Pregnancy-Induced Hypertension: Overview, Complications & Management - PDF

Pregnancy Complications PREGNANCY –INDUCED HYPERTENSION Hypertension: a blood pressure reading in two occasions of at least 140/90 or a rise of 30mm/hg systolic and 15 mm/hg diastolic. BP should be taken in two occasions 4 to 6 hours apart Gestational Hypertension: BP 140/90 mm/Hg develops for the f...

Pregnancy Complications PREGNANCY –INDUCED HYPERTENSION Hypertension: a blood pressure reading in two occasions of at least 140/90 or a rise of 30mm/hg systolic and 15 mm/hg diastolic. BP should be taken in two occasions 4 to 6 hours apart Gestational Hypertension: BP 140/90 mm/Hg develops for the first time during pregnancy, but there is no proteinuria and within 12 weeks postpartum the BP is normal. Pregnancy Induced Hypertension: Hypertension that develops after the 20th week of gestation to a previously normotensive woman. PIH include preeclampsia, eclampsia and gestational hypertension. Preeclampsia: Hypertension of BP 140/90, that develops after 20 weeks gestation accompanied by proteinuria (300 mg/24Hours) and edema. Eclampsia: all the signs and symptoms of preeclampsia accompanied by convulsions or coma that is not caused by any other conditions. Superimposed Eclampsia and Preeclampsia: Occurs when a woman having chronic hypertension develops preeclampsia or eclampsia during pregnancy Chronic Hypertension: The presence of hypertension before pregnancy MANAGEMENT: or hypertension that develops before 20 weeks gestation in the absence Screening and early diagnosis of H-mole that persists after 12th week postpartum 1.Roll-over Test: or supine-pressor test. Given between 28 and 32 weeks gestation. BP is taken at the brachial artery in the lateral recumbent position, the woman then rolls over to the supine position PREDISPOSING FACTORS and pressure id measured immediately and again after 5 minutes. An Said to be a disease of primiparas – higher incidence in primiparas below 20 and above 40 years increase of 20mmHg or greater in diastolic pressure is a positive indicator that the woman is likely to develop PIH. Preexisting disease – diabetes, collagen vascular disease, chronic Initial Hospitalization hypertension or chronic renal disease Low socioeconomic status and inadequate prenatal care 1.Patients who show signs of preeclampsia are initially hospitalized for further evaluation and stabilization Poor nutrition a. CBC with platelet, BUN, creatinine, uric acid levels Pregnancy complications – H-mole, DM, multiple pregnancy, polyhydramnios, Rh incompatibility, renal disease, heart disease b.Liver function test c.A 24-hour urine for total protein and creatinine clearance Hereditary d. Daily weights Multiparity e. UTZ for fetal size, amniotic fluid volume and fetal well being Black race f. Ongoing (monitoring) assessment Multigravida CAUSES OF PREGNANCY INDUCED HYPERTENSION g. Deep tendon reflexes (DTR’s) at the patellar site are recorded on a scale of 0 to 4: No definite cause known 0: no response highly correlated with the antiphospholipid syndrome or the presence of antiphospholipid antibodies 1+: diminished 2+: normal protein deficiency theory and dietary deficiencies 3+: brisker than average, possibly developing disease endothelin theory – Endothelin are potent vasoconstrictors produced by the endothelin 4+: very brisk, hyperactive, associated with clonus and developing disease PATHOPHYSIOLOGIC CHANGES 2. To assess the clonus at the ankle joint, the nurse should dorsiflex the In normal pregnancy, plasma volume increases but systemic vascular resistance decreases resulting in normal blood pressure. foot and observes for movement when it is released. Clonus is evidenced by a rhythmic jerking indicating hyperreflexias Presence of overabundance of chorionic villi with or without fetus is After evaluation: associated with vasospasm – the cause of arterial hypertension. This is seen in multiple fetuses and H-mole. Vasospasm is the underlying Severe preeclampsia: woman remains hospitalized for treatment Mild preeclampsia with normal laboratory values: woman is cause of preeclampsia’s insidious disease