Pregnancy induced hypertension

This presentation incudes a description of pregnancy induce hypertension, it's risk factor, medical as well as nursing management.

1. Pregnancy Induced Hypertension Presented by – Chetna Bhatt Roll No – 038 IV the Year

2. Introduction The Pregnancy induced hypertension is defined as the hypertension that develops as a direct result of the gravid state. Hypertension is one of the most common complication during pregnancy It includes Gestational Hypertension , Pre-eclampsia and Eclampsia 3

3. Pre-eclampsia 1

4. Definition It is a multisystem disorder of unknown etiology characterized by development of hypertension to the extent of 140/90 mm of Hg or more with proteinuria after the 20th week in a previously normotensive and non- proteinuric women 5

5. Diagnostic Criteria Hypertension BP> 140/90 mmHg. Rise of BP should be evident at least on two occasion , at least 4 hours apart. Edema Pitting edema over the ankles after 12hours of bed rest Excessive weight gain . Proteinuria Presence of total protein in 24 hour urine of 0.3g or +1 (30mg/dl) protein in at least two random clean catch urine samples tested 4 hours apart . 6

6. Pre-disposing factors  Primigravida Pre-existing hypertension. Previous pre-eclampsia. Family history of pre-eclampsia.  Hyperplacentosis i.e. excessive chorionic tissue as in hydatidiform mole, multiple pregnancy, uncontrolled diabetes mellitus and foetal haemolytic diseases. Obesity.  New paternity and Thrombophilias 7

7. Clinical Features: Symptoms: Mild:  Slight swelling over the ankle Gradually swelling may be extend to the face, abdominal wall, vulva even the whole body. Alarming:  Headache Disturbed sleep Diminished urinary output 8 Epigastric pain Eye symptoms- blurring, dimness of vision or at times complete blindness. Vision usually regained within 4-6 weeks following delivery.

8. Signs: Abnormal weight gain Rise of blood pressure Edema There is no manifestation of chronic cardiovascular or renal pathology Pulmonary edema Abdominal examination my reveal evidences of chronic placental insufficiency such as scanty liquor or growth retardation of the fetus 9

9. Investigations: Urine: 24 hours urine collection for protein measurement is done. Urine become solid on boiling (10-15 g/L) A few hyaline cast, epithelial cells or few red cells.  Ophthalmoscopic examinations: In severe cases- retinal edema, constriction of arterioles, alteration of normal ration of vein, nicking the veins, hemorrhage. 10

10. Blood values: Blood Values : Serum uric acid level >4.5 mg/dl indicates presences of pre-eclampsia Blood urea level remains normal Abnormal coagulation profile Raised hepatic enzyme levels 11

11. Antenatal fetal monitoring: Daily fetal kick count USG of fetal growth Liquor pockets  Cardiotocography Umbilical artery flow velocimetry 12

12. Complications (Maternal) During prengnancy : a. Eclampsia (2%) b. Accidental hemorrhage c. Oliguria and anuria d. Dimness of vision even blindness e. Pre-term labor f. HELLP syndrome g. Cerebral hemorrhage h. Acute respiratory distress syndrome (ARDS) During labor : a. Eclampsia b. Post partum hemorrhage (PPH) Puerperium : a . Eclampsia b. Shock c. Sepsis 13

13. Complications 14 Fetal: a. Intrauterine death (IUD) b. Intrauterine growth retardation (IUGR) c. Asphyxia d. prematurity Remote: a. Residual hypertension b. Recurrent pre-eclampsia c. Chronic renal disease d. Risk of placental abruption

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15. Prophylactic Measures for Prevention  Proper antenatal care: To detect the high risk patients who may develop PIH through the screening tests Early detection of cases who have already developed PIH and examine them more frequently  Low dose aspirin: Low-Dose Aspirin (LDA) : 50-150mg daily beginning early in pregnancy in potentially high-risk patient is given. 16

16. Prophylactic Measures for Prevention C alcium supplementation 2g/day reduced the risk of GH Antioxidants Vitamin C and E , Zn ,Mg and low salt diet Balanced diet Rich in protein may reduce the risk 17

