PIH Nursing Management

Nursing management of PIH through case scenario

1. NURSING MANAGEMENT OF PREGNANCY INDUCED HYPERTENSION (PIH) PRESENTED BY: LAMNUNNEM HAOKIP MSC (N) 2 ND YEAR SNSR,SU

2. DISORDERS SYMPTOMS ONSET Gestational hypertension Blood pressure elevated > 140/90 mm Hg After 20 weeks gestation Preeclampsia Blood pressure elevated >140/90 mmHg and +1 or greater proteinuria on dipstick After 20 weeks pregnancy Eclampsia Preeclampsia with neurologic symptoms/seizures After 20 weeks pregnancy Chronic hypertension Pre-existing hypertension Exists prior to pregnancy Preeclampsia/eclampsia superimposed on chronic hypertension Blood pressure increases >30 mm Hg systolic or >15 mm Hg diastolic from baseline with onset of significant proteinuria >20 weeks pregnancy CLASSIFICATIONS OF PIH

3. ETIOLOGY Nulliparity Pre-eclampsia in a previous pregnancy Maternal age >35 years or<18 years Family history of PIH Chronic HTN Chronic Renal Disease Inherited Thrombophilia DM

4. CLINICAL SCENARIO Q. A 29-year old primigravida at 28 weeks of gestational age has a blood pressure reading of 150/100 mm Hg obtained during a routine visit . Her baseline blood pressure during the pregnancy was 120/70 mm Hg. The patient denies having headache, blurry vision, nausea, vomiting or abdominal pain. Her repeat BP is 160/100 mm Hg and urinalysis is 1+ for protein by dipstick. What is the most likely diagnosis? PRE-ECLAMPSIA

5. Identification of Pre-eclampsia: BP measurement Peripheral Edema Excessive weight gain High risk history Urine protein analysis Evaluation of severity Headache Blurring vision Epigastric pain Decreased urine output Breathlessness Assess the fetal well being

6. Investigations done to look for end organ changes CBC – Platelet count < 1 lac/mm3 LFT – elevated SGOT and SGPT (2 times above normal) KFT – Serum Creatinine >1.1 mg/dl If anytime, any end organ changes seen or the BP is shooting up beyond 160/110 mm Hg. (sever PE)

7. The definitive management for Pre-eclampsia? Termination of pregnancy.(37 completed). Baseline workup and investigations. Watch for development of severe PE. Watch for fetal growth and well being.

8. Q. A 25-year old nulliparous woman at 30 weeks comes for ANC check-up in OPD. Her BP is 170/110 mm Hg and urinalysis shows 2+ by dipstick . There is no complaint of headache, vision change, pain or decreased urine output. The FHS is 140 bpm . What is the diagnosis? SEVERE PRE-ECLAMPSIA

9. Management of severe PE Admit the woman Baseline investigations and follow Control the BP and monitoring Watch for S/S of impending Eclampsia Evaluate the well being of the baby. (<34 weeks) Steroids for fetal lung maturity.(Inj. Betamethasone 2 doses of 12 mg IM 24 hours apart). Reassess on daily basis. If the gestation is >34 weeks, termination of pregnancy if no S/S of impending eclampsia.

10. Q. A female with 35 week gestation , presents in emergency with complaint of headache and blurring of vision since morning. Her BP is 170/120 mm Hg . Her urine analysis is 3+ by dipstick. How is the patient managed? Admit and observe. Admit, control BP and continue pregnancy till term. Admit, start MgSO4 and antihypertensive and terminate the pregnancy. Start antihypertensive and follow in OPD.

11. MANAGEMENT

12. NURSING MANAGEMENT MILD PRE-ECLAMPSIA Rest Diet: no added salt Monitoring of the mother and fetus : Monitor blood pressure twice daily every 4 – 6 hours and urine examination. Fetal growth and well being have to be monitor. If gestation <37 weeks: DBP settles and proteinuria becomes insignificant, the patient may be allow to continue pregnancy. If gestation >37 weeks, after ensuring fetal maturity, labour is induced.

