Hypertensive disorders of pregnancy (also known as pregnancy-associated hypertensive disorders, pregnancy induced hypertension) are the most common complications that occur during pregnancy and are a major cause of maternal and fetal morbidity and mortality. These disorders include gestational hypertension, preeclampsia, eclampsia, chronic hypertension, and chronic hypertension with superimposed preeclampsia. If left untreated, preeclampsia can lead to a life-threatening complication called HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome. It is estimated that preeclampsia alone complicates 2-8% of pregnancies globally.
Hypertensive disorders in pregnancy include five categories of hypertension and are defined as such by the American College of Obstetricians and Gynecologists (ACOG):
Gestational Hypertensive Disorders
- Gestational hypertension. Defined as a systolic blood pressure of 140 mm Hg or more, and/or diastolic blood pressure of 90 mm Hg or more on two blood pressure readings at least four (4) hours apart after 20 weeks of gestation in a woman with previously normal blood pressure. Gestational hypertension does not persist longer than 12 weeks postpartum and usually resolves after a week postpartum.
- Preeclampsia. Preeclampsia is a pregnancy-specific condition and is defined as a new-onset of hypertension that occurs most often after 20 weeks of gestation. Blood pressure is elevated more than 140 mm Hg systolic, more than 90 mm Hg diastolic. Hypertension is usually accompanied by new-onset proteinuria although other signs and symptoms of preeclampsia (thrombocytopenia, impaired liver function, pulmonary edema, visual disturbance) may present in some women in the absence of proteinuria.
- Eclampsia. Eclampsia is the onset of seizure activity or coma in a woman with preeclampsia with no history of preexisting pathology that can result in seizure activity. Seizure leads to severe maternal hypoxia, injury, and aspiration pneumonia. Eclampsia has an increased maternal mortality rate especially in settings with low resources.
Chronic Hypertensive Disorders
- Chronic hypertension. Chronic hypertension as hypertension diagnosed or present before pregnancy or before 20 weeks of gestation. It is more prevalent with increasing late childbearing and in persons with obesity. Additionally, hypertension that is diagnosed for the first time during pregnancy and that does not resolve postpartum is also classified as chronic hypertension.
- Chronic hypertension with superimposed preeclampsia. Preeclampsia is considered superimposed when it complicates preexisting chronic hypertension. About half of women with chronic hypertension may develop superimposed preeclampsia. It is associated with increased maternal or fetal mortality.
Nursing Care Plans
Nursing care planning and management for pregnant clients with hypertensive disorders or preeclampsia involve early detection, thorough assessment, and prompt treatment of preeclampsia. Another priority is to ensure the mother’s safety and deliver a healthy newborn as close to a full term as possible.
- Decreased Cardiac Output UPDATED!
- Risk for Imbalanced Fluid Volume UPDATED!
- Ineffective Tissue Perfusion UPDATED!
- Risk for Injury UPDATED!
- Imbalanced Nutrition: Less Than Body Requirements UPDATED!
- Deficient Knowledge UPDATED!
- Other Possible Nursing Care Plans NEW!
Decreased Cardiac Output
A decrease in circulating blood volume due to the shifting of fluid from the intravascular to the interstitial spaces occurs in a pregnant client with a hypertensive disorder due to the decrease of the circulating blood volume and the total vascular volume and an increase in the systemic vascular resistance, the heart rate decreases as well as the stroke volume. These mechanisms lead to a decrease in cardiac output seen among clients with hypertensive disorders in pregnancy.
Related factors may include
- Decreased venous return
- Increased systemic vascular resistance
Possibly evidenced by
- Change in blood pressure/hemodynamic readings
- Diminished peripheral pulses
- Shortness of breath/dyspnea
- Alteration in mental status
- Decreased urine output
- The client remains normotensive throughout the remainder of the pregnancy.
- The client reports absence and/or decreased episodes of dyspnea.
