SEMINAR

HYPERTENSION
DISORDER DURING
PREGNANCY

SUBMITTED TO, SUBMITTED BY,

Prof.Dr.S.Kalabharathi Mrs.R.Hemavathi
Principal Msc(Nursing) ll year
HOD of OBG SCON,SIMATS
SCON,SIMATS
SEMINAR HYPERTENSION DISORDER
DURING PREGNANCY
INTRODUCTION:

It is associated with severe maternal obstetric complications. Incidence is 5-10%.

The most frequent cause of iatrogenic prematurity. Preterm delivery Intrauterine
growth restriction (IUGR) Perinatal death ,Maternal cerebrovascular accidents
Placental abruption .

DEFINITION:

Hypertension disorders of Pregnancy also known as maternal Hypertensive

disorders is a group of disease that includes

Pre-eclampsia , Eclampsia, Gestational Hypertension and Chronic

Hypertension.

CLASSIFICATION OF HYPERTENSION IN PREGNANCY:

1. Gestational Hypertension

2. Pre-Eclampsia

3. Eclampsia

4. Chronic Hypertension

5. Pre-Eclampsia or Eclampsia super imposed on Chronic Hypertension

1.GESTATIONAL HYPERTENSION:

New onset of hypertension after 20 weeks of gestation without proteinuria or other

features of preeclampsia, followed by return of B.P. to normal within 12 weeks
post-partum. This terminology replaces the term

“Pregnancy Induced Hypertension.”

DIAGNOSIS:

 Determine the severity of hypertension

  Measure protein excretion
 24-hour urine collection
 Evaluate for signs/symptoms of severe preeclampsia
 Perform laboratory evaluation

MANAGEMENT:

Mild Gestational HTN:

 Managed as outpatients (weekly antepartum visits)

 Daily fetal movement/kick counting
 NST + AFI
 Fetal growth monitoring every 3-4 weeks
 No antihypertensive therapy
 No antenatal corticosteroids
 Deliver patients no later than their EDD

Severe Gestational HTN:

 SBP ≥160 mmHg or DBP

 ≥110 mmHg is treated with antihypertensive agents

 > 34 wks à DELIVER!

 < 34 wks à give steroids

2.PRE-ECLAMPSIA –PREGNANCY INDUCED HYPERTENSION:

Definition:

A multisystem disorder of unknown aetiology characterized by development

of Hypertension to the extent of 140/90 mm hg or more with proteinuria after the
20th week in a previously normotensive and nonproteinuric woman. -D.C.Dutta
New onset of hypertension after 20 weeks of gestation along with properly
documented proteinuria or end-organ dysfunction symptoms, followed by return
of B.P. to normal within 12 weeks post-partum.
Preeclampsia can also occur without proteinuria, with end- organ dysfunction
manifestations. Edema is no longer considered a specific diagnostic criterion for
preeclampsia.

