Puzzling out

preeclampsia

20 Nursing made Incredibly Easy! March/April 2010

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About 8% of all pregnant

women develop preeclampsia.
What risk factors contribute
to the development of this
syndrome, hows it managed,
and whats your role in providing the best possible care for
your patient? We give you the
tools you need to keep mother
and baby healthy.
By Karen Buley, BSN, RN
Registered Nurse Community Medical Center
Missoula, Mont.

Preeclampsia, formerly known as toxemia

or pregnancy-induced hypertension, has a
new look. Previously characterized by a
triad of symptoms, now preeclampsia has
only two: hypertension and proteinuria,
occurring after 20 weeks gestation. Edema,
once a defining symptom, may or may not
be present.
In this article, Ill define preeclampsia,
review its possible causes and risk factors,
and discuss important management strategies and nursing interventions.

Getting down to definitions

Hypertension during pregnancy doesnt

automatically lead to a diagnosis of
preeclampsia. During pregnancy, there are
four hypertensive classifications (see Classification of high BP in pregnancy):
chronic hypertension
preeclampsia/eclampsia
chronic hypertension with superimposed
preeclampsia or eclampsia
gestational (or transient) hypertension.
Chronic hypertension is present when a
womans BP is 140/90 mm Hg or greater
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before pregnancy or before 20 weeks gestation, or when her BP remains high 12 weeks
after delivery. Some women may not be
aware that they have hypertension, so early
prenatal care is vital. If a womans BP is high
initially or if the expected decrease in BP
between 8 and 28 weeks gestation doesnt
occur, she must be monitored carefully for
chronic hypertension.
Preeclampsia is present when a previously normotensive woman develops increased
BP after 20 weeks gestation (140/90 mm Hg
or higher on two occasions, taken at least 6
hours apart).
In mild preeclampsia, a womans BP is
higher than 140/90 mm Hg, her urine protein is generally 1+ to 2+, liver enzymes may
be minimally elevated, and edema may or
may not be present.
In severe preeclampsia, a womans BP is
160/110 mm Hg or higher, with 3+ to 4+
proteinuria. Headaches, visual changes
(blurring or seeing spots), worsening edema,
hyperreflexia, decreased urine output, lab
results indicative of HELLP syndrome
(hemolysis, elevated liver enzymes, and a
low platelet count), and right upper quadrant or epigastric pain may be present. Right
upper quadrant painthought to be caused
by liver inflammationoften signifies
impending eclampsia.
Preeclampsia becomes eclampsia when the
patient experiences a grand mal seizure. She
may have only one or as many as 20. The
onset may occur before, during, or after labor.
Chronic hypertension with superimposed
preeclampsia or eclampsia is characterized
by a BP of greater than or equal to 140/90
mm Hg before the 20th week of pregnancy,
with superimposed proteinuria and with or
without signs of preeclampsia syndrome.
Gestational (or transient) hypertension
develops after 20 weeks gestation. Theres
March/April 2010 Nursing made Incredibly Easy! 21

Edema is no
longer a defining
symptom of
preeclampsia.

no accompanying proteinuria and the

womans BP returns to normal within 12
weeks after birth.

Understanding the dangers

Preeclampsia, with its resulting vasoconstriction, leads to decreased blood flow to

maternal organs and the placenta. Risks
to the mother include:
pulmonary edema
thrombocytopenia
oliguria and renal failure
cerebral hemorrhage, edema, and
thrombosis
pulmonary embolism
hepatic injury
seizures and coma
abruptio placentae (the premature
separation of the placenta from the uterine
wall after 20 weeks gestation)

disseminated intravascular coagulation

death.
Risks to the fetus include:
intrauterine growth restriction (the fetus
doesnt grow at the normal rate inside the
uterus)
hypoxia
preterm birth
nonreassuring fetal status related to
abruptio placentae.

