Hypertensive Disorders in Pregnancy PDF

Dr. Nungruetai K.  Describe the definition/types of hypertensive Disorder in Pregnancy Explain etiology, pathophysiology S/S , maternal and fetal effects, investigation, and treatment Discuss about nursing management  Incidence: worldwide: 7-12% The most common and yet serious condit...

Dr. Nungruetai K.  Describe the definition/types of hypertensive Disorder in Pregnancy Explain etiology, pathophysiology S/S , maternal and fetal effects, investigation, and treatment Discuss about nursing management  Incidence: worldwide: 7-12% The most common and yet serious conditions seen in obstetrics cause substantial morbidity and mortality in the mother and fetus Death due to cerebral hemorrhage, aspiration pneumonia, hypoxic encephalophathy, thromboembolism, hepatic rupture, renal failure 1. Pregnancy-induced hypertension 1.1 Mild preeclampsia 1.2 Severe preeclampsia 1.3 Eclampsia 2. Gestational hypertension 3. Chronic hypertension preceding pregnancy 4. Chronic hypertension with superimposed PIH Superimposed preeclampsia Superimposed eclampsia 1. Pregnancy-induced hypertension: Hypertension associated with proteinuria and edema, occurring primarily after the 20th week or near term. 1.1 Mild Preeclampsia : BP ≥ 140/90mmHg (or) SBP baseline BP ≥ 30 mmHg DBP ≥ baseline BP 15 mmHg and Proteinuria (dipstick 1 + to 2+ or ≥ 300mg/24-hr urine collection or ≥ 30mg/dl) With or without others S/S such as (or) Weight gain of 2 lbs (1 kg per week on the 2nd trimester) and 1 lb (1/2 kg per week on the 3rd trimester) (or) Slight edema in upper extremities and face  1.2) Severe Pre-eclampsia BP ≥ 160/110 mmHg and Marked proteinuria (3+ or more or >1-2 g/24-hr urine collection ) with at least one of the bellowed S/S Cerebral / visual disturbances such as headache and blur vision Epigastric (or) right upper quadrant pain (probably caused by subcapsular hepatic edema / hemorrhage) Mark edema in upper-lower extremities and face Oliguria (less than 500 ml/24 hrs) Pulmonary edema or cyanosis Hepatic dysfunction, or thrombocytopenia (Low platelet counts))  Occurrence: 0.5 -4 %, with 25% occurring in 1.3 Eclampsia the 1st 72 hs postpartum Meets the criteria of preeclampsia and Presence of convulsions, not attributable to other neurological disease 2. Gestational hypertension: not mentioned in the ACOG Finding of hypertension in late pregnancy in the absence of other findings or preeclampsia Transient hypertension of pregnancy May develop into chronic hypertension if elevated BP persists beyond 12 weeks postpartum 3. Chronic hypertension proceeding pregnancy (essential or secondary to renal disease, endocrine disease, or other causes) BP ≥ 140/90 mmHg Presents before () 12 week postpartum 4. Chronic hypertension with superimposed preeclampsia or eclampsia Coexistence of preeclampsia (or) eclampsia with preexisting chronic hypertension Quick Review  Nulliparous 40 ys Family history Has previous gestational hypertensive disorders Underlying medical problems e.g. Chronic nephritis Diabetic, Thyroid Multiple pregnancy (or) Twin pregnancy Hydatidiform mole* Malnutrition Low social status  In Preeclampsia Endothelial prostacyclin (PGI2) production is decreased Thromboxane A2 (TXA2) secretion by activated platelets during hemostasis is increased  Increased sensitivity to infused angiotensin II  Systematic Vasoconstriction  resistance and subsequent hypertension  Diminished blood flow vital organ dysfunctions, necrosis, and hemorrhage The Texbook’s Kidney Disease and Hypertension in Pregnancy, 2003 Williams Obstetric 22 edition, Chapter 34: Hypertensive Disorders in Pregnancy  Systematic Vasoconstriction  activation and dysfunction (damaged) of the vascular endothelium  increased capillary permeability  Secrete toxic radicals/substances into the maternal circulation  elevated blood concentrations  to promote coagulation Williams Obstetric 22 edition, Chapter 34: Hypertensive Disorders in Pregnancy Pregnancy Effects: Risk of placental abruption – premature separation of a normally situated placenta from the wall of uterus Risk of preterm delivery (often iatrogenic) – delivery before 37 weeks of gestation Intrauterine growth restriction (IUGR) – an abnormally restricted symmetric or asymmetric growth of fetus Oligohydramnios – abnormally low volume of amniotic fluid Systemic Effects: Vital organs dysfunction e.g. Renal failure , Hepatic damage, Pulmonary edema ***HELLP syndrome (Hemolysis,Elevated liver enzymes levels,Low platelet count) DIC (5%) Seizures  HELLP SYNDROME This is an acronym for:- 1) Haemolysis : by using blood smear 2) Elevated liver enzymes : SGOT> 70 IU/L, LDH>600 IU/L 3) Low platelet count ( 1.020 Blood test: elevated Hb or Hct, in severe cases, anemia secondary to hemolysis, thrombocytopenia, C. Laboratory FDP increase, decreased coagulation factors findings(1) Liver function: ALT and AST increase, alkaline phosphatase increase, LDH increase, serum albumin Renal function: uric acid: 6 mg/dl, serum creatinine may be elevated Retinal check: Other tests: ECG, placenta function, fetal maturity, cerebral angiography, etc.  