Pregnancy induced hyper tension

‫الرحيم‬ ‫الرمحن‬ ‫هللا‬ ‫بسم‬
َ‫ك‬َ‫ن‬‫ا‬َ‫ح‬ْ‫ب‬ُ‫س‬ ْ‫ا‬‫و‬ُ‫ل‬‫ا‬َ‫ق‬َ‫ل‬ َ‫م‬ْ‫ل‬ِ‫ع‬ َ‫ال‬ّ‫ال‬ِ‫إ‬ ‫آ‬َ‫ن‬
ّ‫ن‬ِ‫إ‬ ‫آ‬َ‫ن‬َ‫ت‬ْ‫م‬ّ‫َل‬‫ع‬ ‫ا‬َ‫م‬َ‫ع‬ْ‫ال‬ َ‫ت‬ْ‫ن‬َ‫أ‬ َ‫ك‬ُ‫م‬‫ي‬ِ‫ل‬
ُ‫م‬‫ي‬ِ‫ك‬َ‫ح‬ْ‫ال‬
‫العظيم‬ ‫اهلل‬ ‫صدق‬
‫سورة‬‫البقرة‬‫أية‬32
Thursday, April 5, 2018 Dr. Soad Abd El salam Ramdan 1

PREGNANCY INDUCED
HYPERTENSION

3
• Chairman of obstetrics &woman health
nursing department
• Pre. Vice dean for students &Education
Affair
Thursday, April 5, 2018 Dr. Soad Abd El salam Ramdan

Definition:-
Hypertension is the
most common medical
disorder in pregnancy that
can significantly comprise
maternal and fetal well-
being.

Pregnancy induced hypertension
is still one of the most common
causes of maternal and prenatal
mortality and morbidity.
It is characterized by vasospasm
that leads to poor perfusion of
many vital organs including the
feto/placental unit.
6

Pre-eclampsia and eclampsia are
two categories of pregnancy
induced hypertension.
The HELLP syndrome is a severe
sequel of pregnancy induced
hypertension.
7

Classification:
(1) Pregnancy-Induced Hypertension
(PIH): is an acute or specific
hypertension, which includes:
◦ Transient hypertension ( develop
after 20 week's' gestation
Without proteinuria).
◦ Preeclampsia (hypertension with
proteinuria and / or
edema after 20 weeks of pregnancy).
◦ Eclampsia (Preeclampsia +
convulations ).Thursday, April 5, 2018 Dr. Soad Abd El salam Ramdan 8

Cont.
(2) Chronic Hypertension: hypertension is
present before pregnancy, before 20 weeks
of pregnancy or that persists for more than
42 days postpartum.
(3) Chronic Hypertension with
Superimposed preeclampsia -
eclampsia: development of preeclampsia –
eclampsia in patient with chronic
hypertension

Grades of hypertension:-
Mild hypertension
diastolic blood pressure 90–99 mmHg, systolic blood
pressure140–149 mmHg.
Moderate hypertension
diastolic blood pressure 100–109 mmHg, systolic
blood pressure 150–159 mmHg.
Severe hypertension
diastolic blood pressure 110 mmHg or greater,
systolic bloodpressure 160 mmHg or greater

Incidence:-
5-7% of all pregnancies.
If a woman has chronic
hypertension, she has a 25
to 35% risk of developing
PIH
11

Prenatal Factors Increasing
the Risk of PIH:-
 Primigravida.
 Grand multigravidit.
 Essential hypertension
 Family history of
hypertension or
vascular disease.
 Diagnosis of PIH in
previous pregnancy

 Low socioeconomic
status.
 Diabetes mellitus.
 Obesity.
 Malnutrition.
 Age (under 17 or over
35 years old).
 Underweight or
overweight.
12

Part 1: Preeclampsia
Definition:
 Development of hypertension accompanied by
proteinuria, edema, or both after 20 weeks of
gestation or during the early postpartum period.
Classification:
 Mild:
 Moderate:
 Severe:

Pre-eclampsia:
 Hypertension: 140/90
 Proteinuria:
300mg or more in 24h
 Edema:
greater than I pitting edema after 12 hour bed
rest or weight gain of 2.3kg or more in one week
or both after 20 week of gestation
14

