PIH

• Preterm labor


  Occurs before the end of week 37 of gestation
• Preterm labor is responsible for almost two thirds of all infant deaths in the neonatal period (American College of Obstetricians and Gynecologists [ACOG], 2016a)
• Actual labor


  A woman is documented as being in actual labor rather than having false labor contractions if contractions have caused cervical effacement over 80% or dilation over 1 cm
• Maintaining general health during pregnancy


  • The best preventive measure to avoid preterm birth
• Educating woman about the signs of labor

  Knowing the signs of labor can help women identify if preterm birth is beginning because some women wait before they seek help for preterm labor because they diagnose back pain or contractions as nothing more than extremely hard Braxton Hicks contractions
• Factors associated with preterm labor

  • Dehydration
  • Urinary tract infection
  • Periodontal disease
  • Chorioamnionitis
  • Large fetal size
  • Strenuous jobs during pregnancy or shift work leading to extreme fatigue
  • Intimate partner violence and the trauma this causes
• Common symptoms of early preterm labor

  • Persistent, dull, and low backache
  • Vaginal spotting
  • A feeling of pelvic pressure or abdominal tightening
  • Menstrual-like cramping
  • Increased vaginal discharge
  • Uterine contractions
  • Intestinal cramping
• Therapeutic management of preterm labor

  1. Woman admitted to hospital and placed on bed rest

  2. External fetal and uterine contraction monitors attached

  3. Intravenous fluid therapy to keep her well hydrated

  4. Vaginal and cervical cultures and a clean-catch urine sample prescribed to rule out infection
• Terbutaline


  A drug approved to prevent and treat bronchospasm but may be used as a tocolytic agent (i.e., an agent to halt labor)
• Terbutaline


  • Should not be used for over 48 to 72 hours of therapy because of a potential for serious maternal heart problems and death
  • Should not be used in an outpatient or home setting because its administration requires constant professional assessment
• Magnesium sulfate


  Used prior to 32 weeks for fetal neuroprotection to help prevent cerebral palsy in premature infants
• Corticosteroid (betamethasone)


  Accelerates the formation of lung surfactant, thus reducing the possibility of respiratory distress syndrome or bronchopulmonary dysplasia
• Corticosteroid administration


  If the pregnancy is under 34 weeks, a woman may be given two doses of 12 mg betamethasone I.M. 24 hours apart, or four doses of 6 mg dexamethasone I.M. 12 hours apart
• Pregnancy-induced hypertension (PIH)


  A condition in which vasospasm occurs during pregnancy in both small and large arteries
• Pregnancy-induced hypertension


  • Reduced responsiveness to blood pressure changes due to prostaglandin release
  • Vasoconstriction occurs, leading to increased blood pressure
• Pregnancy-induced hypertension


  Beginning about the 20th week of pregnancy, almost all body systems begin to be affected
• Pregnancy-induced hypertension


  • Reduced blood supply to organs, most markedly the kidney, pancreas, liver, brain, and placenta
  • Poor placental perfusion reduces the fetal nutrient and oxygen supply
• Pregnancy-induced hypertension


  • Ischemia in the pancreas can result in epigastric pain and an elevated amylase–creatinine ratio
  • Spasm in the arteries of the retina can cause vision changes
  • Retinal hemorrhage can result in blindness
• Pregnancy-induced hypertension


  • Vasospasm in the kidney increases blood flow resistance, leading to degenerative changes of the kidney glomeruli due to back pressure
  • Increased permeability of the glomerular membrane allows serum proteins albumin and globulin to escape into the urine (proteinuria)
  • Decreased glomerular filtration leads to lowered urine output and clearance of creatinine
• Pregnancy-induced hypertension


  • Increased kidney tubular reabsorption results in sodium retention and fluid accumulation (edema)
  • Extreme edema can lead to maternal cerebral and pulmonary edema and seizures (eclampsia)
  • Thrombocytopenia or a lowered platelet count occurs as platelets cluster at the sites of endothelial damage
• Risk factors for pregnancy-induced hypertension

  • Multiple pregnancy
  • Primiparas younger than 20 y.o. or older than 40 y.o.
  • Women who have polyhydramnios
  • Low socioeconomic background
  • Underlying diseases (heart disease, diabetes, essential hypertension)
• Signs and symptoms of pregnancy-induced hypertension

  • Hypertension
  • Edema
  • Proteinuria
• Gestational hypertension


  BP 140/90 mmHg, or Systolic BP >30 mmHg; Diastolic > 15 mmHg above pregnancy level, with no proteinuria nor edema, and BP returns to normal after birth
• Mild preeclampsia


