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TOPICS: • Endothelin theory

• Pregnancy-Induced Hypertension
• Eclampsia CONDITIONS THAT ARE PRONE TO DEVELOP PIH
• Pre-eclampsia
• HELLP Syndrome • black race
• multiple pregnancy
PREGNANCY INDUCED HYPERTENSION • young primigravid ( 20 yo )
• old primigravid ( older than 40 yo )
th
• poor socioeconomic condition that may lead to
• Hypertension that develops after the 20 week of
history of malnutrition
gestation to a previously normotensive woman.
• experiencing polyhydramnious
• It includes preeclampsia, eclampsia and gestational
• cardio , renal and dm complications
hypertension
PATHOPHYSIOLOGIC CHANGES
Definition of Terms

HYPERTENSION

• A blood pressure reading in two occasions of a at

least 140/90 or a rise of 30 mmHg and 15 mmHg
diastolic.
• Blood pressure should be taken on two occasions 4
to 6 hours apart
GESTATIONAL HYPERTENSION

• BP of 140/90 mmHg develops for the first time

Pre-Eclampsia
during pregnancy, but there is no proteinuria and
within 12 weeks postpartum the BP is normal
• is a hypertension disorder of pregnancy developing
PREECLAMPSIA
after 20-week gestation and characterized by
• BP OF 140/90 that develops after 20 weeks of edema, hypertension and proteinuria
gestation accompanied by proteinuria (300 mg/24
hours) and with edema
ECLAMPSIA

• All the signs and symptoms of preeclampsia

accompanied by convulsions or coma that is not
caused by other conditions
SUPERIMPOSED PREECLAMPSIA & ECLAMPSIA
• Occurs when a woman having chronic hypertension
develops preeclampsia or eclampsia during
pregnancy •

Pregnancy induced hypertension ASSESSMENT FINDINGS

• Predisposing Factors: • Clinical manifestations of Mild preeclampsia:

• Disease of primiparas • BP exceeding 140/90 mmHg
• Preexisting diseases • excess above baseline of 30mmHg in
• Low socioecono`mic status systolic pressure or 15 mmHg in diastolic
• Pregnancy complications pressure on 2 readings taken 6 hours apart
• Hereditary • Generalized edema of the face, hands and ankles
• Black Race • Wt. gain of about 1.5kg (3.3 lbs) per month
• Lifestyle in the 2nd trimester or more than 1.3 to 2.3
• Poor nutrition kg (3-5lbs) in the 3rd trimester
CAUSES OF PIH • Proteinuria 1+ to 2+ or 300 mg/dl in a 24-
hour sample
• Unknown
• Genetic Predisposition
• Autoimmune reaction WARNING SIGNS OF WORSENING PRE-ECLAMPSIA
• Protein and Dietary deficiencies
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• rapid rise in BP • exist once the patient has experienced a grand mal
• rapid weight gain seizure
• generalized edema
• Increased proteinuria EFFECTS OF PREECLAMPSIA AND ECLAMPSIA
• epigastric pain
• severe headache • Cardiovascular changes:
• visual disturbances • Decreased cardiac output,
• oliguria (<120 ml in 4 hrs) Hemoconcentration, Thrombocytopenia,
• severe nausea and vomiting Prolonged thrombin time, Abnormal
formation of red blood cells
Clinical manifestations of severe Preeclampsia • Endocrine and Metabolic changes:
• Increased levels of the hormones such as
• BP exceeding 160/110 mmHg on two readings Renin, Angiotension II, Aldosterone, ADH
taken 6 hours apart with the client on bed • Increased extracellular fluid volume
• Proteinuria exceeding 5g/24 hrs. • Renal Changes
• Oliguria <than 400ml in 24 hours • Reduced renal perfusion and glomerular
• headache filtration rate
• blurred vision, spots before the eyes • Elevated creatinine, uric acid, and urea
• pitting edema of the sacrum, face, upper extremities • Decreased excretion of calcium in the urine
• dyspnea, nausea and vomiting • Decreased urine output
• epigastric pain • Proteinuria
COMPLICATIONS
Signs & Symptoms
• Abruptio Placenta
• Cerebral Hemorrhage
• Hepatic Failure
• Acute Renal Failure
• Prematurity
• Perinatal death
• Maternal death

MANAGEMENT CRITERIA

` HOME MANAGEMENT

• BP is 140/90 below
• There is low proteinuria
• There is no fetal growth retardation
• Fetal well being is assured; good fetal movement
PREECLAMPSIA

• Edema HOSPITAL MANAGEMENT

• Where?
• BP is equal to or greater than 160/100 mmHg
• Hypertension
• Proteinuria of 3+ or 4+
• BP?
• Rapid weight gain
• Proteinuria
• Oliguria
• How much?
• Visual disturbances
• Abnormal fetal movement
ECLAMPSIA Initial Hospitalization

• All signs and symptoms of eclampsia • Evaluate laboratory status such as BUN, creatinine,
• Convulsion followed by coma liver enzymes and 24-hour uric acid levels
• Oliguria • Monitor daily weight
• Pulmonary edema • Monitor fetal well-being
• Deep tendon reflexes
• After evaluation:
ECLAMPSIA • Severe preeclampsia remain for
hospitalization.
• is an extension of preeclampsia and is characterized
by the client experiencing seizures

