PREGNANCY INDUCED HYPERTENSION

PREGNANCY INDUCED HYPERTENSION (PIH)

The hypertension develops as a direct result of the gravid state. The

woman does not have a history of previous hypertension or evidence
of it. The clinical types of PIH are:

 Pre- Eclampsia

 Eclampsia

 Gestational hypertension
 PRE ECLAMPSIA
definition

It is a multisystem disorder characterized by development of

hypertension to 140/90 mm Hg or above with proteinuria after 20

week in a previously normotensive and non-proteinuria patient.

 CAUSES

• The exact cause is unknown. The following are thought to be the cause

of preeclampsia:

• There is a relative or absolute deficiency of vasodilator prostaglandins

I2 (PGI2), a potent vasoconstrictor.

• There is an increased vascular sensitivity to the vasopressor agent

angiotensin II.
• Nitric oxide, which relaxes vascular smooth muscles inhibits

platelet aggregation and prevents intervillous thrombosis, is

found deficient in preeclamptic clients. Hence, preeclampsia

is characterized by complex endothelial cell dysfunction.

• In preeclampsia, trophoblastic invasion of the spiral arteries

is thought to be inhibited by some immunological mechanism.

 elevated plasma protein concentration due to physiological
changes, deficiency of vasodilator prostaglandins I2 (PGI2), a
potent vasoconstrictor.

Dysfunction of the maternal endothelium is believed to result in vasospasm,

microthrombosis, and vascular permeability

diminished renal blood flow, decreased glomerular filtration

rate and increased tubal reabsorption.

anoxic damage to the endothelium of the glomerular tuft,

increased capillary permeability

proteinuria
 deficiency of vasodilator prostaglandins
I2 (PGI2), a potent vasoconstrictor.

Excessive retention of sodium is due to increased aldosterone,

proteinuria
Excessive accumulation of fluids in the extracellular space

edema
Diagnostic Criteria of Preeclampsia
 Hypertension: An absolute rise of blood pressure of at least 140 diastolic pressure
90 mm Hg or rise in systolic pressure of at least 30 mm Hg, diastolic pressure of at
least 15 mm Hg over the previously known is blood pressure called PIH.
Calculation based on mean arterial pressure is done as following:
MAP= Systolic pressure + (diastolic pressure × 2)
3
A rise of 20 mm Hg over the previous reading, or when MAP is 105 mm Hg or more
should be considered significant.
 Edema: Demonstration of rapid gain in weight of more than 1 lb a week or more
than 5 lb in a month in later month of pregnancy is the evidence of preeclampsia.
 Proteinuria: Presence of total protein in 24 hours urine of more than 0.3 g or>2+ (1
g/L) on at least two random clean catch urine samples tested >4 hours apart in
absence of urinary tract infection(UTI) is considered significant.
Sign and Symptoms
Mild Symptoms
 On rising from the bed in morning Slight swelling over the ankles, tightness of
ring finger.
 Gradually, Swelling may extend to face, abdominal wall, vulva and whole body.
Alarming Symptoms
 Headache: Over occipital/ frontal region
 Disturbed sleep
 Diminished urine output: (less than ml in hours).
 Epigastric pain: Associated with vomiting, at times coffee coloured due to
haemorrhagic gastritis or subcapsular haemorrhage in liver.
 Eye symptoms: Blurring or dimness of vision or at times complete blindness.
Signs

 Abnormal weight gain: A rapid gain in weight of more than Ib a month or more
than Ib a week in later months of pregnancy is significant.

 Rise of blood pressure >_ 140/90 mm Hg

 Edema: over ankle, face , abdominal wall and whole body

 Pulmonary edema: Due to leaky capillaries and whole body

 Abdominal examination revels scanty liquor or intrauterine growth restriction

(IUGR) due to placental insufficiency.
 Investigations
 Urine: 24 hours urine collection for protein measurement is done.
 Ophthalmoscopic examination: In severe cases, there may be retinal edema,
constriction of arterioles, alteration in vein: arteriole diameter ratio, nicking of
veins.
 Blood values: Biochemical marker of preeclampsia i.e. Uric acid more than 4.5
mg/dl. Blood urea remains normal or slightly raised. Serum creatinine level more
than 1 mg/dL. Thrombocytopenia or abnormal coagulation profile. Hepatic
enzymes may be increased.
 Antenatal fetal monitoring: By clinical examination, daily fetal kick count,
ultrasonography for fetal growth and liquor pockets, cardiotocography, umbilical
artery flow velocimetry and biophysical profile.
 COMPLICATIONS
MATERNAL FETAL
• During pregnancy
Intrauterine death
 Eclampsia
 Accidental hemmorhage Intrauterine growth retardation
 Oliguria and anuria Asphyxia
 Dimness of vision and even blindness Prematurity
 Preterm labor
 Hemolysis, elevated liver enzymes and low platelets
count (HELLP) syndrome
• During labor
 Eclampsia
 Postpartum hemorrhage
• Puerperium
 Eclampsia
 Shock
 Sepsis
 Management of Preeclampsia
Preventive Measures