CLASSIFICATION OF PRE-ECLAMPSIA:
The Pre-Eclampsia is classified as
A. Primary -70%
• Pre-eclampsia
• Eclampsia
B . Secondary -30%
• Pre-eclampsia-eclampsia superimposed on chronic hypertension (25%)
• Pre-Eclampsia-Eclampsia superimposed on Chronic renal disease (5%)
CLASSIFICATION BASED ON SEVERITY:
1. Mild Pre-Eclampsia
2. Moderate Pre-eclampsia
3. Severe Pre-eclampsia
MILD-MODERATE PRE-ECLAMPSIA:
• Systolic B.P 140-160 mmhg
• Diastolic B.P 90-100 mmhg
• Proteinuria upto ++
SEVERE PRE-ECLAMPSIA
• Systolic B.P >160 mmhg
• Diastolic B.P >110 mmhg
• Proteinuria upto +++ or more
• Epigastric pain
RISK FACTORS:
• Primigravidae(Young or elderly)
• Family history of hypertension, pre-eclampsia
• Placental abnormalities
– Hyperplacentosis: (molar pregnancy twins, diabetes)
– Poor placentation
– Placental ischemia.
– Molar pregnancy
• Genetic disorders
• Immunological phenomenon
• Pre-existing vascular disease
• New paternity
• Thrombophilias
SIGNS:
• Abnormal weight gain->5lb/month or 1lb/week in later months
• Rise in blood pressure
• Edema- ankles, then spread all over the body
• Pulmonary edema
• Abdominal examination-chronic placental insufficiency (scanty liquor or
IUGR)
MILD SYMPTOMS:
• Slight swelling over the ankles which persists on rising from the bed in the
morning or tightness of the ring on the finger is the early manifestation of
pre-eclampsia oedema.
• Gradually, the swelling may extend to the face, abdominal wall, vulva and
even the whole body
 ALARMING SYMPTOMS:
• Headache —occipital or frontal region
• Disturbed sleep
• Diminished urinary output—Urinary output of less than 400 ml in 24 hours,
• Epigastric pain
• Eye symptoms—blurring, dimness of vision or complete blindness.
INVESTIGATIONS:
• Urine-proteinuria
• Opthalmoscopic examination-retinal edema ,constriction of arterioles
• Blood values
– BUN
– Serum creatinine
– Thrombocytopenia
– Coagulation profile
– Liver function test
• Antenatal fetal monitoring
– USG
– Fetal kick count
– Cardio tocography
– Umbilical artery flow velocimetry
– Biophysical profile
MATERNAL COMPLICATIONS-IMMEDIATE:
• Antenatal
– Eclampsia(2%)
– Accidental haemorrhage
 – Oliguria and anuria
– Dimness of vision and even blindness
– Preterm labor
– HELLP syndrome
During labour
– Eclampsia
– Post partum haemorrhage
During Puerperium:
– Eclampsia (usually within 48 hrs)
– Shock.
FETAL COMPLICATIONS:
• Intrauterine deaths
• Intrauterine growth restriction
• Asphyxia
• Prematurity
PREVENTIVE MEASURES:
• Regular antenatal check up
• Antithrombotic agents-low dose aspirin 60 mg daily
• Calcium supplementation-2gm/day to reduce risk of pre eclampsia
• Anti oxidants-vitamin E & C
• Nutritional supplementation with Magnesium,Zinc,Fish oil, high protein and
low salt diet
MANAGEMENT OF PRE-ECLAMPSIA OBJECTIVES. :
1. To stabilise hypertension and to prevent its progression to severe
preeclampsia.
 2. To prevent the complications
3. To prevent eclampsia.
4. Delivery of a healthy baby in optimal time.
5. Restoration of the health of the mother in puerperium
REST:
• In left-lateral position as much as possible.
• It lessen the effects of vena caval compression.
• Increases the renal blood flow → diuresis
• Increases the uterine blood flow → improves the placental perfusion
• Reduces the blood pressure.
DIET:
• Should contain adequate amount of daily protein (about 100 gm).
• Total calorie approximate 1600 cal/day.
• Usual salt intake is permitted.
• Fluids need not be restricted.
SEDATIVES:
• To cut down emotional factor, mild sedative may be given orally
(phenobarbitone 60mg or diazepam 5mg at bedtime is given)
DIURETICS:
• Should not be used injudiciously as they can harm to the baby by
diminishing placental perfusion and by electrolyte imbalance.
• Indications for diuretics use are:
– Cardiac failure
– Pulmonary oedema
– Along with selective antihypertensive drug therapy
 – Massive oedema
ORAL ANTIHYPERTENSIVES DRUGS:
• Methyl dopa-250-500mg TID/QID-central & peripheral anti-adrenergic
action.
• Labetalol 250 mg TID/QID- Adrenoceptor antagonist
• Nifedipine 10-20mg BID –Calcium channel blockers
• Hydralazine 10-25mg BID-vascular smooth muscle relaxant
METHODS OF TERMINATION INDUCTION OF LABOUR:
• Aggravation of the pre-Eclamptic features in spite of medical treatment
and/or appearance of newer symptoms
• Hypertension persists in spite of medical treatment with pregnancy reaching
37 weeks or more.
• Acute fulminating pre-eclampsia irrespective of the period of gestation
