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1. PREGNANCY-INDUCED
HYPERTENSION
(PIH)
by:
Trixie Mariel E. Araune
Jenn Christian C. Bonono

2. WHAT IS PIH?
► a condition in in which vasospasm
occurs during pregnancy in both small &
large arteries
► originally called toxemia
► occurs in 5% - 7% of pregnancies
Signs of PIH:
 edema (interstitial effect)
 hypertension (vascular effect)
 proteinuria (kidney effect)

3. Cause: UNKNOWN
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

4. CLASSIFICATION OF PIH
1) Gestational HPN
2) Mild pre-eclampsia
3) Severe pre-eclampsia
4) Eclampsia

5. ANATOMY & PHYSIOLOGY
Internal anatomy of the heart

6. ANATOMY & PHYSIOLOGY
Blood flow through the circulatory system

7. ANATOMY & PHYSIOLOGY
Diagram of human circulation

8. PATHOPHYSIOLOGY
Vasospasm
Vascular effects Kidney effects Interstitial effects
Vasoconstriction ↓ed glomeruli Diffusion of fluid
filtration rate & from bloodstream
↑ed glomeruli into interstitial
membrane
Poor organ tissue
permeability
perfusion
↑ed serum BUN,
↑ed BP uric acid, & Edema
creatinine
↓ed urine output
& proteinuria

10. Excretory System Anatomy & Physiology
“ without me in your body, you are nothing but - a waste…”

11. 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.

12. the anatomy

13. 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.

14. the anatomy [the ureters]
 About 28 cm long
Carry 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.

15. the anatomy [the urinary bladder]
 It can store about 0.5 to 1 litre of urine
The 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.
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 water
Limit caffeine alchohol and fizzy drinks
Do pelvic floor exercises
Don't go to the toilet 'just in case' however also don't hold on too
long
Keep your weight under control
Don't smoke
Don't strain when going to the toilet

16. 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.

17. the .com
references
 http://www.tena.com.au/professionals/healthcare-professionals/incontinence-management-centre/about-incont
 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/

19. 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)

20. • 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.

21. Mild Pre-eclampsia
This 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.

22. • 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.

23. 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.

24. Severe Preeclampsia

25. 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

26.  Hepatic dysfunction
 Elevated serum
creatinine more than
1.2 mg/dL
 Extensive peripheral
edema
 Pulmonary edema
 Epigastric pain

27. SEVERE
PREECLAMPSIA

29. NURSING INTERVENTIONS
a. Support bed rest
b. Monitor maternal well- being
c. Monitor fetal well- being
d. Support nutritious diet
e. Administer medications to prevent
eclampsia

30. 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.

31. Support bed rest
•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 

32. Monitor maternal well- being
•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

33. Monitor maternal well- being
•Obtain daily hematocrit
levels as ordered
•Assess optic fundus
•Obtain daily weights at the
same time each day
NORMAL:more than
600mL per 24 hours(>
•Indwelling catheter may be 30mL/hr), output lower
than this suggests
inserted OLIGURIA

34. Monitor maternal well- being
•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

35. SEVERE PREECLAMPSIA MILD PREECLAMPSIA
5g per 24 hours(3+ or 4+ on bet 0.5 and 1g of protein
individual specimen) every 24 hours(1+ on
sample)

36. . Monitor fetal well-being
•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

37. MEDICATIONS
DRUG INDICATION DOSAGE COMMENT
Magnesium Muscle Loading dose Infuse loading dose slowly over
sulfate relaxant; 4–6 g 15–30 min.
Pregnancy prevents Maintenance Always administer as a
risk category seizures dose 1–2 g/h IV piggyback infusion
B Assess 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

38. MEDICATIONS
DRUG INDICATION DOSAGE COMMENT
Hydralazine Antihypertensiv 5–10 mg/IV Administer slowly to avoid sudden
(Apresoline) e fall in blood pressure.
Pregnancy risk Maintain diastolic pressure over
category C 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 Antidote for 1 g/IV (10 mL of Have prepared at bedside when
gluconate magnesium a 10% solution) administering magnesium sulfate.
Pregnancy risk intoxication Administer at 5 mL/min.
category C

39. Eliciting A Patellar Reflex
and Ankle Clonus
PATELLAR REFLEX RESULTS:
0 = No response; hypoactive;
abnormal
1+ = Somewhat diminished
response but not abnormal
2+ = Average response
3+ = Brisker than average but
not abnormal
4+ = Hyperactive; very brisk;
abnormal

40. ANKLE CLONUS
RESULTS:
Mild (2 movements)
Moderate (3–5
movements)
Severe (over 6
movements)

41. PROGNOSIS
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.

42. 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.

