PREGNANCY-INDUCED HYPERTENSION(PIH)

by:

Trixie Mariel E. Araune

Jenn Christian C. Bonono

► a condition in in which vasospasm occurs during pregnancy in both small & large arteries ► originally called toxemia► occurs in 5% - 7% of pregnancies

WHAT IS PIH?

Signs of PIH: edema (interstitial effect)

hypertension (vascular effect)

proteinuria (kidney effect)

Cause:

Risk factors: multiple pregnancy primiparas (< 20 y.o or > 40 y.o) low socioeconomic backgrounds ( poor

nutrition) 5 or more pregnancies hydramnios heart dse, diabetes, & essential

hypertension

UNKNOWN

CLASSIFICATION OF PIH

1) Gestational HPN2) Mild pre-eclampsia3) Severe pre-eclampsia4) Eclampsia

ANATOMY & PHYSIOLOGY

Internal anatomy of the heart

ANATOMY & PHYSIOLOGY

Blood flow through the circulatory system

ANATOMY & PHYSIOLOGY

Diagram of human circulation

PATHOPHYSIOLOGY

Vasospasm

Vascular effects

Vasoconstriction

Poor organ perfusion

↑ed BP

↓ed glomeruli filtration rate & ↑ed glomeruli

membrane permeability

Kidney effects

↑ed serum BUN, uric acid, & creatinine

↓ed urine output &

proteinuria

Interstitial effects

Diffusion of fluid from

bloodstream into interstitial

tissue

Edema

“ without me in your body, you are nothing but - a waste…”

Excretory System Anatomy & Physiology

the functions

Urinary system, often called as ‘excretory system’, is a body system that separates wastes from the body – usually as urine or sweat.

As a system, the kidneys, ureters, urinary bladder & the urethra works through:

Maintaining body’s fluid & electrolyte balance. Collects water & filter body fluids. Removes excess, unnecessary or dangerous

materials in the body to help maintain homeostasis.

the anatomy

the anatomy [the kidneys]

Are dark-red, slightly flattened, bean shaped organs about 10 cm long, 5 cm wide and 4 cm thick weighing approximately 150 grams. Kidneys weigh about 0.5 percent of total body weight. A mass of tiny tubes & each tube is a knot of capillaries.Each kidney is composed of numerous microscopic coiled tubules called nephron or renal tubules or uriniferous tubules. The inner surface has a deep notch called hilus. The ureters, renal artery, renal vein and the nerves enter the kidney through the hilus.The kidney is divided into 2 regions, an outer region called renal cortex and the inner region termed renal medulla.

the anatomy [the ureters]

 About 28 cm longCarry the urine from the kidneys to the urinary bladder. Arise from the renal pelvis on the medial aspect of each kidney before descending towards the bladder on the front of the psoas major muscle.This "pelviureteric junction" is a common site for the impaction of kidney stones.  In the female, the ureters pass through the mesometrium on the way to the urinary bladder.

the anatomy [the urinary bladder]

Tips for a healthy bladder 

Here are some tips you can pass onto clients and patients to help them achieve a healthy bladder

Drink plenty of waterLimit caffeine alchohol and fizzy drinks

Do pelvic floor exercisesDon't go to the toilet 'just in case' however also

don't hold on too longKeep your weight under control

Don't smokeDon't strain when going to the toilet

It can store about 0.5 to 1 litre of urineThe lower part or neck of the bladder is guarded by 2 rings of muscle fibres called sphincters.The act of voiding of urine is called micturition.

the anatomy [the urethra]

Tube that passes urine from the urinary bladder to the outside of the body. In females it is about 2 - 3 cm long and carries only urine.In male, urethra is about 20 cm long and carries urine as well as the spermatic fluid.

the references

http://www.tena.com.au/professionals/healthcare-professionals/incontinence-management-centre/about-incontinence/

http://www.medterms.com/script/main/art.asp?articlekey=5907

http://education.yahoo.com/reference/gray/subjects/subject/255

http://www.lake-mills.k12.ia.us/msources/Health-SS7/ExcretorySystem.htm

http://www.emc.maricopa.edu/faculty/farabee/biobk/biobookexcret.html

https://www.facebook.com/

.com

Pre-eclampsia• Serious metabolic disturbance (toxemia) of

pregnancy that occurs most often following the twentieth week of pregnancy.

• Involves a systemic malfunction of the tissue lining the blood vessels (vascular endothelium) and is characterized by high blood pressure (hypertension), swelling (edema), and high amounts of protein in the urine (proteinuria)

• It is one of a group of disorders that appear to be progressive steps in a single process that includes gestational hypertension (blood pressure of 140/90 or greater)

Gestational Hypertension - when women develops an elevated blood

pressure (140/90mmHG) but has no proteinuria or edema.

