pregnancy-induced-hypertension final-1.pdf

Pregnancy-induced-hypertension is hypertension that occurs after 20 weeks of gestation in women with previously normal blood pressure. Pregnancy-induced hypertension (PIH) complicates 6-10% of pregnancies. It is defined as systolic blood pressure (SBP) >140 mmHg and diastolic blood pressure (DBP) >90 mmHg. It is classified as mild (SBP 140-149 and DBP 90-99 mmHg), moderate (SBP 150-159 and DBP 100-109 mmHg) and severe (SBP ≥ 160 and DBP ≥ 110 mmHg).

2. Pregnancy-induced
hypertension

3. Presented by:
Yasmine mahmoud

4. Out lines:
▪Definition of hypertensive disorders of
pregnancy.
▪Classification of hypertensive disorders of
pregnancy.
▪Definitions of pregnancy-induced
hypertension.
▪Causes ofpregnancy-induced
hypertension.

5. Out lines:
✓Pre –eclampsia
-Definition
–Clinical pictures
–Diagnosis
–Treatment
✓E-clampsia
-Definition
–stages of convulsion
–severity of convulsion
–Treatment

6. Hypertensive disorders of
pregnancy
Definition:
Agroupofdisordersoccurringduring
pregnancycharacterizedbyoneor
moreofthefollowingsigns:
•Hypertension
•Proteinuria and edema
➢N.B:recentlyedema/hasnodiagnosticor
prognosticvalue(itispresentin50%of
normalpregnantwomen)

7. Incidence
•Hypertensive disorders are among the most significant &
still now unresolving problem complicating almost one in
ten pregnancies
•Responsible for 16% of Maternal Mortality in developing
countries
•Commonest cause of iatrogenic prematurity accounting
15% of all premature births & 20% of very LBW births

8. Hypertension in Pregnancy
•Systolic B.P. > 140 mmHg
•and/or
•Diastolic B.P. > 90 mmHg
•Documented on two occasions
•At least 6 hours apart
•Not more than 7 days apart
•Other Criteria (Not part of definition currently)
•SBP increased by 30mmHg
•DBP increased by 15mmHg

9. I.Pre-eclampsia
II.Eclampsia
III.Pregnancy associated hypertension
IV.Gestational Hypertension
V.Super-imposed pre-eclampsia or
eclampsia
Classification:

11. (1) Pre-eclampsia:
•Isadevelopmentofhypertensionwithproteinuria,edema
orbothduetopregnancyafter20
th
weekofpregnancy,
followedbyreturnofB.P.tonormalwithin12weekspost-
partum
Preeclampsi
a
Gestational
Hypertensio
n
Proteinuri
a

12. (2) Eclampsia:
•Generalized tonic-clonic seizurein a patient with Preeclampsia
not attributed to any other cause.
Seizure/
Convulsion/
Coma
Preeclampsi
a
Eclampsia
➢N.B:These fits are not caused by any associated
neurological disease e.g. epilepsy

13. (3)Pregnancy associated hypertension(chronic
hypertensive disease)
Presenceofpersistenthypertension
beforepregnancyorinthe1
st
20weeks
ofgestation(intheabsenceofvesicular
mole)orpersistenthypertensionafter6
weekspostpartum.

14. ➢causes
1.Essential HTN (Most Common).
2. Secondary H.T.N :
✓Endocrine problems
✓Chronic vascular disease(essential hypertension)
✓Chronic nephritis
✓Systematic lupus erythematous

15. Chronic Hypertension
•Treatmentofmildtomoderatechronic
hypertensionneitherbenefitsthefetusnor
preventspreeclampsia.
•Excessivelyloweringbloodpressuremayresult
indecreasedplacentalperfusionandadverse
perinataloutcomes.
•WhenBPis150to180/100to110mmHg,
pharmacologictreatmentisneededtoprevent
maternalend-organdamage.

