testing

• 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 (PIH)

  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 or hypertension that develops before 20 weeks gestation in the absence of H-mole that persists after 12th week postpartum
• Predisposing Factors for Pregnancy Induced Hypertension

  • Said to be a disease of primiparas – higher incidence in primiparas below 20 and above 40 years
  • Preexisting disease – diabetes, collagen vascular disease, chronic hypertension or chronic renal disease
  • Low socioeconomic status and inadequate prenatal care
  • Poor nutrition
  • Pregnancy complications – H-mole, DM, multiple pregnancy, polyhydramnios, Rh incompatibility, renal disease, heart disease
  • Hereditary
  • Black race
  • Multigravida
  • Multiparity
• Causes of Pregnancy Induced Hypertension

  • No definite cause known
  • Highly correlated with the antiphospholipid syndrome or the presence of antiphospholipid antibodies
  • Protein deficiency theory and dietary deficiencies
  • Endothelin theory – Endothelin are potent vasoconstrictors produced by the endothelin
• Pathophysiologic Changes in Normal Pregnancy

  1. Plasma volume increases

  2. Systemic vascular resistance decreases

  3. Results in normal blood pressure
• Pathophysiologic Changes in Pregnancy Induced Hypertension

  1. Presence of overabundance of chorionic villi with or without fetus is associated with vasospasm

  2. Vasospasm is the underlying cause of preeclampsia's insidious disease process
• Effects of Preeclampsia


  • Decreased blood supply to the brain resulting in cerebral ischemia
  • Vasogenic edema
  • Hyperreflexia
  • Convulsions
  • Decreased blood supply to the uterus and placenta resulting in IUGR
  • Decreased blood supply to kidney resulting in decreased glomerular filtration rate (GFR) and efficiency of kidney to remove metabolic waste products from the blood and decrease urine formation
  • Decreased renal perfusion results in damage to kidney structures allowing passage of large molecules such as protein
  • Serum levels of blood urea nitrogen (BUN), creatinine, and uric acid rise leading to acidosis and decreased urinary output
  • Proteinuria
  • The amount of circulating plasma volume falls, resulting in hemoconcetration
  • Rise in hemoglobin and hematocrit
  • Sodium retention leading to edema
  • Vasospasm and hypertension
  • Damaged endothelium promotes coagulation and increases sensitivity to pressor agents
  • Elevated platelets
  • Decrease in synthesis of potent vasodilators such as prostaglandin PGE2 and prostacyclin PG2 further contributing to vasospasms and vascular changes that cause the end-organ disturbances seen in severe preeclampsia
  • Continuous vasospasm cause diminished blood supply resulting in damage to blood vessels and tissues in the placenta and decidua leading to abruption placenta
  • Fetal Hypoxia and distress
• Laboratory Studies in Mild vs Severe Preeclampsia


  • Mild Preeclampsia: Normal hematocrit, uric acid, creatinine
  • Severe Preeclampsia: Increased hematocrit, creatinine, and uric acid; liver enzymes are markedly elevated & thrombocytopenia maybe present
• Signs & Symptoms in Mild vs Severe Preeclampsia


  • Mild Preeclampsia: BP 140/90, Digital edema, Dependent edema, 2 lb/week weight gain, Urinary output not less than 400 ml/24 hours, Occasional headache
  • Severe Preeclampsia: BP 160/110, Pitting edema (4+), Generalized edema, More rapid weight gain, Less than 400 ml/24 hours urinary output, Severe frontal headache, photophobia, blurring, spots before the eyes, nausea, vomiting, Hyperreflexia, 4+, RUQ pain (aura to convulsion due to swelling of hepatic capsule)
• Screening and Early Diagnosis

  Roll-over Test: BP is taken at the brachial artery in the lateral recumbent position, the woman then rolls over to the supine position and pressure is measured immediately and again after 5 minutes. An increase of 20mmHg or greater in diastolic pressure is a positive indicator that the woman is likely to develop PIH
• Initial Hospitalization


