1. Pfaff, Nicole Franzen CNM, MSN

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Keeping up to date on the literature surrounding labor and delivery can be an overwhelming task for any nurse. There are constant changes in definitions and diagnostic criteria from the most basic terms to the most complex principles. While providing excellent care to the patient is the first priority, it is essential to understand and be able to explain to women why providers are recommending the treatment pathways. Most recently, the American College of Obstetricians and Gynecologists assembled a group of experts in the management of hypertension in pregnancy and developed updated, evidence-based recommendations for clinical practice.1


It is important to understand that hypertension can be classified into 4 categories during pregnancy: (1) preeclampsia/eclampsia, (2) chronic hypertension, (3) chronic hypertension with superimposed preeclampsia, and (4) gestational hypertension.1 All 4 categories of hypertension are defined differently, but the risks for the woman and fetus are similar. Some of the risks include abruption, stroke, intrauterine growth restriction, stillbirth, medication exposure, pulmonary edema, heart failure, and iatrogenic prematurity.2 Because of the significant morbidity and mortality associated with these risks, it is not only crucial to understand the management of these disorders, it is also essential to understand the definition of each and the changes, if any, that have been made in the new guidelines.


The definition of preeclampsia has been the most modernized by the expert analysis on hypertension in pregnancy. Preeclampsia will no longer be defined as "mild" and "severe."1 Because preeclampsia is a dynamic process, the task force is discouraging health care providers from labeling it as "mild." The word "mild" denotes minor and underplays the severity of the disease. Preeclampsia is a progressive process that needs to be constantly reevaluated. Preeclampsia will, however, still use the "severe" label to define when certain features are met as new management guidelines are indicated at the "severe" level.1


The most notable change surrounding preeclampsia is that proteinuria is no longer a requirement for the diagnosis.1 It has been recognized that preeclampsia is a systemic process that affects multiple systems and rigidly defining it solely on the basis of findings of blood pressure and proteinuria has ignored this fact. The task force now recommends that preeclampsia be defined as 2 blood pressures higher than or equal to 140 (systolic) and 90 (diastolic) mm Hg, at least 4 hours apart, after 20 weeks with either proteinuria (300 mg/24 h, protein/creatinine ratio 0.3 mg/dL or 1+ urinary protein dipstick if no other means are available) or new onset of any other systemic finding including thrombocytopenia, impaired liver function (elevation of liver transaminases), and renal insufficiency (elevated serum creatinine in the absence of other renal disease).1 Severe preeclampsia is diagnosed with the presence of any of the following findings: systolic blood pressure of 160 mm Hg or higher or diastolic blood pressure of 110 mm Hg or higher on 2 occasions at least 4 hours apart while the patient is on bed rest; the presence of significant thrombocytopenia (<100 000/microliter); impaired liver function (twofold or greater elevation of liver transaminases), severe persistent right upper quadrant or epigastric pain unresponsive to medication and not accounted for by alternative diagnoses or both; progressive renal insufficiency (serum creatinine concentration >1.1 mg/dL or double the normal serum concentration), pulmonary edema, or new-onset headache or visual changes.1


Two diagnostic changes have also been made as it relates to severe preeclampsia. Massive proteinuria has been removed as diagnostic criteria because the quantity of protein is not predictive of the outcome of the pregnancy.1 For the labor nurse, this means that a woman with more than 5 g of proteinuria will no longer be considered severe on the basis of protein levels alone. Also, intrauterine growth restriction has been removed as diagnostic criterion for severe preeclampsia because it also occurs outside of this specific disease process.1


The other 3 categories of hypertension in pregnancy have not had any changes made in their definitions; however, it is still essential to make sure that there is an accurate understanding of each term. Chronic hypertension is defined as high blood pressure that predates the pregnancy.1,2Gestational hypertension is defined as high blood pressure that occurs after 20 weeks of gestation in the absence of proteinuria or other systemic findings consistent with preeclampsia.1,2 Superimposed preeclampsia is preeclampsia occurring in someone who already has chronic hypertension.1,2


Management recommendations for the woman with hypertensive disorders during pregnancy have also been modernized. The recommendations given are dependent on 2 key factors: the maternal/fetal status and the gestational age. Key changes in recommendations have been made in regard to bed rest, antihypertensive use, induction of labor, and when to administer magnesium sulfate. It is vital for the nurse to be able to clarify the plan if there are questions and provide some anticipatory guidance as many women during this time can be scared and confused. Table 1 illustrates which women the nurse can plan to be induced and which will be managed expectantly.