17. Management of Pre-eclampsia 18

18. General Measures (Observation)  Maternal Blood pressure twice daily Urine volume and proteinuria daily Edema daily Body weight twice weekly Fundus oculi once weekly Blood picture including platelet count, liver and renal functions particularly serum uric acid on admission  Fetal Daily foetal movement count Serial sonography Non-stress and stress test if needed 19

19. Hospital Management Rest – left lateral position Diet – should contain adequate amount of daily protein (about 100g). Total calorie – 1,600 cal/day Diuretics – Lasix 40 mg PO after breakfast for 5 days in a week . Antihypertensives 20

20. Medical treatment Antihypertensives: Decrease the maternal cerebral and cardiovascular complications but do not affect the foetal outcome Alpha-methyl- dopa : It reduces the central sympathetic drive Dose: 250-500 mg every 6-8 hours (tid or qid) up to a maximum dose of 4 gm/day . A loading single dose of 2 gm may act within 1-2 hours  Side effects : headache and nightmares 21

21. Medical treatment (cont) Hydralazine :  It is a vasodilator, increases renal and uteroplacental blood flow  Dose : 10-20 mg slowly IV initially followed by 5mg every 20 min. until diastolic blood pressure is 100-110 mmHg. This regimen is used for severe and acute hypertension . Oral hydralazine can be used in the chronic situation as a second line treatment in a dose of 25-75 mg/ 6hours  Side effects : tachycardia, headache, flushing, nausea and vomiting 22

22. Medical treatment (cont.) Calcium channel blockers ( Nifedipine ):  It is a vasodilator acting by blocking the Ca influx into smooth muscle cells  It can be given sublingually (acts within 10 minutes) or orally (acts within 30 minutes) in a dose of 10-20 mg 2-3 times daily  The higher the starting blood pressure the greater is the hypotensive effect.  Side effects : headache and flushing 23

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24. Obstetric measures 25 Postpartum care Timing of delivery Intrapartum care Method of delivery P T I M

25. Timing of delivery: Severe pre-eclampsia is usually treated conservatively till the end of the 36th week to ensure reasonable maturation of the fetus. Indications of termination before 36th week include: 1. Aggravation of pre- eclamptic features 2. Hypertension persists 3. Acute fulminating pre-eclampsia 26

26. Method of delivery  Vaginal delivery may be commenced in vertex presentation by:  Amniotomy + oxytocin if the cervix is favorable Prostaglandin vaginal tablet (PGE2) if the cervix is not favorable  Caesarean section is indicated in: Foetal distress Late deceleration occurs with oxytocin challenge test Failure of induction of labor Other indications as contracted pelvis, and malpresentations 27

27. Intrapartum care Close monitoring of the fetus is indicated Proper analgesia to the mother Anti-hypertensive may be given if needed 2nd stage of labor may be shortened by forceps 28

28. Postpartum care  Methergin ( Ergometrine ) is better avoided as it may increase the blood pressure Continue observation of the mother for 48 hours Anti- hypertensive drugs are continued in a decreasing dose for 48 hours 29

29. Prognosis If it is detected early with prompt and effective treatment it subsides completely and prognosis in not unfavorable . If the cases are left uncared with acute onset , serios complications are likely to occur . In this condition , both the mother and the baby are in danger . 30

30. Nursing Interventions Provide bed rest and place the client in the lateral position. Monitor blood pressure and weight. Monitor neurological status because changes can indicate cerebral hypoxia or impending seizure. Monitor deep tendon reflexes and for the presence of hyperreflexia or clonus , because hyperreflexia indicates increased central nervous system irritability Provide adequate fluids. 31

31. Nursing Interventions Monitor intake and output; a urinary output of 30 mL/hour indicates adequate renal perfusion. Increase dietary protein and carbohydrates with no added salt. Administer medications as prescribed to reduce blood pressure; blood pressure should not be reduced drastically because placental perfusion can be compromised. Monitor for HELLP syndrome. 32

32. Gestational hypertension 33

33. A sustained rise of blood pressure to 140/90 mm of Hg or more on at least two occasions 4 or more hours apart beyond the 20th week of pregnancy or within the first 48 hours of delivery in a previously normotensive women

