Maternity - Pregnancy, part 12: Complications: Preeclampsia, HELLP Syndrome, Amniotic Fluid Abnormalities
by Meris Shuwarger BSN, RN, CEN, TCRN September 13, 2021 Updated: August 09, 2023 6 min read
This article concludes our discussion of complications of pregnancy, including hypertensive disorders, group B strep, and amniotic fluid disorders. The Maternity Nursing series follows along with our Maternity Nursing Flashcards, which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.
Hypertensive disorders in pregnancy
Hypertensive disorders can cause systemic vasoconstriction (narrowing of blood vessels) and vasospasm (another condition where the blood vessels narrow) in the patient, leading to impaired circulation to the organs (including the placenta) during pregnancy, which may affect the fetus. For example, hypertension in the patient might lead to placental insufficiency, as well as causing additional problems for the patient and their baby.
Among the types of hypertensive disorders are gestational hypertension, preeclampsia, eclampsia, and HELLP syndrome.
Gestational hypertension is a form of hypertension. Indications include a blood pressure greater than 140/90 after 20 weeks of gestation. Note that in diagnosing gestational hypertension, a single blood pressure reading is not diagnostic — it is necessary to take at least two blood pressure readings four hours apart from one another to confirm this diagnosis. Also: a urine test will indicate that there is no protein in the urine.
Preeclampsia is a very serious condition and if untreated, can progress to eclampsia. Preeclampsia can be mild or severe.
Remember that in a urinalysis test, protein is measured as none, trace, 1+, 2+, 3+, 4+. An elevated blood pressure and 1+ protein in the patient's urine indicates mild preeclampsia.
A patient with severe preeclampsia will be experiencing even more hypertension. Their blood pressure will be over 160/100. And they will have proteinuria at or above 3+.
Another symptom of severe preeclampsia is prolonged, severe headache. Note that while headache is very common in pregnancy, a headache that is severe and won’t go away needs to be investigated.
Additional symptoms include blurred vision, which is not normal in pregnancy. A patient who reports blurred vision or that they're seeing spots or floaters in their vision is an indication they might have preeclampsia.
Other signs and symptoms of severe preeclampsia are epigastric pain (pain above that belly button), thrombocytopenia (decreased platelets), impaired liver function (increased AST, ALT), impaired kidney function (an increase in creatinine), edema (swelling), and hyperreflexia (over-responsive reflexes, which can result in twitching).
You can learn more about the lab values for liver enzymes and more with our Lab Values Study Guide & Flashcard Index is a list of lab values covered in our Lab Values Flashcards for nursing students and can be used as an easy reference guide.
Eclampsia may follow mild or severe preeclampsia and, in terms of symptoms, includes the onset of seizures.
For a patient who is preeclamptic and in the hospital, it is important to institute seizure protocols, in the event a preeclamptic patient's condition worsens and they start to seize.
HELLP is a life-threatening liver disorder thought to be a type of severe preeclampsia, although HELLP syndrome may occur without warning and is not always associated with preeclampsia.
H-E-L-L-P, is a mnemonic that stands for “Hemolysis, Elevated Liver enzymes and Low Platelets.” As noted, this condition has a high risk of maternal death.
The patient is likely going to complain of epigastric or right upper quadrant pain because of the involvement of the liver. Their labs will show elevated liver enzymes, (AST, ALT), and they will have low platelets (thrombocytopenia).
You can learn more about the lab values for liver enzymes and more with our Lab Values Study Guide & Flashcard Index, a list of lab values covered in our Lab Values Flashcards for nursing students and can be used as an easy reference guide.
Remember that ACE (angiotensin-converting enzyme) inhibitors and ARBs (angiotensin receptor blockers) are classes of drugs that are contraindicated during pregnancy. So you should not be administering those medications to a patient during pregnancy. Hydralazine and labetalol are usually the go-to drugs and will help lower the patient's blood pressure.
Treatment for hypertension will likely also include magnesium, an important electrolyte for nerve and muscle function, which may calm the patient's symptoms — recall that magnesium sulfate is an anticonvulsant.
