Health

Impact of pregnancy on the blood pressure of a woman

Introduction

The heart beats and pumps blood throughout the body to provide the required oxygen and energy to the body. When the blood moves through the blood vessels of the body it exerts a pressure on the walls of the vessels and this pressure is known as Blood Pressure (BP). In case of high BP, the pressure exerted by the blood on the arteries of the wall is higher in comparison to the normal pressure and this condition leads to heart attack or stroke. The condition of high BP or hypertension is usually asymptomatic and to monitor the fluctuations observed in the blood pressure one has to monitor the condition at regular intervals. Women who are pregnant for the first time may experience high blood pressure (gestational BP), changes in the heart rate but the condition does not arise fortunately for the second time (Cutler, et al, 2008).

Impact of gestational blood pressure:

According to the reports of National High Blood Pressure Education Program (NHBPEP) Working Group Report on the condition of hypertension during pregnancy, the condition prevails within 6-8% of women in their pregnancy stage in the United States. During pregnancy the body of a woman goes through several changes to support and the growth and development of the foetus. Though it is expected to have a normal BP throughout the period of 9 months but unfortunately the individual may develop high/low BP and other problems after 20 weeks of pregnancy. Preeclampsia is a condition when an individual with normal BP suddenly develops high BP after certain weeks of pregnancy. If the woman suffers from high BP from the beginning then there is a high risk that the woman may develop preeclampsia. It can also be observed that the woman while carrying the baby may develop low BP as the circulatory system expands during that time and suddenly cause a drop in the BP. Moreover, the condition of severely high BP may result in premature birth, low birth weight of the baby (as the baby will grow slowly due to the depletion of the oxygen and nutrients) and placental abruption. Moreover if the woman is having high BP throughout the gestational period, it is more likely that the woman will go for cesarean birth (also called c-section) (Magriples, et al, 2013).

It can be observed that the BP may lower down during the first 24 weeks of the pregnancy and there are several factors that may contribute to this condition such as: anaemia, dehydration, internal bleeding, few medicines, prolonged bed rest during this period, due to cardiovascular problems, hormonal disorders, malnutrition and because of any allergic reactions. The problem of low BP may result in still birth and low birth weight of the baby (Wilson, et al, 2003).

The symptoms associated with high and low BP during pregnancy:

Symptoms associated with Preeclampsia: Extremely high blood pressure, presence of excessive protein in the urine (a condition known as proteinuria), swelling of the hands and face, the frequency of the headaches increases and the pain does not alleviate, blurring of the vision or appearance of spots, pain in the upper part of the right abdomen and facing problems during breathing.

Symptoms associated with low BP: the patient may feel light headedness during standing or sitting position, dizziness, fainting, nauseating tendencies, tiredness, blurring of the vision, experience of unusual thirst, cold skin. The patient may appear pale and clammy (Duley, et al, 2013; Hermida, et al, 2001).

Key stages of the investigation process and the methodologies to be adopted to monitor blood pressure during the pregnancy:

The hypertension observed during the pregnancy can be divided into four different subtypes: chronic hypertension, the condition of preeclampsia-eclampsia, presence of preeclampsia over the condition of chronic hypertension and gestational hypertension. The strategy followed in the treatment process of hypertension during the pregnancy is with the aim to prevent the risk of maternal cerebrovascular and associated cardiac complications and also maintain the uteroplacental and the circulation of the foetus while lowering the chances of toxicity induced by medication in the foetus. Therefore the treatment strategies falls under two categories: the management of the condition of acute hypertension during the pregnancy such as the case of preeclampsia-eclampsia and management of the condition of chronic hypertension. The definitive treatment process of the acute hypertension during pregnancy is delivery; the expected management is the close monitoring of the concerned patient within the 32 weeks of gestation. A comprehensive care plan should be adopted for women with hypertensive disorder during pregnancy and it includes the following steps: prenatal counselling, the frequent follow ups during the pregnancy, delivery of the child at the appropriate time, accurate care during intrapartum monitoring and also the postpartum follow up session. The women should be educated and made aware of her condition about the risk associated with her foetus and her health condition so that an informed decision can be taken (Program, N.H.B.P.E., 2000).