Physiologic changes with pregnancy-induced hypertension

Severe pre-eclampsia :-
 Blood pressure:160/110
 Proteinuria 5 g in 24 hour urine
collection
 Oliguria: less than 700 to 800 ml in 24
hours or <30 ml/hr.
 Hypereflexia
 Visual disturbances
 Headache, blurred vision
 Pulmonary edema or cyanosis.
 Epigastric pain
16

Diagnosis :
1. General physical examination:
◦ Check blood pressure repeatedly.
◦ Opthalmoscopic examination.
◦ Daily check body weight.
◦ Test tendon reflex
◦ Monitor the obstetric condition.
◦ Urinary examination.
◦ Blood examination: hematocrit /hemoglobin /blood
coagulation /electrolytes.
◦ Determine of function of liver and kidney.
◦ Mother’s emotional status.

Diagnosis :
2. Diagnostic data
 Blood: CBC, hematocrit may be high because of
hypovolemia.
 Liver enzymes: should not be increased
 24 hour urine collection for total protein
 Tests for fetal well-being.
◦ Non-stress test: FHR acceleration in response
to fetal movements are a reflection of fetal
well-being.
◦ Ultrasonography: determines fetal age,
growth, and amount of amniotic fluid and
placental location.

Complications
Maternal complications
 PIH progressing to eclampsia.
 Abruption placenta
 DIC/HELLP syndrome
 Acute Renal Failure
 Liver failure & Hemmorhage
 Stroke
 Death
 Long term cardiovascular morbidity

Neonatal complications
 Preterm delivery
 IUGR
 Hypoxic neurological injury
 Perinatal death
 Low birth weight with long term
morbidity

Nursing Management of Pregnancy
Induced Hypertension (PIH)
Preventive measure
Counsel all women prior to conception
regarding health behaviors that minimize risk
of hypertension, e.g.:
 Correct dietary deficiencies.
 Attain ideal pre-pregnancy weight.
 Stop smoking.
 Manage stress positively.
 Alter coping style.
21

 Receive regular antenatal care
 Screen all patients for PIH each prenatal visit
by evaluating blood pressure, edema,
proteinuria
 Low dose of asprine
 Calcium supplementation
 Magnesium supplementation
 Antioxidants as vitamin C and E
 Salt restriction
22

Treatment:-
Expectant treatment
Control hypertension
Prevent and control convulsion
Treatment of eclampsia
Termination of pregnancy
23

General and first aid measures
 Isolation in single ,quite ,semi dark room
 An efficient nurse should be present
 The following equipment must be present
Airway, oxygen source ,suction apparatus
Bed with side ray
 Put pt in trendlenburg position
 Insert a catheter ,nothing by moth and fluid chart
 Observation
1-Vital signs
2- Level of consciousness and duration of coma
3- Urine out put and albumineuria
4- Number of convulsion
24

Expectant treatment :-
 Rest
 Diet increase protein and carbohydrate and low salt
 Sedation
 Observation
Mother (BP, pulse, respiration ,protein urea
Investigation
Fetus , fetal well being as fetal movement ,Us
25

Nursing Management:
Ante natal care:
 Frequent antenatal visit:
 Hospitalization
 Bed rest: the mother should be nursed in bed and will be
encouraged to adopt sitting position or lie on left lateral
position.
 Diet : rich in protein, fiber and vitamins and low-salt diet
 Weight : should be estimated and recorded twice weekly.
 Urine : should be tested for protein and ketoses.
 Blood pressure :is ascertained 4-hourly in moderate
preeclampsia but taken 2-hourly in sever preeclampsia.
 Fluid intake and output: should be conscientiously measured.
 Abdominal examination
 Monitor fetal heart rate and kick charts are maintained to
monitor the fetal movement.
 Sedation : may be required.

Nursing Management:
Intra natal care:
◦ The nurse should remain with the mother throughout the
course of labour.
◦ Fluid balance should be monitored carefully.
◦ Vital signs especially Bp is measured half hourly.
◦ Epidural analgesia may procure the best pain relief.
◦ Fetal conditions should be monitored continuously.
◦ A short second stage may be prescribed depending on the
maternal and fetal condition.
Post natal care:
The maternal condition should to be monitored at least
every 4hours for the next hours.

Eclampsia
Definition:
Development of
convulsions in
preeclampsia patients.

