Presentation on pregnancy Induced hypertension

Description about pregnancy Induced hypertension, types, management and nursing care. Good for student nurses as well as nurse practitioners. Simple terms, complete theoretical aspect covered in small points.

1. PREGNANCY INDUCED HYPERTENSION

2. PATIENT PARTICULARS NAME : Mrs Guddan AGE : 34 yrs HUSBAND'S NAME : Hav Nawab Ali ADDRESS : Village- Gheja , Uttar Pradesh DATE OF ADMISSION : 02/11/2019 LMP : 19/02/2019 EDD : 26/11/2019 OBSTETRIC SCORE : G3P2L2 GESTATIONAL SCORE : 36 Weeks 05 Days DIAGNOSIS : ANC With Pre- eclampsia with GDM

3. PRESENTING COMPLAINTS Mrs Guddan, a 34 yr old multigravida, known case of GDM and pre-eclampsia was admitted at 36 weeks 05 days period of gestation for safe confinement and early termination of pregnancy with induction of labour planned after completion of 37 weeks period of gestation

4. PRESENT HISTORY OF ILLNESS Known case of GDM and pre- eclampsia , was started of OHA's and insulin therapy and oral antihypertensives at 31 weeks POG Mrs Guddan got admitted to maternity ward on 02/11/2019 for safe confinement and BP monitoring and early termination of pregnancy after completion of 37 weeks POG Blood sugar and BP monitored throughout her stay- within normal limit Induction done at 37 weeks 02 days POG with cerviprime on 07/11/2019 .

5. PAST MEDICAL/SURGICAL HISTORY OF ILLNESS No known significant medical history Fracture humerus(left) operated in 2016 FAMILY HISTORY OF ILLNESS No significant medical or surgical history of illness

6. PERSONAL HISTORY NUTRITION Dietary Habits : Non Vegetarian Meal Pattern : 3 meal pattern Smoking : Non Smoker Alcohol : Non Alcoholic HYGIENE Patient performs all activities of daily living herself and was well groomed

7. PERSONAL HISTORY SLEEPING PATTERN Normal sleeping pattern, slept 1-2 hours in the afternoon and around 6-7 hours at night everyday ELIMINATION No history of constipation. No history of urinary retention or incontinence

8. PERSONAL HISTORY ALLERGIC REACTION No known history of any allergic reactions CONTRACEPTIVE HISTORY No contraceptives used post marriage

9. MENSTRUAL HISTORY Menarche : 15 years Cycle : 28-30 days/ 4-5 days and regular LMP : 19/02/2019 EDD :26/11/2019 MARITAL HISTORY Patient married at the age of 19 years Married since past 12 years Had a non consanguineous marriage

10. OBSTETRIC HISTORY PAST OBSTETRIC HISTORY PRESENT OBSTETRIC HISTORY 1st TRIMISTER Booked case, her first visit at MH Jalandhar was on 13/06/19 at 16 wks 04 days POG Vomiting and nausea present during first trimester SL NO YEAR CONCEPTION PREGANCY OUTCOME PUERPARIUM DETAILS OF CHILD 1. 2011 Spontaneous Normal Vaginal Delivery Uneventful Male 3.5kg 2. 2012 Spontaneous Normal Vaginal Delivery Uneventful Female 3.5kg 3. 2019 Spontaneous Present Pregnancy

11. OBSTETRIC HISTORY 2. 2nd TRIMESTER Quickening felt at 19 weeks POG Two doses of Inj TT taken 3. 3rd TRIMESTER: Presence of GDM and PIH detected 30 weeks: Derranged blood sugar level, started on OHAs 31 weeks 02 days: Had raised Blood pressure, admitted for BP and Blood sugar monitoring to Maternity ward. Started on antihypertensives 35 weeks : Started on Lispro and Glargin and added Tab Labetatol, due to persisteantly raised Blood sugars and BP

12. PHYSICAL EXAMINATION VITAL SIGNS: Temp : 98.4F Pulse : 90/min Respiration : 22/min BP : 144/90 mmHg Nutritional status : Good Build : Average Height : 164cm Weight : 68kg BMI : 26.5 kg/m 2

13. CONTINUED Pallor : Not present Icterus : Not present Breast : Enlarged in size, primary and secondary areola present, montgomery tubercles prominent, no colostrum seen Thyroid : Not enlarged Pedal edema : Present Varicose vein : Not present Heart, liver & spleen: NAD Lungs : No signs of breathlessness, normal lung sounds

14. ABDOMINAL EXAMINATION INSPECTION Size : Appropriate for period of gestation Shape : Ovoid Contour : Even Fetal movements : Visible fetal movements Skin : Linea niagra and straie gravidarum present Umbilicus : Slightly protruded

