What are the nursing responsibilities for pregnancy induced hypertension?

Pre-eclampsia is a serious condition that can occur during pregnancy where there is high blood pressure and increased protein in the urine.

Although most cases of pre-eclampsia are mild and cause no trouble, the condition can get worse and be serious for both mother and baby. It can cause fits (seizures) in the mother, which is called 'eclampsia', and can affect the baby’s growth. It is life-threatening for mother and baby if left untreated.

Women can have pre-eclampsia and have no symptoms. It is therefore vital to have regular antenatal checks of blood pressure and urine to detect the condition before it becomes dangerous for mother and baby. If you have an antenatal appointment that you can’t attend, it is important to reschedule it.

Pre-eclampsia is sometimes called pregnancy-induced hypertension (PIH), pre-eclamptic toxemia or hypertensive disease of pregnancy.

Get medical help immediately if you are pregnant and you have severe abdominal pain, headache, dizziness, vision problems, confusion, nausea or vomiting, or if you experience a seizure, sudden swelling in your hands, ankles or face, trouble speaking, numbness or sudden and rapid weight gain.

Who is at risk?

About 3 to 4 in every 100 pregnant women in Australia and New Zealand develop pre-eclampsia. The exact causes are not known but you may be at higher risk of developing pre-eclampsia if you:

• have chronic hypertension (high blood pressure)
• have a chronic condition such as diabetes, an autoimmune disease or a kidney disorder
• have had pre-eclampsia before
• are aged 40 years or more or aged under 18 years
• are expecting twins or triplets
• have a family history of pre-eclampsia (i.e. your mother had pre-eclampsia)
• are very overweight at the beginning of your pregnancy (body mass index of 35 or more)
• have had a gap of 10 years or more since your last pregnancy
• conceived with in vitro fertilisation (IVF)
• have an autoimmune disorder such as rheumatoid arthritis

If you have any of these risk factors, it is very important to attend regular check-ups to have your blood pressure and urine tested.

What are the symptoms of PIH?

Pre-eclampsia can occur at any time during pregnancy, and up to 6 weeks after birth. It is most common after 20 weeks of pregnancy and in first pregnancies. It can develop gradually over many weeks, or come on suddenly over a few hours.

Early symptoms

The first signs of pre-eclampsia are a sudden rise in blood pressure (hypertension) and protein in the urine.

You probably won't notice these symptoms, but your doctor or midwife should pick them up during your antenatal appointments.

Progressive symptoms

As pre-eclampsia develops, it can cause fluid retention (oedema), which often causes sudden swelling of the feet, ankles, face and hands.

Oedema is another common symptom of pregnancy, but it tends to be in the lower parts of the body, such as the feet and ankles. It will gradually build up during the day. If the swelling is sudden, and it particularly affects the face and hands, it could be pre-eclampsia.

As pre-eclampsia progresses, it may cause:

• severe headaches that don’t go away with painkillers
• vision problems, such as blurring or seeing flashing lights
• severe pain in the upper abdomen (just below the ribs)
• heartburn that doesn’t go away with antacids
• excessive weight gain due to fluid retention
• feeling generally unwell

If you experience any of these symptoms, contact your doctor or midwife straight away.

However, it is possible to have severe pre-eclampsia without any symptoms.

Pre-eclampsia can also develop soon after childbirth, and you should alert your doctor or midwife of any concerns you may have after your baby is born.

Symptoms in the unborn baby

The main sign of pre-eclampsia in the unborn baby is slow growth. This is caused by poor blood supply through the placenta to the baby. The growing baby is starved of oxygen and nutrients and this will affect their growth.

How is PIH diagnosed?

If you are pregnant, your blood pressure will be checked at every antenatal appointment because a rise in blood pressure can be the first sign of pre-eclampsia. Pre-eclampsia can also be diagnosed by checking whether there is protein in the urine.

If your doctor or midwife is concerned about pre-eclampsia, they may order blood tests, an ultrasound or monitor the baby’s heart rate.

How is PIH treated?

Once pre-eclampsia develops, it does not go away until after the baby is born. Treatment may start with rest at home, but some women need to be admitted to hospital and to take medicines that lower high blood pressure and control the amount of fluid in the body. You may also have medication to prevent seizures.

Occasionally, the only way to treat pre-eclampsia is to deliver the baby early, either by induction of labour or a caesarean section.

After the birth, pre-eclampsia usually goes away quickly. However, there may still be complications so you may need to stay in hospital for several days and keep taking medication to keep your blood pressure down. If your baby is small or premature, they may need care in a special nursery.

How is PIH managed?

If you are concerned about pre-eclampsia, contact your doctor or midwife straight away.

If you are managing pre-eclampsia at home, make sure you drink enough to keep your urine a pale yellow colour. Do not use alcohol, drugs or cigarettes and make sure you go to all your antenatal appointments.

Gentle exercise and keeping your feet raised when you’re sitting down can help.

