PRESENTED BY RESHMA RAJ GOVT COLLEGE OF NURSING KOTTAYAM

HYPERTENSIVE DISORDERS IN PREGNANCY

Incidence
7% to 9% of all pregnancies.
Varies among different hospitals, regions and countries.
Pre-eclampsia- 80% and chronic hypertension - 20%.


CLINICAL CLASSIFICATION APPROVED BY THE INTERNATIONAL
SOCIETY FOR THE STUDY OF HYPERTENSION IN PREGNANCY
A. Gestational hypertension and or proteinuria

B.Chronic hypertension and Chronic Renal Disease

C.Unclassified hypertension and /or proteinuria

D. Eclampsia











NHBPEP 2000 CLASSIFIED HYPERTENSIVE
DISORDERS IN PREGNANCY IN TO FIVE
CATEGORIES:


GESTATIONAL HYPERTENSION
Blood Pressure 140/90 on two or more occasions
- at least 4 hours apart
-in a previously normotensive
and non proteinuria patient
- after 20 weeks gestation or first 24 hrs after
delivery
- returning to normal 6 weeks
following delivery





CHRONIC HYPERTENSION
Hypertension diagnosed before pregnancy or a Blood
Pressure 140/90 before 20 weeks of gestation on two
occassions 6 hrs apart

CASE SCENARIO
Mrs jiji ,25yrs primigravida , 32 weeks of gestation (EDC-
jan 21) got admitted with c/o generalized edema and
decreased urine output.
Investigations
Bp=160/100
urine albumin=3+
S.LDH =1380
Platelet =1.6 lakhs
Uric acid =4mg/dl
PT/INR =14.5/1


CASE SCENARIO
Diagnosis pre eclampsia
BP elevated to 200/130 inspite of emdopa and
nicardia.client further managed on mgso4 and
inj.labebet.
EASI instilled for termination of pregnancy and she
delivered a live female preterm baby of 1.5kg on
12-11-13.
During postpartum period she developed severe
headache BP=170/90 and continued to manage
with mgso4 and nicardia.

RISK FACTORS

Primigravida younger
Family history
Placental abnormalities
Obesity -BMI> 35
Hypercoagulability (inherited thrombophilia)
Antiphospholipid syndrome(acquired thrombophilia)
Black race
women with diabetes, hypertension, vascular
diseases,and kidney disease


Diagnostic criteria of pre-eclampsia:

Hypertension
Oedema or rapid weight gain
Proteinuria 0.3gm/24 hours

ETIOPATHOGENESIS OF PRE-ECLAMPSIA
Defective placentation
In the first trimester cytotrophoblast invades upto decidual
segments.

In the second trimester invades upto the myometrial segments.


Spiral arterioles thereby become distended, tortuous and funnel
shaped.

Transforms the spiral arterioles into a low resistance, low pressure,
high flow system
In pre eclampsia the cytotrophoblastic tissue of the
placenta fails to adequately migrate down the
maternal spiral arteries

decreasing spiral artery remodeling
decreasing placental perfusion(Defective
placentation)

ETIOPATHOGENESIS OF PRE-ECLAMPSIA

Hypertension:
Defective trophoplast invasion - hypoperfused placenta - release
factors (growth factors,Cytokines) - endothelial injury and
dysfunction- intense vasospasm
Imbalance in different components of prostaglandins
deficiency of vasodialator prostaglandins PGI2 and increased
synthesis of thromboxane a potent vasoconstrictor
Increased sensitivity to the pressor agent angiotensin II
Nitric oxide deficiency contributes to hypertension

INFLAMMATORY MEDIATORS
PGI2
TXA2
Vasoconstriction
Platelet aggregation
Vasopressor
response
uterine activity
ETIOPATHOGENESIS OF PRE-ECLAMPSIA
PROTEINURIA
Spasm of the afferent glomerular arterioles

Anoxic change to the endothelium of the glomerular
tuft

Glomerular endotheliosis

Increased capillary permeability

Increased leakage of proteins.