16. Treatment of Chronic Hypertension
•labetalol,andnifedipinemostcommonoral
agents.
•AVOID:atenolol,thiazidediuretics
•Womeninactivelaborwithuncontrolled
severechronichypertensionrequire
treatmentwithintravenouslabetalolor
hydralazine.

17. (4)Gestational Hypertension
Newonsetofhypertensionafter20weeksofgestation
withoutproteinuria,followedbyreturnofB.P.tonormal
within12weekspost-partum.

18. :(5)Super imposed hypertension
•Development of pre-eclampsia or eclampsia in a patient with
chronic hypertensive disease.
Diagnosis:
•Rise of 30 mmhg in systolic BP and rise of diastolic BP 15
mmhg.
•Development of proteinuria in hypertensive patient
•Development of hypertension in protienuric patient.

19. New onsetproteinuriain hypertensive women but
no proteinuria before 20 weeks' gestation
•A sudden increasein proteinuria or blood pressure or
platelet count < 100,000/L in women with hypertension and
proteinuria before 20 weeks' gestation

20. Pregnancy induced hypertension
(pre-eclampsia &Eclampsia)
➢Incidence:
•Pre-eclampsia 5-10% of pregnant women
•10-15 % of primi gravid women
•Eclampsia 1/1000-1/2000 pregnant wpmenEclampsia : pre-eclampsia
1 100

21. Causes of PIH
Not exactly known but common in certain groups of females
they are called PIH prone
1. parity
▪PIH is almost entirely the disease of primigravida especially
the elderly
▪Occur in multi gravida under the following conditions:
✓Those who changed their partner
✓Those who had vesicular mole

22. Causes of PIH Cont.………,
2-Age
3-Multifetal pregnancy(5times commoner)
4-Chronic hypertension
5-Chronic nephritis
6-Diabetes mellitus
7-Vesicular mole
8-Obesity
9-Family history

23. Pathology
(1)pathologic physiology:
Withoutknowncausethereisfailure
ofoftrophoplasticinvasionthat
leadingtovasospasmofbloodvessels
inarteriolswhichleadingtodecrease
placenralperfusionandleadingto
IUGR-IUFD

24. •Thevasospasmcausingreleaseofmediators(toxins)
whichreachtobloodinallorgansandcausingvascular
endothelialcelldamage
•vascularendothelialcelldamagecausingconstrictionand
fibrosistoendotheliumofbloodvesselsthatdestroy
bloodcomponentsandleadingtohemolysis

25. (2) Pathologic biochemistry:
•Duetoconstrictionofbloodvessels
endotheliumshiftingoffluidfrom
intravasculartoextravascularcausing
edema
•Allbloodcomponentatextravascular
cellsismostlyfluidbecausehemolysis
andthatcausingDIC

26. 3-Placental isocheimal theory:
oPlacentalischemialeadstodecreasedkidneyfunctionand
causeprotienurea
oDecreaseofliverfunctionleadingtoelevatedinliverenzymes
oDecreaseofbraininfusionleadingtobrainedema

27. (4) Pathologic anatomy
damageOrgan
IUGRutero-placenta
Epistaxis, DIC like features, hem
concentration
Hematological
Cerebral edema, cerebral hge→seizuresCNS
Sub endothelial hge , focal necrosis & hge,
cardiomyopathy, heart failure
Heart
Pulmonary edema, hemorrhagic
bronchopneumonia
Lungs
glomerular endotheliosis, oliguriaKidneys
Sub capsular hge, ischaemia→periportal
necrosis, HELLP
liver

28. Clinical picture of pre-
eclampsia
Signs:
3 cardinal signs:
hypertension * protienuria * edema *
1-hypertension: normal 120/80
Diagnosis of hypertension:
A.B.P : 140/90 or more
B.Rise of systolic B.P >30 mmHg.
C.Rise of diastolic B.P >15 mmHg.