43. 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.

44. 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

45. • 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.

46. The most evident symptoms of overdose
from magnesium sulfate administration
include:
• decreased urine output
• depressed respirations
• reduced consciousness
• decreased deep tendon
reflexes

47. • 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.

48. 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.

49. • 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

50. 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

51. TABLE 15.7 Drugs Used in Pregnancy-Induced
Hypertension
Drug Indication Dosage
Magnesium sulfate Muscle relaxant; Loading dose 4–6 g
Maintenance dose 1–2
Pregnancy risk prevents seizures
g/h IV
category B

53.  Is a grand mal seizure  Symptoms:
which passes the -Seizure or coma
stages of: accompanied by signs
 A) Tonic-Clonic and symptoms of pre-
 B) Coma eclampsia
 Usually happens in late
pregnancy
 But can happen up to
48 hrs after birth

54.  Causes of poor fetal  If premature
prognosis: separation of the
 Hypoxia placenta from
 Consequent fetal vasospasm occurs, the
acidosis fetal prognosis is
graver.
 If a fetus must be born
before term, all the
risks of immaturity will
be faced.

55.  A woman’s blood pressure  Reflexes become
rises suddenly from hyperactive
additional vasospasm  May experience a
 Temperature rises sharply premonition that
to 103 to 104 degrees “something is happening”
Fahrenheit  Vascular congestion of the
 Blurring of vision or severe liver and pancreas can lead
headache to severe epigastric pain
and nausea
 Urinary output may
decrease abruptly to less
than 30 mL/hr.

56.  Risk factors:  gestational diabetes
- greater in nulliparous  prepregnancy obesity
compared to parous  weight gain during
women pregnancy
- Being a young mother
(<20 years) or an older
mother (≥35 years)
were each associated
with elevated
eclampsia risk

57. Nursing Interventions for a woman
with Eclampsia

58. 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

59. 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

60. 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 INTERVENTION
Magnesium Sulfate or Diazepam (Valium) may
be administered intravenously

61. 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

62. 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

63. 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.

64. HELLP
SYNDROME
a variation of PIH named for
the common symptoms that
occur:
-hemolysis
-elevated liver enzymes
-low platelets.

65. 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

66. SYMPTOMS
 nausea
 Epigastric pain
 General malaise
 Right Upper Quadrant tenderness from
liver inflammation.

67. SYMPTOMS
 Laboratorystudies 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)

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

69. COMPLICATIONS
 Subcapsular liver hematoma
 Hyponatremia
 Renal failure
 Hypoglycemia

70.  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.

71. Nursing Diagnoses:
Pregnancy –Induced

72. Decreased cardiac output related to
hypovolemia
It can also be related to decreased venous return.
Possibly evidenced by:
d. Edema
e. Shortness of breath
f. Change in mental status
g. Decreased urine output

73. Deficient Fluid Volume related to loss
to subcutaneous tissue
It can also be related to a plasma protein loss.
Possibly evidenced by:
d. Edema formation
e. Sudden weight gain
f. Hemoconcentration
g. Nausea & vomiting
h. Epigastric pain
i. Headache
j. Visual changes
k. Decreased urine output

74. Ineffective Tissue Perfusion related
to vasoconstriction of blood vessels
It could be related to vasospasm of spiral arteries & relative
hypovolemia.
Possibly evidenced by:
e. Changes in Fetal heart rate
f. Reduced weight gain
g. Premature delivery

75. 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

76. Woman with ECLAMPSIA:
II. 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