Puzzling out possible causes

The jury remains out on what causes

preeclampsia, although several theories
have been presented:
immune response. The mothers body
develops an allergic reaction in response
to the placenta and fetus, with resulting
damage to her blood vessels.
genetic link. The genetic makeup of the
fetus may predispose a woman to
Classification of high BP in pregnancy
preeclampsia,
particularly if her
Classification
Description
own mother, or
her partners
Chronic hypertension
BP greater than or equal to 140/90 mm Hg thats
mother, had
present and observable before the 20th week
preeclampsia
of pregnancy; hypertension thats diagnosed
for the first time during pregnancy and doesnt
while pregnant
resolve after pregnancy is also classified as
with either of
chronic hypertension
them.
blood vessel
Preeclampsia/eclampsia
Pregnancy-specific syndrome of BP elevation
defect. The blood
(BP greater than or equal to 140/90 mm Hg) that
vessels
constrict
occurs after the first 20 weeks of pregnancy
during pregnancy,
and is accompanied by proteinuria (urine
rather than dilate as
excretion of 0.3 g of protein in a 24-hour
expected. Vasoconspecimen); eclampsia is present when the
striction reduces
patient experiences a grand mal seizure
blood flow to
Chronic hypertension
Chronic hypertension (BP greater than or
maternal organs
with superimposed
equal to 140/90 mm Hg before the 20th week
and to the placenta.
preeclampsia or
of pregnancy) with superimposed proteinuria
gum disease. Baceclampsia
and with or without signs of preeclampsia
teria that cause perisyndrome
odontal disease
may travel to the
Gestational (or transient)
BP elevation, without proteinuria, thats detected
placenta or produce
hypertension
for the first time during mid-pregnancy and
chemicals that cause
returns to normal by 12 weeks postpartum
preeclampsia.

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Whos most at risk?

Approximately 8% of all pregnant women

develop preeclampsia. In addition to gum
disease and a family history of preeclampsia, other risk factors include:
maternal age (under age 17 or primiparous women over age 35)
first pregnancy (or first pregnancy with a
new partner)
African American ethnicity
multiple gestation
history of a preexisting medical condition,
such as chronic hypertension, diabetes,
autoimmune disorders (such as lupus),
or kidney disease
maternal infection (either viral or bacterial)
low socioeconomic status
gestational diabetes
obesity
history of preeclampsia (results in a one
in three chance of developing preeclampsia
in subsequent pregnancies).

Management strategies

Because the cause of preeclampsia remains

unknown, no sure-fire methods have been
proven to prevent it. Wise management of
all pregnancies includes early and continued
prenatal care, good oral hygiene and prophylactic dental care, monitoring and management of preexisting medical conditions,
and adequate nutrition. Vitamins, minerals,
and nutritional supplements (vitamins C
and E, folic acid, magnesium, calcium, and
fish oil) may help prevent preeclampsia.
Also, studies have shown that low-dose aspirin and chocolate consumption during
pregnancy may lower the risk.
Management of preeclampsia depends
on the severity of the symptoms, although
the only cure is delivery of the fetus and the
placenta.
Home care is possible for a woman with
mild preeclampsia, although compliance is
essential. Activity restrictions (either modified bed rest or frequent rest periods) will be
advised, along with dietary modifications,
such as eating a high-protein diet (80 to
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100 g/day or 1.5 g/kg/day), limiting sodiVasoconstriction

um to less than 6 g/day, and drinking at
leads
to decreased
least eight 8-oz glasses of noncaffeinated
beverages each day.
blood flow to the
The woman should monitor her
mothers organs
weight, BP, urine protein, and fetal
and the placenta.
movement, and should notify her
healthcare provider about any
worsening signs or symptoms.
If preeclampsia worsens, the
woman will need to be hospitalized.
Treatment depends on the severity of
the symptoms and the gestational
age of the fetus. If the woman is
at or near term, her healthcare
provider may proceed with induction of labor. If shes preterm and
stable, her provider may choose to
hold off on delivery. In-hospital treatment of a woman with mild preeclampsia
typically includes:
bed restpreferably in the left lateral
position to decrease pressure on the inferior
vena cava and facilitate venous return
dietary modificationsprotein intake of
80 to 100 g/day or 1.5 g/kg/day, sodium
intake of less than 6 g/day, and eight 8-oz
glasses of noncaffeinated beverages each
day (A high-fiber diet is also important for
a woman on bed rest.)
corticosteroidsmay be administered between 24 and 34 weeks gestation to enhance fetal lung development
fetal surveillancefetal movement records,
nonstress tests, serial ultrasounds to assess
fetal growth, biophysical profiles, and an
amniocentesis to assess fetal lung maturity
lab workliver enzymes, lactate dehydrogenase, bilirubin, uric acid, blood urea
nitrogen (BUN), creatinine, hematocrit,
and platelet count
Doppler velocitybeginning at 30 to
32 weeks gestation to screen for fetal
compromise.
Treatment for severe preeclampsia may
include:
complete bed rest in the left lateral position
a high-protein, moderate-sodium diet
March/April 2010 Nursing made Incredibly Easy! 23

A closer look at magnesium sulfate

Overview of obstetric action

Fetus/newborn adverse reactions

Magnesium sulfate, a central nervous system depressant,

reduces the possibility of convulsions. Secondarily, it relaxes
smooth muscle, with a resulting effect of lowering BP.
In addition, it may decrease the strength and frequency
of uterine contractions.

