Pregnancy-Induced

Hypertension (PIH)
See also ...

Handouts/Teaching sheets What is pregnancy-induced hypertension (PIH)?

Pregnancy-induced hypertension (PIH) is a form of high
blood pressure in pregnancy. It occurs in about 7 to 10
percent of all pregnancies. Another type of high blood
pressure is chronic hypertension - high blood pressure that
is present before pregnancy begins. 

Pregnancy-induced hypertension is also called toxemia or

preeclampsia. It occurs most often in young women with a
first pregnancy. It is more common in twin pregnancies,
and in women who had PIH in a previous pregnancy. 

Usually, there are three primary characteristics of this

condition, including the following: 

 high blood pressure (a blood pressure reading

higher than 140/90 mm Hg or a significant
increase in one or both pressures).
 protein in the urine.
 edema (swelling).

Eclampsia is a severe form of pregnancy-induced

hypertension. Women with eclampsia have seizures
resulting from the condition. Eclampsia occurs in about one
in 1,600 pregnancies and develops near the end of
pregnancy, in most cases. 

HELLP syndrome is a complication of severe preeclampsia

or eclampsia. HELLP syndrome is a group of physical
changes including the breakdown of red blood cells,
changes in the liver, and low platelets (cells found in the
blood that are needed to help the blood to clot in order to
control bleeding).

What causes pregnancy-induced hypertension

(PIH)?
The cause of PIH is unknown. Some conditions may
increase the risk of developing PIH, including the
following: 

 pre-existing hypertension (high blood pressure).

 kidney disease.
 diabetes.
 PIH with a previous pregnancy.
 mother's age younger than 20 or older than 40.
 multiple fetuses (twins, triplets).

Why is pregnancy-induced hypertension a concern?

With high blood pressure, there is an increase in the
resistance of blood vessels. This may hinder blood flow in
many different organ systems in the expectant mother
including the liver, kidneys, brain, uterus, and placenta. 

There are other problems that may develop as a result of

PIH. Placental abruption (premature detachment of the
placenta from the uterus) may occur in some pregnancies.
PIH can also lead to fetal problems including intrauterine
growth restriction (poor fetal growth) and stillbirth. 

If untreated, severe PIH may cause dangerous seizures

and even death in the mother and fetus. Because of these
risks, it may be necessary for the baby to be delivered
early, before 37 weeks gestation.

What are the symptoms of pregnancy-induced

hypertension?
The following are the most common symptoms of high
blood pressure in pregnancy. However, each woman may
experience symptoms differently. Symptoms may include: 

 increased blood pressure.

 protein in the urine.
 edema (swelling).
 sudden weight gain.
 visual changes such as blurred or double vision.
 nausea, vomiting.
 right-sided upper abdominal pain or pain around
the stomach.
 urinating small amounts.
 changes in liver or kidney function tests.

How is pregnancy-induced hypertension diagnosed?

Diagnosis is often based on the increase in blood pressure
levels, but other symptoms may help establish PIH as the
diagnosis. Tests for pregnancy-induced hypertension may
include the following: 

 blood pressure measurement.

 urine testing.
 assessment of edema.
 frequent weight measurements.
 eye examination to check for retinal changes.
 liver and kidney function tests.
 blood clotting tests.

Treatment for pregnancy-induced hypertension:

Specific treatment for pregnancy-induced hypertension will
be determined by your physician based on: 

 your pregnancy, overall health and medical history.

 extent of the disease.
 your tolerance for specific medications,
procedures, or therapies.
 expectations for the course of the disease.
  your opinion or preference.

The goal of treatment is to prevent the condition from

becoming worse and to prevent it from causing other
complications. Treatment for pregnancy-induced
hypertension (PIH) may include: 

 bedrest (either at home or in the hospital may be

recommended).

 hospitalization (as specialized personnel and

equipment may be necessary).

 magnesium sulfate (or other antihypertensive

medications for PIH).

 fetal monitoring (to check the health of the fetus

when the mother has PIH) may include:

o fetal movement counting - keeping track of

fetal kicks and movements. A change in
the number or frequency may mean the
fetus is under stress.

o nonstress testing - a test that measures

the fetal heart rate in response to the
fetus' movements.

o biophysical profile - a test that combines

nonstress test   with ultrasound to observe
the fetus.

o Doppler flow studies - type of ultrasound

that uses sound waves to measure the flow
of blood through a blood vessel.

 continued laboratory testing of urine and blood (for

changes that may signal worsening of PIH).

 medications, called corticosteroids, that may help

mature the lungs of the fetus (lung immaturity is a
major problem of premature babies).

 delivery of the baby (if treatments do not control

PIH or if the fetus or mother is in danger).
Cesarean delivery may be recommended, in some
cases.

