Pregnancy-Induced Hypertension (PIH): Comprehensive Nursing Notes

Introduction

Pregnancy-induced hypertension (PIH) is a significant obstetrical complication affecting 5-10% of all pregnancies worldwide. It represents a spectrum of hypertensive disorders that occur during pregnancy, typically after 20 weeks gestation. PIH is a leading cause of maternal and perinatal morbidity and mortality globally, making it a critical area of focus for nursing care.

PIH was historically referred to as “toxemia” due to the belief that it was caused by maternal toxins in response to fetal proteins. While no such toxins were ever identified, the term illustrates the systemic nature of the condition. Modern understanding of PIH encompasses several distinct conditions, all characterized by elevated blood pressure during pregnancy, with potentially serious outcomes for both mother and fetus.

As nurses, our role in the management of PIH is multifaceted – from early detection through assessment and monitoring to active intervention and patient education. These comprehensive notes aim to provide nursing students with an evidence-based understanding of pregnancy-induced hypertension, its pathophysiology, classifications, assessment techniques, and appropriate nursing interventions.

Pathophysiology

The exact pathophysiology of pregnancy-induced hypertension remains incompletely understood, but significant advances have been made in understanding the underlying mechanisms. Current research indicates that PIH develops through a complex interplay of factors:

Placental Development Abnormalities

The primary pathological process appears to originate in the placenta:

Abnormal trophoblastic invasion: During normal pregnancy, trophoblast cells invade the spiral arteries, replacing the muscular and elastic tissues with fibrinoid material. This physiological change creates low-resistance vessels that can accommodate increased blood flow to the placenta.
Impaired spiral artery remodeling: In PIH, there is inadequate/shallow trophoblastic invasion of the spiral arteries in the myometrium. The arteries remain narrow and retain their muscular walls.
Reduced placental perfusion: The failure of spiral arteries to dilate appropriately leads to placental hypoperfusion and ischemia.

Endothelial Dysfunction and Systemic Response

Placental ischemia triggers a cascade of events leading to widespread endothelial dysfunction:

Angiogenic imbalance: The ischemic placenta releases excessive amounts of anti-angiogenic factors such as soluble fms-like tyrosine kinase-1 (sFlt-1) and soluble endoglin (sEng).
Reduction in pro-angiogenic factors: There are decreased levels of vascular endothelial growth factor (VEGF) and placental growth factor (PlGF).
Systemic endothelial damage: This angiogenic imbalance induces widespread endothelial cell dysfunction in maternal blood vessels.

Memory Aid: The “Two-Stage Disorder”

Stage 1: “Poor Placentation” (Reduced placental perfusion)
Stage 2: “Problematic Proteins” (Release of anti-angiogenic factors)

Remember: PIH = Poor Placentation → Problematic Proteins → Pressure Increase in Hypertension

Systemic Effects

The endothelial dysfunction leads to multiple systemic effects:

Increased vascular sensitivity to vasopressors like angiotensin II
Vasoconstriction leading to hypertension
Increased capillary permeability causing edema
Activation of coagulation cascade resulting in microthrombi
End-organ damage affecting kidneys, liver, brain, and other vital organs

Cardiovascular Changes

Normal pregnancy involves:

Increased cardiac output
Decreased systemic vascular resistance
Decreased sensitivity to vasopressors

In PIH, these adaptations are altered:

Increased systemic vascular resistance
Increased sensitivity to vasopressors
Reduced plasma volume (hemoconcentration)

Classification of Hypertensive Disorders in Pregnancy

Hypertensive disorders of pregnancy encompass a spectrum of conditions. According to the American College of Obstetricians and Gynecologists (ACOG) and international guidelines, they are classified as follows:

