Hypertensive Disorders in Pregnancy

Pregnancy Induced Hypertension Terms :

PIH development of HPN ( BP> 140 /90 during

second half of pregnancy, occurs in previously normotensive woman. Pre-eclampsia renal involvement leads to proteinuria Eclampsia CNS involvement leads to seizures

HELLP clinical picture dominated by

hematologic and hepatic signs and symptoms. Chronic HPN elevation of BP occurs before 20 weeks gestation.

 Hypertensive Disorders of Pregnancy a potentially life-threatening disorder that usually develops after 20 week of pregnancy most common in nulliparous women cause is unknown. systemic vasospasm occur, affecting every organ system

 Two categories of PIH

1 .Preeclampsia Mild / Severe
- non convulsive form of disorder
- maybe mild or severe - occurs after 20 weeks gestation - higher incidence in the low socioeconomic group

 Factors that increases the risk for developing

Pre-eclampsia

1- Primigravidas age 40 yrs and above 2- Women with chronic hypertension /

Renal disease 3- Low socioeconomic status 4- Young maternal age > less than 17 yrs. 5- Women with DM or Multiple pregnancies 6- Dietary deficiencies

 2. Eclampsia - convulsive form of the disorder - occurs between 24 weeks gestation and
the end of the first post partum week

- higher incidence with first pregnancies,

multiple gestations and history of vascular disease

 Assessment Findings:
1. BP over 140/90 mmHg or an increase of 30 mmHg systolic and 15mmHg diastolic over baseline taken on 2 occasions 4-6 hrs. apart. 2. Increase in generalized edema associated with a sudden weight gain of more than 5lbs.( 2.3 Kg) per week 3. Proteinuria 4. Convulsion and or coma

SIGNIFICANT CHANGES IN PIH

Decreased renal perfusion reduces

GFR( Glomerular Filtration Rate) Reduced blood flow to kidneys causing glomerular damage Loss of PRO from kidneys reduces colloid osmotic pressure and allows fluid to shift from vascular to interstitial spaces Hypovolemia additional angiotensin II and aldosterone (retention of Na and water)

 Decreased circulation to the liver

impaired liver function (hepatic edema and subscapular hemorrhage) Vasoconstriction of cerebral vessels small cerebral hemorrhages ( spots before eyes, blurred vision) Decreased colloid oncotic pressure pulmonary capillary leak ( pulmonary edema) Decreased placental circulation infarctions (abruptio placenta)

Changes Associated with PIH

History of Systematic Vasospasm

Effects on the Vascular system

Effects on the renal system

Effects on the Interstitial

Vasoconstriction

Reduced glomerular Filtraction rate: Increased Glomercular membrance permeability Increased serum blood Urea nitrogen and creatinine

Fluid diffusion from Vascular space into Interstitial space

Impaired organ Perfusion

Hypertension

Oliguria and protelnuria

Effects on the Interstitial

 Preventive Measures for PIH:

1. Adequate prenatal care close attention
to weight gain, monitoring BP and urinary protein.

2. Low dose aspirin (6080 mg /day) per

doctors order suppresses synthesis of thromboxane that causes vasoconstriction and platelet aggregation.

 3. Calcium supplementation for less

sensitivity to the pressor effects of angiotensin II and have a lower incidence of HPN.

4. Sedatives ( Diazepam or Phenobarbital)

given if MgSO4 fails in Eclampsia to bring seizures under control.

5. Environment modification

Manifestations / Classic Signs :

1. Generalized edema rapid weight gain
due to fluid retention , present in lower legs, hands and face ( tightening of wedding ring ) 2. Hypertension BP 140/90;30 mmHg systolic and 15mmHg diastolic 3. Proteinuria

Symptoms :
Continuous headache, drowsiness, mental
confusion ( poor cerebral perfusion ) Visual disturbances ( blurring of vision ) arterial spasms, edema of retina Numbness or tingling of hands and feet compression of nerves by retained fluid Epigastric pain or upset stomach distention of hepatic capsule Decreased urinary output poor perfusion of the kidneys > acute renal failure

Nursing Considerations for Pre-eclampsia

1. Sedentary activity for most of the day or bed

rest. 2. Keep record of fetal movements or kick count 3. Check BP 2-4x a day ( same arm, same position) 4. Weigh daily( same time, same scale) 5. Advice on dietary regulation - low or no salt, protein rich foods

 6. Administration of anti-hypertensives and diuretics

per doctors order Hydralazine, Nifedipine or Labetalol 7. Anti convulsant Meds MgSO4 ( to prevent convulsions), Phenytoin , Nifedifine - Check DTR before administration - Keep CA Gluconate on standby ( antidote ) -Monitor urine output ( shd. be 30 ml/hr) RR ( 12 BPM ) Side Effects: CNS depression, depression of Respiratory Center 8. Environment should be kept quiet with dim lights 9. Seizure precautions and prevent injury for eclampsia

 General Nursing Measures:

1. High protein, low salt diet 2. Adequate fluid intake 3. Bed rest in lateral position 4. Antihypertensive methyldopa,
hydralazine

 5. Magnesium sulfate have

antidote ready at bedside (Ca gluconate)

6. Monitor VS, level of consciousness

and DTR

7. Maintain seizure precautions

Symptoms of Magnesium Sulfate Toxicity

1. Decreased deep tendon reflexes or

absent 2. Muscle flaccidity 3. Central Nervous System depression / altered sensorium ( confusion, lethargy, slurring speech, drowsiness, disorientation ) 4. Decreased respiratory rate - < than 12 breaths per minute 5. Decreased renal function 6. Sweating and flushing sensations

 Severe Complications of Eclampsia:

1. Seizures ( eclampsia) 2. Cerebral edema

3. Stroke
4. Abruptio placenta 5. Fetal death

Assessment of Edema

Characteristics
Minimal edema of lower extremities Marked edema of lower extremities

Grade
+1 +2

Edema of lower extremities,face

hands and sacral area

+3

Generalized massive edema that

include ascites

+4

Chronic Hypertensive Vascular Disease (CHVD )

Persistent hypertension before pregnancy

before 20th week of gestation or beyond 42nd wk. postpartum. Seen in older women who are obese and those with DM. Can be attributed to heredity, race Can lead to pre-eclampsia , and seen on the basis of rise in BP, sustained proteinuria and generalized edema

 Management :
High protein diet with adequate salt

Advise woman to weigh herself every 3 days to detect abnormal weight gain
Anti hypertensive drugs if diastolic is consistently higher than 90 mmHg. Anti-hypertensive drugs should not be teratogenic. (methyldopa )