• Mild preeclampsia discharged for home
treatment.
Ambulatory Management
• Bed rest should be emphasized
• Position?
• Diet modification
• Low? High?
• Teach on how to self monitor
• BP, weight, S&S, count fetal movements,
urine specimen
• Report any worsening of condition such as
increasing BP.
NURSING MANAGEMENT
• Monitor for, and promote the resolution of
complications
• Monitor vital signs and FHR
• Minimize external stimuli, promote rest and
relaxation
• Measure and record I&O, protein level and spec
gravity
• Assess for edema of the face, lower and upper
extremities
• Weigh the client daily
• Assess deep tendon reflexes every 4 hrs.
• Assess for separation of placenta, headache and
visual disturbance and altered level of
consciousness
• Provide treatment as prescribed
• Mild preeclampsia – bed rest, balanced
diet, Mg S04
• Severe preeclampsia – CBR, balanced diet,
Mg S04, fluid and electrolyte replacement,
sedative antihypertensive drug,
anticonvulsive drug
• Eclampsia – Mg S04 IV
• Institute seizure precautions
• Address emotional and psychosocial needs
HOSPITAL MANAGEMENT
• The only cure for preeclampsia is delivery
• Check for viability of fetus
• Fluid therapy - Crystalloid infusion
• Medications
• Magnesium Sulfate
• Antihypertensives
• Emphasize bed rest to reduce BP and promote
diuresis.
• Monitor patient closely.
• Take vital signs and fetal heart tome
continuously.
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• Monitor for impending signs of convulsions
• Monitor urinary output accurately
• Weigh daily
• Check laboratory tests
• Initiate safety precautions
• Raise side rails
• Put bed at lowest position
• Have emergency equipment's
available
• Manage during convulsions
• Always monitor for impending
signs of convulsions
• Maintain patent airway and protect patient
from self injury
• Turn patient to side
• Place pillow under patients head
• Do not restrict movements
POSTPARTUM CARE
• The danger of convulsions exist until 24 hour after
delivery, therefore MgSO4 therapy is continued until
the immediate 24 hour postpartum.
• Hydralazine may be given depending on BP.
• Watch out for uterine relaxation and increased
lochia flow
• Watch out for respiratory depression, hypocalcemia
and hypotonia in the infant
• Continue to monitor I&O, vital signs, hematocrit,
platelet count and liver enzymes
• Advise to avoid becoming pregnant until 2 years
ANTIHYPERTENSIVE DRUGS
• Used when diastole is 110 mmHg
• Apresoline-drug of choice
• Side effects – tachycardia, dizziness, faintness,
headache and palpations
MEDICATIONS
• Magnesium Sulfate
• Used to prevent and treat convulsions;
• its primary action is to lower the blood pressure
• decreases neuromuscular irritability and depress the
nervous system
• is irritating to veins, so the infusion site must be
monitored
• is excreted through the kidneys, urine output should
be monitored to prevent toxicity
• is a central nervous depressant, respiratory status
must be monitored
• Depresses deep tendon reflexes
Signs of Magnesium sulfate toxicity
• Absence of deep tendon reflex
• Respiratory depression

• Oliguria
• Antidote for Mg S04 toxicity – Calcium Gluconate
HELLP SYNDROME
• Hemolysis, Elevated Liver Enzyme and Low Platelet
• A variation of PIH
• A serious condition that cause 24 % maternal
mortality rate and infant mortality rate of 35 %
CLINICAL MANIFESTATIONS
• Nausea /vomiting
• Epigastric pain
• General malaise
• Right upper quadrant pain
• Lab result –hemolysis of RBC
• thrombocytopenia(<100,000/cu.mm
• elevated liver enzyme level
• Hemorrhage and liver necrosis
COMPLICATIONS OF HELLP
• Liver hematoma
• Hyponatremia
• Renal failure
• Hypoglycemia
MANAGEMENT
• Improve platelet count –transfusion of fresh-frozen
plasma or platelets
• If hypoglycemia is present, this is corrected by an
intravenous glucose infusion.
• The infant is born as soon as feasible by either
vaginal or cesarean birth.
• Be alert that maternal hemorrhage may occur at
birth because of poor clotting ability.
• Epidural anesthesia may not be possible because of
the low platelet count and the high possibility of
bleeding at the epidural site.
GESTATIONAL DIABETES MELLITUS
- Usually occur at the midpoint of pregnancy when
insulin resistance is noticeable.
RISK FACTORS
• Obesity
• History of large babies
• History of unexplained fetal loss
• History of congenital anomalies in previous
pregnancy
• Family history of diabetes
• Population group
• (Native American, Hispanic and Asian)
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Note:
- fat cell is resistant to insulin..
- Elevated maternal glucose results in elevated fetal
glucose., this stimulates fetal pancreatic production
of insulin which increase fetal hyperinsulemia
resulting into increase growth and fat deposition
- Hyperglycemia is considered teratogenic that
directly affect the yolk sac development.
DIAGNOSIS
50 g oral glucose challenge test:
If, after I hr result
> 130-140mg/ dL ( >7.2 to 7.8mmol/ L) =
scheduled for a 100g, 3 hour fasting glucose
tolerance test.
Note:
- Diagnosis is probably be made based on a
fasting plasma glucose or ramdom paslame
glucose or non fasting ...
- But the recommended screening method has
two steps
- 1. 50 g oral glucose load
- this is usually done using a 50 g oral glucose
challenge test
- After the oral 50 g glucose load, a venous
blood blood sample is taken for glucose
determination 60 mins later. If the serum
glucose level at 1 hr is more than 140mg/ dl,
the woman is scheduled for....
- 3. 3 hr test
- If two of the four blood samples collected for
this test are abnormal or the fasting value is
above 95mg/ dl, a diagnosis of diabetes is
made.
The values are conformed Diabetes are shown below
Monitoring woman with GDM
- glygocylated hgb- is used to detect the degree of
hyperglycemia present.
- This is a measure of the amount of glucose attached
to hgb