It is possible to have too much magnesium, which may result in adverse conditions that affect the patient's deep tendon reflexes, including the reflex that allows them to breathe. So for a patient receiving magnesium, it is important to assess their respiratory status and quality, frequently. Also note if their urine output is dropping — signs of magnesium toxicity. In the event of magnesium toxicity, administer calcium gluconate.
A patient experiencing hypertensive disorders should alter their diet. They should avoid high-sodium foods and limit caffeine. It's also important to maintain a quiet environment to prevent seizures. These patients may also need to be on bed rest, possibly in a hospital where they may be treated.
Group B streptococcus Beta-hemolytic (GBS)
Group B streptococcus (GBS) is Beta-hemolytic. It is a bacterial infection that can be passed to a child during the birthing process and cause life-threatening infections in a newborn.
GBS is a type of bacteria that — for some people — exists on their skin as a normal skin flora, causing them no problem. But the bacteria can be passed to the child during the birthing process and harm the newborn.
To diagnose group B streptococcus, a pregnant patient is tested between 35 and 37 weeks of gestation. Testing is performed with a vaginal and rectal swab — basically, a swab of the whole perineum to see if the patient is a colonizer for group B strep.
For a patient diagnosed with GBS, they will be treated with intrapartum antibiotics (e.g., ampicillin or penicillin G) during birth.
Additionally, a pregnant patient about to give birth may be treated if they have previously delivered an infant having been diagnosed with GBS. Antibiotics will also be administered in the event of an unknown GBS status, if the patient has a fever at or above 38°C (100.4°F), if there has been a prolonged rupture of membranes (more than 18 hours), or during preterm labor (less than 37 weeks).
A mother who has group B strep could experience complications after childbirth, including sepsis and chorioamnionitis (an infection of the placenta and the amniotic fluid).
Amniotic Fluid Abnormalities
Amniotic fluid abnormalities include polyhydramnios, oligohydramnios, and chorioamnionitis.
Polyhydramnios means excess amniotic fluid volume (“poly,” meaning many, “hydramnios,” meaning amniotic fluid).
Risk factors for polyhydramnios
The risk factors for polyhydramnios include gestational diabetes or where there are fetal congenital abnormalities.
Treatment of polyhydramnios
Amniocentesis is a diagnostic procedure that can also be a therapeutic procedure — removing amniotic fluid from the uterus via amniocentesis is a means to treat polyhydramnios.
Oligohydramnios is the opposite of polyhydramnios, that is a decreased volume of amniotic fluid (“oligo” means “little” or “few”).
Risk factors for oligohydramnios
The risk factors for oligohydramnios include the premature rupture of membranes (PROM), as well as uteroplacental insufficiency (decreased blood flow to the baby, which can lead to fetal hypoxia) — if the placenta isn't getting enough blood flow, we might notice decreased amniotic fluid.
Fetal genitourinary abnormalities are another risk factor. These are abnormalities of the fetus’ genital urinary tract. Remember that babies practice breathing in the womb, which means they swallow amniotic fluid. This allows their kidneys to start processing that fluid as urine, which they pee back out. But if the baby has a genitourinary malformation or congenital defect, this may not happen, which could cause oligohydramnios.
Treatment of oligohydramnios
Treatment for oligohydramnios includes amnioinfusion (infusion of normal saline or LR (lactated Ringer's solution, also known as sodium lactate solution)into the amniotic cavity) for umbilical cord compression.
Chorioamnionitis, as noted above, is an infection or inflammation of the amniotic sac (of the chorion and the amnion, hence chorioamnionitis).
Risk factors for chorioamnionitis
Chorioamnionitis is common in a patient who has had a genital urinary infection (e.g, a UTI) or if they had some other sort of infection affecting their reproductive or urinary tract. This infection will cause maternal fever, elevated white blood cells, uterine pain, and a malodorous vaginal discharge.
Treatment of chorioamnionitis
Antibiotics are the go-to treatment for chorioamnionitis.
Hi, I'm Meris. And in this video, I'm going to be talking to you about some complications of pregnancy, including hypertensive disorders, group B strep, and amniotic fluid disorders. I'm going to be following along using our maternity flash cards. These are available on our website, leveluprn.com, if you want to get a set for yourself. And if you already have a set, I would invite you to follow along with me. All right. Let's get started.