Classification	Definition	Key Features
Chronic Hypertension	Hypertension that predates pregnancy or is diagnosed before 20 weeks gestation	BP ≥140/90 mmHg before pregnancy or before 20 weeks gestation Persists beyond 12 weeks postpartum
Gestational Hypertension	New onset of hypertension after 20 weeks gestation without proteinuria or other systemic features	BP ≥140/90 mmHg on two occasions at least 4 hours apart No proteinuria BP returns to normal by 12 weeks postpartum
Preeclampsia	New-onset hypertension after 20 weeks gestation with proteinuria or end-organ dysfunction	Mild: BP ≥140/90 mmHg with proteinuria ≥300mg/24hr (or protein/creatinine ratio ≥0.3 or dipstick 1+) Severe: BP ≥160/110 mmHg with proteinuria and/or end-organ dysfunction
Preeclampsia with severe features	Preeclampsia with one or more severe complications	Severe hypertension (≥160/110 mmHg) Thrombocytopenia (<100,000/μL) Impaired liver function (elevated transaminases 2× normal) Progressive renal insufficiency Pulmonary edema New-onset cerebral or visual disturbances
Eclampsia	Preeclampsia with grand mal seizures not attributable to other causes	Seizures or coma in a woman with preeclampsia Can occur antepartum, intrapartum, or postpartum (up to 72 hours) Medical emergency with high maternal mortality rate
HELLP Syndrome	Variant of severe preeclampsia characterized by Hemolysis, Elevated Liver enzymes, and Low Platelets	Hemolysis (LDH >600 IU/L) Elevated liver enzymes (AST and/or ALT >2× upper limit of normal) Low platelets (<100,000/μL) May occur without hypertension or proteinuria in 15% of cases
Chronic Hypertension with Superimposed Preeclampsia	Chronic hypertension complicated by preeclampsia	Chronic hypertension and new-onset proteinuria after 20 weeks OR sudden increase in previously well-controlled hypertension OR development of severe features of preeclampsia

Memory Aid: “CREEP-HELP”

To remember the classifications:

Chronic Hypertension
Gestational Hypertension
Preeclampsia (mild or severe)
Eclampsia
HELLP Syndrome
Preeclampsia superimposed on chronic hypertension

Risk Factors

Certain factors increase the risk of developing pregnancy-induced hypertension. Understanding these risk factors is essential for early identification and management of high-risk pregnancies.

Category	Risk Factors	Level of Risk
Demographic Factors	First pregnancy (nulliparity) Maternal age <20 or >35 years African American race Low socioeconomic status	Moderate
Obstetric History	Previous history of preeclampsia Multiple gestation (twins, triplets) Interval between pregnancies >10 years History of adverse pregnancy outcome	High
Medical Conditions	Chronic hypertension Pre-existing diabetes (Type 1 or 2) Chronic kidney disease Autoimmune disorders (e.g., SLE, antiphospholipid syndrome) Obesity (BMI >30) Thrombophilias Obstructive sleep apnea	High
Family History	Family history of preeclampsia (mother or sister) Family history of hypertension	Moderate
Placental Factors	Hydatidiform mole Placental abnormalities Hydrops fetalis	High
Genetic Factors	Inherited thrombophilias Specific gene variants	Variable

Risk Assessment Tool

Current guidelines recommend low-dose aspirin (81 mg daily) prophylaxis starting between 12-28 weeks and continuing until delivery for women with:

One or more high-risk factors
Two or more moderate risk factors

Early identification of high-risk women allows for appropriate preventive measures and vigilant monitoring.

Clinical Manifestations

Pregnancy-induced hypertension presents with a range of clinical manifestations that vary in severity based on the classification and progression of the disorder.

Cardinal Signs

Hypertension: Blood pressure ≥140/90 mmHg on two occasions at least 4 hours apart
Proteinuria: ≥300 mg in a 24-hour urine collection, protein/creatinine ratio ≥0.3, or dipstick reading of 1+ (if quantitative methods unavailable)
Edema: While no longer a diagnostic criterion, edema (particularly in the face, hands, and around the eyes) is commonly observed