• Post term pregnancy
MANAGEMENT DURING LABOUR:
• Patient should be on bed
• Liberal sedatives
• Anti-Hypertensives drugs
• Blood pressure & urine output is monitored
• Care monitor of fetal well being
• Labour-ARM and deliver by forceps/ ventouse
• IV Ergometrine is contraindicated
• IM Oxytocin is given
• Sedation immediately-IM Morphine 15mg to prevent postnatal Eclampsia
MANAGEMENT OF PUERPERIUM:
• Close monitoring for at least 48 hours
 • Tab.Phenbarbitone 60mg is repeated for effective sedation
• Anti- Hypertensive drugs is given until diastolic pressure is below 100mmhg
• Patient is hospitalized until B.P brought down to safe level and proteinuria
disappears
3.DEFINITION OF ECLAMPSIA:
Pre-eclampsia when complicated with generalized tonic clonic seizures &/ or
coma is called eclampsia.- D.C.DUTTA
Generalized tonic-clonic seizure in a patient with Preeclampsia not attributed to
any other cause.
If seizures occur beyond 48-72 hours postpartum causes may be more likely other
than eclampsia.
occurs in 2 to 3 percent of severely preeclamptic women not receiving anti-seizure
prophylaxis
RISK FACTORS:
 Epilepsy,
 Intracranial
 haemorrhage/thrombosis,
 Meningitis,
 Cerebral malaria,
 Amniotic fluid embolism can mimic eclampsia.
PATHOPHYSIOLOGY OF ECLAMPSIA:
Since Eclampsia is a severe form of pre-eclampsia the histopathological and
biochemical changes are similar although intensified than those of pre eclampsia
as already described.
STAGES OF ECLAMPTIC CONVULSIONS:
• The Eclamptic fits are epileptiform & consist of four stages , that are :
1).PREMONITORY STAGE :
*The patient becomes unconscious.
*There is twitching of muscles of face, tongue & limbs.
*Eye balls or are turned to one side & become fixed.
*This stage lasts for about 30 second.
2.TONIC STAGE:
The whole body goes into a spam called trunk opisthotonus.
*Limbs are flexed & hands clenched.
*Respiration ceases & tongue protrudes between the teeth.
*Cyanosis appears.
*Eyes balls become fixed.
*This stage lasts for about 30 seconds.
3.CLONIC STAGE:
All the voluntary muscles undergo alternate contraction & relaxation.
*The twitching starts in face then involve one side of extremities & ultimately the
whole body is involved in the convulsion.
*Biting of tongue occurs.
*Breathing is strenuous & blood stained frothy secretions fill the mouth.
*Cyanosis gradually disappears.
*This stage lasts for 1-4 minutes.
4.STAGE OF COMA:
Following the fit , the patient passes on the stage of coma.
*It may last for a brief period or in others deep coma persists till another
convulsion.
*On occasion, the patient appears to be in a confused state following the fit & fails
to remember the happenings.
*Rarely, the coma occurs without prior convulsion
MANAGEMENT OF ECLAMPSIA PRINCIPLES:
• Arrest convulsion.
 • Maintenance of patent airway , breathing & circulation.
• Oxygen administration at the rate 8-10 L/Min.
• Terminate pregnancy.
• Ventilatory support.
• Prevention of complication.
• Hemodynimical stable.
• Prevention of life threatening situation.
FIRST AID TREATME NT:
• The patient , either at home or in the health centres should be shifted
urgently to the tertiary referral care hospitals , because there is no place of
continuing the treatment in such place.
• Sedation
• Maintain airway
NURSING MANGEMENT:
• Aim to prevent serious maternal injury from fall , to prevent aspiration , to
maintain airway & to ensure oxygenation.
• Patient is kept in railed cot & a tongue depressor is inserted between teeth.
• She is kept in the lateral position to avoid aspiration.
• Collect detailed history from the relatives, relevant diagnosis of eclampsia,
duration of pregnancy, number of fits & nature of medication administered
outside.
• Continuous Vital signs monitoring
• Hourly urine output monitoring
• Fetal heart rate monitoring
• Fluid balance
• Antibiotic therapy
SPECIFIC MANAGEMENT ANTIHYPERTENSIVE AND SEDATIVE
REGIMEN:
1.Magnesium sulphate therapy-
IM/Prictchard Regimen-
Loading dose-4gm IV/10-15 min followed by 10gm deep IM (5gm in each buttock)
Maintenance dose-5gm IM Q4H in alternate buttock
• IV Zuspan or sibai regimen
Loading dose-4-6gm/15-20minutes
Maintenance dose -1-2 gm/hr IV
• Lytic cocktail regimen
• Diazepam
• Phenytoin therapy
• Antihypertensive and diuretics.
4.CHRONIC HYPERTENSION IN PREGNANCY:
Hypertension is diagnosed before 20weeks of pregnancy not due to
gestational trophoblastic disease.