Prevention of pregnancy-induced hypertension:

Early identification of women at risk for pregnancy-induced
hypertension may help prevent some complications of the
disease. Education about the warning symptoms is also
important because early recognition may help women
receive treatment and prevent worsening of the disease. 
 Preeclampsia is a common problem during pregnancy. The condition — sometimes referred to as pregnancy-
induced hypertension — is defined by high blood pressure and excess protein in the urine after 20 weeks of
pregnancy. Often, preeclampsia causes only modest increases in blood pressure. Left untreated, however,
preeclampsia can lead to serious — even fatal — complications for both mother and baby.
A.  Mild Preeclampsia
 BP of 140/90
 1+ to 2+ proteinuria on random
 weight gain of 2 lbs per week on the 2nd trimester and 1 lb per week on the 3rd trimester
 Slight edema in upper extremities and face
B. Severe Preeclampsia
 BP of 160/110
 3-4+ protenuria on random
 Oliguria (less than 500 ml/24 hrs)
 Cerebral or visual disturbances
 Epigastric pain
 Pulmonary edema
 Peripheral edema
 Hepatic dysfunction
Eclampsia is an extension of preeclampsia and is characterized by the client experiencing seizures.
NURSING MANAGEMENT
1. Monitor for, and promote the resolution of, complications.
 Monitor vital signs and FHR.
 Minimize external stimuli; promote rest and relaxation
 Measure and record urine output, protein level, and specific gravity.
 Assess for edema of face, arms, hands, legs, ankles, and feet. Also assess for pulmonary edema.
 Weigh the client daily.
 Assess deep tendon reflexes every 4 hours.
 Assess for placental separation, headache and visual disturbance, epigastric pain, and altered level
of consciousness.
 Test Findings
Blood >40%
Hematocrit ?5.5 mg/dL
Renal Function >6.0 mg/dL (severe PIH)
Serum uric acid ?1.0 mg/dL
Creatinine 2.0-3.0 md/dL (severe PIH)
Creatinine clearance <150 mL/min
BUN 8-10 mg/dL (severe PIH)
Coagulation 10-16 mg/dL (severe PIH)
Platelets <100,000 mL (severe PIH)
Fibrin degradation products ?16 µg/mL (severe PIH)
2. Provide treatment as prescribed.
 Mild preeclampsia treatment consists of bed rest in left lateral recumbent position, balanced diet
with moderate to high protein and low to moderate sodium, and administration of magnesium sulfate
 Severe preeclampsia treatment consists of complete bed rest, balanced diet with high protein and
low to moderate sodium, administration of sulfate, fluid and electrolyte replacements and sedative
hypertensives such as diazepam or phenobarbital or an anticonvulsant such as phenytoin
 Eclampsia treatment consists of administration of magnesium sulfate intravenously
3. Institute seizure precautions. Seizures may occur up to 72 hours after delivery.
4. Address emotional and psychosocial needs.

