Pregnancy can unmask unique cardiovascular challenges, and few demand more vigilance than Pregnancy Induced Hypertension. Modern terminology distinguishes gestational hypertension, preeclampsia (with or without severe features), and eclampsia, but frontline nursing priorities remain constant: detect rising blood pressure early, prevent maternal morbidity, protect fetal well-being, and coordinate timely delivery when indicated. With organized protocols and interprofessional teamwork, outcomes improve dramatically.

This nurse-led, evidence-based guide translates current recommendations into practical steps at the bedside clear definitions, risk triage, diagnostic criteria, medication dosing, magnesium sulfate monitoring, delivery timing, and postpartum follow-up alongside a complete nursing care framework.

Table of Contents

Pregnancy Induced Hypertension: Gestational Hypertension, Preeclampsia, Severe Features, Medications, and Nursing Care Plans

Pregnancy Induced Hypertension (PIH) historically described de novo hypertension in pregnancy. Contemporary classifications refine this umbrella into hypertensive disorders of pregnancy (HDP):

Gestational hypertension: New-onset systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg on two occasions ≥4 hours apart after 20 weeks’ gestation, in the absence of proteinuria or end-organ findings.
Preeclampsia: Gestational hypertension plus either proteinuria or end-organ dysfunction (thrombocytopenia, renal insufficiency, impaired liver function with pain, pulmonary edema, or persistent neurologic/visual symptoms).
Preeclampsia with severe features: Severe-range BP (≥160/110 mm Hg) or significant end-organ dysfunction, regardless of proteinuria.
Eclampsia: Seizures not attributable to other causes in the setting of preeclampsia.
Chronic hypertension: Hypertension predating pregnancy or diagnosed before 20 weeks’ gestation.
Superimposed preeclampsia: Preeclampsia criteria developing in a pregnant patient with chronic hypertension.

These definitions anchor nursing assessment, escalation thresholds, and delivery planning.

Key Facts at a Glance (Clinical Quick-Start)

Diagnostic thresholds:
- Gestational hypertension: ≥140/90 after 20 weeks (two readings ≥4 hours apart).
- Severe range: ≥160 systolic or ≥110 diastolic (confirm within minutes to initiate therapy).
Preeclampsia proteinuria:
- ≥300 mg/24 h OR urine protein/creatinine ratio ≥0.3 OR dipstick ≥2+ when quantitative tests unavailable.
Severe features (any qualifies):
- Platelets <100,000/μL; serum creatinine ≥1.1 mg/dL or doubling; AST/ALT ≥2× normal; pulmonary edema; persistent headache or visual changes; severe-range BP.
First-line acute antihypertensives:
- IV labetalol, IV hydralazine, or oral immediate-release nifedipine.
Seizure prophylaxis/treatment:
- Magnesium sulfate: load 4–6 g IV over 20–30 min, then 1–2 g/h. Monitor reflexes, respiratory rate, and urine output; calcium gluconate is the antidote.
Delivery timing (general guidance; follow local protocol):
- Preeclampsia without severe features: deliver at 37 0/7 weeks.
- Preeclampsia with severe features: deliver at ≥34 0/7 weeks or earlier for instability; consider expectant management <34 weeks at specialized centers.
Postpartum risk:
- Hypertension/preeclampsia can present or worsen postpartum; peak BP commonly days 3–6. Reassess at 72 hours and again by 7–10 days.

Pathophysiology

Preeclampsia and related HDP are thought to arise from abnormal placentation and maternal endothelial dysfunction:

Inadequate spiral artery remodeling limits uteroplacental perfusion and promotes placental ischemia.
Release of antiangiogenic factors and inflammatory mediators triggers widespread endothelial activation.
Hallmarks include vasoconstriction, capillary leak, and prothrombotic changes, producing hypertension, proteinuria, and multiorgan involvement (brain, liver, kidney, lung).
Severe features reflect escalating end-organ injury, while eclampsia represents cerebral involvement and seizure activity.
Gestational hypertension may be a precursor phenotype; a significant subset progresses to preeclampsia.

