Recognizing Preeclampsia in the Postpartum Triage Caller
Awareness of rare but high-risk conditions is an important nurse triage skill. Preeclampsia is one such example. It can be easily missed as a concern after delivery. It is important for nurse triagers to be aware of preeclampsia signs and symptoms before it becomes life-threatening. This newsletter gives you the tools to recognize warning signs, assess patient risk, and make critical triage decisions.
Key Points
It is important to screen for signs of preeclampsia during the first six weeks after delivery. Preeclampsia is a serious medical condition that usually starts in the second half of pregnancy. It occurs in 4.6 out of 20 pregnancies worldwide (about five in 20 pregnancies the United States).
One in twenty cases of preeclampsia are diagnosed during the postpartum period, usually within the first few days but sometimes up to six weeks later. Even patients with normal blood pressure readings during pregnancy remain at risk.
Organ damage, seizures (eclampsia), and stroke are serious complications of preeclampsia. It is a leading cause of death related to pregnancy.
Definitions
Chronic Hypertension: High blood pressure that:
Existed before pregnancy
Developed before 20 weeks gestation
Persist beyond 12 weeks postpartum
May be present pre-pregnancy
Gestational Hypertension: New high blood pressure that:
Developed after 20 weeks gestation
Unlike preeclampsia, does not result in abnormal urine protein or organ damage
Preeclampsia: High blood pressure:
After 20 weeks gestation or postpartum that can cause organ damage
Also known as pregnancy-induced hypertension or toxemia
What Are the Symptoms of Preeclampsia?
As with all triage, it is important to identify the patient’s primary reason for call (RFC). Ask: “What is your main symptom or concern?”
Elevated blood pressure may be the only presenting symptom. Recent delivery escalates the urgency of a patient with elevated blood pressure.
Because multiple organs can be affected by preeclampsia, there are a range of symptoms that can occur. These include:
Organ System Symptoms
Cardiovascular system Hand or face swelling, shortness of breath
Gastrointestinal system Nausea or vomiting, upper abdomen pain
Ocular system Vision changes
Renal system Sudden weight gain
Respiratory system Difficulty breathing
Nervous system Severe or persistent headache or confusion
Seizures occur in those who progress from
preeclampsia to eclampsia
Which Guidelines Provide Triage Decision-Support for Postpartum Preeclampsia?
Several triage guidelines contain targeted triage support for postpartum preeclampsia. These include:
Adult Telehealth Triage Guideline
Postpartum - Abdominal Pain
Postpartum - Headache
Postpartum - High Blood Pressure
Postpartum - Leg Swelling and Edema
Postpartum - Vision Loss or Change
These five guidelines contain Triage Assessment Questions (TAQs) that capture the blood pressure changes and common symptoms of preeclampsia. Here are some example TAQs from the Postpartum – Vision Loss or Change guideline that include rule out statements for preeclampsia:
There is also additional information available in the Background Information (BI) section in several of these guidelines. An example is this caution statement in the Postpartum – Vision Loss or Change guideline:
Who Is at Risk of Getting Preeclampsia?
How Is Postpartum Preeclampsia Diagnosed?
Confirmed systolic BP 140 and higher OR diastolic BP 90 and higher, AND...
Spilling protein into the urine (proteinuria), OR...
Laboratory findings or symptoms of multi-organ injury. Examples are abnormal liver or kidney tests, low platelets, confusion, pulmonary edema, severe or persistent headache, and vision changes.
People with preeclampsia may also have HELLP Syndrome. HELLP is an acronym that outlines the main features of this rare syndrome. It stands for Hemolysis, Elevated Liver enzymes, and Low Platelets.
How Is Preeclampsia Treated?
Pregnancy: Delivery is the cure. Earlier delivery for severe cases.
Postpartum: Control blood pressure with IV medications and prevent seizures with magnesium sulfate. Severe hypertension needs emergency treatment to prevent stroke.
Summary
Preeclampsia can cause life-threatening organ damage affecting the blood, brain, kidneys, liver, and lungs.
Seizures are a sign of progression to eclampsia - a medical emergency.
Preeclampsia can occur during the second half of pregnancy and up to six weeks postpartum.
Recent delivery history is a key finding for accurate triage of elevated blood pressure.
Monitor for headache, vision changes, breathing difficulty, abdominal pain, swelling or sudden weight gain.
Five postpartum telehealth triage guidelines provide support for triaging postpartum preeclampsia symptoms.
Authors
Gary Marks, DOP, Medical Editor, Adult Clinical Content
Laurie O’Bryan, RN, Nurse Editor, Adult Clinical Content
References
1. American College of Obstetricians and Gynecologists (ACOG). Preeclampsia and High Blood Pressure During Pregnancy. Available at: https://www.acog.org/womens-health/faqs/Preeclampsia-and-High-Blood-Pressure-During-Pregnancy?utm_source=redirect&utm_medium=web&utm_campaign=otn
2. August P, Baha MS. Preeclampsia: Clinical features and diagnosis. In: Lockwood C (Ed). UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com. Accessed November 19, 2024.
3. Centers for Disease Control and Prevention (CDC). High Blood Pressure During Pregnancy. Available at: https://www.cdc.gov/high-blood-pressure/about/high-blood-pressure-during-pregnancy.html
4. Magee L, Warren M, Qaseem A, DeGeorge K. Hypertensive Disorders of Pregnancy. DynaMed. https://www.dynamed.com. Last updated Dec 18, 2024.
5. Powles K, Gandhi S. Postpartum hypertension. CMAJ. 2017;189(27):E913.