ETIOPATHOGENESIS OF PRE-ECLAMPSIA
OEDEMA
Increased oxidative stress

Endothelial injury

Increased capillary permeability.

Excessive accumulation of fluids in the
extracellular tissue spaces

Clinical types
Mild - Rise of BP of more than 140/90 mm of Hg but less than
160 mm of Hg systolic or 110 mm of Hg diastolic without
significant proteinuria

Severe
1.A persistant systolic BP of160 mm hg or diastolic pressure >110
mm hg
2.excretion of >5 gm/24hrs
3.Oliguria<400 ml/24hr













CLINICAL TYPES
SEVERE
4.Platelet count ,100,000 /mm3
5.HELLP syndrome
6.Cerebral or visual disturbances
7.Persistant severe epigastric pain
8.Retinal hemorrhages,exudates or papiledema
9.IUGR
10.Pulmonary edema
CLASSIFICATION OF PREECLAMPSIA
Mild PE Severe PE
Blood pressure >140/90 >160/110
Proteinuria
On 2 occasions, >4hrs
apart
>0.3gm/ 24 hrs
Dip stic > 1+
>5gm/24 hrs
Dipstic > 3+
S. creatinine normal elevated
Pulmonary edema _ +
oliguria _ +
IUGR _ +
headache _ +
Visual disturbance _ +
Epigastric pain _ +
HELLP syndrome _ +
SIGNS

Abnormal weight gain-more than 5lb a month or more
than 1 lb a week
2. Rise of blood pressure usually diastolic BP tends to
rise followed by systolic BP
3. Pathological Oedema.
4. Pulmonary oedema due to leaky capillaries and low
oncotic pressure
5. scanty liquor
6.growth retardation of fetus


Maternal
Urinalysis by dipstick
24hours urine collection
Full blood count(platelets&haematocrit)
Renal function(uric acid,s.creatinine,urea)
Liver function tests
Coagulation profile
Ophthalmic examination


INVESTIGATIONS
FETAL

Uss(growth parameters,fetal size,AF)
1. CTG
2. BPP
3. Doppler
Complications
Immediate
Maternal
During pregnancy
During labour
During Puerperium

Immediate-fetal
IUD,IUGR

Remote



A LARGE SUBCAPSULAR HEMATOMA
PREDICTION OF PREECLAMPSIA
No screening test is really helpful
Various screening methods are:
Diastolic notch at 24weeks by doppler
ultrasonography
Absence or reversal of end diastolic flow
Average mean arterial pressure 90 mmHg in
second trimester
Roll over test: rise in blood pressure >20 mmHg
from baseline on turning supine at 28-32 weeks
gestation is positive.
Prophylactic measures in pre eclampsia
1) Regular antenatal check up
2) Antithrombotic agent
3) Heparin
4) Calcium supplementation
5) Antioxidants
6) Balanced diet

Management of pre eclampsia

Objectives
1) To stabilize hypertension
2) To prevent complication
3) To prevent eclampsia
4) Delivery of healthy baby
5) Restoration of the health of the mother in peuperium
Home treatment
1) Rest
2) High protein diet
3) warned against the ominous symptoms as headache, visual
disturbance, vomiting, epigastric pain or scanty urine

Hospital management
1) Rest in left lateral position.
2) Diet
3) Diuretics
4) Antihypertensive