  1. CBC with platelet, BUN, creatinine, uric acid levels

  2. Liver function test

  3. A 24-hour urine for total protein and creatinine clearance

  4. Daily weights

  5. UTZ for fetal size, amniotic fluid volume and fetal well being

  6. Ongoing (monitoring) assessment

  7. Deep tendon reflexes (DTR's) at the patellar site are recorded on a scale of 0 to 4
• Assessing Clonus


  The nurse should dorsiflex the foot and observes for movement when it is released. Clonus is evidenced by a rhythmic jerking indicating hyper reflexes
• 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

  2. Fetal well being is assured: good fetal movement

  3. Bed rest: woman must be free from physical and emotional stress. When lying down, they assume a left lateral position

  4. Consult the clinic regularly, usually every two weeks

  5. Regular phone calls and home visit by the nurse to check signs and symptoms of worsening conditions

  6. Diet is high protein and high carbohydrates with moderate sodium restriction
• Patient Education for Ambulatory Management

  • Take and record her BP twice a day
  • Count fetal movement per hour (3/h)
  • Void into specimen pan and check for protein
  • Take and record weight daily
  • Report to health care provider immediately if: Increasing BP, Epigastric pain, Visual disturbances, Severe headache, Nausea and vomiting, Weight gain more than 1 lb a week, Abnormal fetal movement, Abdominal pain
• Hospital Management


  1. Hospitalization maybe required in the following conditions: BP is equal or greater than 160/100 mmHg, Proteinuria of 3+ or 4+, Rapid weight gain, Oliguria, Visual disturbances, Abnormal fetal movement

  2. Expectant management: the only cure for preeclampsia is delivery. Betamethasone to promote lung maturity

  3. Fluid therapy: a crystalloid infusion is preferred, usually lactated Ringers solution or normal saline at a rate of 100 to 125 ml/hour

  4. Magnesium sulfate: drug of choice to treat and prevent convulsions. Dose, nursing considerations, side effects

  5. Antihypertensive: Hydralazine (Apresoline) and Labetalol (Normodyne)

  6. Bed rest is one of the most important principles of care

  7. Monitor patient closely: Take v/s and fht continuously, Monitor for impending signs of convulsion, Weigh daily, Laboratory tests

  8. Fetal Monitoring: Fetal movement counting, Nonstress testing, Biophysical profile, Doppler flow studies

  9. Safety measures: Raise padded side rails, Put bed at lowest position, Have emergency equipments available
• Monitor patient closely


  1. Take v/s and fht continuously

  2. Monitor for impending signs of convulsion. Blurring of vision, severe headache and epigastric pain

  3. Weigh daily at the same time each day using the same weighing scale

  4. Laboratory tests for proteinuria, creatinine, hematocrit
• Fetal Monitoring


  • Fetal movement counting
  • Nonstress testing
  • Biophysical profile
  • Doppler flow studies
• Safety measures


  1. Raise padded side rails at all times to keep the woman from falling if convulsion occurs

  2. Put bed at lowest position

  3. Have emergency equipments available for use: suction apparatus, MgSO4, Calcium gluconate, Oxygen etc
• Care for the woman during convulsion – Eclamptic convulsions occur in about 2% of all pregnancies


  1. Stage of Invasion or Aura: Facial twitching, rolling of the eyes to one side, staring fixedly in space, sudden severe headache, screaming and epigastric pain

  2. Tonic phase: Body becomes rigid as all muscles go into violent spasms or contractions, eyes protrude, arms are flexed with legs inverted, hands are clenched, woman stops breathing. Last for 15 to 20 seconds

  3. Clonic phase: Jaws and eyelids close and open violently, foaming of the mouth; face becomes congested and purple, muscles of the body contract and relaxes alternately. The contractions are so violent that the woman may throw herself out of bed. Lasts for about one minute

  4. Postictal state: contractions cease and woman enters a semicomatose state. The patient will not remember the convulsion and the event immediately before and after the event
• Nursing Responsibilities during Convulsion

