Hypertensive Disorders in Pregnancy

Chronic Hypertension: Hypertension existing prior to pregnancy or diagnosed before 20 weeks of gestation.
Superimposed Preeclampsia: Occurs in patients with chronic hypertension who develop preeclampsia.
Gestational Hypertension: Onset occurs after 20 weeks of gestation without evidence of proteinuria.
Preeclampsia: Hypertension with proteinuria developing after 20 weeks gestation.
Preeclampsia with Severe Features: Preeclampsia characterized by involvement of significant organ dysfunctions.
HELLP Syndrome: A severe form of preeclampsia marked by Hemolysis, Elevated Liver enzymes, and Low Platelet count.
Eclampsia: The occurrence of seizures in a patient with preeclampsia.

< 20 weeks of gestation: Chronic Hypertension.
≥ 20 weeks of gestation:
- Chronic Hypertension with superimposed preeclampsia.
- Gestational hypertension.
- Preeclampsia-eclampsia.

Differentiate between gestational hypertension, preeclampsia, eclampsia, chronic hypertension, superimposed preeclampsia, and HELLP syndrome.
Discuss Management: Preconception, antepartum, intrapartum, and postpartum management of women with chronic hypertension.
Describe Pathophysiology: Explore etiologic theories and pathophysiology of preeclampsia.
Care Management Comparison: Compare care management strategies for women with preeclampsia with and without severe features.
Nursing Actions: Understand appropriate nursing actions during and after an eclamptic seizure.

Definition: Preeclampsia is characterized by hypertension (HTN) and proteinuria that develops after 20 weeks gestation.
Prevalence: Complicates approximately 3%-7% of all pregnancies.
Manifestation: Primarily occurs in the second half of pregnancy with multi-organ system involvement.
Classification:
- Preeclampsia Alone: Standard preeclampsia criteria without severe features.
- Preeclampsia with Severe Features: Includes significant complications requiring intensive management.

Hypertension: Persistent elevation in either:
- Systolic Blood Pressure (BP) > 140 mmHg;
- Diastolic BP > 90 mmHg on 2 occasions at least 4 hours apart.
Proteinuria: Defined as > 300 mg/dL in a 24-hour urine specimen or a protein/creatinine ratio of 0.3 mg/dL. A dipstick reading of +1 may also suffice.
Alternatives to Proteinuria for Diagnosis: In the absence of proteinuria, the following can indicate preeclampsia:
- Thrombocytopenia (Platelet count < 100,000/μL).
- Impaired liver function (elevated liver function tests - AST/ALT twice baseline values).
- New onset renal insufficiency (creatinine > 1.1 mg/dL or doubling of serum creatinine).
- Symptoms of pulmonary edema.
- Cerebral symptoms such as headache or visual disturbances.

Goal of Care: Ensure maternal safety and plan for delivery, considering the severity of the disease.
Outpatient Management: Possible in cases of mild disease with regular monitoring of blood pressure and serial labs.
Delivery Considerations: Delivery is warranted as it is the ultimate cure, regardless of gestational age, though attempts should be made to prolong the pregnancy in cases of preterm gestation.
Management Protocols:
- Bedrest is advised.
- Antenatal steroids (e.g., Betamethasone IM x 2 doses 24 hours apart) if the fetus is < 36 weeks.
- Delivery at 37 weeks suggested for any cases not escalating to severe preeclampsia.
- Biweekly Non-Stress Tests (NSTs) from 28 weeks and serial growth ultrasounds are recommended.

Delivery Approach: Dependent on disease severity and cervical status.
- Initiation of antihypertensives (IV labetalol, hydralazine, or oral nifedipine) for severe-range blood pressure.
- Seizure precautions are critical.
- Magnesium Sulfate protocol, including an initial load of 4 or 6 grams followed by 2 grams/hour infusion.

Hydralazine:
- Start with 5 mg IV or 10 mg IM, repeat every 20 minutes as needed.
Labetalol:
- 20 mg IV bolus initially, with further doses possible every 10 minutes, maximum 220 mg.
Nifedipine:
- Start with 10 mg PO, repeat every 30 minutes if necessary.
Sodium Nitroprusside: Only in rare cases where other drugs fail, starting at 0.25 µg/kg/min, with a maximum dose of 5 µg/kg/min.

Definition: The onset of seizures or coma in women diagnosed with preeclampsia.
Incidence: Approximately one-third of eclamptic seizures may occur after delivery.
Premonitory Signs:
- Persistent headache.
- Blurred vision.
- Epigastric or right upper quadrant (RUQ) pain.
- Altered mental status; sometimes high blood pressure is the only sign.

Pathophysiology: Causes include:
- Arteriolar vasospasm.
- Endothelial cell dysfunction and injury with fibrin deposits.
- Activation of the clotting cascade due to fibrin deposits leading to RBC hemolysis and impaired liver function.
Symptoms: Including but not limited to signs of thrombocytopenia, malaise, abdominal pain, nausea/vomiting, headache, and vague symptoms.

Hypertension in Pregnancy: Defined as blood pressure > 140/90 mmHg.
Gestational Hypertension: Onset in the last trimester, subsiding by three months postpartum, and lacks evidence of organ dysfunction.
Chronic Hypertension: Onset before 20 weeks and persists beyond pregnancy.
Preeclampsia: Characterized by hypertension after 20 weeks and associated with organ dysfunction. Organ dysfunction can manifest through renal, liver, and hematological disturbances, or neurological symptoms such as seizures.

Example: A 36-year-old woman at 28 weeks gestation with high blood pressure (150/94) and symptoms of headache and swelling may indicate a risk of preeclampsia. Further diagnostic tests like proteinuria analysis and liver function tests are advised for confirmation. Possible treatments include close monitoring and preparation for potential early delivery depending on severity and response to management.

Online sources and professional guidelines on management of hypertensive disorders in pregnancy.
Kennedy, B. B. & McMurtry S. (2017). Intrapartum Management Modules (5th ed.). Philadelphia, PA: Wolters Kluwer.
Ricci, S. S. (2017). Essentials of Maternity, Newborn, and Women's Health Nursing (5th ed.). Philadelphia, PA: Wolters Kluwer.