PATHO PHYSIO

Preeclampsia is a characterized, by vsospasms, changes in the coagulation system, and disturbances in systems
related to volume and BP control. Vasospasms results from an increased sensitivity to circulating pressors, such as
angiotensin II, and possibly an imbalance between the prostaglandins prostacyclin and thromboxane A1.
Endothelial cell dysfunction, believed to result from decreased placental perfusion, may account for many changes in
preeclampsia. Arteriolar vasospasm may cause endothelial damage and contribute to an increased capillary
permeability. This increase edema and further decreases intravascular volume, predisposing the woman with
preeclampsia to pulmonary edema.
Immunologic factors may play an important role in the development of preeclampsia. The presence of a foreign
protein, the placenta, or the fetus maybe perceived by the mother’s immune system as an antigen. This may then
trigger an abnormal immunologic response. This theory is supported by the increased incidence of preeclampsia or
eclampsia in first-time mothers or to multiparous woman pregnant by a new partner. Preeclampsia maybe an immune
complex disease in which the maternal antibody system is overwhelmed from excessive fetal antigens in the maternal
circulation. This theory seems compatible with the high incidence of preeclampsia among women exposed to a large
mass of trophoblastic tissue as seen in twin pregnancies or hydatidiform moles.
Genetic predisposition maybe another immunologic factor. Dekker reported a greater frequency of preeclampsia and
eclampsia among daughters and granddaughters of women with a history of eclampsia, which suggests an
autosomal recessive gene controlling the maternal immune response. Paternal factors are also examined.
Diets in inadequate nutrients, especially protein, calcium, sodium, magnesium, and vitamin E and C, maybe an
etiologic factor in preeclampsia. Some practitioners prescribed high-protein diets (90 mg supplemental protein)
without caloric restriction and moderate sodium intake in the prevention and treatment of this disorder. However, data
are limited regarding the association between diet and preeclampsia.
Preeclampsia progress along a continuum from mild disease to severe preeclampsia, HELLP syndrome, or
eclampsia. The pathophysiology of preeclampsia reflects alteration in the normal adaptations of pregnancy. Normal
physiologic adaptations to pregnancy include increase blood plasma volume, vasodilation, and decreased systemic
vascular resistance, elevated cardiac output, and decreased colloid osmotic pressure. Pathologic changes in the
endothelial cells of the glomeruli are uniquely characteristic of preeclampsia, particularly in nulliparous women. The
main pathogenic factor is not an increase in BP but poor perfusion as a result vasospasm. Arteriolar vasospasm
diminishes the diameter of blood vessels, which impedes blood flow to all organs and raises BP. Function in organs
such as the placenta, kidneys, liver and brain is deceased by as much as 40% to 60%.

Are you just pregnant or are you in danger?

The following signs and symptoms of preeclampsia, and variants such as HELLP syndrome, may indicate a problem
or may just be harmless side effects of normal pregnancy.  Awareness of these signs and symptoms is important,
and please follow up with your health care provider if you have any concerns. Technically, a sign is a characteristic of
preeclampsia that can be measured, but may not be apparent to the patient, such as high blood pressure.  A
symptom is something that is experienced by the patient, such as a headache or visual disturbances.

Links:
No Symptoms
Hypertension
Proteinuria
Edema (Swelling)
Sudden Weight Gain
Nausea or Vomiting
Abdominal (stomach area) and/or Shoulder Pain
Lower back pain
Headache
Changes in Vision
Hyperreflexia

Racing pulse, mental confusion, heightened sense of anxiety, shortness of breath, sense of impending doom

No Symptoms

Preeclampsia is a serious condition of pregnancy, and can be particularly dangerous because many of the signs are
silent while some symptoms resemble “normal” effects of pregnancy on your body.  Many women suffering from
preeclampsia don’t feel sick, and may be surprised or become frustrated when they are admitted to the hospital or
prescribed bed rest since they still feel well.

High blood pressure is an important sign of preeclampsia. The disease is sometimes referred to as a silent killer
because most people can’t “feel” their blood pressure going up.  As a result, patient awareness of the warning signs
is one of the most important tools we have to successfully help women receive the care they need. We encourage
you to familiarize yourself with signs and symptoms included here to empower yourself and/or others during
pregnancy.

What you can do...

Proper prenatal care is essential so don’t miss your appointments. Weighing in, checking your blood pressure and
testing your urine for protein, each important for detecting preeclampsia, should take place at every prenatal visit. Do
not be afraid to question your caregiver if any of these tests are omitted.

A good prenatal diet full of vitamins, minerals and the basic food groups are important for any pregnancy, as is
reducing consumption of processed foods, refined sugars and caffeine. Eliminating alcohol and any medication not
prescribed by a physician is essential. Report all medications prescribed by other doctors to your prenatal care
provider so that these products can be checked regarding their safe use during pregnancy. Speak with your health
care professional before taking any nutritional supplement – herbal or otherwise. Although there is no evidence that
these healthy behaviors and choices impact preeclampsia, they do optimize your health for the best pregnancy
possible.

