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Pregnancy Induced Hypertension (PIH) is a condition in which

vasospasms occur during pregnancy in both small and large arteries. Signs
of hypertension, proteinuria, and edema develop. It is unique to pregnancy
and occurs in 5% to 7% of pregnancies in the united states. Despite years of
research, the cause of the disorder is still unknown. Originally it was called
toxemia because researchers pictured a toxin of some kind being produced
by a women in response to foreign protein of the growing fetus, the toxin
leading to the topical symptoms. No such toxins have ever been identified.
A condition separate from chronic hypertension, PIH tends to occur most
frequently in women of color or with a multiple pregnancy; primiparas are
younger than 20 years of age or older than 40 years, women from low socio
economic backgrounds, those who have an underlying disease such as heart
disease, diabetes with vessel or renal involvement and essential
hypertension.
PIH is classified as gestational hypertension, mild preeclampsia, severe
preeclampsia and eclampsia, depending on how far development advances.
Gestational hypertension when develops an elevated blood pressure but has
no proteinuria or edema. Perinatal mortality is not increased with simple
gestational hypertension, so no drug therapy is necessary; and blood
pressure returns to normal after birth. Mild preeclampsia when blood
pressure rises to 140/90 mmHg or systolic pressure elevated 15 mmHg
above pregnancy level; mild edema in upper extremities or face. Severe
preeclampsia when blood pressure has risen to 160 mmHg systolic and 110
mmHg diastolic; proteinuria; pulmonary or cardiac involvement; extensive
peripheral edema; hepatic dysfunction; theombocytopenia. Eclampsia is the
most severe classification of PIH and seizure or coma Accompanied by s/s of
preeclampsia. Any woman who falls into one of the high-risk categories for
PIH should be observed carefully for symptoms at prenatal visits. She needs
instructions about what symptoms to watch for so she can alert her clinician
if additional symptoms occur between visits.
Anatomy and Physiology:
When most people hear the term cardiovascular system, they immediately
think of the heart. We have all felt our own heart "pound" from time to time,
and we tend to get a bit nervous when this happens. The crucial importance
of the heart has been recognized for a long time. However, the
cardiovascular system is much more than just the heart, and from a scientific
and medical standpoint, it is important to understand why this system is so
vital to life.
Most simply stated, the major function of the cardiovascular system is
transportation. Using blood as the transport vehicle, the system carries
oxygen, nutrients, cell wastes, hormones, and many other substances vital
for body homeostasis to and from the cells. The force to move the blood
around the body is provided by the beating heart. The cardiovascular system
can be compared to a muscular pump equipped with one-way valves and a
system of large and small plumbing tubes within which the blood travels.
HEART:
The heart is a muscular organ found in all vertebrates that is responsible for
pumping blood throughout the blood vessels by repeated, rhythmic
contractions. The heart is enclosed in a double-walled sac called the
pericardium. The superficial part of this sac is called the fibrous pericardium.
This sac protects the heart, anchors its surrounding structures, and prevents
overfilling of the heart with blood. It is located anterior to the vertebral
column and posterior to the sternum. The size of the heart is about the size
of a fist and has a mass of between 250 grams and 350 grams. The heart is
composed of three layers, all of which are rich with blood vessels. The
superficial layer, called the visceral layer, the middle layer, called the
myocardium, and the third layer which is called the endocardium. The heart
has four chambers, two superior atria and two inferior ventricles. The atria
are the receiving chambers and the ventricles are the discharging chambers.
The pathway of blood through the heart consists of a pulmonary circuit and a
systemic circuit. Blood flows through the heart in one direction, from the
atrias to the ventricles, and out of the great arteries, or the aorta for
example. This is done by four valves which are the tricuspid atrioventicular
valve, the mitral atrioventicular valve, the aortic semilunar valve, and the
pulmonary semilunar valve. Systemic circulation is the portion of the
cardiovascular system which carries oxygenated blood away from the heart,
to the body, and returns deoxygenated blood back to the heart. The term is
contrasted with pulmonary circulation.
Pulmonary circulation is the portion of the cardiovascular system which
carries oxygen-depleted blood away from the heart, to the lungs, and returns
oxygenated blood back to the heart. The term is contrasted with systemic
circulation. A separate system known as the bronchial circulation supplies
blood to the tissue of the larger airways of the lung.
Arteries are blood vessels that carry blood away from the heart. All arteries,
with the exception of the pulmonary and umbilical arteries, carry oxygenated
blood.
Pulmonary arteries The pulmonary arteries carry deoxygenated blood that
has just returned from the body to the heart towards the lungs, where
carbon dioxide is exchanged for oxygen.