29. How to Measure Blood Pressure
•Sitting Position
•Patient Relaxed
•Arm well supported
•Measured in right arm
•Cuff at heart level
•Proper cuff size
•At 6 hours from the last meal

30. Roll over test:
✓At28-32weeks,theclientisplacedinleftlateral
positionfor20minutes,thenrolledintotheirher
back.
✓Bloodpressureistakenimmediatelyand5
minuteslater.
✓A20mmHgdiastolicriseisaresponsethat
predictsthedevelopmentofPIH

31. Mean arterial pressure (MAP):
•Calculatedbyaddingsystolicpressuretotwicediastolic
pressurethendividetheproductbythree.
•Anincreaseof20mmHginMAPiscondideredominous.
•AMAPof100isabnormal,andaMAPof105indicates
hypertension.

32. 2-protienuria
Definition:
Presence of more than 0.3 gm/liter in 24-hour urine collection
3-edema (2 types):
A.Occult edema: usually develop
before H.T.N. edema of the internal
organ
Diagnosis
Excessive weight gain

33. B.Clinical edema
•usually develop after H.T.N
•Edema is detected at the ankle, leg, lower
abdominal wall ,face and vulva

34. in sever cases only))symptoms
1-headache: usually frontal
2-Eye symptoms: blurring on vision
•Flashes on lights
•Blindness
3-oliguria and anuria:
•Oliguria:urine output<500 cc /day
•Anuria: urine output <100 cc/day or no
urine out put.
4-nausea and vomiting
5-epigastric pain

35. Preeclampsia
•Characterized as mild or severe based on the degree of
hypertension and proteinuria, and the presence of
symptoms resulting from involvement of the kidneys,
brain, liver, and cardiovascular system

36. Pre-eclampsia
Mild Severe
B/P 140/90 160/110
Protein 1+ 2+ 3+ 4+
Edema 1+, lower legs 3+ 4+
Weight <1 lb. / week >2lb. / week
Reflexes 1+ 2+ brisk 3+ 4+(Hyperreflexia) Clonus present
Retina 0 Blurred vision, Scotoma
Retinal detachment
GI, Hepatic 0 N & V, Epigastric pain,
changes in liver enzymes
CNS 0 Headache, LOC changes
Fetus 0 Premature aging of placenta
IUGR; late decelerations

37. Investigations
1)complete urine analysis:
•a-Albumin b-volume
•c-sugar(diabetes)
d-casts(chronic nephritis
2) Kidney function tests
3) Assessment of fetal wellbeing
-daily fetal movement
-Doppler “Biophysical profile”

38. 4) Blood picture(hemolytic anemia)
•N.B: PIH one of the cause of HELLP
syndrome
H Hemolytic anemia
ELElevated liver
enzymes
LPLow platelet count

39. Sever cases of pre-eclampsia are characterized :by
one or more of the following
•BP >180/100
•Protein urea >5gm/Lin 24-hour of urine collection
•Oliguria
•Visual or cerebral disturbance
•Pulmonary edema or cyanosis
•Sever epigastric pain

40. Complication of pre-eclampsia
1-fetal:
✓Hypoxia
✓IUGR , IUFD
✓Hypoxia
✓Prematurity
2-maternal :
✓Hemorrhage(accidenal,cerebral,DIC)
✓Failure (renal, heart, liver)
✓Eclampsia
✓HELLP syndrome
✓Recurrence in the next pregnancy

41. Treatment of pre-
eclampsia
Aim :
In mild pre-eclampsia ,
•conservative management until the fetus
is mature
In sever pre-eclampsia:
•Control of B.P
•Prevention of convulsion
•Delivery to avoid complication

42. A-general medical measures
Mild pre-eclampsia:
➢1-Rest:
•improves venous return leading to:
•Improve renal perfusion
•Decrease edema
•Improve uteroplacental circulation
➢2-diet
•Sodium restriction (2-4 gm/day)

43. ➢3-observation
•Questioning fetal movement daily
•blood pressure monitoring at least 4
times/daily
•Urinary protein daily
•Body weight every other day
•Renal function, liver enzymes and platelet
count
•Ultrasound weekly to detect fetal hypoxia