13. SEVERE PREECLAMPSIA: Anti hypertensive drugs is to be given. Tab. Labetalol – 100 mg orally BD per day. Tab. Nifedipine 10 mg orally, can be titrated according to the BP level. Tab. Hydralazine 10-25 mg bid, orally, Tab. Methyldopa 250 – 500 mg tid , qid , Orally. For quick control of HTN in severe pre-eclampsia, Inj. Labetalol 10 – 20 mg can be given.

14. Q . 8 months pregnant woman is wheeled into the emergency with seizures. Her relatives inform that she had been complaining of severe headache and blurring of vision since morning . What is the diagnosis? How will we managed? Stabilization Airway ECLAMPSIA Termination of pregnancy

15. Dangers of Eclampsia Aspiration pneumonia Pulmonary edema Placental abruption Cardiopulmonary arrest Renal failure Massive cerebral haemorrhage Q. What is the most common cause of sudden death in a woman with eclampsia? Intracranial haemorrhage.

16. ECLAMPSIA CAN OCCUR DURING : Antepartum Intra-partum Postpartum Q. Which is the most dangerous?

17. ECLAMPSIA Magnesium Sulphate (MgSO4) is the drug of choice for treating convulsions. Pritchard regime (MgSO4) Loading dose : 4g 20% MgSO4 should be given IV over 5 – 10 minutes (not less than 3 minutes.) Maintenance dose : 10g of 50% MgSO4 solution deep IM injection into alternate buttocks(5g on left and 5g on right buttock) every 4 hrs.

18. Zuspan regime Loading dose : 4 – 6 g diluted in 100 mL NS, slow IV infusion over 15 – 20 minutes. Maintenance dose: 1 – 2 gm / hour in 100 mL of IV infusion. MONITORING DURING MgSO4 THERAPY: Respiratory rate Knee jerk Urine output Antidote of MgSO4: Inj. Calcium Gluconate 10 mL. IV Therapeutic MgSO4 levels: 4 – 7 mEq /L Loss of knee jerk: 10 mEq /L Respiratory paralysis: 12 mEq /L Cardiac arrest: 15 mEq /L

19. OBSTETRIC MEASURES

20. TIMING OF DELIVERY Severe pre-eclampsia is usually treated consecutively till the end of the 36 th weeks to ensure reasonable maturation of the fetus. Indications of termination before 36 th weeks include: Aggravation of the pre-eclamptic feature. HTN persists Acute fulminating pre-eclampsia

21. METHOD OF DELIVERY: Vaginal delivery may be commenced in vertex presentation by – Amniotomy + Oxytocin PGs, if cervix is not favourable. Caesarean section is indicated in: Oxytocin test fails Failure of induction of labour CPD

22. INTRAPARTUM CARE: Close monitoring of the fetus and mother vitals Proper analgesia Anti-hypertensives may be given if needed 2 nd stage of labour may be shortened by forceps delivery. POST PARTUM CARE: Continue observation of the mother for 48 hours Drugs are continued in a small dose for 48 hours.

23. COMPLICATIONS Injuries Cerebral haemorrhage Hyperpyrexia Renal failure Pulmonary edema: Furosemide 40 mg IV followed by 20 mg of mannitol. Puerperal infection and puerperal psychosis.

24. NURSES RESPONSIBILTIES

25. BIBLIOGRAPHY/REFERENCE Annamma Jabob . A comprehensive textbook of Midwifery and Gynaecological Nursing, Fourth edition.pp 724-741. Lily Podder . Fundamentals of Midwifery and Obstetrical Nursing. ELSEVIER.pp 374-381. DC Dutta’s textbook of Obstetrics. Hiralal Konar 8 th Edition.Jaypee The Health Sciences Publisher.pp 573-585. DAVIS’S DRUG GUIDE for Nurses TWELFTH EDITION. Pp 806-808,869-870. Mosby’s 2020. Nursing Drug Reference. Skidmore, Third South Asia Edition. Pp 801-803,732-734.