( as glucose circulates in the bloodstreams, it binds to a
portion of the total hgb in the blood. The amount of glucose
that attaches to hgb will be high if the hgb has been exposed
to a greater level of glucose than normally present.
- measuring glygocylated hgb is advantageous
because it reflects the average blood glucose level
over the past 4to 6 weeks ( the time the red blood
cells were picking up the glucose). Not just the level
on the day of testing. The upper normal level of
HbA1c is 6% of the total hgb.
2. Ophthalmic- done once during pregnancy for a woman
with GDM and at each trimester for women with known
diabetes.( background retinal changes such as increased
exudate, dot hemorrhage, and macular edema can progress
during pregnancy. If proliferation retinopathy was present
before pregnancy, this also progresses and can lead to
blindness.
- laser- to halt these changes can be done during
pregnancy with risk to the fetus.
3. Urine culture may be done each trimester to detect
asymptomatic UTI . increased glucose concentration in urine
leads to increased infection.
THERAPEUTIC MANAGEMENT
— Early in pregnancy- less insulin need than before
pregnancy.
— Later in pregnancy- need an increased in insulin
— Short acting insulin( regular insulin) combined with
an intermediate type.
— Give 30 mins before breakfast and 30 mins before
dinner.
Note:
1. Insulin- early in pregnancy, less insulin because the
fetus is using so much glucose for rapid cell growth.
Later in pregnancy- bcoz her metabolic rate and need
increase.
Short acting insulin or regular insulin combined with an
intermideate type.
Regular insulin is clear like humulin r and novolin r.
Intermediate insulin is cloudy like humulin n and novolin n.
- self administered
- Women should eat almost immediately after
injecting these short acting insulin to prevent
hypoglycemia before mealtimes.
Oral hypoglycemic agent is not given because they cross the
placenta and are potentially teratogenic to a fetus.
— After administration of insulin, eat your meal.
— Oral hypoglycemia agents are not used for
regulation during pregnancy.
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— Intermediate insulin - given before breakfast- peak
action is after lunch or late in the afternoon just
before dinner.
— Regular insulin- given before breakfast - peak action
is just after breakfast.
Note:
— to prevent hypoglycemia
- Bcoz, they cross the placenta and are potentially
teratogenic to a fetus.
- Knowing when insulin reachers its peak level makes
serum glucose monitoring meaningful and alerts
woman to the time of the day when they are most
apt to be hypoglycemic.
If hypoglycemia is present
— Common time for hypoglycemia
— 2nd and 3rd months before insulin resistance peak
Note:
- She should ingest some form of sustained
carbohydrate such as a glass of milk and some
crackers
- Taking a less concentrated fluid such as milk rather
orange juice and including a complex carbohydrate
helps prevent rebound phenomenon in which a high
glucose level is created that produces even more
pronounced hypoglycemia.
2. Insulin pump therapy ( continuous subcutaneous
insulin)
Because some woman will have some periods of hypo and
hyper no matter how carefully she maintains her diet and
balances her exercise..
- the most effective method to keep serum glucose
constant during pregnancy.
- An insulin pump is an automatic pump about the
size of an MP3 player. A syringe of regular insulin is
placed in the pump chamber and a small gauge
needle is attached to a length of thin polyethylene
tubing and implanted into the subcutaneous tissue
of a woman abdomen or thigh.
- Day and night, at a continuous rate of about 1 unit
per hour, infusing insulin continually into the
subcutaneous tissue.
- depending on individual prescription
- Before a snack or before a meal, a woman can dial
or press a button on the pump, the pump then
pushes the syringe barrel forward to administer the
bulos.
- The site of the pump is cleaned daily and covered
with sterile gauze, the site is changed every 24 or 48
hours to ensure that absorption remains optimal.
- Not allowed to become wet
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- Remove the pump when showering or remove the

complete apparatus to bathe or swim ( not to leave it
disconnected for more one hour)
- To assess whether the pump is delivering insulin at
the designated rate, a woman must do blood
glucose determinations about four times throughout
the day( fasting and 1 hour after each meal)

Preterm Labor Nursing Management

Pathophysiology of PIH