Mild Pre-eclampsiaThis condition is characterized by:

• Blood Pressure reading of 140 mm hg systolic, or an elevation of 30 mm hg or more systolic or 15 mm hg diastolic above the patient's prepregnancy level.

• Bp readings are taken on two occasions 6 hours apart, with special attention to the diastolic pressure, which reflects peripheral vascular spasm.

• Proteinuria of 1+ or 2+ on a reagent test strip or 500 mg/24 hours or more.

• Swelling in the upper part of her body rather than the usual ankle edema associated with pregnancy.

• Weight gain of more than 1 kg (2 pounds) a week in the second trimester and 0.5 kg (1 pound) a week in the third trimester.

Management:• Bed rest to facilitate sodium excretion• Some physicians also prescribe a high-

protein diet to compensate for the protein lost in the urine and, perhaps, mild restriction of sodium intake.

Diuretics are not used for control of edema because they can only aggravate the condition by increasing glomerular vessel permeability and stimulating angiotension activity.

Severe Preeclampsia

Symptoms Blood pressure: 160/110

mmhg Proteinuria: 3–4+ on a

random sample and 5 g on a 24-hour sample

Oliguria: (500 mL or less in 24 hours or altered renal function tests; elevated more than 1.2 mg/dL)

Cerebral or visual disturbances (headache, blurred vision)

Thrombocytopenia

Hepatic dysfunction

Elevated serum creatinine more than 1.2 mg/dL

Extensive peripheral edema

Pulmonary edema Epigastric pain

SEVEREPREECLAMPSI

A

a.Support bed restb.Monitor maternal well- beingc.Monitor fetal well- beingd.Support nutritious diete.Administer medications to

prevent eclampsia

NURSING INTERVENTIONS

•Woman may be admitted to health care facility

•If pregnancy is 36 WEEKS or further along or FETAL LUNG MATURITY can be confirmed by amniocentesis labor can be induced to end pregnancy

•If pregnancy is LESS THAN 36 WEEKS or IMMATURE LUNG FUNCTION can be revealed by amniocentesis interventions will be instituted to attempt to alleviate the sever symptoms and allow fetus to come in term.

NURSING INTERVENTIONS

•woman should be admitted to a PRIVATE ROOM so she can rest undisturbed as possible•raise side rails•darken the room•stress can trigger an INCREASE in BP and can evoke seizures•make sure a woman receives clear explanations and allow opportunities to EXPRESS HER FEELINGS

Support bed rest

•Take BP every 4HOURS or w/ continuous monitoring device

•Obtain blood studies as ordered(complete blood count, platelet count, liver function, blood urea nitrogen, and creatine and fibrin degradation products

•Type and cross-matching

Monitor maternal well- being

•Obtain daily hematocrit levels as ordered

•Assess optic fundus

•Obtain daily weights at the same time each day

•Indwelling catheter may be inserted

Monitor maternal well- being

NORMAL:more than 600mL per 24 hours(> 30mL/hr), output lower than this suggests OLIGURIA

•Urinary protein & specific gravity recorded & measured with voiding or if with indwelling catheter, HOURLY

•24-hour urine sample may be collected for protein and creatinine clearance determinations to evaluate kidney function

Monitor maternal well- being

SEVERE PREECLAMPSIA MILD PREECLAMPSIA

5g per 24 hours(3+ or 4+ on individual specimen)

bet 0.5 and 1g of protein every 24 hours(1+ on sample)

•single Doppler auscultation at approximately 4-hour intervals(FHR may be assessed by an external fetal monitor)•Nonstress test or biophysical profile to assess uteroplacental sufficiency•O2 administration to maintain adequate fetal oxygenation and prevent fetal bradycardia

. Monitor fetal well-being

MEDICATIONSDRUG INDICATIO

NDOSAGE COMMENT

Magnesium sulfatePregnancy risk category B

Muscle relaxant; prevents seizures

Loading dose 4–6 gMaintenance dose 1–2 g/h IV

Infuse loading dose slowly over 15–30 min.Always administer as a piggyback infusionAssess respiratory rate, urine output, deep tendon reflexes, and clonus every hour.Keep in mind that urine output should be over 30 mL/hour and respiratory rate over 12/min. Serum magnesium level should remain below 7.5 mEq/L.Observe for CNS depression and hypotonia in infant at birth

MEDICATIONSDRUG INDICATION DOSAGE COMMENT

Hydralazine (Apresoline)Pregnancy risk category C

Antihypertensive

5–10 mg/IV Administer slowly to avoid sudden fall in blood pressure.Maintain diastolic pressure over 90 mm Hg to ensure adequate placental filling.Administer slowly. Dose may be repeated q 5–10 min (up to 30 mg/hour).Observe for respiratory depression or hypotension in mother and respiratory depression and hypotonia in infant at birth.

