2. Hypertensive Disorders of
Pregnancy
1. Chronic Hypertension (before pregnancy)
2. Gestational (in pregnancy) Hypertension
-
Pre-eclampsia
Severe pre-eclampsia
Eclampsia
HELLP syndrome
3. Hypertensive Disorders of
Pregnancy
• Most commonly reported disorder of
pregnancy
• May occur in 20% of all pregnancies
• One of the leading causes of maternal
morbidity and mortality worldwide
4. Pathophysiology/Etiology
1. Actual cause is unknown.
2. Theories of the etiology include the exposure to chorionic villi for the
first time, or in large amounts, along with
immunologic, genetic, and endocrine factors.
3. The disease is primarily seen in primagravidas.
4. Chronic hypertension, hydatidiform mole, multiple
gestation, polyhydramnios, and diabetes mellitus may
predispose to PIH.
5. Adolescents and women over 35 years of age are at higher risk.
6. Approximately 6% to 8% of pregnancies may be affected.
7. Vasospasms occur and result in increased resistance in vascular
flow, increasing the arterial blood pressure.
8. Increased sensitivity to angiotensin II occurs before the onset of
hypertension.
9. Hemoconcentration occurs due to the vasoconstriction or as a
result of increased vascular permeability or a combination of both.
9. Clinical Manifestations
1. Hypertension, which is defined as a blood pressure of 140/90
mm Hg or greater on two occasions at least 6 hours apart
2. Proteinuria , +, ++, +++, ++++
3. Edema, nondependent, present after 8 to 12 hours of bed rest
,
4. Frequently, a sudden weight gain will occur, of 2 lb or more in
1 week, or 6 lb or more in 1 month. This often occurs before
the edema is present.
5. Altered level of consciousness, visual changes, headache
6. Oliguria
7. Epigastric pain, chest pressure
8. Hyperreflexia with or without clonus
11. Hypertensive Disorders of
Pregnancy
• Pre-eclampsia
Severe
Preeclampsia
PLUS one of the following:
1. Systolic BP > 160 mmHg
2. Diastolic BP > 110mmHg
3. Persistent headache, visual
changes or epigastric pain
4. Creatinine > 1.2 mg/dL
5. Platelets < 100,000
6. Increase liver function tests
14. Hypertensive Disorders of
Pregnancy
• Risk factors
1.
2.
3.
4.
5.
6.
First pregnancy
More than one fetus
Pre-existing disease (diabetes, hypertension)
Obesity
Maternal age (< 20 years, > 40 years)
Family history
15. Diagnostic Evaluation
1. A 24-hour urine for protein of 300 mg or
greater
2. Serum BUN and creatine to evaluate
renal function
3. Sonogram, nonstress testing to evaluate
placenta and fetus
16. Management
1. Directed toward decreasing the maternal blood pressure through the
use of bed rest and antihypertensive medications along with
increase in dietary protein
2. Hospitalization and seizure
3. Medication
a. Magnesium sulfate (MgS04) may be given either IV or IM
Side effect, loss of knee reflex, should be given calcium gluconate
b. Antihypertensive drug; Hydralazine (Apresoline)
* Side effects include
tachycardia, palpitations, dizziness, faintness, headache.
c. Diazepam (Valium) and amobarbital sodium (Amytal Sodium) may
be used if convulsions occur that respond to MgS04.
4. If symptoms are uncontrollable, delivery is planned.
18. Nursing Assessment
• Assessment of mother
1. Blood pressure
2. Protein in the urine
3. Complaints of headache, liver pain,
or strange bruises or bleeding
19. Nursing Diagnoses
A. Fluid Volume Excess related to IV fluid
overload(edema)
B. Altered Tissue Perfusion, Fetal Cardiac
and Cerebral, related to altered placental
blood flow(fetal distress)
C. Risk for Injury related to convulsions
D. Anxiety related to concern for self and
fetus
20. A. Maintaining Fluid Balance
1. Control IV fluid intake using a continuous infusion
pump.
2. Monitor intake and output strictly; notify health
care provider if urine output is less than 30 mL/h.
4. Monitor hematocrit levels to evaluate intravascular
fluid status.
5. Monitor vital signs every hour.
6. Auscultate breath sounds every 2 hours and
report signs of pulmonary edema
(wheezing, crackles, shortness of
breath, increased pulse rate, increased respiratory
rate).
21. B. Promoting Adequate Tissue
Perfusion
1. Position on side, preferably the left side to
promote placental perfusion.
2. Monitor fetal activity.
3. Evaluate nonstress tests to determine
fetal status.
4. Increase protein intake to replace protein
lost through kidneys.
22. C. Preventing Injury
1. Instruct on the importance of reporting
headaches, visual changes, dizziness, and
epigastric pain.
2. Instruct to lie down on left side if symptoms are
present.
3. Keep the environment quiet and as calm as possible.
4. If hospitalized, side rails should be padded and
remain up to prevent injury if seizure occurs.
5. If hospitalized, have oxygen and suction setup, along
with a tongue blade and emergency medications
immediately available for treatment of seizures.
23. D. Decreasing Anxiety
1. Explain the disease process and
treatment plan.
2. Explain that PIH does not lead to chronic
hypertension.
3. Explain that PIH usually does not occur with
subsequent pregnancies.
4. Discuss the effects of all medications on the
mother and fetus.
5. Allow time to ask questions and discuss
feelings regarding the diagnosis and
treatment plan.
24. Patient Education/Health
Maintenance
1. Teach the woman the importance of bed rest in
helping to control symptoms.
2. Encourage the support of family and friends while
on bed rest.
3. Provide and suggest diversional activities while on
bed rest.
4. Provide information on tests and procedures to
evaluate maternal-fetal status, such as laboratory
tests, sonogram, nonstress tests.
5. Include support of the neonatal team for
discussion of fetal prognosis with the woman and
her family.
25. Evaluation
A. No evidence of pulmonary edema; urine
output adequate
B. Fetal heart rate within normal range;
reactivity present
C. No seizure activity
D. Expresses concern for self and the fetus
Hinweis der Redaktion
HELLP syndrome is a severe complication of pregnancy-induced hypertension. It is comprised of Hemolysis, Elevated Liver enzymes, and Low Platelets.1. These findings are frequently associated with DIC and in fact may be diagnosed as DIC.2. The hemolysis of erythrocytes is seen in the abnormal morphology of the cells.3. The elevated liver enzyme measurement is associated with the decreased blood flow to the liver as a result of fibrin thrombi.4. The low platelet count is related to vasospasm and platelet adhesions.5. Treatment is similar to treatment for PIH with close monitoring of liver function and bleeding.6. These women are at increased risk for postpartum hemorrhage
Evaluate blood pressure with patient in a sitting position and in the left lateral position. 2. Check the protein level of a spot urine specimen. 3. Evaluate edema, carefully noting the presence after 12 hours or more of bed rest. Measure weight. 4. Evaluate deep tendon reflexes and clonus.