FHR monitoring Fetal movement counts (FMC) Non stress test Biophysical profile Sonographic Estimated Fetal Weight: to check for presence of IUGR  Antihypertensive; Peripheral vasodilator used to decrease hypertension Dosage: 5 – 10 mg/IV Management:Hydralazine  Administer slowly to avoid sudden fall in blood pressure.  Maintain diastolic pressure over 90 mmHg to adequate placental filling Drug of choice to prevent eclampsia; Reduces edema; Lessens possibility of seizures Management: Mgso4 Loading dose: 4-6 g IV diluted in 100 ml IVF given slowly over 15 to 30 minutes. (Always administer as a piggyback infusion) Continuous infusion: 2g/hr Should be given up to 24Hours after delivery Common side effects : flushing (warmth, redness, or tingly feeling), sweating extreme drowsiness, muscle tightness or contraction, or Headache, N/V anxiety  Severe adverse effect : Mgso4 Toxicity: – Diminished or loss of patellar reflex: poor reflex – Diminished respiration: difficult breathing – Muscle paralysis – Blurred speech – Cardiac arrest: lower BP  Assess RR, UO, DTR, and clonus every hour  Urine output should be over 30 mL/hour and respiratory rate over 12/min. Serum magnesium level should remain below 7.5 mEq/L. Management of toxicity of Mgso4: 1. Slow i.v. 10% calcium gluconate( antidote for magnesium intoxication) 2. Oxygen supplementation 3. Cardiorespiratory support  Antihypertensive; Peripheral vasodilator used to decrease hypertension Dosage: 5 – 10 mg/IV Management: Diazepam  Administer slowly. Dose may be repeated every 5 to 10 minutes (up to 30 mg/hour).  Observe for respiratory depression or hypotension in mother and respiratory depression and hypotonia in infant at birth Quick Review Several nursing diagnoses may be formulated for the woman with pregnancy-induced hypertension. Problems are similar as to a non-pregnant person who is hypertensive. Risk for Maternal Injury : ineffective Tissue Perfusion (affect to vital organs’ function and pregnancy health) relate to vasoconstriction of blood vessels Risk for Fetal Injury related to reduced placental perfusion secondary to vasospasm To prevent maternal and fetal risks & maintain pregnancy : Home management 1. Bed rest is the best method to aid increased evacuation of sodium and promotion of diuresis. 2. Position the client to a lateral recumbent position to avoid pressure on the vena cava and prevent supine hypotension syndrome. 3. Health Teaching Daily Self-monitoring blood pressure, body weight Instruct about danger signals (Aura): severe headache, epigastric pain, visual disturbances, and mark edema to watch for so she can alert her clinician if additional symptoms occur between visits. Daily monitor and record FMC Regular visit for fetal wellbeing assessment at clinic 4. Diet: low fats and sodium diet, restriction if possible. high in protein, calcium and iron. Adequate fluid intake 1. Support bed rest. Restrict visitors to support people only. Darken the room and reduce all possible stimulants to prevent seizure from occurring. Raise side rails to prevent any injury in case a seizure episode occurs. 2. Monitor maternal well-being. Take blood pressure every hour to four hours (up to conditions) to detect any increase, which may indicate that a woman’s condition is worsening. 3. Obtain blood studies as ordered to assess renal and liver function, and to determine the development of DIC, which often accompanies severe vasospasm. 4. Monitor hematocrit levels daily to assess blood concentration. 5. Obtain weight daily Assure that a client is wearing the same type of clothing at the same time of the day. 6. Monitor fetal well-being. Assist in monitoring the fetus as ordered. Nonstress tests and biophysical profiles may be done to determine the status of the fetus. 7. Support a nutritious diet. Administer fluids to reduce hemoconcentration and hypovolemia. 8. Administer medications to maintain BP & prevent eclampsia. Prevention of convulsion: magnesium sulfate or diazepam Control of maternal blood pressure: antihypertensive therapy Monitor client’s response to pharmacologic therapy. Ready calcium gluconate at bedside in case magnesium sulfate toxicity occurs. Provide health education.  Monitor tonic-clonic seizures: a preliminary signal /aura / ominous signs may occur before each seizure episode Maintain a patent airway. Have the woman turn to her side to prevent aspiration. Assess oxygenation by pulse oximetry. Monitor fetal well-being by applying an external fetal heart monitor. Check for vaginal bleeding for possible placental separation. Never restrain the woman Then, Hospitalization Termination of pregnancy when : 1. Preeclampsia close to term 2.