System-Specific Manifestations

Body System	Clinical Manifestations	Nursing Assessment Focus
Cardiovascular	Hypertension Increased cardiac output Reduced plasma volume Peripheral edema	Monitor BP every 4 hours Assess for chest pain Check for jugular venous distension Auscultate heart sounds
Renal	Proteinuria Reduced glomerular filtration rate Oliguria (<30 ml/hr) Elevated serum creatinine	Monitor urinary output Test for proteinuria Track intake and output Monitor for costovertebral tenderness
Neurological	Headache (persistent, frontal) Visual disturbances (blurred vision, scotomata) Hyperreflexia Clonus Seizures (in eclampsia)	Assess for headache Check visual acuity Test deep tendon reflexes Assess for clonus Monitor level of consciousness
Hepatic	Right upper quadrant/epigastric pain Elevated liver enzymes (ALT, AST) Liver edema (subcapsular hematoma) Hepatocellular necrosis	Palpate for RUQ/epigastric tenderness Monitor for nausea/vomiting Check for jaundice
Hematologic	Thrombocytopenia Hemolysis (in HELLP) Disseminated intravascular coagulation (DIC) Increased hemoconcentration	Monitor for petechiae, ecchymosis Check for bleeding from IV sites Assess gums for bleeding
Pulmonary	Pulmonary edema Dyspnea Crackles	Auscultate lung fields Monitor respiratory rate and effort Assess for cough or frothy sputum Check oxygen saturation
Uteroplacental	Placental insufficiency Intrauterine growth restriction Placental abruption Reduced fetal movement	Perform fetal heart rate monitoring Track fetal movement counts Monitor for vaginal bleeding Assess for uterine tenderness

Signs of Severe Preeclampsia

The presence of any of the following indicates severe preeclampsia:

Blood pressure ≥160/110 mmHg on two occasions at least 4 hours apart
Thrombocytopenia (platelets <100,000/µL)
Impaired liver function (elevated transaminases >2x normal)
Progressive renal insufficiency (serum creatinine >1.1 mg/dL or doubling of baseline)
Pulmonary edema
New-onset cerebral or visual disturbances
Severe persistent right upper quadrant or epigastric pain unresponsive to medication

Memory Aid: “HELLP ME”

For severe features of preeclampsia:

Hypertension (≥160/110 mmHg)
Elevated liver enzymes
Low platelets (<100,000/µL)
Liver pain (RUQ/epigastric)
Pulmonary edema
Mental changes/headache
Eye disturbances

Assessment and Diagnosis

Accurate diagnosis of pregnancy-induced hypertension requires comprehensive assessment and diagnostic testing. Nurses play a crucial role in collecting assessment data and facilitating diagnostic procedures.

Nursing Assessment

1. History Taking

Complete obstetric history (gravida, para, previous pregnancy complications)
Medical history (pre-existing conditions, medications)
Family history (hypertension, preeclampsia, cardiovascular disease)
Current pregnancy symptoms (headache, visual changes, epigastric pain)
Timing of symptom onset

2. Physical Examination

Blood pressure measurement: Use appropriate technique following these guidelines:
- Patient seated with back supported
- Arm at heart level
- Appropriate cuff size (bladder encircling 80% of arm)
- At least 5 minutes of rest before measurement
- Readings at least 4 hours apart
Edema assessment: Check for pitting edema in face, hands, sacrum, and lower extremities
Weight measurement: Document recent weight changes (gain of >2 lbs/week in 2nd trimester or >1 lb/week in 3rd trimester suggests fluid retention)
Neurological assessment: Deep tendon reflexes (hyperreflexia), clonus, level of consciousness
Abdominal examination: Right upper quadrant/epigastric tenderness, uterine size/fundal height
Pulmonary assessment: Respiratory rate, effort, auscultate for crackles

3. Fetal Assessment

Fetal heart rate monitoring
Fetal movement assessment
Fundal height measurement (to assess for intrauterine growth restriction)