process. discharged for home treatment Ambulatory Management 1. Home management is allowed only if: BP is 140/90 or below There is low proteinuria There is no fetal growth retardation Fetal well being is assured: good fetal movement 2. Bed rest: woman must be free from physical and emotional stress. When lying down, they assume a left lateral position to shift the weight off the vena cava, maximize uteroplacental flow and increase diuresis to lower BP. Include diversional activities and gentle exercise to decrease setback brought about by prolong bedrest 3. Consult the clinic regularly, usually every two weeks 4. Regular phone calls and home visit by the nurse to check signs and symptoms of worsening conditions 5. Diet is high protein and high carbohydrates with moderate sodium restriction 6. Hospitalization if condition worsens 7. Provide detailed instruction about: a. Dietary modifications High protein – at least 1.5 g/kg of body weight per day Moderate sodium restriction to less than 2 g/day Avoid alcohol Eat a balanced diet that includes 1200 mg calcium is achieved, that is diastolic pressure between 90 mmHg and 100 Measure I and O mmHg During 8-10 glasses of water per day A 20 mg dose of IV labetolol (Normodyne) may also be given every b. Monitor her own health condition: 10 minutes to a maximum dose of 300 mg Take and record her BP twice a day 5. Bed rest is one of the most important principles of care because it Count fetal movement per hour (3/h) reduces BP and promote diuresis Void into specimen pan and check for protein Rest in left lateral recumbent position Take and record weight daily Room should be dim, quiet, away from areas of activity. Avoid bright s/s of preeclampsia lights such as flashlights c. She must report to health care provider immediately if the following Restrict visitors to allow patient to rest occur: Leave BP cuff on patient’s arm so as not to disturb the patient when Increasing BP placing it everytime BP is checked Epigastric pain 6. Monitor patient closely Visual disturbances Take v/s and fht continuously Severe headache Monitor for impending signs of convulsion. Blurring of vision, severe Nausea and vomiting headache and epigastric pain Weight gain more than 1 lb a week Weigh daily at the same time each day using the same weighing scale Abnormal fetal movement Laboratory tests for proteinuria, creatinine, hematocrit Abdominal pain 7. Fetal Monitoring: Hospital Management Fetal movement counting Hospitalization maybe required in the following conditions: Nonstress testing BP is equal or greater than 160/100 mmHg Biophysical profile Proteinuria of 3+ or 4+ d. Doppler flow studies Rapid weight gain 8. Safety measures Oliguria Raise padded side rails at all times to keep the woman from falling if Visual disturbances convulsion occurs Abnormal fetal movement Put bed at lowest position 2. Expectant management: the only cure for preeclampsia is delivery. Have emergency equipments available for use: suction apparatus, Because of this, it is important to know the age of the fetus to determine MgSO4, Calcium gluconate, Oxygen etc viability if maternal condition worsens and necessitated immediate 9. Care for the woman during convulsion – Eclamptic convulsions delivery. occur in about 2% of all pregnancies Bethamethasone to promote lung maturity Stages of Convulsion: Hospital Management Stage of Invasion or Aura: Facial twitching, rolling of the eyes to one 3. Fluid therapy: a crystalloid infusion is preferred, usually lactated side, staring fixedly in space, sudden severe headache, screaming and Ringers solution or normal saline at a rate of 100 to 125 ml/hour epigastric pain Fluid imbalances can exist leading to oliguria because of contracted Tonic phase: Body becomes rigid as all muscles go into violent spasms plasma volume. However, because the essence of disease process is or contractions, eyes protrude, arms are flexed with legs inverted, capillary endothelial damage, fluid therapy must be expertly monitored hands are clenched, woman stops breathing. Last for 15 to 20 seconds as fluid overload could quickly lead to pulmonary edema Clonic phase: Jaws and eyelids close and open violently, foaming of 4. Medications the mouth; face becomes congested and purple, muscles of the body Magnesium sulfate: drug of choice to treat and prevent convulsions. contract and relaxes alternately. The contractions are so violent that the (CNS Depressant) woman may throw herself out of bed. Lasts for about one minute Actions : Postictal state: contractions cease and woman enters a semicomatose Prevent convulsion by depressing CNS & preventing seizures by state. The patient will not remember the convulsion and the event blocking the release of acetylcholine at the myoneural junctions immediately before and after the event Reduce edema Nursing Responsibilities during Convulsion: Reduce BP by reducing muscle excitability Always monitor patient for impending signs of convulsion The two main responsibilities of the nurse during convulsion are: maintaining of patient airway and protection of patient from self-injury MAGNESIUM SULFATE Turn patient on her side to allow drainage of saliva and prevent Nursing Considerations: aspiration Dose: the American College of Obstetricians & Gynecologists Place pillow under the patient’s head to prevent injury recommends a loading dose of 4 g infused over 20 minutes, followed Never leave an eclamptic patient alone by a continuous infusion of 2 g to 3 g per hour Do not restrict movement during convulsion as this could result to Check the following first before administering the drug: fracture Respiration should be above 14 CPM After convulsion: Urine output should be at least 100 ml/hour Watch for the signs of abruption placenta: vaginal bleeding, abdominal Deep tendon reflexes are present (knee-jerk or patellar reflex) loss of pain, decreased fetal activity DTR is often the first sign of toxicity or hypermagnesemia Take v/s and FHT Serum magnesium levels are evaluated periodically: 7-8 mg/dl is Suction nasopharynx as necessary and administer oxygen therapeutic ; 9-12 mg/dl indicates developing toxicity If nor infusing prophylactically, infuse 4 g MgSO4 over 20 minutes, Antidote for magnesium toxicity is Calcium gluconate IV over two followed by a maintenance dose of 2 g/hr. an IV bolus of 2 g is infused minutes and notify physician for recurrent seizures Magnesium sulfate is given up to 24 hours after delivery or from the Sedatives such as Diazepam (Valium) are only used if MgSO4 cannot last convulsion if it happened during the postpartum period control the convulsions If given during postpartum, monitor for uterine atony as it can cause Do not give anything by mouth unless the woman is fully awake after uterine relaxation and increase the risk for postpartum hemorrhage convulsion Side effects of MgSO4: h. Electronic fetal monitoring of the fetus is continued Maternal –CNS depression, hyporeflexia, flushing , confusion i. Take v/s every 5 minutes and then every 15 minutes when the patient Fetal – tachycardia, hypoglycemia, hypocalcemia, hypomagnesemia stabilizes B. Antihypertensive j. Auscultate the patient lungs for possible pulmonary edema Hydralazine (Apresoline) is the medication of choice because it k. Output will need careful monitoring via a urinary catheter reduces BP effectively and safely. An initial 5 mg bolus is followed by l. Physician may order arterial blood gas to assess maternal 5 mg to 10 mg every 20 minutes until a mildly hypertensive pressure oxygenation (acidosis is very common after convulsion) and chest x-ray to rule out aspiration 3. elevated liver enzyme levels (alanine aminotransferase [ALT) and m. Once the patient is stabilized, delivery should commence within 3 serum aspartate aminotransferase [AST]). The liver enzyme levels are to 6 hours elevated from hemorrhage and necrosis of the liver 10. Delivery: COMPLICATIONS The preferred method is vaginal delivery. Labor is induced by Subcapsular liver hematoma amniotomy or oxytocin administration when the condition of the Hyponatremia woman is stable. Local or pudendal anesthesia is used. Prostaglandin renal failure E2 gel is often used to ripen the cervix. Pitocin and magnesium hypoglycemia from poor liver function. can be given simultaneously 5. Mothers complications include: However, cesarean delivery is an excellent option for the seriously ill cerebral hemorrhages patient who might not tolerate induction or if labor induction is aspiration pneumonia unsuccessful and fetal distress is severe that hypoxic encephalopathy the fetus needs to be delivered immediately. 