- The client alters activity level as the condition warrants.
Nursing Assessment and Rationales
1. Assess blood pressure and pulse every one (1) hour or as indicated.
Accurate measurement of blood pressure is essential for the early detection of hypertensive disorders. Hypertension is defined as a systolic blood pressure greater than 140 mm Hg or diastolic blood pressure greater than 90 mm Hg. Blood pressure may be elevated because of the increase in systemic vascular resistance whereas decreased cardiac output may also be reflected by diminished peripheral pulses. Rising blood pressure indicates the progression of preeclampsia. Use a consistent and standardized method when taking blood pressure measurements to maintain accuracy.
2. Assess the mean arterial pressure (MAP) at 11-13 and 20-24 weeks gestation. A pressure of 90 mm Hg is considered predictive of preeclampsia.
Mean arterial pressure (MAP) is the average arterial pressure throughout one cardiac cycle and is influenced by cardiac output and systemic vascular resistance. MAP prediction is best when measured during 11-13 weeks and at 20-24 weeks than at only one of these gestational ranges. MAP is increased from the first trimester in pregnancies developing preeclampsia (Gallo et al., 2014). Women with early-onset preeclampsia have higher mean arterial blood pressure levels at 20 weeks of gestation (Mayrink et al., 2019).
3. Assess for crackles, wheezes, and dyspnea; note respiratory rate/effort. Note client snoring.
Pulmonary edema may transpire with modification in peripheral vascular resistance and a drop in plasma colloid osmotic pressure. Fluid from the intravascular spaces shifts to the interstitial spaces, depleting the circulating blood volume but overwhelming the important organs of the body, especially the lungs. Pregnancy-onset snoring may also be a risk factor for developing gestational hypertension and preeclampsia (O’Brien et al., 2012).
4. Auscultate for the apical pulse and assess the client’s heart rate and rhythm.
Tachycardia may be present when the body compensates for the decrease in circulating volume that can hardly reach the peripheries and distant tissues.
5. Assess the client’s neurological status.
Decreased cardiac output can precipitate alternations in the sensorium due to inadequate cerebral perfusion. Neurologic complications associated with preeclampsia may also manifest. These symptoms include cerebral edema, hemorrhage, irritability, headaches, hyperreflexia, seizures.
6. Assess the client for visual disturbances.
Alteration in the sensorium may indicate inadequate cerebral perfusion secondary to decreased cardiac output. Vision changes are due to arteriolar vasospasms and decreased blood circulation to the retina. These symptoms may include dimming of vision, blind or dark spots in the visual speed, blurring of vision, double vision.
7. Assess the client for indications for an earlier delivery.
Worsening preeclampsia that may progress to eclampsia warrants the need for an emergency early delivery. The fetal blood supply can be cut off, resulting in fetal distress and ultimately fetal death if delivery is not hastened (Sinkey et al., 2020; Espinoza 2012). These symptoms include uncontrolled severe-range blood pressure, refractory headaches, upper abdominal pain, visual disturbances, stroke.
8. Monitor and measure the client’s urine output as per protocol. Maintain strict intake and output.
In preeclampsia, the kidneys respond to reduced cardiac output by retaining water and sodium. Intrarenal vasospasms cause oliguria in severe preeclampsia due to a reduction in glomerular filtration rate. Contraction of the intravascular space secondary to vasospasms worsens renal sodium and water retention (ACOG, 2020).
9. Monitor and measure the client’s 24-hour urine for proteinuria.
Proteinuria is ideally determined by the evaluation of a 24-hour urine collection. However, current guidelines state that massive proteinuria is not considered a severe feature of preeclampsia. Reduced kidney perfusion causes renal deterioration and damages glomerular endothelial cells allowing protein molecules to pass into the urine, causing proteinuria. In some instances where it may be difficult to collect a 24-hour urine sample, preeclampsia may be diagnosed as hypertension with either thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema.