Understanding these mechanisms supports anticipation of complications and structured surveillance.

Epidemiology and Impact

Incidence: Hypertensive disorders affect approximately 5–10% of pregnancies; gestational hypertension and preeclampsia constitute the majority.
Morbidity and mortality: Leading causes of maternal ICU admission, stroke, HELLP syndrome, DIC, placental abruption, and peripartum cardiomyopathy; adverse neonatal outcomes include preterm birth, fetal growth restriction (FGR), and NICU admission.
Long-term health: Increased lifetime risk of chronic hypertension, ischemic heart disease, stroke, and metabolic syndrome.

Risk Factors

First pregnancy, new paternity, short interpregnancy interval
Multifetal gestation
Prior preeclampsia or family history of preeclampsia
Chronic hypertension, diabetes, kidney disease, autoimmune disease (e.g., SLE, antiphospholipid syndrome)
Obesity, obstructive sleep apnea
Advanced maternal age or adolescent pregnancy
In vitro fertilization and donor oocyte pregnancy
Black race (reflecting structural inequities and differential exposures)

Risk stratification informs aspirin prophylaxis (e.g., low-dose aspirin begun in late first trimester per guideline) and enhanced surveillance plans.

Maternal and Fetal Complications

Maternal: Stroke, pulmonary edema, acute kidney injury, liver hemorrhage or rupture, HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets), eclampsia, DIC, postpartum hemorrhage risk.
Fetal/Neonatal: FGR, oligohydramnios, placental abruption, prematurity and associated morbidities, stillbirth risk with severe disease.

Clinical Presentation

Symptoms

Headache unrelieved by analgesics
Visual disturbances (scotomata, blurred vision, photophobia)
Right upper quadrant or epigastric pain
Nausea/vomiting (often with liver involvement)
Dyspnea (possible pulmonary edema)
Edema may be present; generalized edema alone is not diagnostic

Signs

Elevated BP after 20 weeks (or postpartum)
Hyperreflexia and clonus (neurologic irritability)
Decreased urine output
Abnormal weight gain over short intervals
Laboratory abnormalities (thrombocytopenia, elevated AST/ALT, rising creatinine)

Assessment and Diagnostic Criteria

Accurate Blood Pressure Technique

Proper cuff size (bladder encircling 80% of arm circumference)
Seated, back supported, arm at heart level; rest 5 minutes
Two readings ≥4 hours apart for diagnosis, except severe-range BP confirmed within minutes for urgent therapy

Laboratory Evaluation

CBC with platelets (evaluate for thrombocytopenia)
Serum creatinine, electrolytes, uric acid
AST/ALT; LDH when HELLP suspected
Urinalysis; quantitative protein: creatinine ratio (≥0.3 indicates proteinuria) or 24-hour protein/creatinine collection
Coagulation panel if DIC suspected

Fetal Assessment

Non-stress testing (NST) and biophysical profile (BPP) to assess well-being
Ultrasound for fetal growth, amniotic fluid volume
Umbilical artery Dopplers when FGR is present or suspected

HELLP Syndrome Criteria (common schema)

Hemolysis: abnormal smear, bilirubin ≥1.2 mg/dL, LDH ≥600 IU/L
Elevated liver enzymes: AST or ALT ≥2× normal
Low platelets: <100,000/μL

Severity Classification

Preeclampsia without severe features:
- BP ≥140/90 and <160/110
- Proteinuria and/or no severe end-organ signs
Preeclampsia with severe features (any of the following):
- BP ≥160/110 (confirmed)
- Thrombocytopenia (<100,000/μL)
- Renal insufficiency (Cr ≥1.1 or doubling)
- Elevated AST/ALT (≥2× normal) with RUQ/epigastric pain
- Pulmonary edema
- New-onset persistent headache or visual symptoms
Eclampsia: Seizure in context of preeclampsia

This classification determines disposition, treatment intensity, and delivery timing.