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Hypertension (High blood pressure)

High blood pressure is traditionally defined as blood pressure of 140/90 or greater, measured on two separate
occasions six hours apart. This is one of the most important indicators that preeclampsia may be developing.
However, during pregnancy, a rise in the diastolic (lower number) of 15 degrees or more, or a rise in the systolic
(upper number) of 30 degrees or more might be cause for concern, warranting closer observation, even though it is
not, by itself, a criterion for preeclampsia. This relative rise may have added significance if you have other symptoms
of the disease, as well.

What you can do...

Know your blood pressure prior to pregnancy, particularly if it is normally considered low.  Ask, "What is my blood
pressure?" during each visit with your health care provider.

You can buy your own blood pressure monitor at most pharmacies, and some of these stores have a monitor
available for your use, though these are not always reliable. Keep a log of your blood pressure, taken at the same
time each day and in the same position. For accuracy, blood pressure readings should be taken in a sitting position,
with the cuff positioned on the left arm at the level of the heart. Share your log with your health care provider at each
visit.

If you own your own monitor, have it calibrated with those used in the provider’s office. If you are monitoring your
pressures elsewhere, notify your healthcare provider immediately should you find any significant rise.

Please note that home monitors are not always as accurate as those used in clinics or hospitals. Home readings
should therefore not replace prenatal visits, nor should a "normal" reading mean you can ignore other symptoms of
preeclampsia.

If you are diagnosed with preeclampsia, many physicians will recommend bed rest, even though evidence has not
shown it to make a difference in outcomes. Some believe this helps limit potential stressors that could contribute to
elevated blood pressures. During late pregnancy, it may be suggested that you lie on your left side, because lying flat
on your back might cause the pregnant uterus (and the weight of the baby) to restrict the vein that supplies the heart.
Lying flat on your back may also make it difficult for your kidneys to excrete salt, which could lead to further swelling
and also increases in your blood pressure. Health care providers do not always agree on the benefits of lying on
one’s side, but there is no evidence of harm.

If you’ve had preeclampsia previously, or if you have chronic high blood pressure, it may be preferable to be cared for
by a specialist in high-risk OB, such as a maternal-fetal medicine (MFM) specialist, or when such care is not readily
available, to choose a physician who readily consults with such experts or with internists specializing in hypertension
during pregnancy. A resource that can help you locate an MFM near you who focuses on care of hypertensive
diseases in pregnancy is the Physician Locator tool on the Society for Maternal Fetal Medicine’s website. All these
situations are highly variable and are best discussed first with your primary caregiver.
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Proteinuria (Protein in your urine)

Proteinuria, another sign of preeclampsia, is the result of proteins, normally confined to the blood by the filtering role
of your kidney, spilling into your urine. This is because preeclampsia temporarily damages this “filter.” A simple
dipstick test of your urine at each prenatal check-up can screen for proteinuria, though more sophisticated equipment
that can be set up in clinics and doctors’ offices may be used in the future.

What you can do...

During each prenatal visit, ask your health care provider for the results of your urine test. A nurse will have dipped a
reagent strip into a sample of your urine. A reading of trace protein is relatively common and is usually not a cause for
concern. However, if the reading is 1+ or greater, it may signify the onset of preeclampsia, even if your blood
pressure is below 140/90.  If you are concerned, or have had preeclampsia before, you can buy reagent strips at
some pharmacies or online. Should you record a reading of 2+ or greater at home, call your health care provider that
very same day.

Sometimes health care providers will have you collect your urine for 24-hours to determine the exact quantity of
protein in the urine. While this is not a particularly convenient task, be sure to follow your provider’s directions and
make every effort to be accurate.

Dark yellow urine is usually the result of low fluid intake and may be associated with dehydration. However, urine that
looks dark, reddish or the color of cola may indicate a problem. If you observe this, contact your health care provider

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Edema (Swelling)

A certain amount of swelling is normal during pregnancy. For example, your feet may swell making it difficult to wear
your regular shoes throughout pregnancy. Edema is the accumulation of excess fluid, and is more of concern when it
is observed in the face, around the eyes, or hands.

What you can do...