6. Fetal complications can include 11. Postpartum care growth restriction The danger of convulsion exist until 24 hours after delivery, MgSO4 preterm birth therapy is continued. Hydralazine maybe given depending upon the BP MANAGEMENT Watch for uterine relaxation and increase lochia flow if the woman is transfusion of fresh-frozen plasma or platelets. receiving MgSO4 If hypoglycemia is present, this is corrected by an intravenous C. If the mother received large doses of MgSO4 before delivery, the glucosinfusion. newborn may have high serum magnesium level, therefore watch for The infant is born as soon as feasible by either vaginal or cesarean birth. respiratory depression, hypocalcemia, hypotonia in these infants. Newborn toxicity is treated with levallorphan( Lorfan) d. Continue to monitor the patient during the postpartum period: I and O: diuresis is a positive sign that signals resolution of the disease process MULTIPLE PREGNANCY BP and pulse are checked at least every 4 hours for 48 hours When two, three, four or even five fetuses are conceived , grow and Hematocrit is checked daily develop in the uterus at the same time, it is called multiple pregnancy Platelet count and liver enzymes are monitored for risk for HELLP or multifetal pregnancy. syndrome Twins – 2 fetuses Triplets – 3 fetuses Quadruplets – 4 fetuses e. Ergot products such as methergine, are contraindicated because they Quintuplets – 5 fetuses are hypertensive Sextuplets – 6 fetuses f. Two years should elapse before another pregnancy is attempted to Septuplets – 7 fetuses decrease the likelihood that PIH will recur on the subsequent TYPES OF TWINNING pregnancy. Monozygotic or identical twin. Identical twins develop from one ovum and one sperm cell that undergo too rapid cell division after fertilization resulting in the formation of two or more fetuses. Since the fetus came from the same sperm cell and egg cell, they naturally possess the same genetic traits and are always of the same sex a. if twinning occurred within 72 hours after fertilization, there will be two amnions (diamniotic) , two chorions (dichorionic) and two embryos (monozygotic) b. if twinning occurred between the fourth and eight day after fertilization, there will be two amnions, one chorion (monochorionic) and two embryos It is a variation of PIH named for the common symptoms that occur: c. If twinning occurred after eight days, there will be one amnion H - emolysis that leads to anemia (monoanionic), one chorion and 2 embryos E - levated d. If twinning occurred after the embryonic disc is formed, conjoined L - iver enzymes that lead to epigastric pain, and twins will develop. Conjoined twins are classified according to the part L – ow of the body where they are attached: P - latelets that lead to abnormal bleeding/clotting and petechia Anterior – thoracopagus (common) Incidence: Posterior – pyopagus The syndrome occurs in 4% to 12% of patients with PIH. It is a serious Cephalic – craniopagus syndrome because it results in a maternal mortality rate as high as 24% Caudal - ischiopagus and an infant mortality rate as high as 35%. 2. Dizygotic or Fraternal twin: this develop from two or more ova and CAUSE/PREDISPOSING FACTORS sperm cells that were fertilized at the same time. They have different 1.Unknown genetic traits; they may or may not be of the same sex and always have 2.associated with antiphospholipid syndrome or the presence of separate placentas, chorions and amnions antiphospholipid antibodies SIGNS AND SYMPTOMS proteinuria edema increased blood pressure nausea, epigastric pain general malaise right upper quadrant tenderness from liver inflammation LABORATORY STUDIES 1.hemolysis of red blood cells (they appear fragmented on a peripheral blood smear), 2.thrombocytopenia (a platelet count of