 Regular antenatal check-up at frequent interval from the beginning of pregnancy to

detect at the earliest, the rapid gain in weight or a tendency of rising BP especially the
diastolic pressure

 Advise to take adequate rest in bed on her left side at least for 2 hours in the afternoon
from the 20 weeks of pregnancy onwards

 Antioxidants, vitamin C and E from 16-22 weeks onwards

 Well balanced diet, rich in protein, iron and calcium also helps to reduce the risk of
preeclampsia.
 Hospital Management of Preeclamptic Patient

Rest: Admission in hospital

and rest is helpful for Diet: Contain adequate
preeclamptic patient because
it increases the renal blood amount of protein (about
flow→ diuresis, increases 100 g) per day
uterine blood flow→
improves placental
profusion, reduces blood
pressure
Antihypertensives: The commonly used oral drugs are:

Drug Mode of action Dose

Methyldopa Central and peripheral anti 250-50 mg tid/qid

adrenergic acid
Labetalol Adrenoceptor antagonist 250mg tid or qid

Nifedipine Calcium channel blocker 10-20 mg bid

Hydralazine Vascular smooth muscle relaxant 10-25 mg bid

 Sedatives: Mild sedatives are given to reduce the emotional factor that contributes to
elevation of blood pressure, e.g. Phenobarbitone 60 mg or diazepam 5 mg at bedtime
 Laxatives: If woman is constipated, mild laxative like milk of magnesia four teaspoons at
bedtime may be given
 Diuretics: The most patent diuretic commonly used is furosemide (Lasix) 40 mg, given
orally after breakfast for 5 days in a week
 Recording and reporting:
 State of edema and daily weight record
 Evaluation of symptoms such as headache, right upper quadrant or epigastric pain,
visual disturbances, oliguria.
 Fluid intake and urinary output
 For assessing proteins (albumin) urine examination:
 Blood test for hematocrit, platelet count, uric acid, creatinine, liver enzymes,
coagulation profile at least once a week
 Ophthalmoscopic examination
 Assessment of fetal well being
Depending upon the response to the treatment, the patients are
grouped into the following:
Group A: It the pregnancy is less than 37 weeks discharge the patient
and instruct her to attend antenatal clinic weekly. If pregnancy is near
term, try to continue the pregnancy till completion of 37 weeks
thereafter, termination of pregnancy.
Group B: If pregnancy less than 37 weeks, expectant treatment may be
extended judiciously atleast up to 34 weeks.
Group C: Counsel the couple. Termination of pregnancy is safe
irrespective of period of gestation. If gestation is less than 34 weeks,
administer steroid therapy for fetal lung maturity, prevent neonatal
respiratory distress syndrome (RDS), intraventricular hemorrhage (IVH)
and maternal thrombocytopenia. Anticonvulsant magnesium sulfate
should be started.
Method of Delivery
 Induction of labor
 Caesarean section
Induction of labor: It is indicated in case of:
• Persistent hypertension
• Aggravation of preeclamptic features.
• Post maturity
Method: If the cervix is unripe, prostaglandin gel is useful to make the
cervix ripe than low rupture of membrane. If cervix is ripe, then surgical
induction by low rupture of membranes
Cesarean section: It is performed by experienced surgeon and anesthetist
in case of:
• Urgent termination is indicated and cervix is unfavorable
• Severe preeclampsia
• Associated complicating factors such as elderly primigravida, contracted
pelvis, malpresentation twins or polyhydramnios
Nursing Responsibility for Preeclamptic Patient
Primary Goals
 Prevent convulsions through the use of magnesium sulfate
 Ensure adequate kidney function
 Monitor fetal status- assure moderate variability prior to initiating
magnesium sulfate
 Stabilize the woman so that delivery can be accomplished
 The definitive treatment for preeclampsia is delivery
Nursing Management
 Intense maternal monitoring. Assess vital signs, especially blood pressure.
An elevated blood pressure of 140/90 mm Hg and above would indicate
hypertension.
 Presence of protein could be determined through urine tests.
 Assess patient for the presence of edema on the face, fingers, and upper
extremities.
 Magnesium sulfate administration as ordered.
 Antihypertensive medications as ordered.
 Depending on the condition of mother and fetus, delivery might be indicated
 Electronic fetal monitoring
 Nurse to patient ratio is 1:1.
 Assess vital signs based on status to determine worsening of the disease and
response to therapy. Obtain blood pressure with consistent methods
 Record hourly intake and output using a Foley catheter with a urometer
 Reduce stimulation from noise and light.
 Maintain patient on strict bed rest
 Maintain IV access (D5W or LR at nor more than 150 mL/hr)
 Lab work as ordered including: type and cross match and platelets
 Test urine for protein
 Assess deep tendon reflexes
 Ask patient to tell if she develops a headache, blurred vision, dizziness, or
epigastric pain, or if she feels uncomfortable or different.
 Observe the patient for restlessness or apprehension.
Thank you