returns to normal within 12 weeks postpartum
▪ Frequently occurs with multiple gestation (twins, etc.)
o Preeclampsia
▪ Pregnancy-specific condition
▪ Hypertension & proteinuria develop after 20 weeks gestation
▪ Hypertension with thrombocytopenia, or impaired liver function, or renal insufficiency, or pulmonary edema or new-
onset cerebral or visual disturbances (See Table 27-2; p.654)
o Eclampsia
▪ Seizure activity or coma in a woman with preeclampsia with no history of a preexisting condition or seizure disorder
▪ Occurs before, during, or after birth.
• Chronic Hypertensive Disorders
o Chronic HTN
▪ Chronic Hypertension – hypertension that existed prior to pregnancy
▪ Hypertension persisting longer than 12 wks postpartum is classified as chronic hypertension
▪ Superimposed preeclampsia – Chronic Hypertension w/ Superimposed Preeclampsia – difficult to diagnose; associated
with adverse maternal and fetal outcomes
Preeclampsia
Risk Factors for Preeclampsia
• First pregnancy <19 yrs or >40 yrs
• First pregnancy with new partner
• Partner who fathered a preeclamptic pregnancy in another woman
• Obesity
• Pre-existing medical or genetic condition: chronic HTN, pregestational DM, connective tissue disease, thrombophilia
• Common Risk Factors for Preeclampsia
o Primigravida younger than 19 or older than 40
o Preeclampsia with severe features in a previous pregnancy
o Family history (mother/sister) of preeclampsia
o Paternal history (partner previously fathered a preeclamptic pregnancy)
o African descent
o Multifetal gestation
o Maternal infection/inflammation in current pregnancy (i.e., UTI, periodontal disease)
o Preexisting Medical or genetic conditions
▪ Chronic HTN
▪ Renal disease
▪ Pregestation DM
▪ Connective tissue disease – SLE, RA
▪ Thrombophilia
Pathophysiology
• Abnormal vascular remodeling the placenta
• ↓ placental perfusion and hypoxia. Placental ischemia →
• Release of substance toxic to endothelial cells → generalized vasospasms →
• Poor tissue perfusion all organ systems, ↑ peripheral resistance, ↑ BP, ↑endothelial cell permeability →
,NURS 3358 - OB Exam 3 Study Guide.
• Intravascular protein and fluid loss → ↓plasma volume
,NURS 3358 - OB Exam 3 Study Guide.
• Vasospasms cause increased BP
• Arteriolar vasospasms results in decreased perfusion of placenta, kidneys, liver, and brain
• Decreased perfusion in placenta leads to early degenerative aging of the placenta, and decreased oxygen and nutrients to fetus resulting
in IUGR
• 27-1 and 27-2
HELLP Syndrome
• H = Hemolysis of RBCs
• EL = Elevated Liver Enzymes
o AST > 70 (normal 4-20 units/L)
o LDH > 600 (normal 45-90 units/L)
o ALT > 50 (normal 3-21 units/L)
o Sx of hepatic damage (R upper quadrant or epigastric pain; hyperbilirubinemia)
• LP = Low Platelets
o Under 100,000/mm3
o Sx of bleeding
• Clinical presentation nonspecific
• May
Normal Non-Pregnant Preeclampsia HELLP
Hemoglobin, hematocrit 12-16 g/dl, 37%-47% May increase Decreased report
Platelets 150,000-400,000/mm3 < 100,000 <100,000 h/o
Prothrombin time (PT), 12-13 sec, 60-70 sec Unchanged Unchanged
partial thromboplastin
time (PTT)
Fibrinogen 200-400 mg/dl 300-600 mg/dl Decreased
Fibrin split products (FSP) Absent Absent or present Present
BUN 10-20 mg/dl Increased Increased
Creatinine 0.5-1.1 mg/dl >1.1 Increased
Lactase dehydrogenase 45-90 unites/l Increased Increased (>600 unites/L)
(LDH)
Aspartate 4-20 units/l Elevated Elevated >70 unites
aminotransferase (AST)
Alanine aminotransferase 3-21 units/l Elevated Increased
(ALT)
Creatinine clearance 80-125 ml/min 130-180 ml/min Decreased
Burr cells or schistocytes Absent Absent Present
Uric acid 2-6.6 mg/dl > 5.9 mg/dl >10 mg/dl
Bilirubin 0.1-1 mg/dl Unchanged or increased Increased (>1.2 mg/dl)
malaise, flu-like symptoms, epigastric or RUQ pain
• Symptoms tend to worsen at night and improve during the daytime
• Occurs more often in Caucasian women
Care Management
Assessment
• BP Management
, NURS 3358 - OB Exam 3 Study Guide.
