Hypertention

• Chronic hypertension


  Persistent hypertension, of whatever cause, before the 20th week of gestation in the absence of vesicular mole or persistent hypertension beyond 6 weeks postpartum
• Gestational hypertension


  Hypertension that develops only during the later half of pregnancy or during the first 24 hours after delivery. It disappears within 10 days following delivery
• Gestational proteinuria


  Proteinuria during pregnancy in the absence of hypertension, renal infarction or known reno-vascular disease
• Preeclampsia


  Development of hypertension with proteinuria, induced by pregnancy after the 20th week of pregnancy and sometimes earlier when there are extensive hydatidiform changes in the chorionic villi (vesicular mole)

  
• Pregnancy-Induced Hypertension (PIH)


  High blood pressure that develops during pregnancy, typically occurring after 20 weeks of gestation and can lead to complications for both the mother and the baby
• Superimposed preeclampsia or eclampsia


  Development of preeclampsia or eclampsia in a woman with chronic hypertensive vascular or renal disease

  
• The HELLP Syndrome


  Severe sequel of pregnancy induced hypertension (Hemolysis – Elevated Liver Enzymes- Low Platelet count)

  
• ACOG definition of hypertensive disease in pregnancy

  • A rise of 30 mmHg or more in systolic blood pressure
  • A rise of 15 mmHg or more in diastolic blood pressure
  • A systolic blood pressure of 140 mmHg or more
  • A diastolic blood pressure of 90 mmHg or more

  
• Pregnancy-induced hypertension (PIH)


  Hypertension occurring for the first time after 20 weeks' gestation; it covers those specific conditions developing during pregnancy and postpartum, and is still one of the most common causes of prenatal morbidity
• Pre-eclampsia and eclampsia


  Two categories of pregnancy induced hypertension that represent the same process, but eclampsia is reserved for describing the occurrence of generalized convulsions
• Risk factors for PIH


  • First Pregnancy
  • History of PIH
  • Multiple Gestation
  • Maternal Age
  • Obesity
  • Chronic Hypertension
  • Diabetes
  • Renal Disease
  • Autoimmune Disorders
  • Family History
  • Interval Between Pregnancies
  • Assisted Reproductive Technologies
  • Previous Adverse Pregnancy Outcomes
  • Race/Ethnicity
  • Poor Socioeconomic Status

  
• Pathophysiology of PIH


  • Vasospasm and hypoperfusion
  • Endothelial injury leading to platelet adherence, fibrin deposition, and the presence of schistocytes (fragment of an erythrocyte)

  
• Vasospasm in PIH


  Generalized vasospasm results in elevation of blood pressure and reduced blood flow to the brain, liver, kidneys, placenta, and lungs
• Blood volume changes in PIH

  • Shift of fluid from intravascular to the extracellular compartment resulting in hamo-concentration and increased blood viscosity, decreased plasma volume, and increased hematocrit
• Coagulation changes in PIH

  • Increased levels of thrombin time (T.T), thromboxane/prostacyclin imbalance leading to increased thromboxane and decreased prostacyclin
• Other changes in PIH

  • Salt and water retention
  • Hormonal changes (decreased estrogen & progesterone, increased aldosterone)
  • Enzyme changes (decreased histamine, increased liver enzymes)
  • Increased serum uric acid, urea, and creatinine
• Changes in the fundus oculi in PIH

  • Retinal detachment due to edema, indicates immediate delivery as the prognosis is good because it disappears within two days two months after delivery
• Effects of decreased organ perfusion in PIH

  • Decreased liver perfusion leads to impaired liver function and subcapsular hemorrhage
  • Decreased brain perfusion leads to small cerebral hemorrhages and symptoms of arterial vasospasm
  • Decreased kidney perfusion reduces the glomerular filtration rate (GFR), resulting in decreased urine output and increased serum levels of sodium, BUN, uric acid, and creatinine
• Effects of increased capillary permeability in PIH

  • Allows albumin to escape, reducing plasma colloid osmotic pressure and moving more fluid into extracellular spaces, leading to pulmonary edema and generalized edema
• Effects of poor placental perfusion in PIH


  • Contributes to intrauterine growth restriction, premature separation of the placenta (abruptio placentae), persistent fetal hypoxia, and acidosis

  
• Classification of PIH


  • Mild preeclampsia
  • Severe preeclampsia
  • Eclampsia
• Criteria for severity of preeclampsia-eclampsia

  • Blood pressure
  • Proteinuria
  • Hyperreflexia
  • Convulsions
  • Headaches
  • Visual symptoms
  • Oliguria
  • Epigastric pain, liver tenderness
  • Fetal growth retardation
  • HEELP
  • Thrombocytopenia
  • BUN, creatinine, uric acid levels
  • SGOT, SGPT, LDH