ANTI HYPERTENSIVE DRUGS

























DRUGS MOA SIDE EFFECTS C/I & PREVENTION
Methyldopa 250mg-1g
tds or 250-500mg iv
Central and pripheral
anti adrenergic action
Maternal-postural
hypotension,
hemolytic anemia,
sodium retention,
excessive sedation
Fetal-intestinal ileus
Hepatic disorders,
psychic pts., CCF
Labetalol
Oral-100mg tds till
800mg/d
Iv- 20 mg till desired
effect (max. 220mg)
Alpha + beta blocker Maternal-tachycardia,
hypotension
Fetal-bradycardia,
hypotension
Hepatic disorders
Hydralazine
Oral-100mg/d in 4
divided doses
Peripheral
vasodilation
Maternal-
hypotension,
tachycardia,
arrythmia,
palpitations, lupus like
syndrome
Fetal- safe
Neonate-
thrombocytopenia
Causes sodium
retention so use
diuretic
ANTI HYPERTENSIVES CONTD..
DRUGS MOA SIDE EFFECTS C/I & PREVENTION
Nifedipine
Oral: 5-10mg tds
Arteriolar
vasodilation
Flushing,
hypotension,
tachycardia,
inhibition of labor
With MgSO4 and
NMBs
Nitroprusside
0.25-8 mcg/kg/min
Direct vasodilator Maternal- nausea,
vomitting, severe
hypotension
Fetal- cyanide
toxicity


Seizure Prophylaxis
Routinely used in severe PE
Magnesium sulphate: most commonly used
Initiated with onset of labor till 24h postpsrtum
For caesarean, started 2hrs before the section till 12hrs
postpartum
Hypertensive crisis when the BP is 160/110 mm hg or the
mean arterial pressure is>125 mm hg
labetalol 10-20 mg IV every 10 min max of 300mg
hydralazine 5mg IV q30 min max 30 mg IV
nifedippine 10-20 mg oral repeated in 30 min max 240
mg/24 hr
nitroglycerine 5 micro gm/min IVand sodium
nitroprusside 0.25-5 mmicro gm/ kg/min IV short term
therapy only when the other drugs have failed




Progress chart containing
1) Daily clinical evaluation of symptoms,
2) Blood pressure,
3) Oedema and daily weight,
4) Fluid intake and urinary output,
5) Urine examination
6) Blood
7) Ophthalmoscopic examination


Depending on the response to treatment the patients are grouped
into:
( A ) Pre eclamptic features subside and hypertension is mild
( B ) Partial control of features, BP in steady high level

( C ) Persistantly increasing BP to serve level despite the use of
antihypertensive addition of headache, epigastric pain, oliguria,
blurring of vision, help syndrome




Management during labour
vaginal delivery is usually attempted
caesarean birth only in complication
Liberal sedatives such as pethidine is given
Monitor BP, hourly input and output
Decrease anxiety
monitor labour progress
continouse electronic fetal monitoring
continous iv of 5 % D5 and RL at 100-150 ml/hr
prophylactic Mgso4 started when systolic BP 160
diastolic BP 110, MAP 125 mm Hg labour duration
curtailed by LRM in 1
st
stage and forceps and ventouse
in 2
nd
stage contraindication for syntocinin
Methergine is withheld


Puerperium

1) Watch closely for 48 hours
2) Antihyperrtensives continued if BP systolic 150 diastolic 100 , oral
nifedipine 10mg q6hrs till BP remains low for 48 hrs
3) Oral frusemide 20 mg a day for 5 days
4) MgSo4 for 24 hrs for women with severe hypertension and
symptoms of acute fulminate pre eclampsia during the post
partum period
5) Patient kept in hospital Till BP comes to safe level and proteinuria
disappear
PREECLAMPSIA SUPERIMPOSED ON CHRONIC
HYPERTENSION
New-onset proteinuria 300 mg/24 hours in
hypertensive women but no proteinuria before 20
weeks gestation
A sudden increase in proteinuria or blood pressure
or platelet count <1 lakh/mm
3
in women with
hypertension and proteinuria before 20 weeks
gestation
More adverse outcome than preeclampsia alone


HELLP SYNDROME
This is an acronym for:-
1) Haemolysis
2) Elevated liver enzymes
3) Low platelet count ( <100,000/mm
3
)
4) Its a rare complication of pre eclampsia which develop even
without maternal hypertension
5) Its manifested by nausea, vomiting, epigastric or right upper
quadrant pain, with haematological and biochemical changes.