Criteria for severity of eclampsia
 Coma more than 6 hours.
 Temperature more than 39c.(indicate pneumonia
 Systolic blood pressure more than 200mmhg.(risk for
cerebral hge)
 Pulse more than 120/m(acute heart failure) .
 Anuria or oliguria( indicate renal failure)
 Respiratory rate more 40/m (indicate pneumonia (‫ز‬
 More than 10 fit.
29

Eclamptic fit may occur:
Ante partum (65%) with best
prognosis
Intrapartum (20%)
Postpartum (15%)with bad
prognosis which indicated excessive
pathological damage
30

Stages of an eclamptic fits:
A. Premonitory stage: (less than 10-20
seconds).
 Mothers are restless and rapid eye
movement, the head may be drawn to
one side and twitching of facial
muscles occur.
B.Tonic stages: (lasts 10-20 second).
 The muscles of the body go into
spasm and become rigid and her back
become arched, teeth become tightly
clenched and eye staring.

Clonic stages: (lasts 60-90 seconds).
 Salivation increases and foaming at
the mouse occurs the mother bites
her tongue during this episode, face
becomes congested, she is
unconscious, and gradually convulsion
subsides.
D. Stage of coma:
 Torturous breathing continues and
coma may persist for minutes or
hours, further convulsions may occur
before the mother regain
consciousness.

Complications of the Epileptic Fit
 Biting of the tongue.
 Suffocation.
 Heart failure.
 Cerebral hemorrhage.
 Accidental hemorrhage.
 Bronchopneumonia
33

HELLP syndrome
Occurs in 2-12 % of cases
 H : Hemolysis
 EL : elevated liver enzymes
 LP: low platelets
34

Nursing Management during
convulsions:
 Call for assistance.
 Maintain patient airway, turn head to one side
to facilitate drainage of saliva.
 Promote safety: loosen clothes, remove objects
that may hit from areas rails should have been
padded earlier.
 Note characteristics of convulsions, onset and
progression, duration and weather followed by
bowel movement, incontinence or coma.

Nursing care following
convulsion:
 Suction food and fluids from glottis or trachea.
 Start I.V with large bore needle to maintain
adequate hydration.
 Administer O2 by facemask 10-12 L/min.
 Administer medications e.g. (Magnesium Sulfate)
per order.
 Assess FHR:
 Access for labor status, uterine tone, contractions
cervical effacement and dilatation, station of
presenting part and status of membranes.
 Insert indwelling catheter.

Nursing care following
convulsion:
 Monitor blood pressure.
 Monitor kidney function, liver function, and
coagulation system. Blood specimens for cross
matching and other biochemical tests.
 Provide hygiene and quiet environment.
 Support and keep client and family informed.
 Be prepared for birth when mother is stable.
 The volume of urine and albumin urea need to
be monitored four hourly.
 Taking and recording the B.P. and pulse every
15 min. until they are stable, then every 30 to
60 minutes.

Medications used for PIH:
Anti hypertensive:
 Aldomet (methyldopa) 500-100mg orally
 Hydrodiuril 50-100 mg orally daily.
 A presoline (hydralazine):10-40 mg i.v every 4
to 6 hrs.
 Anti convulsions sedatives:
 Valium (Diazepam) 5-10 mg orally
 Magnesium Sulfate: 4-6 g, is given over 15-30
min by volumetric infusion pump followed by
maintenance infusion 2-4 g/hr.
 Diuretics:
 Lasix (Furosemide) 40 mg i.v slow push.
 Thursday, April 5, 2018 Dr. Soad Abd El salam Ramdan 38

Medications used for PIH:
Magnesium Sulfate toxicity:
◦ MgSO4 is C.N.S. depressant the nurse should assess signs and
symptoms of magnesium toxicity:
◦ Respiration < 12 min.
◦ Absence of reflexes.
◦ Urinary output < 30 ml/hr.
◦ Toxic serum level 9.6 mg/dl.
◦ Signs of fetal distress (e.g. fetal tachycardia or Bradycardia).
◦ Significant drop in maternal pulse or B.P.
Nursing intervention in magnesium sulfate toxicity:
◦ Discontinue MgSO4 immediately.
◦ Calcium glyconate (the antidote for MgSO4) should be kept at the
bedside (1g for I.V if given over 3 min).
◦ Call for assistance and immediate care.

40Thursday, April 5, 2018 Dr. Soad Abd El salam Ramdan

Pregnancy induced hyper tension

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