Plan of the study that can be followed:

The hypertensive condition during pregnancy is characterized with a systolic BP ≥ 140 mm Hg, diastolic BP ≥ 90 mm Hg when two different measurements are taken at a difference of 4 -6 hours. The diagnosis of the hypertension during pregnancy can be made with the accurate measurement of BP. Manual measurement of the BP is suggested than automated BP cuffs available. As per the reports of 2000 NHBPEP Working Group Report on high BP during pregnancy suggested that the Korotkoff phase V (disappearance) sound should be used to determine the diastolic pressure. Certain procedures have to be followed to measure accurately the BP at the outpatient setting. The subject should be allowed to sit in a fixed and relaxed position with her legs uncrossed; her back should be supported and should not consume tobacco and caffeine 30 minutes before the test procedure. For the hospitalized patients, the nurse should measure the BP in the left lateral decubitus position to reduce the chances of fluctuation in BP due to the pressurization of the inferior vena cava by the gravid uterus. The value of the BP should be interpreted with respect to the stage of the pregnancy as the BP should change with each of the trimester. The BP usually drops during the first and second trimester within the 20 weeks of the gestation period. Women who did not have any medical check up prior to her pregnancy, the rise in the BP during the third trimester is referred as the “gestational hypertension” but in reality the women can be hypertensive before the onset of pregnancy and the physiological changes during the mid phase of pregnancy have masked the reality. Moreover, if the gestational hypertension does not resolve even after the delivery, then it can be concluded that she was suffering from chronic hypertension.

Ambulatory blood pressure monitoring (ABPM) along with the hyperbaric index (HBI) is preferred as an alternative method to measure the hypertension during pregnancy. The HBI denotes the excess BP during a given period of time above the 90% tolerance limit expressed as mm Hg X hours. Researchers also reported 93% sensitivity and 100% specificity for identification of the preeclampsia (Program, N.H.B.P.E., 2000; Sibai, et al, 1986; Angeli, et al, 2011).

The management of the BP during pregnancy:

Again according to the guidelines of NHBPEP Working Group Report on High BP in Pregnancy and the American College of Obstetrics and Gynaecology (ACOG) guidelines treatment is recommended only when the value of the diastolic BP (DBP) is consistently above 105–110 mm Hg though there is no official record on the systolic BP measurement. As per the supervision of the experts the therapeutic measures should be started when the BP reaches the value of 150/100 mm Hg to prevent any fatal consequences. If the patient is suffering from moderate level of preeclampsia, having the value of DBP 100 mm Hg, the other laboratory findings are normal but associated with low level of proteinuria then the outpatient setting management is considered to be appropriate for the patient. The frequency of the outpatient visit should be more and the foetal non stress testing is also considered to be appropriate for this condition. Though the treatment procedure may lower down the risk of the mother and also allow delay in the deliver but it cannot cure the condition of preeclampsia or the progression towards that condition. The condition of the preeclampsia is associated with more than one criteria such as severe form of hypertension (DBP>100 mm Hg), proteinuria > 5 g/24 hours or > 3+ detected from the random urine samples collected twice 4 hours apart, disturbance in vision, pulmonary oedema, epigastric pain, the altered function of liver, thrombocytopenia or the restricted growth of the foetus. Therefore the only preferable treatment for this condition is delivery. When the situation demands the urgent control of the BP and the delivery is also expected within the next 48 hours certain intravenous agents namely labetalol or hydralazine are the preferred choice. The application of magnesium sulfate is reported to lower the risk of preeclampsia and the death of the mother without causing any significant harm to the baby and the mother (Program, N.H.B.P.E., 2000; Macdonald-Wallis, et al, 2011).

A case study:

The patient is a 29 year old female, married for the past 10 years is admitted to the hospital presenting the following symptoms: epigastric pain for 1-2 hours, had 2 episodes of vomiting, no episode of headache and blurring of vision is reported and had perceived a good movement of the foetus. The menstrual flow of the patient lies for 6 -7 days with regular cycles, consumed oral contraceptive pills for the past 3 years, no allergies reported about any food or medicines, PIH reported, with no personal and family history of hypertension, diabetes, asthma, cancer and others. She is a non smoker, does not consume alcohol, gets adequate rest and sleep, normal bowel movement and the patient maintains a hygienic attitude towards living. The patient follows a balanced diet and supplemented with extra source of vitamins, minerals and proteins.

Past Medical Records:

The patient reported about Intra Uterine Foetal Death (IUFD) about 2 years back due to Pregnancy Induced Hypertension (PIH). There was sudden onset of the epigastric pain with vomiting and no other symptoms were reported. The patient was suffering from amenorrhoea for the past 6 months, pregnancy of 26 + 4 weeks of gestation period.

The patient was investigated and the following vital signs were recorded:

Temperature: 97•F, Pulse rate: 84/min, BP: 140/110 and 150/110 in the right and left hand, respiratory rate: 25/min, weight: 56 Kg, Height: 156cm.

Findings

The patient appeared weak in her appearance, gait was considered to be imbalanced and skin is pale and yellowish. The patient was reported with PIH and severe preeclampsia.