44. ➢4-mild sedative
➢5-antihypertensive
Aim:
•to decrease the maternal complication
•Alpha methy1 dope is commonly uses
250 mg tablets (maximum 2 gm daily)
N.B: Diuretics are not used m as they will
increase hemoconcentration

45. B-sever pre-eclampsia
1-Rest in bed : in semi-dark & quite room
2-fluids should not exceed 125ml/hour to
avoid pulmonary edema
3-observation for:
•Vital signs & urine out put
•Signs of toxicity of magnesium sulphate
•Abdominal tenderness to detect
conclead accidental hemorrhage

46. 4-magnesium sulphate
For prevention of convulsion
Mechanism of action:
Central anticonvulsant on the cerebral
cortex
Dose :
Loading dose : 6gm given IV infusion
Maintenance dose : 4 gm/4 hours given
IV infusion

47. Before administration to prevent
toxicity
a-patellar reflex should be present.
b-The respiratory rate should be more
than 16/min
c-Urine out put should be at least
100ml/4hours.
Side effects:
CNS & respiratory depression

48. 5-emergency antihypertensive:
Aim: to decrease maternal complication
Hydralazine
Action : vasodilator& improve renal perfusion
Dose : 5-10 mg every 20 min till diastolic B.P is 100 mmhg
not less to avoid reduction of placenta perfusion

49. B-Termination of pregnancy
Advantages:
It reduces complication
Disadvantages
Prematurity
Time of deli vary :
Mild pre-eclampsia: at 37
th
weeks

50. Management during labor
•Maternal observationespecially B.P
•Observation of FHS by continuous electronic monitoring

51. E-eclampsia
Definition:
➢Sever pre-eclampsia with convulsion
➢Convulsion due to cerebral edema & hypoxia

52. Diagnosis
1-History
•The majority of cases are preceded by pre-eclampsia.
•Convulsion before pregnancy must be asked for to exclude
epilepsy
2-signs
•In addition to hypertension,edema,protienuria& there are
convulsions showing

53. Stages of eclampsia fit:-
Picture Duration Stage
-Eyes are rolled up
-twitches of the face and hand
30 seconds 1-premonitory stage
-Cry: caused by spasm of the respiratory
muscles and larynx.
-Generalized tonic spasm.
-Cyanosis
30 seconds 2-Tonic stage
Convulsions
-Fetal hypoxia “ distress”.
-Face congested.
-Blood-stained frothy discharge from
the mouth.
-Tongue may be bitten.
-Cyanosis gradually disappears.
-Involuntary passage of stool & urine .
1 –2 minutes3-Clonicstage
Others fits mayoccur during coma Variable (but usually 10
–30 minutes)
4-Coma stage

55. b-Timing of convulsion:
•Ante partum (65%): convulsion during pregnancy
•Intra partum (20%): convulsion during labor
•Post partum (15%): 24-48 hours after labor

56. C-severity(Edenscriteria)
✓Coma for 6 hours or more indicates
cerebral hemorrhage
✓More than 10 convulsions indicates
cerebral hemorrhage
✓Pulse over 120 indicates heart failure
✓Temperature over 39 c due to
pneumonia
✓Respiratory rate over 40/min indicates
pneumonia

57. Treatment :
A.General and medical measures
1-Rest in bed
Room: semi-dark & quite& floor is made of rubber or rubber
shoes is used.
Bed: -raise in foots to help drainage of bronchial secretion.
-No pillow.
2-Nurse:
-efficient
-beside the patient at all times

58. Cont…….,
2-IV fluids should not exceed 125ml/hour
IV glucose 25% to decrease brain edema
3-observation for:
•Vital signs & urine out put
•Respiration & cyanosis
•Signs of magnesium sulphatetoxicity
•Abdominal tenderness to detect canceled accidental
hemorrhage
4-change position of the patient every 4 hours

59. Cont………,
•During convulsion a mouth gag is used to protect the tongue
•Bronchial secretion should be aspirated
5-control of convulsion:
•Magnesium sulphate : the best and the safest drug.
Action:
oCNS depressant
oAnti convulsion