Initial Stabilization and Triage

Activate obstetric hypertension protocol; notify obstetric, anesthesia, and neonatal teams.
Continuous maternal-fetal monitoring; establish IV access.
Severe-range BP: initiate antihypertensive therapy promptly (goal: reduce risk of stroke while avoiding hypotension).
Assess for severe features and HELLP; obtain labs.
If eclampsia suspected or diagnosed, prioritize airway, breathing, circulation; administer magnesium sulfate; control BP; plan delivery after stabilization.

Pharmacologic Management

Acute Severe Hypertension (≥160/110 mm Hg)

Select one first-line agent; repeat doses per protocol until BP <160/110.

Labetalol IV
- 20 mg IV over 2 min; if BP persists, 40 mg in 10 min; then 80 mg every 10 min (max cumulative 220 mg).
- Contraindications: asthma, bradycardia, heart block.
- Adverse effects: hypotension, bradycardia.
Hydralazine IV
- 5–10 mg IV; reassess in 20–40 min; repeat 5–10 mg (max cumulative commonly 20–30 mg initially).
- Adverse effects: headache, flushing, tachycardia.
Nifedipine oral (immediate-release)
- 10 mg PO; repeat 10–20 mg in 20–30 min if needed; then 10–20 mg every 2–6 h.
- Adverse effects: headache, flushing; caution with concurrent magnesium sulfate (monitor BP and reflexes closely).

Avoid ACE inhibitors, ARBs, and direct renin inhibitors during pregnancy.

Ongoing BP Control

Labetalol oral (e.g., 200–400 mg twice daily; titrate)
Nifedipine extended-release (e.g., 30–60 mg daily; titrate)
Methyldopa (less favored for acute control; may be used for maintenance in select cases)

Seizure Prophylaxis and Treatment

Magnesium sulfate (preferred)
- Loading dose: 4–6 g IV over 20–30 minutes.
- Maintenance: 1–2 g/h IV infusion for 24 hours postpartum or after last seizure.
- Monitoring: deep tendon reflexes (DTRs), respiratory rate (hold if <12/min), urine output (≥30 mL/h).
- Signs of toxicity: loss of DTRs, respiratory depression, cardiac conduction delay.
- Antidote: calcium gluconate 10% solution, 10 mL (1 g) IV over 3–5 minutes.

Corticosteroids for Fetal Lung Maturity

Consider when delivery anticipated between 24 0/7 and 33 6/7 weeks (e.g., betamethasone 12 mg IM, two doses 24 h apart).

Thromboprophylaxis

Individualize based on mobility, cesarean delivery, and additional risk factors.

Obstetric Management and Delivery Timing

Delivery is the definitive treatment for preeclampsia; timing balances maternal condition and fetal maturity.

Preeclampsia without severe features:
- Expectant management with close surveillance until 37 0/7 weeks, then delivery.
Preeclampsia with severe features:
- Delivery recommended at ≥34 0/7 weeks or earlier for maternal or fetal instability (uncontrolled BP, eclampsia, pulmonary edema, severe laboratory derangements, abruption, nonreassuring fetal status).
- Expectant management <34 weeks may be considered in a tertiary setting when maternal-fetal status is stable and resources allow intensive monitoring.
Eclampsia: Deliver after stabilization regardless of gestational age.
Mode of delivery: Vaginal birth preferred if feasible; cesarean for standard obstetric indications or urgent maternal/fetal compromise.
Intrapartum care:
- Continuous fetal monitoring; strict I&O; avoid fluid overload.
- Anesthesia planning; epidural may be appropriate with normal platelets.
- Seizure prophylaxis with magnesium sulfate in preeclampsia with severe features and eclampsia.