Calcium gluconatePregnancy risk category C

Antidote for magnesium intoxication

1 g/IV (10 mL of a 10% solution)

Have prepared at bedside when administering magnesium sulfate.Administer at 5 mL/min.

PATELLAR REFLEX

Eliciting A Patellar Reflex and Ankle Clonus

RESULTS:

0 = No response; hypoactive; abnormal1+ = Somewhat diminished response but not abnormal2+ = Average response3+ = Brisker than average but not abnormal4+ = Hyperactive; very brisk; abnormal

ANKLE CLONUS

RESULTS:

Mild (2 movements)

Moderate (3–5 movements)

Severe (over 6 movements)

Sign and symptoms of preeclampsia usually go away within 6 weeks after delivery. However, the high blood pressure sometimes get worse the first few days after delivery.

If you have had preeclampsia, you are more likely to develop it again in another pregnancy. However, it is not usually as severe as the first time.

If you have have high blood pressure during more than one pregnancy, you are more likely to have high blood pressure when you get older.

The infant's risk of death depends on the severity of the condition and how early the baby is born.

PROGNOSIS

Support a Nutritious Diet

A woman needs a diet:•moderate to high in protein•moderate in sodium to compensate for the protein she is losing in her urine,

An intravenous fluid line should be initiated and maintained to serve as an emergency route for drug administration as well as to administer fluid to reduce hemoconcentration and hypovolemia.

Administer Medications to Prevent Eclampsia

A hypotensive drug such as hydralazine (Apresoline) or labetalol (Normodyne) may be prescribed to reduce hypertension.

- Assess pulse and blood pressure after administration. Diastolic pressure should not be lowered below 80 to 90 mm Hg or inadequate placental perfusion could occur.

Magnesium Sulfate – drug of choice to prevent eclampsia

- classified as a cathartic- reduces edema by causing a shift in fluid

from the extracellular spaces into the intestine- also has a central nervous system

depressant action which lessens the possibility of seizures

• For magnesium sulfate to act as an anticonvulsant, blood serum levels must be maintained at 5 to 8 mg/100 mL. If the blood serum level rises above this, respiratory depression, cardiac arrhythmias, and cardiac arrest can occur.

The most evident symptoms of overdose from magnesium sulfate administration include:

• decreased urine output• depressed respirations• reduced consciousness• decreased deep tendon

reflexes

• Because magnesium is excreted from the body almost entirely through the urine, urine output must be monitored closely to ensure adequate elimination.

• If severe oliguria should occur (less than 100 mL in 4 hours), excessively high serum levels of magnesium can result.

Before you administer further magnesium sulfate, assess the following:

• ensure that urine output is above 25 to 30 mL/hour, with a specific gravity of 1.010 or lower

• respirations should be above 12 per minute• a woman should be able to answer questions asked of

her• ankle clonus (a continued motion of the foot) should be

minimal• deep tendon reflexes should be present

Make these assessments every hour if a continuous intravenous infusion is being used.

• a solution of 10 mL of a 10% calcium gluconate solution (1 g) should be kept ready nearby for immediate intravenous administration should a woman develop signs and symptoms of magnesium toxicity, as calcium is the specific antidote for magnesium toxicity

Severe oliguria may be treated by the intravenous infusion of salt-poor albumin.

High colloid solution (salt-poor albumin)

call fluid into the bloodstream from interstitial tissue by osmotic pressure

the kidneys will then excrete the extra fluid along with magnesium sulfate levels

TABLE 15.7 Drugs Used in Pregnancy-Induced Hypertension

Drug Indication Dosage

Magnesium sulfate

Pregnancy risk

category B

Muscle relaxant;

prevents seizures

Loading dose 4–6 gMaintenance dose 1–2 g/h IV

Is a grand mal seizure which passes the stages of:

A) Tonic-Clonic B) Coma Usually happens in

late pregnancy But can happen up

to 48 hrs after birth

Symptoms:-Seizure or coma

accompanied by signs and symptoms of pre-eclampsia

Causes of poor fetal prognosis:

Hypoxia Consequent fetal

acidosis

If premature separation of the placenta from vasospasm occurs, the fetal prognosis is graver.

If a fetus must be born before term, all the risks of immaturity will be faced.