So first up, we're going to be talking about hypertensive disorders of pregnancy. There's a few that you need to know. One of them is gestational hypertension. There's preeclampsia. There's eclampsia. And then there is HELLP syndrome. So let's kind of talk about it.
So in general, hypertensive disorders are going to involve hypertension, but they're going to cause vasoconstriction and vasospasm in the whole body. And this can lead to impaired circulation, which affects the fetus as well. So this could cause placental insufficiency of many different forms. And this could cause a lot of different problems for this patient and their baby.
So gestational hypertension is going to be hypertension, so a blood pressure greater than 140/90, after 20 weeks of gestation. It would be recorded twice, right? So one blood pressure is not diagnostic. It would have to be at least two blood pressures taken four hours apart from one another. There would be no protein in the urine, though, okay, very important, no protein in the urine.
Now, preeclampsia is a very serious condition, and it can progress to something called eclampsia. So preeclampsia can be mild or severe.
Mild preeclampsia is going to be blood pressure over 140/90. But also, we are going to have protein in the urine, which can be measured at 1+. So if you've ever done a urinalysis, you likely remember looking at the stick that has the different colored squares on it. And protein, for instance, would be measured as none, trace, 1+, 2+, 3+, 4+.
So if I have an elevated blood pressure and also 1+ protein in my urine, that's going to be mild preeclampsia, whereas, with severe preeclampsia, I'm going to be experiencing even more hypertension. So I'm going to have a blood pressure over 160/100. I'm going to have proteinuria at or above 3+ levels.
And then here's where you're going to see these other really, really important star-highlight-underline-it kind of symptoms that you need to know as warning signs. So headache, a headache is very common in pregnancy. But a headache that is severe and won't go away needs to be investigated. Blurred vision is not normal in pregnancy. If your patient says that they're having blurred vision or they're seeing spots or floaters in their vision, you need to be thinking preeclampsia. If they have epigastric pain, so pain above that belly button; thrombocytopenia, which is going to be decreased platelets; impaired liver function; impaired kidney function; edema; and hyperreflexia, all of those things are possible signs and symptoms of severe preeclampsia.
Now, eclampsia is all of that plus seizure activity. So for your patient to be diagnosed with eclampsia, they must have a seizure. So if I have a patient who is preeclamptic and in the hospital, what do I need to be thinking as the nurse? Pause the video and think about it for a second.
I hope you paused the video. I need to be thinking, for my preeclamptic patient, that I should be instituting seizure protocols, right? I need to start implementing these now because it's possible my patient could get worse and start to seize.
Okay. Now, HELLP syndrome, H-E-L-L-P, is actually a mnemonic in its own right. So it stands for hemolysis, elevated liver enzyme. So H-E-L is elevated liver and low platelets, L-P. So this is really, really serious.
And you will see, with HELLP syndrome, your patient is likely going to complain of epigastric or right upper quadrant pain because of the liver involvement. They're going to have those elevated liver enzymes, like AST, ALT, and then they're going to have low platelets, thrombocytopenia. So that is a really big deal. So if you were to see those lab values, you need to be thinking HELLP syndrome.
Okay. So now, what am I going to do about it, right? So we've talked about what it is. What are we going to do about it? Well, the treatment is going to be antihypertensive medications, right? The big ones here are going to be hydralazine and labetalol. Remember that ACE inhibitors and ARBs, angiotensin receptor blockers, both of those classes of drugs are contraindicated during pregnancy. So you should not be administering those medications to a patient during pregnancy. So hydralazine and labetalol, those are going to be some really go-to drugs because they're okay in pregnancy, and they're going to work to bring down the blood pressure.
We also are very likely going to be giving these patients magnesium, right? So a patient with preeclampsia is likely to get magnesium. It's going to help to calm everything down. And it's a really great drug for patients who have preeclampsia. But you can have too much magnesium. And if you have too much magnesium, we can take away a patient's deep tendon reflexes, including the reflex that allows them to breathe. So for a patient who is receiving magnesium, you need to be assessing their respiratory status and quality, frequently. Pause the video and think about, what is the antidote to magnesium toxicity?
Okay. I hope you paused it. The answer is calcium gluconate. So if your patient is experiencing these decreased deep tendon reflexes, if they're breathing less than 12 times a minute, if their urine output is dropping, all of those things are signs of magnesium toxicity. We need to be really concerned about that and consider administering the antidote of calcium gluconate.