If you feel your face is getting excessively puffy, find a picture of yourself from just before pregnancy to share with
your health care provider. If the swelling in your extremities becomes severe, you may notice “pitting edema” (when
you press your thumb into your skin, an indentation remains for a few seconds) or discoloration of your legs. If you
suspect pitting edema, notify your health care provider, put your feet up every day (but avoid sitting for extended
periods).

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Sudden Weight Gain

Weight gain of more than 2 pounds in a week may be an indicator of preeclampsia. Damaged blood vessels allow
more water to leak into and stay in your body's tissue and not to pass through the kidneys to be excreted.

What you can do...

Do not try to lose weight during pregnancy by restricting your diet. Eating a healthy, balanced diet, including fresh raw
fruit and vegetables, your prenatal vitamin, and a folic acid supplement is important for all pregnancies. Avoid
excessive salt. Prior to getting pregnant, achieve a healthy weight (a BMI of 30 or greater) since obesity has been
shown to increase the chances of getting preeclampsia.

Given that preeclampsia is a complex disease, women will develop it for different reasons. A healthy, balanced diet
and optimal weight may make a significant difference for some women. However, we urge caution when considering
diets designed for weight-loss or claiming to prevent preeclampsia that encourage large amounts of protein.
Excessive dietary protein may cause problems in women with underlying kidney disease.

Be sure to drink sufficient amounts of fluid, usually dictated by your normal thirst sensations, and to perform moderate
amounts of exercise regularly. During your prenatal visits do not attempt to disguise weight gain by skipping
breakfast, using diet pills or fasting for the day. An accurate weight is vital for a proper diagnosis.

The Preeclampsia Foundation recognizes the importance of a good diet, however we do not recommend any
particular diet or juice product.

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Nausea or Vomiting

Nausea or vomiting is particularly significant when the onset is sudden and after mid-pregnancy. “Morning sickness”
should disappear after the first trimester and the sudden appearance of nausea and vomiting after mid pregnancy
may be linked to preeclampsia.

What you can do...

Call your care provider. Nausea or vomiting can be confused with the flu or gallbladder problems, so insist on getting
your blood pressure checked and checking your urine for proteinuria.

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Abdominal (stomach area) and/or Shoulder Pain

This type of abdominal pain, often called epigastric pain or upper right quadrant (URQ) pain, is usually under the ribs
on the right side. It can be confused with heartburn, gallbladder problems, flu, indigestion or pain from the baby
kicking. Shoulder pain is often called “referred pain” because it radiates from the liver under the right ribs. Lower back
pain is different from muscle strain common to pregnancy, because it is usually more acute and specific. Shoulder
pain can feel like someone is deeply pinching you along the bra strap or on your neck, or it can be painful to lie on
your right side. All of these pain symptoms may be a sign ofHELLP Syndrome or a related problem in the liver.

What you can do...

Pain in this area should be taken very seriously; do not dismiss it and go to bed. Call your health professional
immediately.
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Lower Back Pain

Lower back pain is a very common complaint of pregnancy. However, sometimes it may indicate a problem with the
liver, especially if it accompanies other symptoms of preeclampsia.

What you can do...

Read also Stomach and Right Shoulder Pain (above) and mention this symptom to your health care provider. If this
pain accompanies one or more of the other symptoms, you should call your health care provider immediately.

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Headaches

Dull or severe, throbbing headaches, often described as migraine-like that just won't go away are cause for concern.

What you can do...

If you have tried taking over-the-counter medication without relief, if the headache is very painful or you have light
sensitivity, call your provider immediately and ask to see him/her that day.

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Changes in Vision

Vision changes are amongst the most serious symptoms of preeclampsia, usually requiring immediate evaluation by
a doctor. Changes in vision may be associated with central nervous system irritation, or an indication of cerebral
edema (general swelling of the brain). Vision changes include temporary loss of vision, sensations of flashing lights,
auras, light sensitivity, and blurry vision or spots.

What you can do...

If you experience any of these changes in vision, you should contact your doctor immediately or go directly to the
hospital. We stress that these symptoms are potentially very serious and they should not be left unattended to until
the next morning, or particularly not until the end of the weekend. With preeclampsia, it is better to err on the side of
caution, than to take a chance that might become life-threatening to you or your baby.