o Measure BP with the woman seated or in the lateral recumbent position with the arm at heart level every one should shut up while
taking BP
o Allow 10 minutes of rest before the BP measurement
o Instruct to refrain from tobacco or caffeine use 30 minutes before the BP is taken
o Use right arm each time
o Support the arm in a horizontal position at heart level
o Use proper-sized cuff (80% of arm covered)
o Slow, steady, deflation rate
o Avg. of 2 readings at least 6 hours apart
o Use the Korotkoff phase V to record diastolic pressure
• Edema – pitting =
• Deep tendon reflexes (DTRs)
• Clonus
• 24-hour urine collection – presence of proteinuria
• Other s/s- HA, epigastric pain, RUQ pain, visual disturbances
Classification of Edema (Depth of Indentation)
• +1 = 2 mm indentation
• +2 = 4 mm indentation
• +3 = 6 mm indentation
• +4 = 8 mm indentation
Test for Ankle Clonus – support the leg with knee flexed… with one hand the examiner sharply dorsiflexes the foot, maintains the position for a
moment then releases the foot. Normal response is elicited when no rhythmic oscillations are felt while the foot is held in dorsiflexion.
Interventions – Mild Gestational HTN & Preeclampsia w/o Severe features
• Goals of therapy are to ensure maternal safety and to deliver a healthy newborn as close to term as possible
• Close monitoring of the maternal and fetal status
• Can be managed at home if:
o BP less than 150/100 mmHg
o No increase in proteinuria
o Normal platelet count
o Normal liver enzymes
• Mom needs to be well educated (See Teaching for Self-Management: Assessing and Reporting Clinical Signs of Preeclampsia)
• Initial maternal labs: serum creatinine, platelet count, liver enzymes, 24-hr urine
• Weekly labs: platelet count, liver enzymes
• Also evaluated weekly for s/s of severe features: severe HAs, blurred vision, mental confusion, RUQ or epigastric pain, N/V,
SOB, decreased UO
• BP monitored twice/week
• Proteinuria assessed weekly
• Daily fetal movement counts
• NST or BPP 1x or 2x/week until birth
• US evaluation of amniotic fluid status and estimated fetal weight at the time preeclampsia is dx and serially thereafter
• Restricted activity may be recommended
• Gentle exercise
• Relaxation techniques
• Regular diet
• Protein (60-70 g)
• Calcium (1200 mg)
• Folic acid (600 mcg)
• Zinc (11-12 mg)
• Sodium (1.5 g)
• Fluid intake (6-8 8oz glasses of H20)
• Avoid alcohol and tobacco; limit caffeine
Severe Gestational HTN and Preeclampsia with Severe Features
• Hospitalized immediately for a thorough evaluation of maternal-fetal status
• Magnesium Sulfate (prevent eclamptic seizure)
• Maternal assessment- monitoring BP, UO, cerebral status, epigastric pain, labor, vaginal bleeding
• Maternal labs – platelet count, liver enzymes, serum creatinine
• Continuous EFM
• BPP
• US (fetal growth & amniotic fluid)
• Multidisciplinary plan of care
“Hypertensive Disorders in Pregnancy”
Morbidity and Mortality
• Preeclampsia and eclampsia account for 10-15% of all maternal deaths worldwide (50,000 deaths/year).
• A woman dies every 7 minutes from complications related to preeclampsia (World Health Organization).
• Hypertensive disorders are a major cause of perinatal morbidity and mortality (UPI, preterm birth).