So patient teaching, of course, for hypertensive disorders, it's going to be to change their diet, less salt intake, right? We also want them to limit caffeine. We're going to maintain a quiet environment to hopefully prevent seizures. And these patients may also need to be on bed rest and likely need to be in the hospital for at least a little while, right, while we treat them.
Okay. Moving on to group B strep, so this is group B streptococcus, which is beta hemolytic. This is a type of bacteria that exists on the skin, for some people, just all of the time. This is the normal skin flora for some people. Some people just are colonized by group B strep, at any given time, and it causes them no problem. But it can be passed to the child during the birthing process and cause life-threatening newborn infections. So even though mom can handle it just fine, it could cause a life-threatening infection in the baby.
So this is tested on all pregnant patients between 35 and 37 weeks of gestation. So this is done with a vaginal and rectal swab. So this is going to swab, basically, the whole perineum to see if the patient is a colonizer for group B strep.
And if they are, that's okay. We're just going to treat them with antibiotics during birth. So this would be penicillin G, typically, or ampicillin. It's usually going to be one of those penicillin-family drugs, though. And if I were someone who did not have prenatal care or maybe I went into labor early or maybe I went into labor somewhere and they didn't have my records showing that I had a negative group B strep culture, well then, in that case, they would want to go ahead and treat me with it anyway, right? It's not going to do any real harm to give you antibiotics if you don't need it. I mean, we don't want to do that, but it's not going to hurt the patient. But it could treat an unknown infection of group B strep.
So for moms who have group B strep, they could have complications after childbirth, including sepsis and chorioamnionitis. And for the baby, they could develop meningitis, pneumonia, and sepsis, so really bad-news infections that we don't want these babies to develop, so very easy swab, 35 to 37 weeks.
And lastly, we're going to talk about amniotic fluid abnormalities. So, okay, we have three here that you need to know. So we have polyhydramnios. We have oligohydramnios. And we have chorioamnionitis.
So poly, meaning many, hydramnios, meaning amniotic fluid, so lots of amniotic fluid is polyhydramnios.
This is going to be something that you might see in a patient with gestational diabetes or, in certain fetal congenital abnormalities, could cause polyhydramnios.
So an amniocentesis is a diagnostic procedure we've talked about, but it can also be a therapeutic procedure. We can literally remove amniotic fluid from the uterus to treat polyhydramnios.
Now, oligohydramnios, oligo, meaning little or few, and then amniotic fluid, oligohydramnios is going to be decreased amniotic fluid volume. And this could be, again, for a lot of reasons.
Premature rupture of membranes is going to be a big one there, uteroplacental insufficiency. So if the placenta isn't getting enough blood flow, then we could see decreased amniotic fluid. And then some abnormalities of the fetus' genital urinary tract can cause this as well. Remember that babies practice breathing, and they swallow amniotic fluid as well. And this allows their kidneys to start processing this as urine, right, and they pee it back out. But if the baby has a genital urinary malformation or congenital defect, this may not happen. They may not be urinating it back out, and it could cause oligohydramnios.
Now, chorioamnionitis, this is going to be an infection or inflammation of the amniotic sac of the chorion and the amnion, right?
So this is very common in a patient who has had a genital urinary infection like, maybe, a UTI for instance. Or if they had some other sort of infection affecting their reproductive or urinary tract, they could be at risk for this. And this is going to cause elevated white blood cells. They may have a malodorous, a foul-smelling vaginal discharge. But most importantly, think of this as an infection affecting the mother. We're going to see fever, right? We have that systemic response and then uterine pain as well. It's painful to have inflammation and infection.
So the treatment for that one is going to be antibiotics.
All right. I hope this review was helpful. This is actually it for the pregnancy section of the maternity deck. So next, we're going to be moving on to the labor and delivery portion of maternity, which is always exciting stuff to cover. I hope you enjoyed this review. If you did, please like this video so that I know. I would love to hear a comment. If you have a great way to remember something, I want to know it. And definitely, be sure to subscribe so that you're the first to know when the labor and delivery content comes out next. Thanks so much. And happy studying.
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