Nursing Interventions and Rationales
1. Provide frequent rest periods with bed rest. Restrict activity rather than instituting complete bed rest.
Improves venous return, cardiac output, and renal-placental perfusion. Help the client understand the importance of reduced activity and frequent rest periods and plan ways to manage them. Activity diverts blood from the placenta, reducing the infant’s oxygen supply. Although frequently recommended by healthcare providers, no evidence has been found that complete bed rest improves pregnancy outcomes. Rather, prolonged bed rest can increase the risk of complications due to immobility (e.g., muscle atrophy, weight loss, cardiovascular deconditioning, psychologic stress, etc.). Therefore, restricted activity rather than complete bed rest is recommended (Ghulmiyyah et al., 2012).
2. Instruct the client to elevate legs when sitting or lying down.
Elevating the legs decreases venous stasis and may also reduce the incidence of thrombus and embolus formation in the client on bed rest.
3. Monitor the client’s BP and instruct monitoring of BP at home.
Monitor BP every 15 minutes during the critical phase and every 1 to 4 hours as the client’s condition improves. If the client is an outpatient, instruct both the client and a family member to monitor the BP two to four times per day in the same arm and the same position. A family member must be taught the technique to ensure accurate measurements. Rising blood pressure levels may indicate worsening preeclampsia.
4. Record and graph vital signs, especially BP and pulse.
The client with preeclampsia does not display the normal cardiovascular response to pregnancy (left ventricular hypertrophy, increased plasma volume, vascular relaxation with decreased peripheral resistance). Hypertension (the second manifestation of preeclampsia after edema) occurs due to increased sensitization to angiotensin II, which increases BP and promotes aldosterone release to increase sodium/water reabsorption from the renal tubules constricts blood vessels.
5. Monitor for invasive hemodynamic parameters such as cardiac output, as indicated.
Provides a precise picture of vascular changes and fluid volume. Prolonged vascular constriction, increased hemoconcentration, and fluid shifts decrease cardiac output.
6. Administer low-dose aspirin as indicated.
When initiated before 16 weeks gestation, low-dose aspirin effectively prevents preeclampsia, severe preeclampsia, preterm birth, and intrauterine growth restriction in patients with high-risk pregnancies (Fantasia, 2018; Xu et al., 2015). It is recommended that daily dose aspirin therapy be initiated late in the first trimester for women who have a history of early-onset preeclampsia and subsequent preterm birth at less than 34 weeks of gestation or a history of preeclampsia in more than one previous pregnancy.
7. Administer antihypertensive medications as ordered. Observe for side effects of antihypertensive drugs.
If blood pressure does not respond to conservative measures, short-term medication may be needed with other therapies (e.g., fluid replacement, magnesium sulfate). Antihypertensive treatment should be initiated as soon as reasonably possible for acute-onset severe hypertension that persists (ACOG, 2020). Antihypertensive drugs work directly on arterioles to promote relaxation of cardiovascular smooth muscles and help increase blood supply to the cerebrum, kidneys, uterus, and placenta (Lightstone, 2013). Intravenous hydralazine, or labetalol, and oral nifedipine are three agents commonly used to control hypertension in pregnancy.
- 7.1. Hydralazine (Apresoline, Neopresol).
Administered intravenously, hydralazine reduces blood pressure by relaxing the smooth muscles. The vasodilating effect reduces peripheral vascular resistance. Check BP every minute for 5 mins then every 5 mins for 30 mins.
- 7.2. Labetalol Hydrochloride (Normodyne, Trandate).
Given intravenously, labetalol is an alpha- and beta-blocker that decreases peripheral vascular resistance without significant change in cardiac output or causing tachycardia. Contraindicated with asthma and congestive heart failure. Closely monitor blood pressure after administration.
- 7.3. Methyldopa (Aldomet).
Interferes with chemical neurotransmission to reduce peripheral vascular resistance. Can cause CNS sedation, sleepiness, postural hypotension.