Diagnostic Tests

Diagnostic Test	Purpose	Abnormal Findings in PIH	Nursing Considerations
Urinalysis	Screen for proteinuria	Urine dipstick: ≥1+ protein Protein/creatinine ratio: ≥0.3	Collect clean-catch midstream urine First morning specimen preferred
24-hour urine collection	Quantify proteinuria	≥300 mg protein/24 hours	Educate patient on proper collection Begin after discarding first void Keep specimen refrigerated
Complete blood count	Assess for hematologic changes	Thrombocytopenia (<100,000/µL) Hemoconcentration (elevated HCT) Hemolysis (in HELLP)	Monitor for trends in values Rapid decreases in platelets are concerning
Comprehensive metabolic panel	Evaluate organ function	Elevated creatinine (>1.1 mg/dL) Elevated liver enzymes (AST, ALT) Elevated uric acid Low serum albumin	Assess trends in values Report significant changes promptly
Coagulation studies	Assess for coagulopathy	Prolonged PT/PTT Elevated D-dimer Decreased fibrinogen	Monitor for signs of bleeding Early identification of DIC
LDH and peripheral blood smear	Evaluate for hemolysis	Elevated LDH (>600 IU/L) Schistocytes on blood smear	Important for HELLP diagnosis
Ultrasound	Assess fetal growth and placental status	Intrauterine growth restriction Oligohydramnios Placental abnormalities	Prepare patient for procedure Serial measurements are important
Doppler velocimetry	Assess uterine/umbilical blood flow	Increased resistance in uterine arteries Abnormal umbilical artery flow	Helps evaluate placental function
Non-stress test/Biophysical profile	Assess fetal well-being	Non-reactive NST Low BPP score Decreased fetal movement	Position patient on left side Ensure adequate hydration

Diagnostic Criteria for Preeclampsia (ACOG Guidelines)

Blood pressure ≥140/90 mmHg on two occasions at least 4 hours apart after 20 weeks gestation, and either:

Proteinuria ≥300 mg/24 hours (or protein/creatinine ratio ≥0.3 or dipstick 1+ if quantitative methods unavailable)
OR in the absence of proteinuria, new-onset hypertension with any of the following:
- Thrombocytopenia (platelets <100,000/µL)
- Renal insufficiency (serum creatinine >1.1 mg/dL or doubling from baseline)
- Impaired liver function (elevated transaminases >2x normal)
- Pulmonary edema
- Cerebral or visual symptoms

Nursing Management

Effective nursing management of pregnancy-induced hypertension is essential for optimizing maternal and fetal outcomes. The nursing care focuses on monitoring, interventions to prevent complications, and education.

Monitoring and Surveillance

Parameter	Frequency	Nursing Interventions
Blood Pressure	Mild PIH: Every 4 hours Severe PIH: Every 1-2 hours Intrapartum: Continuous	Use proper technique and equipment Document trends and patterns Report values ≥160/110 mmHg immediately
Urine Output	Mild PIH: Each void Severe PIH: Hourly (may require catheter)	Monitor for oliguria (<30 mL/hour) Check for proteinuria Maintain strict I&O records
Neurological Status	Every 4 hours or with vital signs More frequent if symptoms present	Assess level of consciousness Evaluate for headache, visual disturbances Check deep tendon reflexes and clonus Implement seizure precautions for severe PIH
Edema	Every shift	Assess distribution and severity (1+ to 4+) Check for facial and hand edema Monitor daily weight for rapid increases
Fetal Status	Mild PIH: Daily kick counts Severe PIH: Continuous electronic fetal monitoring	Teach mother to monitor fetal movement Perform NST/BPP as ordered Report abnormal patterns immediately
Laboratory Values	As ordered, typically daily for severe PIH	Monitor trends in values Report significant changes immediately Correlate labs with clinical presentation

Therapeutic Interventions

1. Blood Pressure Management

Medication	Dosage	Nursing Considerations
Labetalol	IV: 10-20 mg initially, then 20-80 mg q10-30min (max 300 mg) PO: 100-400 mg BID-TID	Monitor maternal heart rate Contraindicated in asthma, heart failure Watch for bradycardia
Hydralazine	IV: 5-10 mg q20-40min (max 20 mg)	May cause maternal tachycardia Monitor for hypotension Can cause headache, flushing
Nifedipine	Immediate release: 10-20 mg PO q4-6h Extended release: 30-60 mg daily	Do not administer sublingually Avoid concurrent magnesium sulfate Can cause headache, flushing
Methyldopa	250-500 mg PO BID-TID (max 3g/day)	Long history of safety in pregnancy Slow onset of action May cause drowsiness

Important Note:

Blood pressure management goal in pregnancy:

For severe hypertension: Lower BP to 140-150/90-100 mmHg
Avoid rapid or excessive blood pressure reduction as it may compromise uteroplacental perfusion

ACE inhibitors, ARBs, and nitroprusside are contraindicated in pregnancy due to potential fetal harm.

