Hypertension in Pregnancy

Hypertension in Pregnancy Overview

• Hypertension during pregnancy is a significant concern
• It can lead to severe complications

Gestational Hypertension

• Previously known as toxemia
• Diagnosed with a BP ≥ 140/90 mmHg or an increase of 30 mmHg systolic / 15 mmHg diastolic from baseline
• Characterized by no proteinuria or edema, and BP returns to normal following birth
• Caused by vasospasm in small and large arteries, which raises blood pressure

Pregnancy-Induced Hypertension (PIH)

• Onset occurs at 20 weeks AOG or later
• Represents the 2nd leading cause of maternal death
• Risk factors include: age (<17 or >35), protein malnutrition, primigravida, diabetes mellitus, lack of prenatal care, low socioeconomic status, and previous hypertension
• Can progress to HELLP syndrome, a serious complication
• Classic symptoms include proteinuria, edema, and hypertension

Chronic Hypertension

• Exists before pregnancy or is diagnosed before 20 weeks AOG
• Persists beyond 12 weeks postpartum

Chronic Hypertension with Superimposed PIH

• Existing hypertension with developing preeclampsia/eclampsia
• Presents in two forms: superimposed preeclampsia and superimposed eclampsia

Superimposed Preeclampsia

• Worsening high BP and signs of organ damage in a pregnant woman with pre-existing hypertension

Superimposed Eclampsia

• Seizures develop in a pregnant woman with pre-existing hypertension

Preeclampsia

• More severe than gestational hypertension but occurs before seizures

Mild Preeclampsia

• BP at or above 140/90 mmHg or has increased 30 mmHg systolic / 15 mmHg diastolic
• 1+ to 2+ proteinuria seen in a random sample
• Weight gain includes >2 lbs/week during the 2nd trimester and >1 lb/week during the 3rd trimester
• Mild edema may appear in the face or upper extremities

Mild Preeclampsia Interventions

• Bed rest in the lateral position
• Monitor BP, weight, and neurological status (watch for cerebral hypoxia or seizures)
• Assess deep tendon reflexes (DTRs) & clonus (hyperreflexia = CNS irritability)
• Fluids and antiplatelet therapy are given
• Administer ordered BP medications, avoiding rapid decreases that could affect placental perfusion
• Watch for HELLP syndrome
• Increase protein & carbohydrates with no added salt

Severe Preeclampsia

• BP ≥ 160/110 mmHg
• Proteinuria: either 3+ to 4+ (random sample) or ≥5g (24-hour sample)
• Oliguria (≤500 mL urine/24 hrs or altered kidney function)
• Creatinine >1.2 mg/dL
• Neurological symptoms: Headache and possibly blurred vision
• Lung and heart involvement
• Severe edema & liver dysfunction
• Hyperreflexia
• Thrombocytopenia, bleeding gums, petechiae, purpura
• Epigastric pain (early warning sign of complications)

Severe Preeclampsia Interventions

• Maintain the individual on strict bed rest in a side-lying position
• Monitor the mother & fetus, VS, DTRs, urine output, and lab values
• Administer magnesium sulfate (4-7 mEq/L) to prevent seizures (monitor for toxicity)
• Monitor for mag toxicity, flushing, sweating, low BP, loss of DTRs, CNS depression, respiratory depression, oliguria
• Calcium Gluconate should be available to administer in the event of mag toxicity
• Administer antihypertensives: Hydralazine, Labetalol (Normodyne), and Nifedipine
• Monitor BP & pulse for signs of maternal tachycardia
• Plan for potential labor induction

Severe Preeclampsia Assessment

• Check for twitching around the mouth
• Check for tonic-clonic phases
• Check for breathing stops during seizure
• Check for postictal sleep following seizure

Severe Preeclampsia Intervention

• Make sure there is a clear airway
• Administer oxygen
• Turn the patient to their side (prevent aspiration)
• Keep both side rails up
• No restraints
• Monitor fetal heart rate (FHR) & contractions
• Vaginal delivery is the goal (C-section increases issues with fetal lung fluid)
• Comforting space

Ankle Clonus Test (CNS Irritability Indicator)

• Quickly move the foot 3 times
• Watch how they jerk it back into starting position
• If they move rapidly it means CNS irritability

Eclampsia

• Includes seizures or a coma in combination with preeclampsia symptoms
• It is the most critical form of Pregnancy-Induced Hypertension (PIH)
• Fetal risk: Hypoxia & acidosis
• Can cause cause Tonic-clonic seizures → Possible coma
• Pre-seizure signs: Aura and epigastric pain
• Leads to Hypertensive crisis

HELLP Syndrome

• Life-threatening pregnancy issue, severe form of preeclampsia
• Consists of: Hemolysis (Anemia), Elevated Liver Enzymes (Epigastric/RUQ pain), and Low Platelets (Bleeding, petechiae, risk of DIC)
• Can be idiopathic or occur as a side effect
• Family history can be a risk factor for the mother, and multiparity (>50% of cases), and SARS-CoV-2 infection
• Signs & Symptoms include pain, liver distension, hypertension, proteinuria

HELLP Complications

• Subcapsular liver hematoma (internal bleeding)
• Hyponatremia
• Renal failure
• Hypoglycemia (may need IV glucose)
• DIC (disseminated intravascular coagulation)