Postpartum Care

Blood pressure peaks commonly days 3–6 postpartum; monitor during inpatient stay and arrange follow-up within 7–10 days (or earlier for symptom triggers).
Continue magnesium sulfate for 24 hours postpartum in preeclampsia with severe features and after eclampsia.
Antihypertensives compatible with lactation:
- Labetalol, nifedipine, amlodipine, enalapril/captopril (ACE inhibitors acceptable postpartum for most; confirm with local guidance).
Evaluate for postpartum preeclampsia or eclampsia in the presence of new headache, visual changes, dyspnea, or RUQ pain.
Counsel on long-term cardiovascular risk; plan transition to primary care for risk modification (BP, lipids, weight management, diabetes screening).

Special Populations and Considerations

Chronic hypertension: Differentiate superimposed preeclampsia (sudden BP worsening, new proteinuria, or end-organ signs); adjust medications; consider aspirin prophylaxis in early pregnancy per guideline.
Renal disease: Baseline proteinuria complicates diagnosis; rely on evolving end-organ markers and trend analysis.
Adolescents and advanced age: Elevated risk; ensure close surveillance and social support resources.
Multifetal gestation and IVF: Higher incidence; intensified fetal surveillance.
Resource-limited settings: Emphasize accurate BP measurement, early antihypertensive treatment, magnesium sulfate availability, and timely referral.

Nursing Management: NANDA-NIC-NOC Framework

Priority Nursing Diagnoses (examples)

Risk for Decreased Cardiac Output related to increased afterload and vasoconstriction.
Risk for Ineffective Cerebral Tissue Perfusion related to severe hypertension.
Risk for Ineffective Renal Perfusion related to vasospasm and intravascular volume shifts.
Risk for Maternal-Fetal Dyad Compromise related to placental hypoperfusion.
Anxiety related to acute illness and potential for adverse outcomes.
Knowledge Deficit related to disease process, medications, and warning signs.

Expected Outcomes (NOC)

Blood Pressure Control: Maintain SBP <160 and DBP <110 in the acute phase.
Neurologic Status: Absence of headache, visual changes, seizures.
Respiratory Status: RR ≥12/min, SpO2 ≥95%, no signs of pulmonary edema.
Renal Function: Urine output ≥30 mL/h; creatinine within acceptable range.
Fetal Well-Being: Reassuring NST/BPP; stable growth trajectory when expectant management pursued.
Knowledge: Demonstrates understanding of condition and postpartum follow-up plan.

Nursing Interventions (NIC) with Rationales

Hypertension Management: Implement the antihypertensive protocol and reassess BP per algorithm to reduce the risk of intracranial hemorrhage and maternal stroke.
Seizure Precautions: Dim lights, minimize stimulation, pad rails, prepare suction and oxygen, and administer magnesium sulfate to lower seizure risk and limit injury if a seizure occurs.
Fluid Management: Maintain strict I&O, restrict IV fluids as ordered, and monitor for pulmonary edema to prevent fluid overload since endothelial leak predisposes to edema.
Laboratory Surveillance: Trend CBC, platelets, creatinine, AST/ALT, and LDH, and communicate critical values promptly to enable early identification of HELLP and organ dysfunction that guide delivery timing.
Fetal Surveillance Coordination: Schedule NST/BPP per protocol and report nonreassuring findings to detect evolving fetal compromise.
Education and Support: Provide concise explanations of treatment steps and offer coping strategies to reduce anxiety and improve care-plan adherence.
Safety Checks: Verify drug doses (e.g., magnesium sulfate, antihypertensives) and keep calcium gluconate at the bedside to prevent medication errors and expedite toxicity reversal.
Interprofessional Communication: Use SBAR to update obstetrics, anesthesia, and pediatrics to ensure a shared mental model and rapid response.

