Slide 1Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
Chapter 27Chapter 27Hypertensive DisordersHypertensive Disorders
in Pregnancyin Pregnancy
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Significance and IncidenceSignificance and Incidence Hypertensive disordersHypertensive disorders
5% to 10% of all pregnancies5% to 10% of all pregnancies Preeclampsia Preeclampsia
• Complicates 3% to 7% of all pregnanciesComplicates 3% to 7% of all pregnancies Predispose the woman to serious complicationsPredispose the woman to serious complications Pregnancy associated hypertension accounts for Pregnancy associated hypertension accounts for
10%-15% of maternal deaths worldwide10%-15% of maternal deaths worldwide
Slide 3Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
ClassificationClassificationGestational Hypertensive Disorders Gestational Hypertensive Disorders
Gestational hypertension Gestational hypertension Onset of hypertension without proteinuria after Onset of hypertension without proteinuria after
week 20 of pregnancy week 20 of pregnancy PreeclampsiaPreeclampsia
Pregnancy-specific syndrome in which Pregnancy-specific syndrome in which hypertension develops after 20 weeks of gestation hypertension develops after 20 weeks of gestation in a previously normotensive womanin a previously normotensive woman
Catagorized as Mild or SevereCatagorized as Mild or Severe
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ClassificationClassificationGestational Hypertensive DisordersGestational Hypertensive Disorders
Mild PreeclampsiaMild Preeclampsia
Severe PreeclampsiaSevere Preeclampsia
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EclampsiaEclampsia Onset of seizure activity or coma in a woman Onset of seizure activity or coma in a woman
diagnosed with preeclampsiadiagnosed with preeclampsia
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ClassificationClassificationChronic Hypertensive Disorders Chronic Hypertensive Disorders
Chronic hypertensionChronic hypertension Hypertension present before pregnancy or Hypertension present before pregnancy or
diagnosed before week 20 of gestationdiagnosed before week 20 of gestation Chronic hypertension with superimposed Chronic hypertension with superimposed
preeclampsiapreeclampsia Women with chronic hypertension may acquire Women with chronic hypertension may acquire
preeclampsia or eclampsiapreeclampsia or eclampsia
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Preeclampsia Preeclampsia
EtiologyEtiology Signs and symptoms develop Signs and symptoms develop
during pregnancy and disappear after birthduring pregnancy and disappear after birth Risk factorsRisk factors
Slide 8Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
Preeclampsia Preeclampsia
PathophysiologyPathophysiology Disruptions in placental perfusion Disruptions in placental perfusion
and endothelial cell dysfunctionand endothelial cell dysfunction Inadequate vascular remodeling in uterusInadequate vascular remodeling in uterus Placental ischemia causes cell dysfunction. This in Placental ischemia causes cell dysfunction. This in
turn causes generalized vasospasm which results turn causes generalized vasospasm which results in poor tissue perfusion in all organs, increased in poor tissue perfusion in all organs, increased resistance and B/P, and increased cell resistance and B/P, and increased cell permeability= less plasma volume permeability= less plasma volume
Reduced function in maternal organs (kidneys, Reduced function in maternal organs (kidneys, liver, brain)liver, brain)
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Preeclampsia Preeclampsia Reduced function in placenta contributes to Reduced function in placenta contributes to
iincreased incidence of placental abruption, ncreased incidence of placental abruption, premature birth, early aging of placenta, restriction premature birth, early aging of placenta, restriction of fetal growthof fetal growth
HELLP syndromeHELLP syndrome Laboratory diagnosis for a variant of severe Laboratory diagnosis for a variant of severe
preeclampsia that involves hepatic dysfunctionpreeclampsia that involves hepatic dysfunction Diagnosis associated with increased risk for Diagnosis associated with increased risk for
adverse perinatal outcomesadverse perinatal outcomes
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Care ManagementCare ManagementIdentifying and AssessingIdentifying and Assessing
Mild Preeclampsia: Assessment and home Mild Preeclampsia: Assessment and home carecare Health history for risk factorsHealth history for risk factors Monitoring B/PMonitoring B/P Dependent edema/Pitting edemaDependent edema/Pitting edema Deep tendon reflexes (DTRs)Deep tendon reflexes (DTRs) Lab tests/biophysical monitoringLab tests/biophysical monitoring Activity restrictionActivity restriction DietDiet
Slide 11Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 12Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
Care ManagementCare ManagementHospital ManagementHospital Management
Severe Preeclampsia: Hospital CareSevere Preeclampsia: Hospital Care Bedrest, side rails up, quiet roomBedrest, side rails up, quiet room Fetal monitoringFetal monitoring Magnesium sulfate- administered IVMagnesium sulfate- administered IV Control of blood pressure-antihypertensive Control of blood pressure-antihypertensive
medicationsmedications Eclampsia- immediate care during convulsion- Eclampsia- immediate care during convulsion-
ensure a patent airway and prevent aspirationensure a patent airway and prevent aspiration
Care Management Postpartum Nursing Care
Symptoms of preeclampsia or eclampsia resolve usually within 48 hours