15. CONTINUED PALPATION Lie : Longitudinal Presentation : Cephalic Position : LOA Engagement : Not Engaged Abdominal Girth : 88 cm Fundal Height : 36 cm AUSCULTATION FSH : 144/min

16. INVESTIGATIONS SL NO INVESTIGATIONS PATEINT VALUE NORMAL VALUE REMARKS 1. Hb 11.2 12-16 mg/dl Normal 2. TLC 7600 4000-11000 cumm Normal 3. PLATELET 1,53,000 1.5-3 lakh/cumm Normal 4. S.Bil 0.3 0.1-1 mg/dl Normal 5. SGOT 25 upto 40 Normal 6. SGPT Kit NA upto 40 - 7. Urea 22 10-50 mg/dl Normal 8. Creatinine Kit NA 0.5- 1.4 mg/dl - 9. Uric acid 5.4 <4.5 mg/dl >4.5 indicative of pre-eclampsia 10. 24 Hours urine protein 325 <300mg Proteinurea 11. PBS for hemolysis NAD No hemolysis Normal 12. LDH 552 200-400 s/o hemolysis 13. Urine for ketones Negative Negative Normal

17. INVESIGATIONS SUGAR PROFILE 21/09/19 23/09/19 22/10/19 31/10/19 FASTING PP BL AL BD AD 3AM HBA1C 99mg/dl 115mg/dl 93mg/dl 126mg/dl 156mg/dl 142mg/dl - 8% (4.5-6.3%) 120mg/dl 111mg/dl 148mg/dl 132mg/dl 143mg/dl 166mg/dl - 112mg/dl 155mg/dl 93mg/dl 103mg/dl 116mg/dl 158mg/dl - 90mg/dl 100mg/dl 88mg/dl 104mg/dl 110mg/dl 102mg/dl 95mg/dl USG at 31 weeks : Gravid uterus showing single live fetus, Adequate amniotic flow Placenta posterior, away from the internal os Normal flow in umbilical artery and maternal uterine arteries

18. TREATMENT SNO3. NAME OF DRUG DOSE FREQUENCY TIME 1. TAB METFORMIN 1g BD 7-7 2. TAB LABETALOL 100mg TDS 10-2-10 3. TAB ECOSPRIN 75mg OD 2pm 4. TAB CALCIUM 1 BD 10-10 5. TAB AUTRIN 1 OD 10am 6. INJ LISPRO 6U-6U-6U TDS With meals 7. INJ GLARGIN 6U HS 10pm

19. INTRAPARTUM MANAGEMENT Induction done at 37 weeks 02 days POG with cerviprime on 07/11/2019 cervix- 2cm, Effacement- 20% Head station- -3 , Membranes intact Augmented labor with ARM and inj pitocin infusion Sugar and BP monitored throughout the period of labour Patient gave complaint of uneasiness, BP recorded 150/98mmHg At 1730 hours patient had an episode of seizures (GTCS), Inj MgSO4 4g IV stat administered over 3-5 min and infusion started @1g/ hr and oxygen supplemented via nasal prongs and shifted to OT for emergency LSCS

20. POST OPERATIVE MANAGEMENT Extracted a healthy alive baby TOB- 1836 HOURS DOB- 07/11/2019 SEX - Male B.wt - 3kg Observed closely at ICU for 24 hours, continued on MgSO 4 infusion Monitored hourly- BP, knee jerk, respiration and urine output Started on IV antibiotics Shifted to maternity ward after 24 hours

21. PREGNANCY INDUCED HYEPERTENSION

22. INCIDENCE 3.7% of pregnancies 16% of pregnancy related death Eclampsia 1 in 2000 deliveries

23. CLASSIFICATION OF HYPERTENSION IN PREGNANCY DISORDER DEFINITION 1. HYPERTENSION 2. GESTATIONAL HYPERTENSION 3.PRE-ECLAMPSIA 4. ECLAMPSIA 5. CHRONIC HYPERTENSION 6. SUPERIMPOSED PRE ECLAMPSIA/ECLAMPSIA BP ≥ 140/90 mmhg measured 2 times with atleast a 6 hr interval BP ≥ 140/90 mmhg for the first time in pregnancy after 20 weeks, without proteinuria Gestational Hypertension with proteinuria Women with pre- eclampsia complicated with convulsions Known hypertension before pregnancy or hypertension diagnosed first time before 20 weeks of pregnancy Occurence of new onset of proteinuria in women with chronic hypertension

24. PRE-ECLAMPSIA Multisystem disorder of unknown etiology characteristized by development of hypertension to the extent of 140/90 mmHg or more with protienuria after 20 week in a previously normotensive and nonproteinuric women DIAGNOSTIC CRITERIA Hypertension Oedema: Pitting edema over the ankles over 12 hours bed rest or rapid weight gain 0.5 kg a week Proteinuria: Presence of total protein in 24 hours urine of more than 0.3g or ≥ 2+ (1g/L) on atleast two random clean catch urine samples tested ≥ 4 hours apart in the absence of any UTIs