Systemic arteries Systemic arteries can be subdivided into two types –
muscular and elastic – according to the relative compositions of elastic and
muscle tissue in their tunica media as well as their size and the makeup of
the internal and external elastic lamina. The larger arteries (>10mm
diameter) are generally elastic and the smaller ones (0.1-10mm) tend to be
muscular. Systemic arteries deliver blood to the arterioles, and then to the
capillaries, where nutrients and gasses are exchanged.
The Aorta The aorta is the root systemic artery. It receives blood directly
from the left ventricle of the heart via the aortic valve. As the aorta
branches, and these arteries branch in turn, they become successively
smaller in diameter, down to the arteriole. The arterioles supply capillaries
which in turn empty into venules. The very first branches off of the aorta are
the coronary arteries, which supply blood to the heart muscle itself. These
are followed by the branches off the aortic arch, namely the brachiocephalic
artery, the left common carotid and the left subclavian arteries.
Aorta the largest artery in the body, originating from the left ventricle of the
heart and extends down to the abdomen, where it branches off into two
smaller arteries (the common iliacs). The aorta brings oxygenated blood to
all parts of the body in the systemic circulation.
The aorta is usually divided into five segments/sections:
Ascending aorta—the section between the heart and the arch of aorta
Arch of aorta—the peak part that looks somewhat like an inverted "U"
Descending aorta—the section from the arch of aorta to the point where it
divides into the common iliac arteries o Thoracic aorta—the half of
the descending aorta above the diaphragm o Abdominal aorta—the
half of the descending aorta below the diaphragm
Arterioles Arterioles, the smallest of the true arteries, help regulate blood
pressure by the variable contraction of the smooth muscle of their walls, and
deliver blood to the capillaries. Veins are blood vessels that carry blood
towards the heart. Most veins carry deoxygenated blood from the tissues
back to the lungs; exceptions are the pulmonary and umbilical veins, both of
which carry oxygenated blood. Veins differ from arteries in structure and
function; for example, arteries are more muscular than veins and they carry
blood away from the heart. Veins are classified in a number of ways,
including superficial vs. deep, pulmonary vs. systemic, and large vs. small.
Superficial veins Superficial veins are those whose course is close to the
surface of the body, and have no corresponding arteries.
Deep veins Deep veins are deeper in the body and have corresponding
arteries.
Pulmonary veins The pulmonary veins are a set of veins that deliver
oxygenated blood from the lungs to the heart.
Systemic veins Systemic veins drain the tissues of the body and deliver
deoxygenated blood to the heart. Atrium sometimes called auricle, refers to
a chamber or space. It may be the atrium of the lateral ventricle in the brain
or the blood collection chamber of a heart. It has a thin-walled structure that
allows blood to return to the heart. There is at least one atrium in animals
with a closed circulatory system.
Right atrium is one of four chambers (two atria and two ventricles) in the
human heart. It receives deoxygenated blood from the superior and inferior
vena cava and the coronary sinus, and pumps it into the right ventricle
through the tricuspid valve. Attached to the right atrium is the right auricular
appendix.
Left atrium is one of the four chambers in the human heart. It receives
oxygenated blood from the pulmonary veins, and pumps it into the left
ventricle, via the atrioventricular valve. Ventricle is a chamber which collects
blood from an atrium (another heart chamber that is smaller than a
ventricle) and pumps it out of the heart. Right ventricle is one of four
chambers (two atria and two ventricles) in the human heart. It receives
deoxygenated blood from the right atrium via the tricuspid valve, and pumps
it into the pulmonary artery via the pulmonary valve and pulmonary trunk.
Left ventricle is one of four chambers (two atria and two ventricles) in the
human heart. It receives oxygenated blood from the left atrium via the mitral
valve, and pumps it into the aorta via the aortic valve.
Pathophysiology of Pregnancy Induced Hypertension (PIH):
Clinical Manifestations:
A. Mild Preeclampsia
BP of 140/90
1+ to 2+ proteinuria on random
weight gain of 2 lbs per week on the 2nd trimester and 1 lb per week on the
3rd trimester
Slight edema in upper extremities and face
B. Severe Preeclampsia
BP of 160/110
3-4+ protenuria on random
Oliguria (less than 500 ml/24 hrs)
Cerebral or visual disturbances
Epigastric pain
Pulmonary edema
Peripheral edema
Hepatic dysfunction
C. Eclampsia is an extension of preeclampsia and is characterized by the
client experiencing seizures.

Diagnostic Evaluation:
Based on the presenting symptoms. Often the disease process has been
developing and affecting the renal and vascular system
Frequently a sudden weight gain will occur, of 2 lb. or more in 1 week, or 6
lb. or more within 1 month. This often occurs before the edema is
present.