Complications of pre-eclampsia

If left untreated, pre-eclampsia can increase the risk of a stroke, impaired kidney and liver function, blood clotting problems, fluid on the lungs and seizures. There is also an increased risk that the placenta will separate from the wall of the uterus, causing bleeding (called placental abruption).

The baby may be born small, prematurely or may even be stillborn.

When should I see my doctor?

If you are still concerned about pre-eclampsia or pregnancy-induced hypertension, use healthdirect’s online Symptom Checker to get advice on when to seek medical attention. Ensure you attend regular antenatal visits as directed by your health professional and discuss then follow any professional advice given.

The Symptom Checker guides you to the next appropriate healthcare steps, whether it’s self-care, talking to a health professional, going to a hospital or calling triple zero (000).

Last reviewed: September 2020

Preeclampsia is a serious complication that occurs during pregnancy and affects 5-7% of pregnancies worldwide. It is characterized by high blood pressure and protein in the urine (proteinuria). The exact cause is unknown though research shows genetics or blood vessel abnormalities with the placenta could be a potential cause.

The following risk factors increase the chance of a woman developing preeclampsia:

• Multiple-gestation pregnancy
• Obesity
• Family history of preeclampsia
• Women giving birth for the first time 
• Women younger than 20 years of age or older than 40 years of age
• Overproduction of amniotic fluid (polyhydramnios)
• Underlying diseases like hypertension, diabetes, renal disease, and autoimmune disorders

Hypertension, proteinuria, and edema are the classic triad symptoms of preeclampsia. Other symptoms include:

Preeclampsia, if untreated, can hinder the baby’s growth and may develop into eclampsia. Eclampsia is a severe complication of preeclampsia that can lead to seizures. 

The only way to treat preeclampsia is to deliver the baby. After delivery, preeclampsia usually resolves within days to weeks.

The Nursing Process

Nurses can first identify high-risk pregnancies to prevent preeclampsia. Focus on a thorough nursing assessment, education, and antenatal care. 

The majority of cases are avoidable. Interventions include:

• Monitoring the patient’s blood pressure and symptoms
• Stress management
• Weight management
• Proper nutrition
• Monitoring fetal heart rate (FHR)
• Regular OB/GYN follow-ups and prenatal care

Nursing Care Plans Related to Preeclampsia

Risk for Imbalanced Fluid Volume Care Plan

Risk for imbalanced fluid volume associated with preeclampsia is caused by fluid shifts which can lead to overloading organs and tissues.

Nursing Diagnosis: Risk for Imbalanced Fluid Volume

Related to:

• Plasma protein loss
• Decreased osmotic pressure
• Fluid shifting out of the vascular space
• Narrowing of the blood vessels
• Highly concentrated blood (Hemoconcentration)
• Elevated blood flow resistance
• Body cell degeneration (for pregnant mothers of older age)
• Decreased kidney filtration
• Sodium retention

As evidenced by:

A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Interventions are aimed at prevention.

Expected outcomes:

• Patient will be able to maintain adequate fluid volume as evidenced by blood pressure within normal limits
• Patient will be able to demonstrate efficient fluid intake and output
• Patient will remain free from generalized or pulmonary edema

Imbalanced Fluid Volume Assessment

1. Monitor blood pressure.
High blood pressure during pregnancy causes a concern for preeclampsia. Increased blood pressure may cause the heart to have to work harder due to the additional fluid in the body.

2. Assess for edema, proteinuria, and weight gain.
Proteinuria, edema, and weight gain are symptoms of preeclampsia. Protein in the urine (proteinuria) occurs from impaired renal filtration. Weight gain is likely related to fluid retention.

Note the following symptoms:

• Proteinuria of 1+ to 2+ on a random sample
• Minor facial or upper extremity edema
• Weight gain of more than 2 pounds per week in the second trimester and less than 1 pound per week in the third trimester

3. Monitor fetal well-being and status.
Preeclampsia is a significant factor in fetal death. If fluid is not balanced, the fetus is at higher risk of hypoxia and growth retardation. 

Imbalanced Fluid Volume Interventions

1. Manage preeclampsia.
Collaborate with the healthcare team in treating preeclampsia to manage symptoms of fluid volume imbalance and prevent further complications.

2. Administer fluids.
IV fluids are administered to expand the intravascular volume. Care must be taken to not worsen or cause pulmonary edema.

3. Instruct on diet recommendations.
Limiting sodium and taking calcium, magnesium, and potassium supplements prevent the progression of edema and hypertension in preeclampsia.

4. Monitor intake and output.
Oliguria or reduced urine output can signal decreased kidney function from poor circulatory blood volume.

Decreased Cardiac Output Care Plan

Decreased cardiac output associated with preeclampsia can be caused by increased cardiac demands and decreased blood supply.