25. CLINICAL TYPES MILD PRE-ECLAMPSIA BP ≥ 140/90 mmHg but less than 160/110mmHg without significant proteinuria SEVERE PRE-ECLAMPSIA Persistent BP ≥ 160/110 mmHg Protein excretion > 5g/24 hrs Oliguria <400ml/24 hours Platelet < 100,000/mm 3 Cerebral or visual disturbances

26. ECLAMPSIA Pre-eclampsia when complicated with generalized tonic-clonic convulsions and or coma is called eclampsia May appear before, during or after labor

27. RISK FACTORS Primigravida: Young or elderly Family history Placental abnormalities: excessive exposure to chorionic villi- molar pregnancy, multiple pregnancy, diabetes Obesity Pre-existing vascular diseases Thrombophilias

28. PATHOPHYSIOLOGY

29. PATHOPHYSIOLOGY

30. CLINICAL FEATURES Mild symptoms: Slight swelling over the ankles Gradually extending to the face, abdominal wall, vulva and even the whole body Alarming symptoms: Headache Disturbed sleep Oliguria Epigastric pain Blurring/dimness of vision

31. SIGNS Weight gain Persistent rise of BP > 140/90mmHg Edema over ankles Pulmonary edema Abdominal examination: scanty liqour or IUGR (chronic placental insufficiency) Eclamptic Fit or Convulsions PREMONITORY STAGE TONIC STAGE CLONIC STAGE STAGE OF COMA

32. INVESTIGATIONS Urine : Proteinuria is the last feature of pre-eclampsia to occur Ophthalmic examination : Retinal edema, constriction of the arterioles,hemorrhage etc Blood values : Serum uric acid >4.5 mg/dL Serum creatinine maybe >1mg/dL, Urea normal to slightly raised, Thrombocytopenia , Abnormal coagulation profile and Hepatic enzymes maybe elevated

33. COMPLICATIONS IMMEDIATE : MATERNAL ECLAMPSIA: Injuries, pulmonary failure, neurological deficits, cardiac and renal shutdown, coagulopathies, postpartum psychosis DURING PREGNANCY DURING LABOR PUERPERIUM Eclampsia Antepartum hemorrhage Acute renal failure Cardiac failure Dimness of vision or even blindness Preterm labor HELLP Syndrome ARDS Eclampsia Postpartum hemorrhage Eclampsia Shock Sepsis

34. COMPLICATIONS IMMEDIATE : FETAL Intrauterine fetal death Intrauterine growth retardation Asphyxia Prematurity REMOTE: MATERNAL Residual hypertendion Recurrent pre-eclampsia Chronic renal disease Risk of palental abruption

35. PREVENTION Regular antenatal checkup Antithrombotic agents: Tab Ecosprin 75mg daily in potentially high risk patients Heparin or Low Molecular Weight Heparin is useful in women with thrombophilia and with high risk pregnancy Calcium supplementation 2gm per day Antioxidants: Vitamin E and C Balanced diet rich in protein

36. MANAGEMENT HOSPITAL MANAGEMENT Rest Continuous BP monitoring - every 4 Hourly Blood investigations: Platelet, coagulation profile, uric acid, creatinine, LFT and 24 hour urine protein Daily urine dipstick Ophthalmoscopy Fetal well being assessment: DFMC, NST, CTG, Biophysical profile and USG-Doppler Antihypertensives: Diastolic BP over 110mmHg

37. MANAGEMENT ANTIHYPERTENSIVES DRUG DOSE SCHEDULE MAXIMUM DOSE Tab Labetalol Tab Nifedipine Tab Methydopa Tab Hydralazine 100mg qid 10-20 mg bd 250-500mg tds or qid 10-25 mg bd HYPERTENSIVE CRISIS- BP ≥160/110 mmHg or MAP ≥ 125 mmHg Inj Labetalol Inj Hydralazine Tab Nifedipine Inj NTG Inj Sodium nitropruside 10-20 mg IV/10 min 5mg/30 min 10-20 mg oral, can be repeated in 30 min 5 µg/min IV 0.25-5µg/kg/min IV 300mg 30 mg 240 mg/24 hrs } Only used when other drugs have failed

38. MANAGEMENT COMPLETE CONTROL BP PERSISTENTLY HIGH PERSISTENTLY ↑BP EVEN WITH ANTI-HYPERTENSIVES ADDITIONAL OMNIOUS SYMPTOMS PRETERM: Discharge and attend ANC Clinic TERM: Hospitalization ≥ 37 weeks then deliver Try to continue pregnancy till 37 weeks or atleast 34 weeks then deliver Couple counseling Transfer to tertiary care center Prophylactic anticonvulsant therapy Delivery, irrespective of POG Steroid if < 34 weeks METHOD OF DELIVERY Induction of labour Cesarean