34. It should fulfill the following criteria: Absence of any evidences for the underlying cause of hypertension Generally unassociated with other evidences of pre-eclampsia (edema or proteinuria) Majority of cases are more than or equal to 37 weeks of pregnancy Generally not associated with hemo-concerntation or thrombocytopenia, raised serum uric acid level or hepatic dysfunction - The blood pressure should come down to normal within 12 weeks following delivery 35

35. Complications of gestational hypertension Abruptio placentae Disseminated intravascular coagulation Thrombocytopenia Placental insufficiency Intrauterine growth restriction Intrauterine fetal death HELLP syndrome (a laboratory diagnosis for severe preeclampsia characterized by hemolysis , elevated liver enzyme levels, and low platelet count) 36

36. Nursing Interventions Monitor blood pressure. Monitor fetal activity and fetal growth. Encourage frequent rest periods, instructing the client to lie in the lateral position. Administer antihypertensive medications as prescribed; teach client about the importance of the medications. Monitor intake and output. Evaluate renal function through prescribed studies such as blood urea nitrogen, serum creatinine, and 24-hour urine levels for creatinine clearance and protein. 37

37. Eclampsia

38. Definition Pre-eclampsia when complicated with grandmal seizures (generalized tonic clonic seizures) and/or coma is called eclampsia 39

39. Risk factors: Maternal age less than 20 years Multigravida Molar pregnancy Triploidy Pre-existing hypertension or renal disease Previous severe Preeclampsia or Eclampsia 40

40. Clinical Features Eclamptic convulsions are epileptiform and consist of four stages Premonitory stage: twitching of muscles of face, tongue, limbs and eye. Eyeballs rolled or turned to one side, last for 30 seconds Tonic stage : limbs flexed and hands are clenched. Eyeballs becomes fixed , last for 30 seconds 41

41. Clonic stage: 1-4 min, frothing, tongue bite, stertorous breathing Stage of coma : following the fit patient passes on the stage of coma . Patient appears to be in the confused state. 42

42. Diagnosis: Lab Investigations: Complete Blood Count Platelet count LFT KFT Urine analysis Serum electrolytes 43

43. Peripheral blood smear Prothrombin time Type and screen antibody if present 44

44. 45 Management Control Hypertension Improve intravascular volume Prevent convulsions Prevent complications Deliver viable fetus

45. Control Hypertension: Most commonly, for acute control: Hydralazine Labetalol Nifedipine may be used, but unexpected hypotension may occur when given with MgSO4 For refractory hypertension: nitroglycerin or nitroprusside may be used 46

46. Nitroprusside dose and duration should be limited to avoid fetal cyanide toxicity Usually require invasive arterial pressure monitoring Angiotensin -converting enzyme (ACE) inhibitors contraindicated due to severe adverse fetal effect 47

47. 1. TRANSITION HEADLINE Let’s start with the first set of slides IV : 5 or 10 mg

48. Improve intravascular volume: Fluid recommendation : crystalloid solution (Ringer’s solution) to be administered at the rate of 1-2 ml/kg /hr Total fluids should not exceed 2 litres in 24 hours 50

49. Seizure Prophylaxis & Treatment Magnesium sulphate therapy. Magnesium sulfate has many effects; its mechanism in seizure control is not clear. It blocks the neuronal calcium influx . The therapeutic level of serum magnesium is 4-7mEq/L 51

50. Detection of Magnesium Toxicity : Decreased respiratory rate (<16 per minute) Urine output (<30ml/h) Chest pain, heart block, pulmonary edema O2 saturation monitoring (PaO2<95%) Loss of deep tendon reflexes Renally excreted Magnesium levels must be monitored frequently either clinically (patellar reflexes) or by checking serum levels for 6-8 hours 52

51. Treatment of magnesium toxicity: Stop MgSO4 IV 1 g 10% calcium gluconate slow Administer Oxygen Secure airway Ventilation 53

52. Treatment of Eclampsia: Seizures are usually short-lived. If necessary, small doses of barbiturate or benzodiazepine (STP, 50 mg, or midazolam , 1-2 mg) and supplemental oxygen by mask If seizure persists or patient is not breathing, rapid sequence induction with cricoid pressure and intubation should be performed 54

53. Patient may be extubated once she is completely awake, recovered from neuromuscular blockade, and magnesium sulfate has been administered 55