• Hypertensive Disorders are one of the top causes of maternal morbidity and mortality in USA and Canada. Death related to:
o Renal Failure
o Coagulopathy
o Cardiac or Liver Failure
o Placental abruption
o Eclampsia (seizures) and Stroke
Classifications of Hypertensive Disorders During Pregnancy
• Gestational Hypertensive Disorders
o Gestational HTN
▪ Onset of hypertension after 20 weeks gestation and no proteinuria
▪ BP > 140/90 (only one pressure needs elevation; systolic OR diastolic)
▪ Need two elevated measures at least 4 hours apart
▪ BP returns to normal within 12 weeks postpartum
▪ Frequently occurs with multiple gestation (twins, etc.)
o Preeclampsia
▪ Pregnancy-specific condition
▪ Hypertension & proteinuria develop after 20 weeks gestation
▪ Hypertension with thrombocytopenia, or impaired liver function, or renal insufficiency, or pulmonary edema or new-
onset cerebral or visual disturbances (See Table 27-2; p.654)
o Eclampsia
▪ Seizure activity or coma in a woman with preeclampsia with no history of a preexisting condition or seizure disorder
▪ Occurs before, during, or after birth.
• Chronic Hypertensive Disorders
o Chronic HTN
▪ Chronic Hypertension – hypertension that existed prior to pregnancy
▪ Hypertension persisting longer than 12 wks postpartum is classified as chronic hypertension
▪ Superimposed preeclampsia – Chronic Hypertension w/ Superimposed Preeclampsia – difficult to diagnose; associated
with adverse maternal and fetal outcomes
Preeclampsia
Risk Factors for Preeclampsia
• First pregnancy <19 yrs or >40 yrs
• First pregnancy with new partner
• Partner who fathered a preeclamptic pregnancy in another woman
• Obesity
• Pre-existing medical or genetic condition: chronic HTN, pregestational DM, connective tissue disease, thrombophilia
• Common Risk Factors for Preeclampsia
o Primigravida younger than 19 or older than 40
o Preeclampsia with severe features in a previous pregnancy
o Family history (mother/sister) of preeclampsia
o Paternal history (partner previously fathered a preeclamptic pregnancy)
o African descent
o Multifetal gestation
o Maternal infection/inflammation in current pregnancy (i.e., UTI, periodontal disease)
o Preexisting Medical or genetic conditions
▪ Chronic HTN
▪ Renal disease
▪ Pregestation DM
▪ Connective tissue disease – SLE, RA
▪ Thrombophilia
Pathophysiology
• Abnormal vascular remodeling the placenta
• ↓ placental perfusion and hypoxia. Placental ischemia →
• Release of substance toxic to endothelial cells → generalized vasospasms →
• Poor tissue perfusion all organ systems, ↑ peripheral resistance, ↑ BP, ↑endothelial cell permeability →
,NURS 3358 - OB Exam 3 Study Guide.
• Intravascular protein and fluid loss → ↓plasma volume
,NURS 3358 - OB Exam 3 Study Guide.
• Vasospasms cause increased BP
• Arteriolar vasospasms results in decreased perfusion of placenta, kidneys, liver, and brain
• Decreased perfusion in placenta leads to early degenerative aging of the placenta, and decreased oxygen and nutrients to fetus resulting
in IUGR
• 27-1 and 27-2
HELLP Syndrome
• H = Hemolysis of RBCs
• EL = Elevated Liver Enzymes
o AST > 70 (normal 4-20 units/L)
o LDH > 600 (normal 45-90 units/L)
o ALT > 50 (normal 3-21 units/L)
o Sx of hepatic damage (R upper quadrant or epigastric pain; hyperbilirubinemia)
• LP = Low Platelets
o Under 100,000/mm3
o Sx of bleeding
• Clinical presentation nonspecific
• May
Normal Non-Pregnant Preeclampsia HELLP
Hemoglobin, hematocrit 12-16 g/dl, 37%-47% May increase Decreased report
Platelets 150,000-400,000/mm3 < 100,000 <100,000 h/o
Prothrombin time (PT), 12-13 sec, 60-70 sec Unchanged Unchanged
partial thromboplastin
time (PTT)
Fibrinogen 200-400 mg/dl 300-600 mg/dl Decreased
Fibrin split products (FSP) Absent Absent or present Present
BUN 10-20 mg/dl Increased Increased
Creatinine 0.5-1.1 mg/dl >1.1 Increased
Lactase dehydrogenase 45-90 unites/l Increased Increased (>600 unites/L)
(LDH)
Aspartate 4-20 units/l Elevated Elevated >70 unites
aminotransferase (AST)
Alanine aminotransferase 3-21 units/l Elevated Increased
(ALT)
Creatinine clearance 80-125 ml/min 130-180 ml/min Decreased
Burr cells or schistocytes Absent Absent Present
Uric acid 2-6.6 mg/dl > 5.9 mg/dl >10 mg/dl
Bilirubin 0.1-1 mg/dl Unchanged or increased Increased (>1.2 mg/dl)
malaise, flu-like symptoms, epigastric or RUQ pain
• Symptoms tend to worsen at night and improve during the daytime
• Occurs more often in Caucasian women
Care Management
Assessment
• BP Management
, NURS 3358 - OB Exam 3 Study Guide.
