Editing Maternal and Newborn Nursing (section)

=== Hypertensive disorders ===

* '''Chronic hypertension''': present before pregnancy or before 20 weeks.
* '''Gestational hypertension''': new hypertension after 20 weeks without proteinuria or severe features.
* '''Preeclampsia''': after 20 weeks, blood pressure of 140/90 mm Hg or higher on two occasions at least 4 hours apart, ''plus'' proteinuria (300 mg or more per 24 hours, protein to creatinine ratio of 0.3 or more, or 2+ dipstick when other methods are unavailable). Preeclampsia can also be diagnosed '''without proteinuria''' if new hypertension is accompanied by thrombocytopenia, elevated liver enzymes, renal insufficiency, pulmonary edema, or new cerebral or visual symptoms. The underlying problem is abnormal placental development with widespread endothelial dysfunction and vasospasm, which is why it affects the brain, liver, kidneys, lungs, platelets, and placenta all at once.
* '''Severe features''' include systolic 160 mm Hg or higher or diastolic 110 mm Hg or higher, platelets below 100,000/mm3, transaminases roughly twice normal or severe persistent right upper quadrant pain, creatinine above 1.1 mg/dL or doubled, pulmonary edema, and new cerebral or visual disturbance.
* '''Eclampsia''': generalized seizure in a patient with preeclampsia, not explained by another cause.
* '''HELLP syndrome''': '''H'''emolysis, '''E'''levated '''L'''iver enzymes, '''L'''ow '''P'''latelets. It may present with malaise and right upper quadrant pain and can occur with only mildly elevated blood pressure, so it is missed if the nurse anchors on blood pressure alone.

'''Nursing care.''' Definitive treatment is birth. Until then: quiet low-stimulation environment, seizure precautions with suction and oxygen at the bedside, strict intake and output, deep tendon reflexes and clonus, serial blood pressures, daily weights, fetal surveillance, and teaching the patient to report headache, visual change, and epigastric pain.

'''Magnesium sulfate''' is given for '''seizure prophylaxis''', not to lower blood pressure. It is a central nervous system depressant and a smooth muscle relaxant, typically a loading dose followed by a continuous infusion on a pump. Monitor '''deep tendon reflexes, respiratory rate, level of consciousness, urine output, and fetal heart rate'''.
* Earliest reliable sign of toxicity: '''loss of deep tendon reflexes'''. Then respiratory depression (respirations below 12 per minute), then decreased level of consciousness, then cardiac arrest.
* Urine output below 30 mL/hour is a red flag because magnesium is cleared renally and will accumulate.
* '''Antidote: calcium gluconate IV''', kept immediately available whenever magnesium is infusing.
* Expect flushing, warmth, and sedation; these are effects, not toxicity. Newborns of mothers on magnesium may be hypotonic and sleepy with respiratory depression.

Acute severe hypertension is treated with '''IV labetalol, IV hydralazine, or oral immediate-release nifedipine'''. '''ACE inhibitors and ARBs are contraindicated in pregnancy''' because of fetal renal injury and death.