39. MANAGMENT: ECLAMPSIA Maintain: airway, breathing and circulation Oxygen administration 8-10 l/min Arrest convulsions Ventilatory support (if needed) Prevention of injuries Hemodynamic stabilization Organize investigations Deliver by 6-8 hours Prevention of complications Postpartum care

40. MANAGMENT: ECLAMPSIA FIRST AID OUTSIDE THE HOSPITAL MEDICAL and NURSING MANAGEMENT Shift to tertiary cary hospital immediately All maternal documents Stabilize BP, arrest convulsions MgSO 4 : Pritchard/Zuspan Inj Labetalol 20 mg IV Diuretics: Pulmonary edema Diazepam 5 mg: Avoid apnoe or cardiac arrest Trained medical personnel or a midwife Supportive care: Management during fits Detailed history Examination: General, abdominal and vaginal examination Monitoring: Half hourly-pulse, respiration and BP hourly- Urine output Fluid balance: Total fluid previous UO + 1000ml (RL) Antibiotics: In Ceftriaxone 1g BD

41. MANAGMENT: ECLAMPSIA MANAGEMENT DURING FITS : Placed in a railed cot, mouth gag to be placed in premonitory stage Lateral decubitus position Clear air passage to avoid aspiration Oxygen 8-10 l/min Continous monitoring ABG if oxygen saturation < 92% STATUS EPILEPTICUS: Inj Thiopentone sodium 0.5 g dissolved in 20 ml 5%D IV slow Anesthesia, muscle relaxants and assisted ventilation

42. ANTICONVULSANT AND SEDATIVE REGIMEN LOADING DOSE MAINTENANCE DOSE INTRAMUSCULAR (PRITCHARD) 4g IV, over 3-5 min followed by 10g deep IM (5g in each buttock) 5g IM 4 hours in alt buttock INTRAVENOUS (ZUSPAN OR SIBAI) 4-6g IV over 15-20 min 1-2g/hr IV infusion Recurret fits : 2g repeat IV bolus over 5 min in the above regimen

43. MANAGEMENT: ECLAMSIA ECLAMPSIA : IN LABOR ARM: Forceps, ventose Cesarean: Uncontrolled fits, unconscious patient with poor prospect of vaginal delivery, malpresentations ECLAMPSIA: NOT IN LABOR FITS CONTROLLED FITS NOT CONTROLLED (6-8 HOURS) Term: Deliver- Induce or CS Preterm: Steroid then deliver Dead: Induce and deliver Deliver Favourable vaginal findings: ARM, oxytocin Unfavourable finding: CS

44. NURSING MANAGEMENT: ASSESSMENT Early prediction and prevention: Look for omnious signs and symptoms Intensive monitoring of the patient i . Continuous fetal monitoring ii.Assess vital signs Ask patient to tell if she develops a headache, blurred vision, dizziness or epigastric pain Age and parity Predisposing factors

45. NURSING DIAGNOSIS Altered tissue perfusion related to decreased uteroplacental perfusion, maternal hypovolemia Fluid volume deficit related to decreasing plasma colloid and ongoing renal shutdown Decreased cardiac output related to hpovolemis /decreased venous return and increased systemic vascular resistenace Ineffective airway clearance related to possible chances of aspiration due to convulsions Risk for maternal injury related to tonic clonic convulsions Impaired physical mobility related to decreased muscle strength Risk for fetal injury Risk for infections

46. NURSING INTERVENTION Faciliate early prenatal care Assess physical parameters Provide diet instructions Instruct regarding medications Anticipate seizure:Prompt seizure prophylaxsis Maintain IV assess, catheterize the patient Special considerations during MgSO 4 infusion: Continue infusion only if Knee jerks are present, Urine output is >30ml/ hr and RR is >12/min Therapeutic serum magnesium level is 4-7mEQ/L Administer Inj calcium gluconate for MgSO 4 toxicity Prepare for labour induction or cesarean Continue MgSO 4 for 24 hours after delivery

47. HEALTH EDUCATION Regular antenatal checkup Drug compliance Dietary changes: High protein diet Teach and patient about the alarming signs of PIH Seek care immediately Counselling: Possible early termination of pregnancy, premature new born Family support

48. SUMMARY Mrs Guddan, 34 year old multigravida, known case of pre-eclampsia with GDM got admitted to MH JRC at 36 weeks 06 days POG for safe confinement and induction of labor at 37 weeks POG. During labor after induction as planned, she developed eclampsia, immediate care was given and shifted for emergency LSCS. Postpartum continued to have ↑BP. She was diagnosed as a case of Chronic Hypertension and was diacharged after 10 days on Tab Amlodipine 5mg OD

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