  
• Complications of PIH


  • Fetal growth retardation
  • Intra uterine fetal death
  • Accidental haemorrhage, coagulation disturbances
  • Eclampsia cerebral haemorrhage

  
• Management of mild preeclampsia

  1. Bed rest in left lateral recumbent position

  2. Balanced diet with moderate to high protein & low to moderate sodium

  3. Administration of magnesium sulfate
• Management of severe preeclampsia

  1. Complete bed rest

  2. Balanced diet with high protein & low to moderate sodium

  3. Administration of magnesium sulfate

  4. Fluid & electrolyte replacements

  5. Sedative antihypertensive or anticonvulsant
• Nursing care for prevention of PIH

  • Adequate Nutrition
  • Adequate Rest
  • Early and Appropriate Care
• Magnesium sulfate


  Most commonly used medication for the treatment or prevention of seizure activity in patients with preeclampsia and eclampsia
• Monitoring of patients receiving magnesium sulfate

  • Urinary output
  • Patellar reflex
  • Respiratory rate
• In-depth patient history


  Includes age, parity, and medical history of diabetes, persistent hypertensive disorders, and familial history of preeclampsia or eclampsia
• On each prenatal visit

  1. Patient should be weighed

  2. Accurate blood pressure reading obtained

  3. Early-morning urine checked for protein
• Preeclampsia and eclampsia


  Associated health problem
• Monitoring of patients receiving magnesium sulfate


  1. Urinary output

  2. Patellar reflex

  3. Respiratory rate
• Mg++ is eliminated by the kidneys, so monitoring of the urinary output is extremely important
• Management of pre-eclampsia


  • Individualized based on the severity of the condition, gestational age, and the overall health of the mother and baby
  • Timely and appropriate intervention is essential to prevent complications and ensure the well-being of both the mother and the fetus
• Hospital precautionary measures for pre-eclamptic patient

  • Quiet - Non stimulating environment
  • Continuous monitoring of blood pressure, urine output, and other vital signs
  • Regular assessment of symptoms such as headaches, visual disturbances, and epigastric pain
  • Reduced activity or complete bed rest
  • Left lateral positioning to improve blood flow to the placenta and reduce blood pressure
  • Continuous monitoring of fetal well-being
  • Administration of antihypertensive medications to manage and control elevated blood pressure
  • Intravenous fluids may be administered cautiously to maintain optimal hydration and prevent dehydration
  • Balanced and low-sodium diet may be recommended
  • Adequate protein intake may be emphasized
  • Magnesium sulfate may be administered to prevent the development of eclampsia
  • Regular monitoring of laboratory parameters, including liver function, renal function, and blood clotting factors
  • Corticosteroids may be given to enhance fetal lung maturity if preterm delivery is anticipated
  • Frequent assessment for signs of worsening pre-eclampsia or progression to eclampsia
  • Patient education about signs and symptoms of worsening pre-eclampsia
  • Collaboration with obstetricians, maternal-fetal medicine specialists, and other relevant healthcare providers

  
• Eclampsia


  Occurrence of convulsions as a complication of pre-eclampsia
• Stages of eclamptic fit

  1. Premonitory stage (15-30 seconds)

  2. Tonic stage (3-60 seconds)

  3. Clonic stage (60-90 seconds)

  4. Coma stage (from few minutes to few days)
• Complications of eclamptic fits

  • Bitting tongue
  • Suffocation due to inhalation of vomitus
  • Bronchopneumonia
  • Heart failure
  • Accidental and cerebral haemorrhage
• Nursing management of eclamptic patient

  1. Hospitalized in a single darkened, quiet room at absolute bed rest

  2. Do not disturb the patient for unnecessary procedures

  3. Turn the patient on her side to prevent supine hypotension or aspiration of vomitus

  4. Suction machine to aspirate mucus or vomitus from the mouth and an oxygen

  5. Insert a retention catheter to accurately measure the amount of urine passed

  6. Assist in performing essential laboratory studies

  7. Assist in physical examination

  8. Check the blood pressure hourly during the acute phase and every 2-4 hours thereafter

  9. Evaluate fetal heart rate every time the mother's blood pressure is obtained

  10. Assist in ophthalmoscopic examination daily

  11. Examine the face extremities, and especially the sacrum for edema
• Care for eclamptic fit

  1. Maintain airway clear

  2. Administer O2 between fits

  3. Turn patient every hour to prevent hypostatic pneumonia

  4. Administer the prescribed medication

  5. Record intake and output and vital signs

  6. Observe fetal wellbeing and report any abnormal signs related to mother or fetus