Table 1 - Click to enlarge in new windowTable 1. Delivery versus expectant management of women with preeclampsia and gestational hypertension

Women with mild gestational hypertension and preeclampsia without severe features can continue their pregnancies, if stable, until after 37 weeks and no longer need to have antihypertensive therapy, bed rest, or intrapartum magnesium sulfate. The task force still recommends magnesium sulfate therapy for pregnant women with severe preeclampsia, eclampsia, and HELLP syndrome at any gestational age. Delivery is recommended for women with severe preeclampsia including HELLP syndrome after 34 0/7 weeks or for those with unstable maternal and/or fetal conditions at any gestational age as soon as maternal stabilization is achieved. Immediate delivery is recommended for women who develop severe preeclampsia or HELLP syndrome prior to viability.


Recommendations for women between 24 and 34 weeks' gestation are more complex. Generally, recommendations include corticosteroids (ie, betamethasone), management of care at a tertiary care center, and antihypertensive therapy if blood pressure reading reaches the "severe" (160/110 mm Hg) range. For women who remain stable, daily fetal movement counting, twice weekly blood pressure checks, and weekly serum platelet counts and liver transaminases, biweekly antenatal testing, and serial growth scans are recommended. Delivery is indicated for women in the 24- to 34-week range after completion of corticosteroids with preterm premature rupture of membranes, labor, persistent twofold increase in liver function tests, platelet count less than 100 000/microliter, fetal growth restriction less than 5 percentile, severe oligohydramnios, reversed end-diastolic flow on umbilical artery Doppler studies, and/or new-onset or worsening kidney dysfunction. Delivery may be expedited prior to completion of steroids if any of the following complications occur: uncontrollable, severe hypertension; eclampsia; pulmonary edema; abruption; disseminated intravascular coagulation; and nonreassuring fetal status or intrapartum fetal demise.


Postpartum recommendations for women with hypertensive disorders in pregnancy except chronic hypertension have changed as well. The task force now recommends 72 hours of observation during the immediate postpartum period.1 After the initial observation period, the blood pressure must be reassessed in 7 to 10 days; however, the development of any symptoms of preeclampsia is an indication for immediate reassessment. The task force does not recommend the use of antihypertensive medication until the blood pressure is 150 mm Hg systolic or 100 mm Hg diastolic or higher on at least 2 occasions 4 hours apart.


The management of women with a prior history of preeclampsia has been made clearer and nurses play a key role in both education and anticipatory guidance. If possible, identification of lifestyle factors that can contribute to hypertensive and cardiovascular disorders such as obesity, low activity level, smoking, and poor diet need to be addressed. This is not only important for the health of any subsequent pregnancies, but because information continues to accrue that indicates that a woman who has had a preeclamptic pregnancy is at increased risk of cardiovascular disease later in life. Education to modify lifestyles to address these issues is a cornerstone of nursing care. For pregnancy, current recommendations state women with a prior history of a preterm birth due to preeclampsia or preeclampsia in more than 1 pregnancy, the use of low-dose aspirin therapy is suggested. Women can also be counseled in a subsequent pregnancy to expect more frequent visits, especially earlier in the pregnancy, including an early ultrasound. For women who are no longer planning future pregnancies, counseling is directed at attaining a healthy weight, exercising, not smoking, and have yearly wellness examinations to monitor cholesterol, blood sugar, and blood pressure readings.


In summary, nurses are the front line of health care. Nurses are the people most patients remember and with whom they spend most of the time. It is vital that the new recommendations are wholly understood so that nurses can fully assess care and assist the team as well as provide anticipatory guidance to women. Most startling are the changes in the diagnosis of preeclampsia. With the recognition that proteinuria does not need to be present to make a diagnosis of preeclampsia, assessment skills need to be sharpened and a full assessment of the entire person must be made to come to an accurate diagnosis. Also, it is imperative to acknowledge that these are recommendations, not policies. Not all providers will agree completely with the recommendations3 as each patient is an individual, each case is unique, and each provider will make a judgment call on the basis of the clinical picture.


-Nicole Franzen Pfaff, CNM, MSN


University of Wisconsin School of Medicine and Public Health


Madison, Wisconsin




1. American College of Obstetricians and Gynecologists. Hypertension in pregnancy. Obstetr Gynecol. 2013;122(5):1122-1131. [Context Link]


2. Up To Date. Management of hypertension in pregnant and postpartum women. Accessed February 17, 2014. [Context Link]


3. Lockwood CJ. ACOG task force on hypertension in pregnancy: a step forward in management. Contemporary OB/GYN. Published 2013. Accessed February 17, 2014. [Context Link]