Nursing Diagnosis: Decreased Cardiac Output

Related to:

• Hypovolemia
• Decreased venous return
• Increased systemic vascular resistance

As evidenced by:

• Alterations in blood pressure
• Alterations in hemodynamic readings
• Edema
• Dyspnea
• Alterations in mental status

Expected outcomes:

• Patient will be able to maintain adequate blood pressure within acceptable limits

Decreased Cardiac Output Assessment

1. Assess the patient’s blood pressure.
During pregnancy, hypertension is defined as blood pressure >140/90 mm Hg. Preeclampsia is diagnosed with new onset hypertension with proteinuria after 20 weeks of pregnancy. 

2. Assess for indications of poor cardiac function and impending heart failure.
The nurse can assess for the following symptoms:

• Excessive fatigue
• Intolerance to exertion
• Sudden or rapid weight gain
• Edema in the extremities
• Progressive or worsening shortness of breath

4. Assess the patient’s platelet count.
In preeclamptic women, a low platelet count is linked to a higher risk of abnormal coagulation and decreased cardiac output.

5. Assess for fetal growth.
Preeclampsia reduces cardiac output and can affect the arteries that provide blood to the placenta. The fetus may not get enough oxygen or nutrients which may result in fetal growth restriction.

Decreased Cardiac Output Interventions

1. Position the patient comfortably on the left side-lying position.
Left side-lying promotes adequate circulation. This position makes it easier for nutrient-rich blood to flow from the heart to the placenta to support the fetus. 

2. Administer oxygen as prescribed.
Increase the amount of oxygen available for heart function which will increase the blood supply to the placenta and fetus.

3. Administer antihypertensives.
Cardiac medications should be administered to reduce hypertension with precautions that are safe for the mother and the fetus.

4. Restrict fluids as ordered.
If there is the presence of edema and cardiopulmonary congestion, restrict fluid intake as ordered. 

6. Encourage reduced activity.
Rest periods and reduced activity is recommended. Physical activity diverts blood away from the placenta. Complete bed rest is not necessary.

7. Prepare for cesarean section.
If complications of preeclampsia due to decreased cardiac output are present, an emergency cesarean section is performed. This is to prevent maternal and fetal death.

Deficient Knowledge Care Plan

Deficient knowledge associated with preeclampsia can result in delayed recognition and treatment and poorer outcomes.

Nursing Diagnosis: Deficient Knowledge

Related to:

• Pathophysiology of preeclampsia
• Management of preeclampsia
• Risk factors for preeclampsia
• Self-care and nutritional needs of preeclampsia
• Complications of preeclampsia
• Lack of exposure to preeclampsia
• Inaccurate information about preeclampsia
• Misconceptions about preeclampsia

As evidenced by:

• Rapid progress of preeclampsia
• Development of preventable complications
• Unawareness of symptoms
• Inquiries about preeclampsia
• Misconceptions about preeclampsia
• Inaccurate or insufficient instructions in the prevention or management of preeclampsia

Expected outcomes:

• Patient will be able to verbalize understanding of preeclampsia and its management
• Patient will be able to verbalize possible complications and when to contact a healthcare provider
• Patient will be able to demonstrate behavior and lifestyle modifications in the prevention of preeclampsia

Deficient knowledge Assessment

1. Determine the patient’s knowledge level of preeclampsia.
Assessing the patient’s current knowledge and understanding of preeclampsia will help the nurse determine appropriate resources to guide learning.

2. Determine misconceptions about preeclampsia.
Preeclampsia can be misinterpreted by the patient due to past information or influences by family, friends, and cultures. Ask the patient directly about their understanding and clarify any questions as needed.

4. Assess readiness to learn.
Pregnancy can be an exciting and frightening journey, especially for first-time moms. Establish an uninterrupted time to provide information on preeclampsia that is not overwhelmed by other instructions. 

Deficient knowledge Interventions

1. Instruct on symptoms to report.
Provide verbal and written instructions on symptoms to report to the healthcare provider such as blurred vision, headaches, epigastric pain, or difficulty breathing.

2. Involve the support system.
A mother requires support from her partner and family members. Information can be provided to support persons to monitor the patient and encourage healthy habits.

3. Encourage using positive reinforcement.
Positive reinforcement can be used to encourage behavior modification and teach new skills. It promotes motivation for further attempts at learning.

4. Instruct on appointments and tests.
Completing follow-up appointments, glucose monitoring, and blood pressure assessments will ensure a healthy pregnancy and delivery.

References and Sources

1. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
2. Moura, S. B., Lopes, L. M., Murthi, P., & Costa, F. D. (2012, December 17). Prevention of Preeclampsia. PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3534321/
3. Pillitteri, A., & Silbert-Flagg, J. (2015). Nursing Care of a Family Experiencing a Sudden Pregnancy Complication. In Maternal & child health nursing: Care of the childbearing & Childrearing family (8th ed., pp. 1210-1224). LWW.
4. Silvestri, L. A., & CNE, A. E. (2019). Risk Conditions Related to Pregnancy. In Saunders comprehensive review for the NCLEX-RN examination (8th ed., pp. 687-688). Saunders.