HELLP Diagnosis

• Hemolysis (LDH ≥ 600 IU/L)
• Elevated liver enzymes (AST, ALT)
• Low platelets (Thrombocytopenia < 100,000)
• Presence of schistocytes (fragmented RBCs) on blood smear
• ↑ Bilirubin and ↓ Haptoglobin

HELLP Classification

• Class I: < 50,000 (Severe)
• Class II: 50,000 – 100,000
• Class III: 100,000 – 150,000

HELLP Management

• Requires hospitalization
• Delivery of the baby is the goal
• Monitor if 32 weeks >, Monitor closer if 32 weeks3, elevated liver enzymes, low platelets)

Hyperemesis Gravidarum

• Severe and excessive nausea & vomiting during pregnancy
• Causes electrolyte, metabolic, and nutritional imbalances
• Can occur with or without food intake and beyond the first trimester

Hyperemesis Gravidarum Causes

• High hCG levels (e.g., molar pregnancy, multiple gestation)
• Increased estrogen levels
• Slowed gastric motility

Hyperemesis Gravidarum Risk Factors

• First-time pregnancy
• Unmarried white women
• Family-related stress & ambivalence toward pregnancy
• Thyroid dysfunction

Hyperemesis Gravidarum Pathophysiology

• Persisent nausea & appetite disturbances triggerer for the first 16 weeks of pregnancy
• It can be related to Psychological factors
• It is more frequent in molar pregnancies & multiple gestations
• Causes electrolyte imbalances dehydrations etc

Hyperemesis Gravidarum Manifestation

• Severe, persistent nausea & vomiting with or without food intake
• Weight loss (5-10% of body weight lost)
• Dehydration symptoms
• Fetid, fruity breath odor and signs of acidosis

Hyperemesis Gravidarum Implementation

• IV therapy to start rehydrating & prescribe fluids
• Monitor Electrolytes:
• Provide anitemetics
• Assess intake and output
• Encourage proper nutrition

Hyperemesis Gravidarum Patient Education

• Eat smaller and more frequent meals
• Self care to prevent dizziness etc
• Dextrose & electrolyte based

Pharmacological Interventions

• Vitamin B6 and Doxylamine are used to tackle Nausea and Vomiting

Metoclopramide (Biclomet, Clomitene, Reglomar)

• Antiemetic
• It impacts brain receptor function
• Enhances motility & empyting
• Does not stimulate pancreas, only liver and gallbladder
• Increases lower esophageal sphincter tone
• Nausea & Vomiting

Promethazine (Metagon, Phenerzin)

• Treat Nausea and vomitting
• IM injection in use, give IV slowly

Ondansetron (Emodan, Zofran)

• Moderate to highly emetogenic cancer chemotherapy
• Hyperemeisis
• Make sure it is not mixed with other forms of therapy

Prochlorperazine (Compazine)

• Manages NAusea and Vomitting It acts as an anti vertigo

Hemorrhagic Disorders

• Conditions where bleeding occurs.

Early Bleeding Disoders during early gestation ( before 20 weeks)

• Spontaneous , Ectopic, Abnormally fertilized, Cervical Insufficiency (Incompetent cervix leading to pregnancy loss)

Early Bleeding - Abortion

• A spontaneous or planned event that interrupts the pregnancy
• It may either interupt the genetic abnormalities ( at 1st Trimester) or the internal maternal environments

Abortion Types of Early Bleeding

• Threatened
• Inevitable/Imminent
• Incomplete
• Complete
• Missed Abortion
• Recurrent/Habitiual

Types of Spontaneous Abortion

• Threatened: A vaginal bleeding in first 20 weeks, without certical or internal abnormalities

Types of Spontaneous Abortion

• Imminent : As vagina bleed but internals are opened
• Complete: The feutus comes out
• Missed: No bleed but feutus dies internally

Causes for Abortion and Signs

• Check for the amount of blood loss and vital signs
• Asses the persons general understanding and level of distress

Recurrent Recurrent/Habitual

• The mothers body has trouble sustaining pregnancies
• It may lack certain needed componetets/environments to facilitate child birth

Key notes about abortions

• Watch for key causes in abortions
• Give anti abortion pills and make sure patients are stable

Late bleeding disorders occur after 20 Weeks Gestation

• Placeta previa, Abrupto placeta
• There may be a bleeding after delivery due to issues inside the reproductive tract of the mother.

Infection Signs

• Follow a fever, a foul smell might be prevalent Follow lab tests

Placent Previa

• Part of the placental structure comes close to the babies head blocking it.

Abrupto Placent

• Leads to the ripping of placental membranes
• It occurs with key causes Key to have an open O2/ Air access

Premature Labor - Preterm Labor

Early signs of delivery

• Regular uterus contraction
• Cerical dial at 2 coms
• Effacement
• Dilation

Early Preterm labor management

• Assess the vitals and levels of the body fluids
• The baby is strong and well enough
• Administer drugs the stabilize vitals

PROM and what to do - Premature Rupture of Membrane

• Educate mother
• Inform of water break & fluid leaks
• Give the medicine to the patient

What's the role of Amniotic Fluid?

When will amniotic change in color?

Gestational Trophoblastic Disease (GTD)

• Normal preganncy
• Get tested
• Follow 6-12
• No preganncy
• Follow monitor

Post Term Preganny

• Get tested if pregancy longer then 42 weeks
• Ensure no problems from test