2. Seizure Prevention and Management

Magnesium Sulfate is the drug of choice for seizure prophylaxis and management in preeclampsia and eclampsia.

Administration	Dosage	Nursing Monitoring
Loading Dose	4-6 g IV over 15-20 minutes	Respiratory rate (>12/min) Deep tendon reflexes (present) Urine output (>30 mL/hour) Level of consciousness Serum magnesium levels (therapeutic range: 4-7 mEq/L)
Maintenance	1-2 g/hour continuous IV infusion
For Active Seizure	Additional 2 g IV bolus over 3-5 minutes	Support airway, breathing, circulation Position patient on left side Protect from injury
Toxicity Antidote	Calcium gluconate 1 g IV over 3-5 minutes	Keep at bedside when administering magnesium Use for respiratory depression, hyporeflexia, or cardiac arrhythmias

Memory Aid: “MAGNESIUM Toxicity – 10-5-2-1”

10 mEq/L: Cardiac arrest
5 mEq/L: Loss of deep tendon reflexes
2 mEq/L: ECG changes
1 mEq/L: Therapeutic level for normal physiology

Remember: “Respiratory Rate, Reflexes, and Renal output” – The 3 R’s for monitoring magnesium sulfate therapy

3. Fluid and Electrolyte Management

Maintain fluid balance with careful monitoring of intake and output
IV fluid rate typically 80-125 mL/hour (avoid fluid overload)
Monitor for signs of pulmonary edema (crackles, dyspnea, decreased O2 saturation)
Maintain accurate fluid balance records

4. Position and Activity Modifications

Promote left lateral position to enhance uterine blood flow and reduce pressure on vena cava
Limited activity or modified bed rest may be prescribed (complete bed rest is no longer routinely recommended)
Minimize environmental stimuli (low lighting, reduced noise)

5. Patient Education

Explain the condition, its risks, and warning signs
Teach self-monitoring techniques (blood pressure, fetal movement, symptom recognition)
Provide information on dietary recommendations (moderate sodium restriction, adequate protein)
Explain medication regimens, including side effects to report
Stress the importance of follow-up appointments

Preventive Measures

Low-Dose Aspirin for High-Risk Women

81 mg aspirin daily started between 12-28 weeks gestation
Continue until delivery
Recommended for women with high risk factors:
- Previous preeclampsia
- Multifetal pregnancy
- Chronic hypertension
- Type 1 or 2 diabetes
- Renal disease
- Autoimmune disease (SLE, APS)

Delivery Considerations

The definitive treatment for preeclampsia is delivery of the fetus and placenta. Timing depends on:

Gestational age
Severity of maternal condition
Fetal status

Clinical Scenario	Recommended Timing of Delivery
Preeclampsia with severe features	<34 weeks: Delivery after maternal stabilization and steroid administration if possible ≥34 weeks: Immediate delivery after maternal stabilization
Preeclampsia without severe features	<37 weeks: Expectant management with close monitoring ≥37 weeks: Delivery
Gestational hypertension	<37 weeks: Expectant management ≥37 weeks: Consider delivery
Chronic hypertension	38-39 weeks: Consider delivery
Eclampsia	Immediate delivery after maternal stabilization regardless of gestational age

Postpartum Care

Continue monitoring for at least 72 hours postpartum, as risk for complications remains high
Most severe complications (eclampsia, stroke, pulmonary edema) occur in the postpartum period
Continue antihypertensive therapy as needed
Modify medication if breastfeeding
Educate about signs and symptoms to report after discharge
Schedule close follow-up (within 7-10 days of discharge)
Discuss contraception and risks for future pregnancies

Practice Point: Postpartum Vigilance

Up to 25% of eclamptic seizures occur postpartum, with most occurring within the first 48 hours. However, eclampsia can occur up to 6 weeks postpartum. Maintain high vigilance during this period, especially for women who had severe preeclampsia.

Complications

Pregnancy-induced hypertension can lead to serious complications affecting both the mother and fetus if not properly managed. Understanding these potential complications is essential for early recognition and intervention.