Careful assessment of • vital signs• intake and output• DTR’s• level of consciousness• uterine tone/ lochia flow- boggy uterus and
heavy lochia flow due to magnesium sulfate
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Chronic Hypertension Chronic Hypertension Affects 4%-5% of all pregnanciesAffects 4%-5% of all pregnancies Associated with increased incidence of:Associated with increased incidence of:
Postpartum complications include:Postpartum complications include: Pulmonary edemaPulmonary edema Renal failureRenal failure Heart failureHeart failure EncephalopathyEncephalopathy
ATI QuestionATI Question A client with preeclampsia is receiving IV A client with preeclampsia is receiving IV
magnesium sulfate. Which of the following magnesium sulfate. Which of the following should the nurse include in the plan of care? should the nurse include in the plan of care? (select all that apply)(select all that apply)a.a. Keep calcium gluconate at the bedsideKeep calcium gluconate at the bedsideb.b. Maintain lights at dim settingMaintain lights at dim settingc.c. Have side rails up at all timesHave side rails up at all timesd.d. Keep a padded tongue blade at the bedsideKeep a padded tongue blade at the bedsidee.e. Encourage intake of clear fluidsEncourage intake of clear fluids
Slide 17Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
Key Points Key Points
Hypertensive disorders during pregnancy are Hypertensive disorders during pregnancy are a leading cause of worldwide infant and a leading cause of worldwide infant and maternal morbidity and mortalitymaternal morbidity and mortality
Cause of preeclampsia unknown, and there Cause of preeclampsia unknown, and there are no known reliable tests for predicting are no known reliable tests for predicting which women are at risk for preeclampsiawhich women are at risk for preeclampsia
Preeclampsia is a multisystem disease rather Preeclampsia is a multisystem disease rather than only an increase in BPthan only an increase in BP
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Key Points Key Points
Failure of trophoblastic invasion of spiral Failure of trophoblastic invasion of spiral arterioles is proposed as triggering arterioles is proposed as triggering mechanism that leads to vasospasm and mechanism that leads to vasospasm and organ ischemiaorgan ischemia Cure is delivery of fetus and placentaCure is delivery of fetus and placenta
Pathologic changes of preeclampsia, Pathologic changes of preeclampsia, involving every organ system in the body, are involving every organ system in the body, are present long before clinical manifestations present long before clinical manifestations are evidentare evident
Slide 19Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
Key Points Key Points
Historic risk factors are associated with a higher Historic risk factors are associated with a higher incidence of preeclampsiaincidence of preeclampsia First pregnancy or pregnancy of new genetic makeupFirst pregnancy or pregnancy of new genetic makeup History of vascular diseaseHistory of vascular disease Multiple gestationMultiple gestation
Progression of hypertensive disorders during Progression of hypertensive disorders during pregnancy is unpredictablepregnancy is unpredictable Mild hypertension must be taken seriously and Mild hypertension must be taken seriously and
managed as for preeclampsiamanaged as for preeclampsia
Slide 20Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
Key Points Key Points
Once preeclampsia clinically evident Once preeclampsia clinically evident Therapeutic intervention is palliative: bed rest, dietTherapeutic intervention is palliative: bed rest, diet May slow progression of disease and allow May slow progression of disease and allow
pregnancy to continuepregnancy to continue
Slide 21Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
Key Points Key Points
Home care management an option only for Home care management an option only for women women Whose condition is stableWhose condition is stable Who are able to comply with medical regimenWho are able to comply with medical regimen Reliably perform self-monitoringReliably perform self-monitoring Immediately recognize and report abnormal signs Immediately recognize and report abnormal signs
and symptomsand symptoms
Slide 22Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
Key Points Key Points
HELLP syndrome can occur in women with HELLP syndrome can occur in women with severe preeclampsia and is considered life severe preeclampsia and is considered life threateningthreatening
Magnesium sulfate, the anticonvulsive agent Magnesium sulfate, the anticonvulsive agent of choice for preventing eclampsia, requires of choice for preventing eclampsia, requires careful monitoring of reflexes, respirations, careful monitoring of reflexes, respirations, and urinary outputand urinary output Antidote, calcium gluconate, should be available at Antidote, calcium gluconate, should be available at
bedsidebedside
Slide 23Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
Key Points Key Points
Intent of emergency interventions for Intent of emergency interventions for eclampsia is to:eclampsia is to: Prevent self-injuryPrevent self-injury Ensure adequate oxygenationEnsure adequate oxygenation Reduce aspiration riskReduce aspiration risk Establish seizure control with magnesium sulfateEstablish seizure control with magnesium sulfate Correct maternal acidemiaCorrect maternal acidemia
Chronic hypertension in pregnancy associated Chronic hypertension in pregnancy associated with abruptio placentae and superimposed with abruptio placentae and superimposed preeclampsiapreeclampsia