o Measure BP with the woman seated or in the lateral recumbent position with the arm at heart level every one should shut up while
taking BP
o Allow 10 minutes of rest before the BP measurement
o Instruct to refrain from tobacco or caffeine use 30 minutes before the BP is taken
o Use right arm each time
o Support the arm in a horizontal position at heart level
o Use proper-sized cuff (80% of arm covered)
o Slow, steady, deflation rate
o Avg. of 2 readings at least 6 hours apart
o Use the Korotkoff phase V to record diastolic pressure
• Edema – pitting =
• Deep tendon reflexes (DTRs)
• Clonus
• 24-hour urine collection – presence of proteinuria
• Other s/s- HA, epigastric pain, RUQ pain, visual disturbances
Classification of Edema (Depth of Indentation)
• +1 = 2 mm indentation
• +2 = 4 mm indentation
• +3 = 6 mm indentation
• +4 = 8 mm indentation
Test for Ankle Clonus – support the leg with knee flexed… with one hand the examiner sharply dorsiflexes the foot, maintains the position for a
moment then releases the foot. Normal response is elicited when no rhythmic oscillations are felt while the foot is held in dorsiflexion.
Interventions – Mild Gestational HTN & Preeclampsia w/o Severe features
• Goals of therapy are to ensure maternal safety and to deliver a healthy newborn as close to term as possible
• Close monitoring of the maternal and fetal status
• Can be managed at home if:
o BP less than 150/100 mmHg
o No increase in proteinuria
o Normal platelet count
o Normal liver enzymes
• Mom needs to be well educated (See Teaching for Self-Management: Assessing and Reporting Clinical Signs of Preeclampsia)
• Initial maternal labs: serum creatinine, platelet count, liver enzymes, 24-hr urine
• Weekly labs: platelet count, liver enzymes
• Also evaluated weekly for s/s of severe features: severe HAs, blurred vision, mental confusion, RUQ or epigastric pain, N/V,
SOB, decreased UO
• BP monitored twice/week
• Proteinuria assessed weekly
• Daily fetal movement counts
• NST or BPP 1x or 2x/week until birth
• US evaluation of amniotic fluid status and estimated fetal weight at the time preeclampsia is dx and serially thereafter
• Restricted activity may be recommended
• Gentle exercise
• Relaxation techniques
• Regular diet
• Protein (60-70 g)
• Calcium (1200 mg)
• Folic acid (600 mcg)
• Zinc (11-12 mg)
• Sodium (1.5 g)
• Fluid intake (6-8 8oz glasses of H20)
• Avoid alcohol and tobacco; limit caffeine
Severe Gestational HTN and Preeclampsia with Severe Features
• Hospitalized immediately for a thorough evaluation of maternal-fetal status
• Magnesium Sulfate (prevent eclamptic seizure)
• Maternal assessment- monitoring BP, UO, cerebral status, epigastric pain, labor, vaginal bleeding
• Maternal labs – platelet count, liver enzymes, serum creatinine
• Continuous EFM
• BPP
• US (fetal growth & amniotic fluid)
• Multidisciplinary plan of care