HELLP SYNDROME
Diagnosis:
1. Hemolysis:
Peripheral smear
bilirubin >1.2mg/dL,
LDH>600 IU/L
2. Elevated liver enzymes:
SGOT> 70 IU/L
LDH>600 IU/L
3. Low platelets: <1 lakh /mm
3




Management
1) Same as that of pre eclampsia
2) Anti seizure prophylaxis with MgSo4
3) Corticosteroids
4) Caesarean section
5) Epidural aneasthesia if platelet>1,00,000/mm
3

6) Platelet transfusion if count < 50,000/ mm
3

7) Expectant management done when pregnancy <34 weeks with
bed rest, Plasma volume expansion, anti Thrombotic agents,
immunosuppressive agents

ECLAMPSIA
Definition
Its a Greek word meaning like a flash of lightening occur abruptly
without any warning manifestations
Pre eclampsia when complicated with generalized tonic clonic
convulsion and/or coma is called eclampsia


Incidence
Varies widely from country to country and even between different
zones of the same country.

In India ranges from 1 in 500 to 1 in 30.

Its more common in primigravidae,

5 times more common in twins,


Cause of convulsion

Cerebral irritation provoked by anoxia , cerebral edema cerebral
dysrhythmia. There is excessive release of excitatory
neurotransmitters (glutamate).

EPIDEMIOLOGY
0.1- 5.5 per 10,000 pregnancies
Decreasing incidence with time
Antepartum(50%): mostly in third trimester
Intrapartum(30%):
Postpartum(20%): usually within 48hours, fits beyond
7days generally rules out eclampsia

CLINICAL FEATURES
Eclamptic convulsions consist of four stages
Premonitory stage: twitching of muscles of face, tongue,
limbs and eye. Eyeballs rolled or turned to one side, 30s
Tonic stage: opisthotonus, limbs flexed, hands clenched,
30s
Clonic stage: 1-4 min, frothing, tongue bite, stertorous
breathing
Stage of coma: variable period.




Maternal complication
1) Injuries-tongue bite fall
2) Pulmonary-oedema,pneiumonia respiratory distress
3) Hyper pyrexia
4) Cardiac-acute left ventricular failure
5) Renal failure
6) Hepatic-necrosis
7) Cerebral-edema
8) Neurological deficits
9) Disturbed vision
10) Haematological-thrombocytopenia
11) Postpartum-shock,sepsis,psychosis
OPHTHALMOSCOPY SHOWS SCATTERED
YELLOWISH, OPAQUE LESIONS OF THE RETINA
Management
Prediction and prevention
Rest
Effective institutional treatment
Judicious termination
Prophylactic anticonvulsant therapy
Timely delivery
Close monitoring

First aid treatment outside the hospital
1) Shifted urgently
2) Needs neonatal and obstetrical intensive care
3) All records and detailed summary
4) BP stabilized and convulsion arrested
5) Magnesium sulfate 4gm IV loading dose with 10gm IM
6) Labetalol 20mg IV for hypertension
7) Diuretics if pulmonary edema
8) Diazepam 5mg slowly over 1 min for apnea and cardiac arrest
9) Trained midwife


In Hospitals-principles followed
1) Maintain ABC
2) Oxygen administration 8-10 ltr/min
3) Arrest convulsion ventilator support prevention of injury
4) Haemodynamic stabilization
5) Organize investigation
6) Delivery 6-8 hours
7) Prevention of complications
8) Postpartum care

General management
Supportive care
Keep in a railed cot,
Tongue blade is inserted between the teeth,
Lateral decubitus position,
Frequent suctioning,
Face mask 8-10l/min,


Arterial blood gas analysis
Sodium bicarbonate is given when the ph is below 7
Constant supervision
Detailed history is to be taken
Balanced salt solution 1 ml/kg per hour
Dextrose or crystalline solutions should not be used-calculate
fluid
Quick general abdominal and vaginal examinations are made
Self retaining catheter
Urine is tested for protein
Half hourly pulse BP are recorded
Hourly urinary output,
Uterus should be palpated
Fetal heart rate
Fluid balance
CVP monitoring
Antibiotic

Specific management
Anticonvulsant and sedative
Magnesium sulphate is the drug of choice
Antihypertensive and diuretics