Maternal Complications

Complication	Clinical Presentation	Nursing Implications
Eclampsia	Grand mal seizures Loss of consciousness May be preceded by severe headache, visual disturbances	Implement seizure precautions Maintain airway Administer magnesium sulfate Monitor for aspiration
HELLP Syndrome	Hemolysis Elevated liver enzymes Low platelets Right upper quadrant pain Nausea, vomiting	Monitor for bleeding Assess for jaundice Monitor liver function tests Prepare for potential delivery
Placental Abruption	Vaginal bleeding (may be concealed) Uterine tenderness/tetany Abdominal pain Fetal distress	Monitor for bleeding Assess uterine tenderness Monitor fetal heart rate Prepare for emergency delivery
Pulmonary Edema	Dyspnea Crackles on auscultation Decreased oxygen saturation Frothy sputum	Elevate head of bed Administer oxygen Restrict fluids Monitor respiratory status
Acute Kidney Injury	Oliguria or anuria Elevated BUN and creatinine Fluid overload Electrolyte imbalances	Strict intake and output monitoring Daily weights Electrolyte assessment Potential dialysis preparation
Cerebral Hemorrhage	Severe headache Altered mental status Focal neurological deficits Loss of consciousness	Frequent neurological checks Blood pressure control Prepare for neuroimaging Neurosurgical consult
DIC (Disseminated Intravascular Coagulation)	Abnormal bleeding from multiple sites Petechiae, ecchymosis Prolonged clotting times Decreased fibrinogen, elevated D-dimer	Monitor for bleeding Blood product administration Frequent coagulation studies Pressure to bleeding sites
Liver Rupture/Hematoma	Sudden, severe RUQ/epigastric pain Shoulder pain Signs of shock Abdominal distention	Monitor vital signs Assess for signs of shock Prepare for emergency surgery Blood transfusions
Long-term Cardiovascular Risk	Increased risk of chronic hypertension Higher cardiovascular disease risk Increased stroke risk Potential for chronic kidney disease	Patient education on long-term risks Encourage lifestyle modifications Recommend regular health screenings Referral to specialists as needed

Fetal/Neonatal Complications

Complication	Clinical Presentation	Nursing Implications
Intrauterine Growth Restriction (IUGR)	Fetal weight <10th percentile for gestational age Reduced fundal height measurements Asymmetric growth on ultrasound	Serial growth ultrasounds NSTs and BPPs Doppler flow studies Monitor for signs of fetal compromise
Oligohydramnios	Reduced amniotic fluid (AFI <5 cm) Difficult to palpate fetal parts Cord compression during labor	Monitor fetal heart rate for decelerations Position mother on left side Consider amnioinfusion during labor
Preterm Birth	Delivery before 37 weeks gestation Associated complications of prematurity	Administer antenatal corticosteroids Prepare for NICU admission Educate parents about preterm care
Perinatal Asphyxia	Low Apgar scores Metabolic acidosis Need for resuscitation	Prepare for neonatal resuscitation Ensure pediatric/neonatology team presence at delivery Monitor cord blood gases
Fetal Demise	Absence of fetal heart tones Absence of fetal movement Confirmation on ultrasound	Provide emotional support Grief counseling Memory creation (footprints, photos as appropriate) Support during delivery
Long-term Effects	Neurodevelopmental delays Increased risk of hypertension Metabolic abnormalities	Educate parents about follow-up care Early intervention services Developmental screening

Critical Time Periods

The risk for complications remains elevated during specific time periods:

At presentation: Risk for eclampsia, placental abruption, and fetal distress
During labor and delivery: Risk for cerebral hemorrhage, placental abruption, and HELLP syndrome
24-48 hours postpartum: Peak risk for pulmonary edema and eclampsia
Up to 6 weeks postpartum: Continued risk for hypertension and late eclampsia

Vigilant monitoring should continue throughout these periods.

Nursing Care Plans

Comprehensive nursing care plans for patients with pregnancy-induced hypertension address key nursing diagnoses and provide structured interventions to optimize maternal and fetal outcomes.