  BP 140/90 mmHg, Systolic BP >30 mmHg; Diastolic > 15 mmHg above pregnancy level, Proteinuria +1 to +2, Weight gain 2 lbs/wk. in 2nd trimester; 1 lb./wk in 3rd trimester, Mild edema in upper extremities or face
• Severe preeclampsia


  BP 160/110 mmHg, Proteinuria: 3+ to 4+ on a random sample, Oliguria: 500 ml or less in 24 hrs, Pulmonary involvement: shortness of breath, Hepatic dysfunction, Epigastric pain due to ischemia in the pancreas and liver, Cerebral edema, Visual disturbances, Severe headache, Marked hyperreflexia, Ankle clonus, Extreme edema
• Eclampsia


  Seizure or coma occurs
• NI: Mild Preeclampsia

  A. Monitor Antiplatelet Therapy

  1.Because of the increased tendency for platelets to cluster along arterial walls, a mild antiplatelet agent, such as low-dose aspirin, may prevent or delay the development of preeclampsia

  2. Be certain they purchase low-dose aspirin (81 mg, sold as baby aspirin) as excessive salicylic levels can cause maternal bleeding at the time of birth
• NI: Mild Preeclampsia

  B. Promote Bed Rest

  1.When the body is in a recumbent position, sodium tends to be excreted at a faster rate than during activity

  2. Be certain women know to rest in a lateral recumbent position to avoid uterine pressure on the vena cava and prevent supine hypotension syndrome
• NI: Mild Preeclampsia

  C. Promote Good Nutrition

  1. Assess if a woman has someone to help her prepare food, or either bed rest or nutrition may be compromised

  C. Provide emotional support
• NI: Severe Preeclampsia

  A. Support bed rest

  1.Needs hospitalization so bed rest can be enforced and woman can be observed closely

  2. Restrict visitors to support people (e.g. husband)

  3. Raise side rails (padded) to prevent injury

  4. Room needs to be dimly lit
• NI: Severe Preeclampsia

  B. Monitor maternal well-being

  1.Monitor Bp

  2. Obtain blood studies as ordered

  3. Obtain daily hematocrit levels as ordered

  4. Assess weight: same time, daily

  5. Indwelling catheter may be inserted
• NI: Severe Preeclampsia

  C. Monitor Fetal well-being

  1.External fetal monitor is attached

  2. O2 adm. may be necessary to maintain adequate fetal oxygenation
• NI: Severe Preeclampsia

  D. Support a nutritious diet

  1. Moderate to high protein diet

  2. Moderate sodium in the diet

  3. IVF line should be initiated and maintained to serve as an emergency route for drug adm.
• NI: Severe Preeclampsia

  E. Admister medications to prevent eclampsia

  1. Hydralazine (Apresoline) to reduce hypertension (5 – 10 mg/IV)

  2. Magnesium Sulfate (Loading dose 4–6 g Maintenance dose 1–2 g/hr IV)

  3. Diazepam (Valium) to halt seizures (5–10 mg IV, administer slowly, may be repeated q 5–10 minutes (up to 30 mg/hr))

  4. Calcium gluconate as antidote for MgSO4 intoxication (10 ml of a 10% calcium gluconate (1 g I.V.) must be prepared at bedside when administering MgSO4, administer at 5 ml/min)
• ECLAMPSIA: Preliminary signs before seizure

  1. Bp rises suddenly from additional spasm

  2. Temperature rises (39.4 - 40°C) from increased cerebral pressure

  3. Blurring of vision or severe headache from increased cerebral edema

  4. Hyperactive reflexes

  5. Epigastric pain & nausea from vascular congestion of the liver or pancreas
• Tonic seizures


  1. Back arches

  2. Arms & legs stiffen

  3. Jaw closes abruptly

  4. Respirations stop

  5. Lasts for approx. 20 sec.

  6. Maintain patent airway

  7. Adm. O2 by mask
• Clonic seizure


  1. Body muscles contract & relax repeatedly

  2. Inhales & exhales irregularly

  3. Incontinence of urine & feces may occur

  4. Lasts up to 1 min.

  5. O2 therapy continued

  6. MgSO4 or diazepam (Valium) may be administered IV as an emergency measure
• Postictal state


  1. Semi-comatose

  2. Keep woman on side lying position

  3. Keep NPO

  4. Continue monitoring FHR and uterine contractions

  5. Check for vaginal bleeding every 15 min.
• Birth


  1. Labor may be induced as soon as the woman's condition stabilizes, usually 12 – 24 hrs. after seizure

  2. Preferred method of delivery for eclamptic patient is vaginal delivery

  3. C/S is preferred if fetus is in imminent danger
• Nursing interventions during the postpartum period

  Monitoring blood pressure in the postpartum period and at healthcare visits and being alert for preeclampsia, which can occur as late as 2 weeks postbirth, are essential to detect this residual hypertension