RECOMMENDED REGIME FOR MGSO
4


Zuspan or sibai regime: 4-6 gm i.v over 15
min f/b infusion of 1-2 gm/hr

Pritchard regime: 4 gm i.v over 3-5min f/b 5
gm in each buttock with maintenance of 5 gm i.m
in alternate buttock 4 hrly

MAGNESIUM LEVELS MONITORING
Normal Serum levels- 1.7- 2.4 mg/dl
Therapeutic range- 4- 7mg/dl
Patellar reflex lost- 7-10mg/dl
Respiratory depression- 10- 13 mg/dl
Cardiac arrest- >25mg/dl

SIDE EFFECTS OF MGSO
4


Maternal : flushing, perspiration, headache,
muscle weakness, pulmonary edema
Neonatal: lethargy, hypotonia, respiratory
depression

Care of patients receiving mgso4
Explain reason for use
Reactions to expect from medication
Monitor to anticipate
Administration
Maternal and fetal assessment
Reportable conditions
Emergency measures
Documentation



Other regimens are
1) Lytic cocktail using chlorpromazine, promethazine and pethadine
2) Diazepam
3) Phenytoin



Management during fit
1) A mouth gag placed
2) Air passage cleared off
3) Head turned to one side pillow taken off
4) Raising foot end of bed facilitates postural drainage
5) Oxygen is given until cyanosis is disappeared


Status epilepticus-
Thiopentone sodium
Antibiotics
Frusemide followed by mannitol
Aspiration of the mucous
Oxygen inhalation ,parenteral lasix and digitalis


STATUS EPILEPTICUS

Dopamine infusion
Cold sponge and antipyretics
Chlorpromazine or eskazine
Intensive care monitoring
Blood sugar analyse
Central venous pressure monitoring
Steroids and diuretic therapy
Obestric management



Follow up and Prognosis.
1) six week time
2) Persistence of hypertension proteinurea abnormal blood
biochemistry necessitates consultation with physician.
3) Further pregnancy should be deferred till they are controlled.
4) Recurrence risk varies between 2-25 %.
5) Atiypical eclampsia is defined when eclampsia occurs 20 th weeks
of pregnancy or more than 48 hours postpartum treated with
parental magnesium sulphate.

ESSENTIAL HYPERTENSION IN PREGNANCY

Incidence varies from 1-3%.
Diagnosis criteria
1) Rise of BP of 140/90mm of hg during pregnancy prior to the 20
th

week
2) Cardiac enlargement
3) Presence of medical disorders
4) Persistent rise of BP even after 42 days following delivery



MANAGEMENT:
The principles of management are:
To stablised the blood pressure to below 160/100 mm of Hg.
To prevent superimposed of pre-eclampsia
To monitor the maternal the and fetal well being.
To terminate pregnancy at the optimal time.


GENERAL MANAGEMENT

In mild cases with blood pressure less than 160/100 mm of Hg,
adequate rest ,low salt diet The check up should be more frequent 1-
2 weeks interval up to 28 weeks and thereafter weekly.

In severe cases ,the patient should be hospitalized
Antihypertensive Drugs:
Benefit the mother but reduce the placental perfusion.
Obsteric management:
In mild cases, spontaneous labour is awaited.

In severe or complicated cases, try to continue till 34 weeks or till 37
week for fetal maturity and terminate.
Nursing assessment
Cardiovascular
Renal
Central nervous system
Pulmonary
Hepatic
Hematology
Reproductive
Fetal surveillance


1 Deficient Fluid Volume
2. Decreased Cardiac Output
3 .Ineffective Tissue Perfusion:uteroplacental
4.Risk for maternal injury

DEGREES OF EDEMA
Risk for imbalanced less than body requirements
related to insufficient intake to meet metabolic
demands and replace losses
Knowledge deficit regarding condition, prognosis, self
care and treatment related to lack of
exposure/unfamiliarity with information resources,
misinterpretation

Ineffective individual/family coping related to woman
restricted activity and concern over a complicated
pregnancy.

Powerlessnessness related to inability to prevent or
control condition and outcome