Hypertension diagnosed after 20 weeks but persisitance after 12 weeks of

postpartum.

Etiology :

1. Essential HTN (Most Common)

2. Secondary HTN :

1. Genetic: Glucocorticoid remediable aldosteronism, Liddle Syndrome

2. Renal : Parenchymal, Renovascular

3. Endocrine : Primary hyperaldosteronism, cushing syndrome,

Pheochromocytoma
 4. Vascular : Aortic coarctation, Estrogen use

5. Others

5.HELLP SYNDROME:

HELLP syndrome is a rare but serious condition that can happen when
you’re pregnant or right after you have your baby. HELLP stands for the different
things that happen when you have it:
Hemolysis: This is the breakdown of red blood cells. These cells carry oxygen
from your lungs to your body.
Elevated Liver Enzymes: When levels are high, it could mean there’s a problem
with your liver.
Low Platelet Count: Platelets help your blood clot.
HELLP syndrome can cause major complications. These include:

 Seizures
 Stroke
 Liver rupture
 Placental abruption (separation of the placenta from the wall of the
uterus before the baby is born)

RISK FACTORS:

 Age above 35years

 African-American
 obescity
 Previous pregnancies
 Diabetes or kidney disease
 High blood pressure
 History of preeclampsia

Symptoms:
These often come on quickly. They include:
  Fatigue
 Blurred vision
 Sudden weight gain
 Swelling, especially in the face and hands
 Headache
 Nausea or vomiting
 Seizures
 Pain in the upper right part of your belly
 Nosebleed
 Bleeding that doesn’t stop as quickly as usual

Diagnosis:
If you have symptoms of HELLP syndrome, talk to your doctor. She’ll
do a physical exam and tests to check for things like:

 High blood pressure

 Pain in the upper right side of your belly
 Enlarged liver
 Swollen legs
 Liver function
 Blood platelet count
 Bleeding into your liver

MANAGEMENT:

 blood transfusions to treat anemia and low platelet levels

 magnesium sulfate to prevent seizures
 antihypertensive medication to control blood pressure
 corticosteroid medication to help your baby’s lungs mature in case an early
delivery is needed

COMPLICATIONS:

 liver rupture
  kidney failure
 acute respiratory failure
 fluid in the lungs (pulmonary edema)
 excessive bleeding during delivery
 placental abruption, which occurs when the placenta detaches from the
uterus before the baby is born
 stroke
 Death

CONCLUSION:
It is associated with severe maternal obstetric complications. Incidence is 5-10%.
The most frequent cause of iatrogenic prematurity. Preterm delivery Intrauterine
growth restriction (IUGR) Perinatal death ,Maternal cerebrovascular accidents
Placental abruption .

JOURNAL REFERENCES:

Pregnancy Induced Hypertension and Associated Factors among Women

Attending Delivery Service at Mizan-Tepi University Teaching Hospital, Tepi
General Hospital and Gebretsadik Shawo Hospital, Southwest, Ethiopia
Ethiop J Health Sci. 2019 Jan; 29(1): 831–840

Background
Disorders of pregnancy induced hypertensive are a major health problem in the
obstetric population as they are one of the leading causes of maternal and perinatal
morbidity and mortality. The World Health Organization estimates that at least one
woman dies every seven minutes from complications of hypertensive disorders of
pregnancy. The objective of this study is to assess pregnancy induced hypertension
and its associated factors among women attending delivery service at Mizan-Tepi
University Teaching Hospital, Gebretsadikshawo Hospital and Tepi General
Hospital.
Methods
A health facility based cross-sectional study was carried out from October 01 to
November 30/2016. The total sample size (422) was proportionally allocated to the
three hospitals. Systematic sampling technique was used to select study
participants. Variables with p-value of less than 0.25 in binary logistic regression
were entered into the multivariable logistic regression to control cofounding. Odds
ratio with 95% confidence interval was used. P-value less than 0.05 was
considered as statistically significant.

Results
The prevalence of pregnancy induced hypertension was 33(7.9%); of which
5(15.2%) were gestational hypertension, 12 (36.4%) were mild preeclampsia,
15(45.5%) were severe preeclampsia and 1 (3%) eclampsia. Positive family history
of pregnancy induced hypertension [AOR5.25 (1.39–19.86)], kidney diseases
(AOR 3.32(1.04–10.58)), having asthma [AOR 37.95(1.41–1021)] and gestational
age (AOR 0.096(0.04-.23)) were predictors of pregnancy induced hypertension.

Conclusion
The prevalence of pregnancy induced hypertension among women attending
delivery service was 7.9%. Having family history of pregnancy induced
hypertension, chronic kidney diseases and gestational age were predictors of
pregnancy induced hypertension.

Theory application:
Betty Neuman: The System Model
•Focuses on the response of the client system to actual or potential environmental
stressors and the use of several levels of nursing prevention intervention for
attaining, retaining and maintaining optimal client system wellness.
•Neuman defines the concern of nursing is preventing stress invasion.
•If stress is not prevented then the nurse should protect the client's basic structure
and obtain or maintain a maximum level of wellness.
•Nurses provide care through primary, secondary and tertiary prevention modes.

BIBLIOGRAPHY:
 D.C.Dutta’s, textbook of obstetric”,8th edition,Hiralal konar,New
delhi,p232-240.
 Basker Nimma,midwifery and obstetrical nursing,2nd edition,jaypee
publication,New delhi,
 Brar kaur navdeep,Text book of advanced nursing practice,3rd
edition, jaypee publication,New delhi.