Sample Nursing Care Plan Snapshot (Severe-Range Preeclampsia)

Assessment: BP 168/112; headache and visual spots; platelets 92,000/μL; AST 95 IU/L; protein/creatinine ratio 0.7; fetus reactive on NST.
Diagnosis: Risk for Ineffective Cerebral Tissue Perfusion related to severe hypertension and endothelial dysfunction.
Goals: SBP <160 and DBP <110 within 60 minutes; headache resolved; no seizure activity; stable fetal tracing.
Interventions:
- Labetalol 20 mg IV; repeat per protocol until target BP achieved.
- Magnesium sulfate 6 g load, then 2 g/h; monitor reflexes, RR, urine output.
- Strict I&O; lung auscultation each shift and with symptom reports.
- Serial labs q6–12 h; notify provider for platelets <100,000/μL or rising AST/ALT.
- Prepare for delivery planning; corticosteroids if <34 weeks and time allows.
Evaluation: BP 148/92; headache improved; DTRs 2+; urine output 35 mL/h; NST remains reactive.

Education Topics for Patients and Families

Condition overview and rationale for close monitoring
Medication purpose and common side effects (labetalol, hydralazine, nifedipine, magnesium sulfate)
Warning signs requiring immediate evaluation: severe headache, visual changes, RUQ pain, dyspnea, heavy vaginal bleeding, sudden swelling, decreased fetal movement
Postpartum blood pressure expectations and follow-up schedule (72 hours and 7–10 days)
Long-term cardiovascular risk after HDP and importance of primary care follow-up
Breastfeeding-compatible medications and pain control options

Note: Provide language-concordant materials and culturally sensitive education.

Quality, Safety, and Systems Preparedness

Unit hemorrhage and hypertension bundles visible at point of care
Ready access to emergency medications and dosing guides (including magnesium sulfate and calcium gluconate)
Regular drills for severe hypertension and eclampsia scenarios
Weight- and cuff-size–appropriate equipment available
Structured debriefs after events to drive continuous improvement
Equity focus: screening for social determinants, offering transportation support, and ensuring interpreter services

Frequently Asked Questions (FAQ)

What is the difference between gestational hypertension and preeclampsia?

Gestational hypertension is new-onset BP ≥140/90 after 20 weeks’ gestation without proteinuria or end-organ dysfunction. Preeclampsia adds proteinuria and/or signs of end-organ injury (e.g., thrombocytopenia, renal insufficiency, elevated liver enzymes with pain, pulmonary edema, or persistent neurologic symptoms).

Which medications rapidly treat severe-range blood pressure in pregnancy?

First-line options are IV labetalol, IV hydralazine, or oral immediate-release nifedipine. The goal is to lower systolic BP below 160 and diastolic below 110 promptly while avoiding hypotension that could compromise uteroplacental perfusion.

How is magnesium sulfate given and monitored?

A common regimen is a 4–6 g IV loading dose over 20–30 minutes followed by 1–2 g/h infusion for 24 hours postpartum or after the last seizure. Monitoring includes deep tendon reflexes, respiratory rate (hold for <12/min), and urine output (≥30 mL/h). Calcium gluconate 1 g IV is used to reverse toxicity.

When is delivery recommended in preeclampsia?

Delivery is recommended at 37 weeks for preeclampsia without severe features. For severe features, delivery is recommended at or beyond 34 weeks, or earlier if maternal or fetal status is unstable. Eclampsia generally necessitates delivery after stabilization regardless of gestational age.

Can hypertensive disorders begin after birth?

Yes. Postpartum preeclampsia and eclampsia can present de novo, often in the first 7–10 days. Warning signs include severe headache, visual changes, dyspnea, and RUQ pain; urgent evaluation is essential.

Conclusion

Pregnancy Induced Hypertension requires decisive, protocol-driven action rooted in accurate assessment, timely pharmacologic therapy, thoughtful delivery planning, and meticulous postpartum follow-up. Nursing professionals sit at the center of that response recognizing evolving symptoms, administering high-alert medications safely, coordinating fetal surveillance, educating families, and advocating for equity in care. With vigilant teamwork and evidence-based pathways, maternal and newborn outcomes improve, and the experience of a high-risk pregnancy becomes safer, clearer, and more compassionate.

Educational Note: This article supports clinical education and does not replace local protocols or specialist consultation. Management decisions should follow institutional guidelines and current professional recommendations.