54. Nursing Interventions 56

55. Maintain bed rest. Administer magnesium sulfate (use a controlled infusion device) as prescribed to prevent seizures; magnesium sulfate may be continued for 24 to 48 hours postpartum. Monitor for signs of magnesium toxicity; keep antidote (calcium gluconate) available for immediate use, if necessary. Administer antihypertensives as prescribed. Prepare for the induction of labor. 57

56. Eclampsia Event Remain with the client and call for help. Ensure an open airway, turn the client on her side, and administer oxygen by face mask at 8 to 10 L/minute. Monitor fetal heart rate patterns. Administer medications to control the seizures as prescribed. 58

57. After the seizure has ended, insert an oral airway and suction the client’s mouth as needed. Prepare for delivery of the fetus after stabilization of the client, if warranted. Document occurrence, client’s response, and outcome. 59

58. Research Study

59. Hypertension in Pregnancy: A Community-Based Study Indian Journal of Community Medicine : Official Publication of Indian Association of Preventive & Social Medicine Article information – To study the prevalence and correlates of hypertension in pregnancy in a rural block of Haryana. Indian J Community Med. 2015 Oct-Dec Bharti Mehta, Vijay Kumar, Sumit and Debjyoti Mahopatra Dept. of Community Medicine , PG Institute of Medical Science Rohtak , Haryana Dept. of Community Medicine , DR. RML Hospital , New Delhi , India 61

60. Hypertension in Pregnancy: A Community-Based Study Abstract Background : Hypertensive disorders during pregnancy occur in women with preexisting primary or secondary chronic hypertension, and in women who develop new-onset hypertension in the second half of pregnancy. The present study was undertaken to study the prevalence and correlates of hypertension in pregnancy in a rural block of Haryana. 62

61. 63 Materials and Methods: This cross-sectional study was carried out in the all 20 subcenters under Community Health Center (CHC) Chiri , Block Lakhanmajra . All the pregnant women registered at the particular subcenter at a point of time of visit were included in the study. Appropriate statistical tests were used for analysis. During the study period , a total of 1,104 antenatal women were registered at the subcenter . A total of 931 pregnant women were included in the present study.

62. 64 Results: A total of 931 pregnant women were included in the present study. Prevalence of hypertension in pregnancy was found to be 6.9%. Maternal age ≥25 years, gestational period ≤20 weeks, history of cesarean section, history of preterm delivery, and history of hypertension in previous pregnancy were found to be significantly associated with prevalence of hypertension in pregnancy.

63. 65 Conclusion: Nearly one in 14 pregnant women in rural areas of Haryana suffers from a hypertensive disorder of pregnancy. Early diagnosis and treatment through regular antenatal checkup is a key factor to prevent hypertensive disorders of pregnancy and its complications

64. Summary The Pregnancy induced hypertension is defined as the hypertension that develops as a direct result of the gravid state. Hypertension in pregnancy is the most common medical complication. It includes Gestational Hypertension , Pre-eclampsia and Eclampsia Pre-eclampsia is a syndrome of multiple organ dysfunction . It is manifest for the first time after 20t week and is characterized by the appearance of hypertension to the extent of 140/90 mmHg or more and proteinuria with or without pathological edema. Gestational hypertension is not associated with edema, proteinuria or other hematological changes. BP usually subsides within 12 weeks following delivery Eclampsia is a complication of pre-eclampsia is characterized by grandmal seizures and it is significant cause of maternal death. The convulsion has 4 stages . Management includes general care of the patient , to arrest convulsion , control of hypertension and to expedite delivery 66

65. Questions What is Pregnancy Induced Hypertension? What are the prophylactic measures for the prevention of pre-eclampsia ? What is the Nursing management of a patient with preeclampsia ? What is the management of eclampsia ? What steps to be followed for an eclampsia event ? 67

66. 68 Page Number Edition Author’s Name Name of the Textbook 207-226 9 th Edition DC Dutta DC Dutta’s Textbook of Obstetrics 320-322 7 th Edition Linda Anne Silvestri Saunders Comprehensive Review for the NCLEX-RN Examination Bibliography

67. 69 Website Title https://www.ncbi.nlm.gov (National Center For Biotechnology Information ) Research Study Google Images Pictures Used

68. Thank You