Decreased fetal heart rate variability may occur but, in

general, magnesium sulfate doesnt pose a risk to the fetus.
The newborn may exhibit respiratory depression, loss of
reflexes, muscle weakness, and neurologic depression.

Route, dosage, and frequency for treatment of

preeclampsia

Monitor BP closely.
Monitor fetal heart rate continuously.
Monitor maternal serum magnesium levels as ordered (usually every 6 to 8 hours). Therapeutic levels are in the range of
4.8 to 9.6 mg/dL. Reflexes often disappear at levels of 8 to
12 mg/dL, respiratory depression occurs at 15 to 17 mg/dL,
and cardiac arrest occurs at levels above 30 mg/dL.
Assess patellar reflex. Loss of reflexes is often the first sign
of developing toxicity. Also assess for marked lethargy,
decreased level of consciousness, and hypotension.
Assess urine output.
Monitor the respiratory rate.
Observe the newborn closely for signs of magnesium toxicity for 24 to 48 hours if the mother received magnesium sulfate
close to birth.
Continue the magnesium sulfate infusion for approximately
24 hours after birth for seizure prophylaxis.
If the respirations or urinary output fall below specified levels,
or if the reflexes are diminished or absent, magnesium sulfate
should be stopped until these factors return to normal.
Keep an ampule of calcium gluconate (the antidote to
magnesium sulfate) at the bedside. The usual dose is 1 g
over about 3 minutes.

Magnesium sulfate is given I.V. via an infusion pump. A loading dose of 4 to 6 g is given over 5 minutes. Then, a maintenance dose of 2 g/hour is given.
Maternal contraindications
The only absolute contraindication is diagnosed maternal
myasthenia gravis. A history of myocardial damage or heart
block is a relative contraindication due to the effects on nerve
transmission and muscle contractility. Use extreme caution in
women with impaired renal function. The drug is eliminated by
the kidneys, so toxic magnesium levels may develop quickly.
Maternal adverse reactions
Maternal adverse reactions are dose related and can include
flushing, sweating, a feeling of warmth, nasal congestion,
nausea/vomiting, constipation, visual blurring, headache,
lethargy, weakness, slurred speech, and pulmonary edema.
Signs of developing toxicity include loss of reflexes,
urine output of less than 30 mL/hour, respiratory rate less
than 12 breaths/minute, confusion, circulatory collapse,
and respiratory paralysis. Rapid administration of large
doses may cause cardiac arrest.

Nursing considerations

daily weights
daily lab work, including hematocrit
(a rising number may signify decreasing
vascular volume), liver enzyme tests, bilirubin (rising values indicate progression of
preeclampsia), uric acid, BUN, creatinine
(reflects renal status), and platelet counts
(daily if less than 100,000/mm3; every 2
or 3 days if higher than 100,000/mm3)
medication.
Magnesium sulfate reduces the possibility of seizures by depressing the central
nervous system (see A closer look at magnesium sulfate). Hydralazine is typically
given for a persistent systolic BP of 160
mm Hg or higher or a persistent diastolic
BP of 105 mm Hg or higher. Labetalol is a
second-line I.V. medication that may be
24 Nursing made Incredibly Easy! March/April 2010

given, although it shouldnt be used in

women with asthma or congestive heart
failure. Methyldopa is generally used to
control mild-to-moderate hypertension in
pregnancy. Betamethasone or dexamethasone may be given if the lungs of the fetus
are immature. Corticosteroids may also
be beneficial for women with HELLP
syndrome.
Eclampsia, manifested by a grand mal
seizure, requires teamwork and immediate
action:
Dont leave the patient unattended.
Give an I.V. bolus of magnesium sulfate
(4 to 6 g over 5 minutes). A sedative, such
as diazepam or amobarbital, is given if
seizures persist, and phenytoin may be
used for seizure prevention.
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 Keep side rails up; pad if necessary.

Maintain a patent airway.
Auscultate the lungs to assess for
pulmonary edema; give I.V. furosemide
if indicated.

Continuously monitor the fetus and uterine activity (if the woman hasnt delivered).
Assess for vaginal bleeding and abdominal
rigidity every 15 minutes, which may indicate placental abruption.