60. oDiuretics
oVasodilator
➢Intialdose : 6-10 gm IM or I.V drip
➢Maintenance dose : 4-6 gm IM /4-6 hours
•Or 4-5 gm I.V infusion over 20 min
•Then 1-3 gm/hour I.V infusion
•Conditions to be fulfilled before
maintenance dose are:
(1) urine out put > 100 C.C from last dose
(2) respiration > 16 minutes
(3) knee jerk is present

61. Side effects of magnesium sulphate:
•Maternal :
✓Respiratory depression
✓Cardiac arrest
✓Hypocalcaemictetany
✓Poor control of fits
✓Post partum hemorrhage
•Fetal :
✓Absent beat or beat variation
✓Respiratory depression

62. Signs of magnesium sulphate
toxicity
1.Absent knee jerk.
2.Respiratory rate <16 minute.
3.Urine < 100 C.C from last dose.
➢Anti dote :
Calcium gluconate 10 C.C is given if signs
of Mgso4 toxicity.

63. Cont………..,
5-emergency antihypertensive as
hydralazine
6-oxygen is given
➢Delivery
•If labor does not start spontaneously
within 24 hours after control of fits
delivery is essential as the convulsion
may occur

64. •Phenytoin: 25 mg/kg initially followed by 500mg IV every
12 hours
•Other drugs : IV diazepam

65. Nursing Care Plan
For the Woman with Preeclampsia
➢Nursing Diagnosis:
1)DeficientFluidVolumerelatedtofluidshiftfrom
intravasculartoextravascularspacesecondaryto
vasospasm
➢Goal:
Patientwillberestoredtonormalfluidvolumelevels.

66. ➢Expected Outcome:
The signs and symptoms of preeclampsia will
diminish as evidenced by decreased blood
pressure, urine protein levels of zero, and a
return of the deep tendon reflexes to normal.

67. ➢Nursing intervention:
•Encourage woman to lie in the left lateral recumbent position.
•Assess blood pressure every 1 to 4 hours as necessary.
•Monitor urine for volume and proteinuria every shift or every
hour.
•Assess deep tendon reflexes and clonus.
•Assess for edema.

68. Cont..,
•Administer magnesium sulfate per infusion pump as ordered.
•Assess for magnesium sulfate toxicity.
•Provide a balanced diet that includes 80 to 100 g/day or 1.5
g/kg/ day of protein.

69. ➢Nursing diagnosis:
2)Ineffective Cerebral Tissue Perfusionrelated to interruption
of blood flow, occlusive disorders, hemorrhage, cerebral
vasospasm, cerebral edema.
➢Expectant outcome:
-Maintain a balaneinput and output with
urinary output greater than 30ml/hr.

70. ➢Nursing intervention:
•Monitor or record the neurological status as often as possible
and compare it to standard or normal state.
•Monitor vital signs.
•Record the data changes such as the blindness of vision, or
visual field disturbances in perception.
•Assess the higher functions, such as speech function.

71. Cont..,
•Putheadslightlyelevatedpositionandtheanatomical
position(neutral).
•Maintainastateofbedrest,creatingapeacefulenvironment,
limittheactivitiesofvisitorsorpatientsasindicated.
•Helppreventtheoccurrenceofstrainingduringdefecation
andbreathingforce(continuouscough).
•Collaborationinoxygenanddrugsasindicated

72. ➢Nursing Diagnosis:
3)Riskforimpairedinfetalwellbeingrelatedto
uteroplacentalinsufficiencysecondarytovasospasm.
➢Expected Outcome:
•Thefetuswillhaveanadequatesupplyofoxygenand
nutrientsasevidencedbyabsenceofsignsofnon
reassuringfetalstatusandbfetaldiagnostictestresults
withinnormallimits.

73. ➢Nursing intervention:
•Instruct patient to count fetal movements three times
a day for 20 to 30 minutes.
•Encourage patient to rest in the left lateral recumbent
position.
•Continuous electronic fetal monitoring.
•Perform non stress test (NST) as ordered.
•Report any signs of reassuring to physician.