Medical Treatment and Evaluation:
Magnesium Sulfate (Pregnancy risk category B) muscle relaxant, prevent
seizures loading dose 4-6g, maintenance dose 1-2g/h IV infuse IV
dose slowly over 15-30 min. •Always administer as a piggy back
infusion. •Assess PR, urine output, DTR, and clonus every hour.
•Observe for CNS depression and hypotonia in infant at birth.
Hydrazaline (Apresoline) Pregnancy risk category C anti hypertensive
(peripheral vasodilator) use to decrease hypertension 5-10mg/IV
Administer slowly to avoid sudden fall of BP •Maintain diastolic
pressure over 90 mmHg to ensure adequate placental filling.
Diazepam (Valium) Pregnancy risk category D halt seizures 5-10mg/IV
administer slowly. Dose may be repeated every 10-15 min. (up to
30mg/hr) •Observe for respiratory depression for both mother and
infant at birth.
Calcium Gluconate (Pregnancy risk category C) antidote for Magnesium
Sulfate 1g/IV (10 mL of a 10% solution) have prepared at bed side
when administering Magnesium Sulfate administer at 5mL/min.
Complications of PIH:
Intrauterine growth restriction (IUGR) – an abnormally restricted symmetric
or asymmetric growth of fetus
Oligohydramnios – abnormally low volume of amniotic fluid
Risk of placental abruption – premature separation of a normally situated
placenta from the wall of uterus
Risk of preterm delivery (often iatrogenic) – delivery before 37 weeks of
gestation
Coagulopathy
Stillbirth
Seizures
Coma
Renal failure
Maternal hepatic damage
Hemolysis
Elevated liver enzymes levels
Low platelet count (HELLP syndrome)
Nursing Interventions:
Intervention for mild PIH: Rationale:
1. Assess maternal VS and fetal -to detect any increase which is
heart rate. warning that a women’s condition
is worsening.
2. Encourage elevation of -to increase venous blood return.
edematous arms and legs.
3. Encourage compliance with bed -to increase evacuation of sodium
rest in a lateral recumbent and encouraging diuresis and
position. lateral recumbent position can
avoid uterine pressure on the
vena cava and prevent supine
hypotension syndrome.
4. Provide emotional support. -this can make a women
underestimate the severity of the
situation.
5. Support patient with bed rest -because a bright light can
and darken the room if possible. trigger seizures.
6. Obtain daily hematocrit levels -to monitor blood concentration
as ordered. and help to the extent of plasma
loss to interstitial space or extent
of the edema.
7. Obtain blood studies (CBC, -to assess for renal and liver
platelets count, liver function, BUN function and the development of
and creatinine, and fibrin disseminated intravascular
degregation). coagulation which often
accompanies severe vasospasms.
8. Obtain daily weights at the -to evaluate tissue fluid retention.
same time each day.
9. Raise side rails. -to help prevent injury if seizure
should occur.
10. Support nutritious diet of -to compensate for protein she is
moderate to high in protein and losing in her urine.
moderate in sodium.
11. An indwelling catheter may be -to allow accurate recording of
inserted as ordered. output and comparison with
intake.
12. Oxygen administration to the -to maintain adequate fetal
mother may be given as ordered. oxygenation and prevent fetal
bradycardia.
13. Administer medication for -to prevent seizures and
seizures and hypertension hypertension.
episodes as ordered.

Rationale:
Intervention for severe PIH:
1. Maintain patient’s airway by not -to prevent broken of teeth which
putting a tongue blade between a could then be aspirated.
women’s teeth during seizures.
2. Turn a woman on her side. -to allow secretions to drain from
her mouth.

Discharge Plan:
Exercise
encourage patient’s on deep breathing exercises.
move extremities when lying.
elevate the head part when sleeping, to promote increase peripheral
circulation
encourage overall passive and active exercises program during pregnancy to
prevent need for cesarean birth.
exercises like tailor sitting, squatting, kegel exercise, pelvic rocking, and
abdominal muscle contraction will promote easy delivery.
Treatment:
use of drugs
catheterization
obtaining labs. (CBC, platelets count, liver function, BUN and creatinine, and
fibrin degregation)
Health Teaching:
Encourage patient foe sodium restriction.
Encourage to avoid foods rich in oil and fats.
Encourage patient to limit her daily activities and exercises.
Ongoing Assessment:
Observe carefully for symptoms at prenatal visit.
Give instruction about what symptoms to watch for so she can alert her
clinician if additional symptoms occur between visits.
Diet:
low fats and sodium diet, restriction if possible.
high in protein, calcium and iron.
Adequate fluid intake
Sex:
limit sexual activity
sexual intercourse at 2nd trimester should be avoided.
View Nursing Care Plan – Pregnancy Induced Hypertension (PIH)