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TOPICS: • black race

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

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 Pre-Eclampsia
• BP of 140/90 mmHg develops for the first time during
pregnancy, but there is no proteinuria and within 12 weeks • is a hypertension disorder of pregnancy developing after
postpartum the BP is normal 20-week gestation and characterized by edema,
PREECLAMPSIA hypertension and proteinuria
•
• BP OF 140/90 that develops after 20 weeks of 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 systolic
• Low socioecono`mic status
pressure or 15 mmHg in diastolic pressure on 2
• Pregnancy complications
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 in the
• Lifestyle
2nd trimester or more than 1.3 to 2.3 kg (3-5lbs)
• Poor nutrition
in the 3rd trimester
CAUSES OF PIH
• Proteinuria 1+ to 2+ or 300 mg/dl in a 24-hour
• Unknown sample
• Genetic Predisposition
• Autoimmune reaction
WARNING SIGNS OF WORSENING PRE-ECLAMPSIA
• Protein and Dietary deficiencies
• Endothelin theory • rapid rise in BP
• rapid weight gain
• generalized edema
CONDITIONS THAT ARE PRONE TO DEVELOP PIH
• Increased proteinuria
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• epigastric pain •Decreased cardiac output, Hemoconcentration,

• severe headache Thrombocytopenia, Prolonged thrombin time,
• visual disturbances Abnormal formation of red blood cells
• oliguria (<120 ml in 4 hrs) • Endocrine and Metabolic changes:
• severe nausea and vomiting • Increased levels of the hormones such as Renin,
Angiotension II, Aldosterone, ADH
Clinical manifestations of severe Preeclampsia • Increased extracellular fluid volume
• Renal Changes
• BP exceeding 160/110 mmHg on two readings taken 6 • Reduced renal perfusion and glomerular filtration
hours apart with the client on bed rate
• Proteinuria exceeding 5g/24 hrs. • Elevated creatinine, uric acid, and urea
• Oliguria <than 400ml in 24 hours • Decreased excretion of calcium in the urine
• headache • Decreased urine output
• blurred vision, spots before the eyes • Proteinuria
• pitting edema of the sacrum, face, upper extremities COMPLICATIONS
• dyspnea, nausea and vomiting
• epigastric pain • Abruptio Placenta
• Cerebral Hemorrhage
Signs & Symptoms • 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

HOSPITAL MANAGEMENT

• BP is equal to or greater than 160/100 mmHg

PREECLAMPSIA • Proteinuria of 3+ or 4+
• Edema • Rapid weight gain
• Where? • Oliguria
• Hypertension • Visual disturbances
• BP? • Abnormal fetal movement
• Proteinuria Initial Hospitalization
• How much? • Evaluate laboratory status such as BUN, creatinine, liver
enzymes and 24-hour uric acid levels
ECLAMPSIA • Monitor daily weight
• Monitor fetal well-being
• All signs and symptoms of eclampsia • Deep tendon reflexes
• Convulsion followed by coma • After evaluation:
• Oliguria • Severe preeclampsia remain for hospitalization.
• Pulmonary edema • Mild preeclampsia discharged for home
treatment.
Ambulatory Management
ECLAMPSIA
• Bed rest should be emphasized
• is an extension of preeclampsia and is characterized by the • Position?
client experiencing seizures • Diet modification
• exist once the patient has experienced a grand mal seizure • Low? High?
• Teach on how to self monitor
EFFECTS OF PREECLAMPSIA AND ECLAMPSIA • BP, weight, S&S, count fetal movements, urine
specimen
• Cardiovascular changes:
• 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.
• 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.
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• 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
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• 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.
- 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

GESTATIONAL DIABETES MELLITUS

- Usually occur at the midpoint of pregnancy when insulin

resistance is noticeable.
Monitoring woman with GDM
RISK FACTORS
- glygocylated hgb- is used to detect the degree of
hyperglycemia present.
 Obesity
- This is a measure of the amount of glucose attached to hgb
 History of large babies
 History of unexplained fetal loss ( as glucose circulates in the bloodstreams, it binds to a portion of the
 History of congenital anomalies in previous pregnancy total hgb in the blood. The amount of glucose that attaches to hgb
 Family history of diabetes will be high if the hgb has been exposed to a greater level of glucose
 Population group than normally present.
 (Native American, Hispanic and Asian)
- measuring glygocylated hgb is advantageous because it
reflects the average blood glucose level over the past 4to 6
Note: weeks ( the time the red blood cells were picking up the
- fat cell is resistant to insulin.. glucose). Not just the level on the day of testing. The upper
- Elevated maternal glucose results in elevated fetal glucose., normal level of HbA1c is 6% of the total hgb.
this stimulates fetal pancreatic production of insulin which
increase fetal hyperinsulemia resulting into increase growth 2. Ophthalmic- done once during pregnancy for a woman with GDM
and fat deposition and at each trimester for women with known diabetes.( background
- Hyperglycemia is considered teratogenic that directly affect retinal changes such as increased exudate, dot hemorrhage, and
the yolk sac development. macular edema can progress during pregnancy. If proliferation
retinopathy was present before pregnancy, this also progresses and
DIAGNOSIS can lead to blindness.

- laser- to halt these changes can be done during pregnancy

50 g oral glucose challenge test:
with risk to the fetus.

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
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.
Because some woman will have some periods of hypo and hyper no
- self administered
matter how carefully she maintains her diet and balances her
- Women should eat almost immediately after injecting these
exercise..
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.
— 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
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created that produces even more pronounced
hypoglycemia.
2. Insulin pump therapy ( continuous subcutaneous insulin)
- 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
- 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
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