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Hyperreflexia
Hyperreflexia is when your reflexes are so strong that when your knee is tapped by a rubber “hammer”, your leg
bounces back hard. This sign is generally measured by a health care provider and otherwise difficult for you to
observe yourself.

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Racing pulse, mental confusion, heightened sense of anxiety, shortness of breath,

sense of impending doom

If these symptoms are new to you, they could indicate an elevated blood pressure, or more rarely, fluid collecting in
your lungs (pulmonary edema).

What you can do...

Contact your health care provider if these symptoms are new. If these conditions are not new for you, be sure to
mention them to your care provider during your next visit so he/she can monitor them throughout your pregnancy.

When we urge women to trust themselves, we are referring to the intuitive feeling that preeclamptic women often
have that “something is not right.”  While these feelings may be nothing, it is important for women to report any
concerns and for care providers to be diligent, particularly if accompanied by other signs or symptoms.

The most important thing to remember is to never be afraid to call and discuss anything unusual with your caregiver.
No matter how busy, he or she does not mind (or should not) being bothered for what at first may seem unimportant.
The worst outcomes of preeclampsia are best avoided by early recognition.

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What causes preeclampsia?

The cause (etiology) of preeclampsia remains unknown. Numerous proposed theories have led to various attempts at
prevention and intervention strategies, none of which have proven to be overwhelmingly successful. There is,
however, general agreement that the placenta plays a key role in preeclampsia, and women with chronic
hypertension and certain metabolic diseases like diabetes are more susceptible. Obesity is another major risk factor –
one that is perhaps modifiable.

Speak to your physician about your risks, and what you can do to minimize them, but recognize that no definitive
answers to the cause or causes of preeclampsia yet exist.

There are a number of theories about the initiating cause of preeclampsia and the descriptions in research articles
can be difficult to understand. We’ve included in the chart below some current medical terms for the various theories
and a layperson’s interpretation. A more detailed article about the potential causes is also available here.

Medical Description Layperson's Description

Uterine ischemia/
Insufficient blood flow to the uterus
underperfusion
 Excessive maternal inflammatory response to
Inflammation
pregnancy

Factors regulating the formation of new blood

vessels in the placenta are overproduced which in
Angiogenesis
turn affect the blood vessel health in the mother
leading to hypertension and kidney damage.

Prostacyclin /
Disruption of the balance of hormones that
thromboxane
maintain the diameter of the blood vessels.
imbalance (ASA)

Damage to the lining of the blood vessels that

Endothelial
keeps fluid and protein inside the blood vessels,
activation and
keeps blood from clotting, and regulates elasticity
dysfunction
of the blood vessel.

Calcium helps maintain blood vessels and normal

Calcium deficiency blood pressure. A deficiency may lead to increased
blood pressure.

Injury to the blood vessels due to excessive blood

flow or pressure. For example one might compare
Hemodynamic
the condition to what would happen if a garden
vascular injury
hose was hooked up to a fire hydrant.

The mother has undiagnosed high blood pressure

Preexisting maternal or other preexisting problems such as diabetes,
conditions lupus, sickle cell disorder, hyperthyroidism, kidney
disorder, etc.

The mother’s immune system mistakenly responds

Immunological as if damage has occurred to the blood vessel and
Activation in trying to fix the "injury" actually makes the
problem worse.

Nutritional Insufficient protein, excessive protein, fish oil,

Deficiencies vitamin D, and other diet factors.

High body mass index (BMI) is linked to the

genetic tendency for high blood pressure, diabetes
Obesity
and insulin resistance, and also to the effect of
obesity on the inflammatory system.
 The hereditary transmission of inherited
Genetic Tendency
characteristics among family members

Pathophysiology of HELLP

The exact cause of HELLP is unknown, but general activation of the coagulation
cascade is considered the main underlying problem. Fibrin forms crosslinked networks
in the small blood vessels. This leads to a microangiopathic hemolytic anemia: the
mesh causes destruction of red blood cells as if they were being forced through a
strainer. Additionally, platelets are consumed. As the liver appears to be the main site of
this process, downstream liver cells suffer ischemia, leading to periportal necrosis.
Other organs can be similarly affected. HELLP syndrome leads to a variant form
of disseminated intravascular coagulation (DIC), leading to paradoxical bleeding, which
can make emergency surgery a serious challenge.