Assessing deep tendon reflexes

Biceps reflex

Triceps reflex

Brachioradialis reflex

Position the patients arm so his elbow is

flexed at a 45-degree angle and his arm is
relaxed. Place your thumb or index finger
over the biceps tendon. Strike your finger
with the pointed end of the reflex hammer,
and watch and feel for the contraction of the
biceps muscle and flexion of the forearm.

Ask the patient to adduct his arm and

place his forearm across his chest. Strike
the triceps tendon about 2! (5 cm) above
the olecranon process on the extensor surface of the upper arm. Watch for contraction of the triceps muscle and extension of
the forearm.

Ask the patient to rest the ulnar surface

of his hand on his abdomen or lap with
the elbow partially flexed. Strike the radius, and watch for supination of the
hand and flexion of the forearm at
the elbow.

Patellar reflex

Achilles reflex

Ask the patient to sit with his legs dangling

freely. If he cant sit up, flex his knee at a
45-degree angle and place your nondominant hand behind it for support. Strike the
patellar tendon just below the patella, and
look for contraction of the quadriceps muscle in the thigh with extension of the leg.

Ask the patient to flex his foot. Strike the

Achilles tendon, and watch for plantar flexion of the foot at the ankle.

Making the grade

Grade deep tendon reflexes using
this scale.
0 = Absent impulses
+1 = Diminished impulses
+2 = Normal impulses
+3 = Increased impulses
+4 = Hyperactive impulses

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March/April 2010 Nursing made Incredibly Easy! 25

With your
help, a healthy
baby is on
the way.

Digoxin may be given for circulatory

failure.
Because of the serious nature of
eclampsia, women are often transferred
to the ICU.

Important nursing
interventions

Nursing care of a woman hospitalized with

preeclampsia includes monitoring and assessment of:
BP, pulse, and respirations every 1 to
4 hours, or more frequently if indicated
temperature every 4 hours, or every
2 hours if elevated
fetal heart rate along with maternal vital signs, or continuous fetal monitoring
if indicated
urine output (output should be 700
mL or greater in 24 hours, or at least
30 mL/hour)
urine protein and urine specific gravity, as ordered (5+ proteinuria indicates a
24-hour protein loss of 5 g or more; specific
gravity readings over 1.040 correlate with
proteinuria and oliguria)
weight (measured at the same time, with
the patient wearing similar clothing, each
day; this may be omitted if the woman is
on complete bed rest)
edema (To assess for pitting edema,
press over a bony area, usually the shin,
for 3 to 5 seconds. 1+ pitting edema leaves
a slight depression; 4+ leaves a 1-inch indentation.)
deep tendon reflexes (see Assessing deep
tendon reflexes) and clonus (To assess for
clonus, support your patients leg with the
knee slightly flexed. Sharply dorsiflex the
foot, hold it momentarily, and release, keeping your hand against her foot. When the
foot beats against your hand, clonus is present. 1+ clonus is one beat.)
breath sounds (crackles will be present
with pulmonary edema) and coughing
lab results daily, or as ordered
your patients emotional status, coping
responses, and level of understanding re26 Nursing made Incredibly Easy! March/April 2010

garding her condition (Provide emotional

support; teach her about her diagnosis and
treatment; and arrange for ancillary support, such as social services or pastoral care,
as needed.)
signs and symptoms of progression of the
condition: increasing BP; headache; visual
changes; increasing edema, particularly of
the hands and face; epigastric pain; and
disorientation.
Additional nursing interventions include:
Encourage your patient to rest in a left
lateral recumbent position.
Provide a quiet, restful environment by
dimming the lights and limiting visitors
when indicated.
Encourage her to eat a high-protein, highfiber, moderate-sodium diet.
Administer medications, as ordered.
Monitor and assess for signs and symptoms of magnesium sulfate effectiveness
or toxicity.

Patient teaching pearls

All pregnant women, and women considering pregnancy, should be taught the importance of proper nutrition (pregnant
women need 300 extra calories per day,
and vitamin and mineral supplements)
and the importance of early and regular
prenatal care. We must reinforce to
women how imperative it is for them to
engage in good oral hygiene and receive
monitoring and management of preexisting medical conditions.
An important part of prenatal education
is instructing women about warning signs
during pregnancy. Signs and symptoms of
developing or worsening preeclampsia
may include headaches, vision changes
(blurring, spots, or double vision), swelling
of the face and hands or persistent ankle
swelling, sudden or excessive weight
gain, upper abdominal pain or nausea,
decreased urine output, and decreased fetal
movement. Educate women to contact their
healthcare provider if any of these signs or
symptoms manifest.
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Whats on the horizon?