A woman’s blood pressure rises suddenly from additional vasospasm

Temperature rises sharply to 103 to 104 degrees Fahrenheit

Blurring of vision or severe headache

Reflexes become hyperactive

May experience a premonition that “something is happening”

Vascular congestion of the liver and pancreas can lead to severe epigastric pain and nausea

Urinary output may decrease abruptly to less than 30 mL/hr.

Risk factors:- greater in nulliparous

compared to parous women

- Being a young mother (<20 years) or an older mother (≥35 years) were each associated with elevated eclampsia risk

 gestational diabetes

prepregnancy obesity

 weight gain during pregnancy 

Nursing Interventions for a woman with Eclampsia

Tonic-Clonic Seizure

TONIC PHASE- Last approximately 20 secs.• all the muscles of the woman’s body contract• Back arches• Arms and legs stiffen• Jaw closes abruptly• Respirations halt because her thoracic muscles

are held in contraction

Nursing Interventions:• Priority Care: Maintain a patent airway• Do not put tongue blade• Administer oxygen by face mask• Assess oxygen saturation via a pulse oximeter• Apply an external fetal heart monitor

Clonic Phase-last up to 1 minute• Bladder and bowel muscles contract and relax• Incontinence of urine and feces may occur.• Remains cyanotic and may need continued

oxygen therapy for the fetus

NURSING INTERVENTIONMagnesium Sulfate or Diazepam (Valium) may

be administered intravenously

Postictal State• A woman is semicomatose and cannot be

roused except by painful stimuli for 1 to 4 hours

• Part of the seizure that may cause premature separation of the placenta

• Labor may begin during this period and a woman will be unable to report the sensation of contraction

Nursing Interventions:• Keep a woman on her side so secretions can

drain• Nothing per Orem• Continuously assess fetal heart sounds and

uterine contractions.• Check for vaginal bleeding every 15 minutes

Birth

There is evidences that the fetus does not continue to grow after eclampsia happens, so terminating the pregnancy at this point is appropriate for both mother and child.

A woman with eclampsia is not a good candidate for surgery: she may become hypotensive with regional anesthesia.

HELLP SYNDROME

a variation of PIH named for the common symptoms that occur:

-hemolysis-elevated liver enzymes -low platelets.

HELLP SYNDROME Occurs in approximately 1 in every 150

births. Results in maternal mortality rate as

high as 24% and an infant mortality rate as high as 35%.

It occurs in:-primigravidas-multigrvidas-some women with pre-eclampsia

SYMPTOMS nausea Epigastric pain General malaise Right Upper Quadrant tenderness from

liver inflammation.

SYMPTOMS Laboratory studies reveals:

1. Hemolysis of RBCs-appears fragmented on peripheral blood smear

2.Thrombocytopenia- platelet count below 100,000/mm3

3. Elevated liver enzyme levels (alanine aminotransferase-ALT and serum aspartate aminotransferase-AST)

THERAPY

Improve the platelet count by transfusion of fresh-frozen plasma or platelets.

COMPLICATIONS

Subcapsular liver hematoma Hyponatremia Renal failure Hypoglycemia

The infant is delivered as soon as feasible by either vaginal or cesarean birth.

Maternal hemorrhage may occur at birth because of poor clotting activity.

Epidural anesthesia may not be possible because of the low platelet count and the high possibility of bleeding at the epidural site.

Laboratory results return to normal after birth.

Nursing Diagnoses:

Pregnancy –Induced

Decreased cardiac output related to hypovolemia

It can also be related to decreased venous return.

Possibly evidenced by:

a. Edema

b. Shortness of breath

c. Change in mental status

d. Decreased urine output

Deficient Fluid Volume related to loss to subcutaneous tissue

It can also be related to a plasma protein loss.

Possibly evidenced by:a. Edema formationb. Sudden weight gainc. Hemoconcentrationd. Nausea & vomitinge. Epigastric painf. Headacheg. Visual changesh. Decreased urine output

Ineffective Tissue Perfusion related to vasoconstriction of

blood vesselsIt could be related to vasospasm of spiral

arteries & relative hypovolemia.

Possibly evidenced by:

a. Changes in Fetal heart rate

b. Reduced weight gain

c. Premature delivery

Nursing Interventions

Woman with MILD PIH: Monitor Antiplatelet Therapy Promote Bed Rest Promote Good Nutrition Provide Emotional Support

Woman with SEVERE PIH: Support bed rest Monitor maternal well-being Monitor fetal well-being Support a nutritious diet Administer medications to prevent Eclampsia

Woman with ECLAMPSIA:I. Patient that has tonic-clonic seizure: Maintain a patent airway Administer Oxygen face mask Turn the woman in her side to prevent aspirations Administer Magnesium Sulfate or diazepam via IV Assess oxygenation via pulse oximeter