1. Risk for Decreased Cardiac Output

Assessment	Nursing Interventions	Rationale	Expected Outcomes
Monitor vital signs, especially BP and heart rate Assess for peripheral edema Check for dyspnea, orthopnea Auscultate heart and lung sounds Monitor I&O	Position patient in left lateral position Administer antihypertensive medications as ordered Restrict fluid intake as ordered Monitor laboratory values (hemoglobin, hematocrit) Administer oxygen as needed	Left lateral position enhances venous return and reduces pressure on vena cava Antihypertensives reduce afterload and improve cardiac output Fluid restrictions prevent pulmonary edema Lab values reflect hemoconcentration and help guide therapy Supplemental oxygen improves tissue oxygenation	Patient will maintain systolic BP between 140-150 mmHg and diastolic BP between 90-100 mmHg Patient will show no signs of pulmonary edema Fetus will show adequate heart rate and variability Patient will demonstrate adequate urine output (>30 mL/hr)

2. Risk for Injury (Maternal and Fetal)

Assessment	Nursing Interventions	Rationale	Expected Outcomes
Assess neurological status (reflexes, clonus, headache, visual changes) Monitor for signs of eclampsia Assess fetal heart rate and movement Monitor for vaginal bleeding	Implement seizure precautions Administer magnesium sulfate as ordered Maintain quiet environment Monitor fetal status Have emergency equipment readily available Monitor for signs of magnesium toxicity	Seizure precautions prevent injury during eclamptic seizure Magnesium sulfate prevents seizures Quiet environment reduces central nervous system stimulation Regular fetal monitoring detects early signs of distress Emergency equipment ensures prompt response to complications	Patient will not experience seizures Patient will maintain stable neurological status Fetus will maintain reassuring heart rate pattern Patient will demonstrate no signs of placental abruption

3. Risk for Ineffective Tissue Perfusion

Assessment	Nursing Interventions	Rationale	Expected Outcomes
Monitor organ function (renal, hepatic, cerebral, uteroplacental) Assess urine output Monitor for RUQ pain Assess laboratory values	Maintain blood pressure within target range Position patient in left lateral position Administer prescribed medications Monitor fetal heart rate and movement Assess peripheral perfusion	Blood pressure control improves tissue perfusion while maintaining uteroplacental flow Left lateral position enhances blood flow to vital organs and placenta Medications improve vascular function Fetal assessment reflects placental perfusion	Patient will maintain adequate urine output Patient will not develop RUQ pain or liver function abnormalities Patient will maintain normal cognitive function Fetus will demonstrate adequate growth and well-being

4. Deficient Knowledge

Assessment	Nursing Interventions	Rationale	Expected Outcomes
Assess current knowledge of PIH Identify learning needs Determine readiness to learn Assess understanding of home care requirements	Provide information about PIH and its management Teach signs and symptoms requiring medical attention Instruct on importance of follow-up care Educate on medication regimen Teach home blood pressure monitoring techniques Provide written educational materials	Education empowers patient to participate in care Understanding warning signs allows for early intervention Follow-up care ensures ongoing monitoring and adjustment of treatment Medication adherence improves outcomes Home monitoring allows for early detection of worsening condition	Patient will verbalize understanding of PIH and its management Patient will identify signs and symptoms requiring immediate medical attention Patient will demonstrate correct technique for blood pressure measurement Patient will verbalize plan for follow-up care

5. Anxiety

Assessment	Nursing Interventions	Rationale	Expected Outcomes
Assess level of anxiety Identify specific concerns Evaluate support systems Assess coping mechanisms	Provide accurate information Allow expression of fears and concerns Maintain calm environment Involve partner/family in discussions Provide reassurance and emotional support Teach relaxation techniques	Accurate information reduces fear of the unknown Expression of concerns helps identify specific areas for intervention Calm environment reduces stress Family involvement enhances support system Emotional support builds trust and reduces anxiety Relaxation techniques help manage physiological response to stress	Patient will verbalize decreased anxiety Patient will demonstrate use of effective coping strategies Patient will report improved sense of control Patient will demonstrate normal vital signs not influenced by anxiety

Memory Aids

These memory aids will help nursing students remember key aspects of pregnancy-induced hypertension.