- 7.4. Nifedipine (Adalat).
Calcium channel blocker that dilates arterioles and decreases systemic vascular resistance by relaxing arterial smooth muscle. Nifedipine can potentiate the CNS effects of magnesium sulfate. Closely monitor blood pressure after administration.
- 7.5. Sodium Nitroprusside (Nitropress).
Used in rare scenarios where other antihypertensive agents have failed to control blood pressure.
8. Prepare for the birth of fetus by cesarean delivery, labor when severe preeclamptic or eclamptic condition is stabilized, but vaginal delivery is not feasible.
If conservative treatment is ineffective and labor induction is ruled out, then surgical procedure is the only means of halting the hypertensive problems. Delivery of the fetus is the cure for preeclampsia. If preeclampsia is severe, the fetus is often in greater danger from being in the uterus because its oxygen and nutritional supply may be cut off or its growth can be restricted. Fetal death sometimes can occur.
References and Sources
References and sources for this nursing care plan for hypertensive disorders in pregnancy.
- Abais-Battad, J. M., Lund, H., Fehrenbach, D. J., Dasinger, J. H., Alsheikh, A. J., & Mattson, D. L. (2018, 31 December). Parental Dietary Protein Source and the Role of CMKLR1 in Determining the Severity of Dahl Salt-Sensitive Hypertension. Hypertension, 73(2).
- American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice. (2020). Practice Bulletin #222: Gestational Hypertension and Preeclampsia. Obstetrics & Gynecology, 135, 237-260.
- Arulkumaran, N., & Lightstone, L. (2013). Severe pre-eclampsia and hypertensive crises. Best Practice & Research Clinical Obstetrics & Gynaecology, 27(6), 877-884.
- Benigni, A., Gregorini, G., Frusca, T., Chiabrando, C., Ballerini, S., Valcamonico, A., … & Remuzzi, G. (1989). Effect of low-dose aspirin on fetal and maternal generation of thromboxane by platelets in women at risk for pregnancy-induced hypertension. New England Journal of Medicine, 321(6), 357-362.
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- El Allani, L., Benlamkaddem, S., Berdai, M. A., & Harandou, M. (2020, June 9). A case of massive hepatic infarction in severe preeclampsia as part of the HELLP syndrome. The Pan African Medical Journal, 36(78).
- Espinoza, J. (2012). Uteroplacental ischemia in early‐and late‐onset preeclampsia: a role for the fetus?. Ultrasound in obstetrics & gynecology, 40(4), 373-382.
- Fantasia, H. C. (2018). Low-dose aspirin for the prevention of preeclampsia. Nursing for women’s health, 22(1), 87-92.
- Fox, R., Kitt, J., Leeson, P., Aye, C. Y.L., & Lewandowski, A. J. (2019, October 4). Preeclampsia: Risk Factors, Diagnosis, Management, and the Cardiovascular Impact on the Offspring. Journal of Clinical Medicine, 8(10), 5-6. MDPI.
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- Gallo, D., Poon, L. C., Fernandez, M., Wright, D., & Nicolaides, K. H. (2014, April 15). Prediction of Preeclampsia by Mean Arterial Pressure at 11–13 and 20–24 Weeks’ Gestation. Fetal Diagnosis and Therapy.
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- He, G., Chen, Y., Chen, M., He, G., & Liu, X. (2020, November 13). Efficacy and safety of low dose aspirin and magnesium sulfate in the treatment of pregnancy-induced hypertension A protocol for systematic review and meta-analysis. Medicine (Baltimore), 99(46).
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- Xu, T. T., Zhou, F., Deng, C. Y., Huang, G. Q., Li, J. K., & Wang, X. D. (2015). Low‐Dose aspirin for preventing preeclampsia and its complications: a meta‐analysis. The Journal of Clinical Hypertension, 17(7), 567-573.
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With contributions by Marianne B., and Matt V.