The nursing management of preeclampsia:

The vital signs of the patient will be monitored regularly especially the BP. The BP fluctuates and shows a sudden rise, so the changes will be monitored cautiously. If the sign of oedema is present then the location and the degree of the pitting will be identified. Though swelling is considered to be normal during pregnancy, pitting oedema is significantly different and is an indication of lower cardiac output. The blood pressure of the patient will be monitored by following the guidelines as mentioned above via the manual method. The weight of the patient will have to be monitored regularly as the sudden increase in the weight of the patient indicates about the retention of the fluid and progression of the disease or the impaired renal function. The heart and the lungs will have to be auscultated and the note and the rhythm have to be recorded. They should administer oxygen if necessary. The nurses should monitor the signs of pulmonary oedema, should monitor the signs of crackles along with the presence of dyspnea. They will administer intravenous fluids and medications if needed such as antihypertensive hydralazine will be administered to the above patient to decrease the DBP. The heart rate of the foetus will also be monitored to identify the condition of stress caused by maternal BP, diminished flow of placental blood and decreased oxygenation. As the patient reported about the blurring of the vision the nurse should monitor the vision disturbance regularly. The laboratory findings denoting protenuria, higher level of blood glucose, rise in the level of liver enzymes and the diminished functioning level of kidney will be monitored. The patient reported none of the above conditions. Moreover the patient was advised with low salt diet, bed rest with her feet elevated to reduce the BP. The patient was also advised to rest on her left side to prevent the compression of vena cava. The other vital suggestion includes daily foetal movement count, ultrasound technique to monitor the growth and well being of the foetus and NST. If the condition of the foetus or the mother worsens then as usual delivery will be induced by administering antenatal corticosteroid which will accelerate the maturity of the lungs and with the absence of any obstetric indication it will prepare the grounds of c – section (Ferreira, et al, 2016).

Conclusion:

Blood pressure fluctuation can indicate several health related disorders. During pregnancy most of the women undergo fluctuation in their BP. If elevated BP is reported then it is referred as gestational hypertension. If the BP suddenly shoots up during pregnancy then it is called Preeclampsia which can have fatal effect on the mother and the foetus. Different study plan has been discussed to manage the condition of gestational hypertension. A case study of preeclampsia has been discussed and the following nursing management role for the patient also has been discussed in the report. The only limitation that can be stated is the need for designing the care protocols based on scientific evidence for the daily clinical nursing practice which will help to provide more quality and safe care to these patients.

References

• Cutler, J.A., Sorlie, P.D., Wolz, M., Thom, T., Fields, L.E. and Roccella, E.J., 2008. Trends in hypertension prevalence, awareness, treatment, and control rates in United States adults between 1988–1994 and 1999–2004. Hypertension, 52(5), pp.818-827.
• Magriples, U., Boynton, M.H., Kershaw, T.S., Duffany, K.O., Rising, S.S. and Ickovics, J.R., 2013. Blood pressure changes during pregnancy: impact of race, body mass index, and weight gain. American journal of perinatology, 30(05), pp.415-424.
• Duley, L., Meher, S. and Jones, L., 2013. Drugs for treatment of very high blood pressure during pregnancy. Cochrane Database of Systematic Reviews, (7).
• Wilson, B.J., Watson, M.S., Prescott, G.J., Sunderland, S., Campbell, D.M., Hannaford, P. and Smith, W.C.S., 2003. Hypertensive diseases of pregnancy and risk of hypertension and stroke in later life: results from cohort study. Bmj, 326(7394), p.845.
• Macdonald-Wallis, C., Tilling, K., Fraser, A., Nelson, S.M. and Lawlor, D.A., 2011. Established preeclampsia risk factors are related to patterns of blood pressure change in normal term pregnancy: findings from the Avon Longitudinal Study of Parents and Children. Journal of hypertension, 29(9), pp.1703-1711.
• Hermida, R.C., Ayala, D.E. and Iglesias, M., 2001. Predictable blood pressure variability in healthy and complicated pregnancies. Hypertension, 38(3), pp.736-741.
• Angeli, F., Angeli, E., Reboldi, G. and Verdecchia, P., 2011. Hypertensive disorders during pregnancy: clinical applicability of risk prediction models. Journal of hypertension, 29(12), pp.2320-2323.
• Program, N.H.B.P.E., 2000. Report of the national high blood pressure education program working group on high blood pressure in pregnancy. American journal of obstetrics and gynecology, 183(1), pp.s1-s22.
• Sibai, B.M. and Anderson, G.D., 1986. Pregnancy outcome of intensive therapy in severe hypertension in first trimester. Obstetrics and gynecology, 67(4), pp.517-522.
• Ferreira, M.B.G., Silveira, C.F., Silva, S.R.D., Souza, D.J.D. and Ruiz, M.T., 2016. Nursing care for women with pre-eclampsia and/or eclampsia: integrative review. Revista da Escola de Enfermagem da USP, 50(2), pp.324-334.