The “5 P’s” of Preeclampsia Pathophysiology

Placental dysfunction (poor placentation)
Pressure elevation (hypertension)
Proteinuria (renal involvement)
Peripheral edema (fluid shifts)
Platelet dysfunction (coagulation changes)

CLASP: Warning Signs for Severe Preeclampsia

Cerebral symptoms (headache, visual disturbances)
Liver involvement (RUQ pain, elevated enzymes)
Altered kidney function (oliguria, proteinuria)
Severe hypertension (≥160/110 mmHg)
Platelet abnormalities (<100,000/µL)

“RIGHT SIDE”: Nursing Priorities for PIH

Rest in left lateral position
Input/output monitoring
Gauge blood pressure regularly
Hyperreflexia assessment
Treat symptoms promptly
Seizure prevention (magnesium sulfate)
Inform about danger signs
Delivery planning
Evaluate fetal well-being

MAGNESIUM Monitoring: “The 3 R’s + B”

Respiratory rate (>12/min)
Reflexes (present)
Renal function (urinary output >30 mL/hr)
Blood levels (therapeutic: 4-7 mEq/L)

ABCS of PIH Management

Assess blood pressure, protein, and edema
Bed rest (modified activity) in left lateral position
Calcium gluconate (antidote for magnesium toxicity)
Seizure prevention with magnesium sulfate

HELLP Syndrome: Remember the Definition

Hemolysis
Elevated
Liver enzymes
Low
Platelets

Best Practices & Updates

Nursing care for pregnancy-induced hypertension continues to evolve as new research emerges. Here are three key updates to current practice that all nursing students should be aware of:

1. Low-Dose Aspirin Prophylaxis

The American College of Obstetricians and Gynecologists (ACOG) now recommends daily low-dose aspirin (81 mg) for women at high risk of preeclampsia. This should be initiated between 12-28 weeks of gestation and continued until delivery.

Clinical Implications: Nurses should identify high-risk women early in pregnancy for aspirin prophylaxis and educate them about the importance of adherence. This intervention can reduce the risk of preeclampsia by 24% and the risk of preterm birth by 14%.

2. Revised Diagnostic Criteria for Preeclampsia

Current guidelines no longer require proteinuria for the diagnosis of preeclampsia. Hypertension after 20 weeks gestation with evidence of end-organ dysfunction (thrombocytopenia, renal insufficiency, liver involvement, pulmonary edema, cerebral symptoms) is sufficient for diagnosis.

Clinical Implications: Nurses should remain vigilant for signs of preeclampsia even in the absence of proteinuria. This change allows for earlier detection and management of atypical presentations of preeclampsia.

3. Extended Postpartum Monitoring

Recent evidence indicates that women with hypertensive disorders of pregnancy should be monitored for at least 72 hours postpartum, with extended follow-up for up to 12 weeks. The risk of complications, including eclampsia and stroke, extends well into the postpartum period.

Clinical Implications: Nurses should educate patients about the importance of postpartum follow-up and the need to report concerning symptoms. Blood pressure should be checked within 7-10 days postpartum for all women with hypertensive disorders, with earlier checks for those with severe features.

Evidence-Based Practices for PIH Management

Blood Pressure Targets: Current evidence supports treatment of severe hypertension (≥160/110 mmHg) to reduce the risk of stroke and other complications. The goal is to maintain BP between 140-150/90-100 mmHg rather than normalization.
Magnesium Sulfate Therapy: Remains the gold standard for seizure prophylaxis in preeclampsia with severe features. It reduces the risk of eclampsia by more than 50% compared to placebo.
Delivery Timing: For preeclampsia with severe features, delivery after 34 weeks is recommended. For preeclampsia without severe features, delivery at 37 weeks optimizes maternal and neonatal outcomes.
Modified Bed Rest: Complete bed rest is no longer routinely recommended due to increased risk of thromboembolism. Activity modification with periods of left lateral rest is preferred.
Calcium Supplementation: In populations with low calcium intake, supplementation during pregnancy may reduce the risk of preeclampsia by up to 64%.

References

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American College of Obstetricians and Gynecologists. (2019). ACOG Practice Bulletin No. 203: Chronic hypertension in pregnancy. Obstetrics & Gynecology, 133(1), e26-e50. https://doi.org/10.1097/AOG.0000000000003021
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