In a longitudinal study, Yale researcher Dr.

Irina Buhimschi and colleagues identified a
unique protein fingerprint in urine that appeared 10 weeks before clinical manifestation in women with preeclampsia. This
finding may lead to early discovery and interventions, such as dietary changes, hydration, and low-dose aspirin administration. If
these interventions prove successful in abating preeclampsia, we may be on our way to
prevention.

In summary

Buhimschi IA, Zhao G, Funai EF, et al. Proteomic profiling of urine identifies specific fragments of SERPINA1
and albumin as biomarkers of preeclampsia. Am J Obstet
Gynecol. 2008;199(5):551.e1-e16.
Conde-Agudelo A, Villar J, Lindheimer M. Maternal infection and risk of preeclampsia: systematic review and
metaanalysis. Am J Obstet Gynecol. 2008;198(1):7-22.
Davidson MR, Wieland Ladewig PA, London ML. Clinical
Handbook for Olds Maternal-Newborn Nursing & Womens
Health Across The Lifespan. 8th ed. Upper Saddle River, NJ:
Pearson Prentice Hall; 2008:42-50.
Fedorka PD, Heasley SW. Preeclampsia: the little-known
truth. Am Nurs Today. 2008;3(2):9-11.
Gauer R, Atlas M, Hill J. Clinical inquiries. Does low-dose
aspirin reduce preeclampsia and other maternal-fetal
complications? J Fam Pract. 2008;57(1):54-56.
London ML, Wieland Ladewig PA, Ball JW, Bindler RC.
Maternal & Child Nursing Care. 2nd ed. Upper Saddle
River, NJ: Pearson Prentice Hall; 2007:350-361.
Maternal-Neonatal Nursing Made Incredibly Easy! 2nd ed.
Philadelphia, PA: Lippincott Williams & Wilkins; 2007:
234-240.

Preeclampsia is characterized by hypertension and proteinuria occurring after 20

weeks gestation. Nurses are instrumental
in educating and assessing their patients
and providing appropriate interventions.
Management depends on the severity of
signs and symptoms; however, the only
cure for preeclampsia is delivery of the fetus and placenta. Although we dont know
what exactly causes preeclampsia, promising research may pave the way for early
discovery and intervention and a resulting
abatement of this potentially life-threatening condition.

Rustveld LO, Kelsey SF, Sharma R. Association between

maternal infections and preeclampsia: a systematic review
of epidemiologic studies. Matern Child Health J. 2008;12(2):
223-242.

Learn more about it

Triche EW, Grosso LM, Belanger K, Darefsky AS,

Benowitz NL, Bracken MB. Chocolate consumption in
pregnancy and reduced likelihood of preeclampsia.
Epidemiology. 2008;19(3):459-464.

Barton JR, Sibai BM. Prediction and prevention of

recurrent preeclampsia. Obstet Gynecol. 2008;112(2):
359-372.

Wu Wen SW, Chen XK, Rodger M, et al. Folic acid supplementation in early second trimester and the risk of
preeclampsia. Am J Obstet Gynecol. 2008;198(1):45.e1-e7.

Murkoff H, Mazel S. What To Expect When Youre Expecting. 4th ed. New York, NY: Workman Publishing; 2008:
413,549-550,562.
Porth CM, Matfin G. Pathophysiology: Concepts of Altered
Health States. 8th ed. Philadelphia, PA: Lippincott Williams
& Wilkins; 2009:522.
Qiu C, Coughlin KB, Frederick IO, et al. Dietary fiber
intake in early pregnancy and risk of subsequent
preeclampsia. Am J Hypertens. 2008:21(8):903-909.
Ruma M, Boggess K, Moss K, et al. Maternal periodontal
disease, systemic inflammation, and risk for preeclampsia.
Am J Obstet Gynecol. 2008;198(4):389.e1-e5.

On the Web
These online resources may be helpful to your patients and their families:
Mayo Clinic: http://www.mayoclinic.com/health/preeclampsia/DS00583
MedlinePlus: http://www.nlm.nih.gov/medlineplus/ency/article/000898.htm
National Heart, Lung, and Blood Institute: http://www.nhlbi.nih.gov/health/public/heart/hbp/hbp_
preg.htm
National Institute of Child Health and Human Development: http://www.nichd.nih.gov/health/
topics/Preeclampsia_and_Eclampsia.cfm
Preeclampsia Foundation: http://www.preeclampsia.org.

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March/April 2010 Nursing made Incredibly Easy! 29