  1. Always monitor patient for impending signs of convulsion

  2. Maintain patient airway and protect patient from self-injury

  3. Turn patient on her side to allow drainage of saliva and prevent aspiration

  4. Place pillow under the patient's head to prevent injury

  5. Never leave an eclamptic patient alone

  6. Do not restrict movement during convulsion as this could result to fracture

  7. After convulsion: Watch for signs of abruption placenta, take V/S and FHT, suction nasopharynx, infuse MgSO4, continue electronic fetal monitoring, take v/s every 5 minutes then 15 minutes, auscultate lungs for pulmonary edema, monitor output via urinary catheter, physician may order ABG and chest x-ray, deliver within 3-6 hours if patient stabilized
• Delivery


  1. Preferred method is vaginal delivery. Labor is induced by amniotomy or oxytocin administration when the condition of the woman is stable. Local or pudendal anesthesia is used. Prostaglandin E2 gel is often used to ripen the cervix. Pitocin and magnesium can be given simultaneously

  2. Cesarean delivery is an excellent option for the seriously ill patient who might not tolerate induction or if labor induction is unsuccessful and fetal distress is severe that the fetus needs to be delivered immediately
• Postpartum care


  1. Danger of convulsion exist until 24 hours after delivery, MgSO4 therapy is continued. Hydralazine maybe given depending upon the BP

  2. Watch for uterine relaxation and increase lochial flow if the woman is receiving MgSO4

  3. If the mother received large doses of MgSO4 before delivery, the newborn may have high serum magnesium level, therefore watch for respiratory depression, hypocalcemia, hypotonia in these infants. Newborn toxicity is treated with levallorphan (Lorfan)

  4. Continue to monitor the patient during the postpartum period: I and O, BP and pulse, Hematocrit, Platelet count and liver enzymes

  5. Ergot products such as methergine, are contraindicated because they are hypertensive

  6. Two years should elapse before another pregnancy is attempted to decrease the likelihood that PIH will recur on the subsequent pregnancy
• HELLP Syndrome


  Variation of PIH named for the common symptoms: Hemolysis, Elevated Liver enzymes, Low Platelets
• The syndrome occurs in 4% to 12% of patients with PIH. It is a serious syndrome because it results in a maternal mortality rate as high as 24% and an infant mortality rate as high as 35%.
• Predisposing Factors for HELLP Syndrome


  • Unknown
  • Associated with antiphospholipid syndrome or the presence of antiphospholipid antibodies
• Signs and Symptoms of HELLP Syndrome

  • Proteinuria
  • Edema
  • Increased blood pressure
  • Nausea
  • Epigastric pain
  • General malaise
  • Right upper quadrant tenderness from liver inflammation
• Laboratory Status in HELLP Syndrome

  • Hemolysis of red blood cells (they appear fragmented on a peripheral blood smear)
  • Thrombocytopenia (a platelet count of <100,000/mm)
  • Elevated liver enzyme levels (alanine aminotransferase [ALT) and serum aspartate aminotransferase [AST])
• Complications of HELLP Syndrome

  • Subcapsular liver hematoma
  • Hyponatremia
  • Renal failure
  • Hypoglycemia from poor liver function
• Management of HELLP Syndrome

  1. Transfusion of fresh-frozen plasma or platelets

  2. Correct hypoglycemia with IV glucose infusion

  3. Deliver the infant as soon as feasible by either vaginal or cesarean birth

  4. Bed rest

  5. MagSul to prevent seizure

  6. Corticosteroid for lung maturation
• Multiple Pregnancy


  When two, three, four or even five fetuses are conceived, grow and develop in the uterus at the same time
• Types of Multiple Pregnancy

  • Twins – 2 fetuses
  • Triplets – 3 fetuses
  • Quadruplets – 4 fetuses
  • Quintuplets – 5 fetuses
  • Sextuplets – 6 fetuses
  • Septuplets – 7 fetuses
• Monozygotic or 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. They possess the same genetic traits and are always of the same sex.
• Monozygotic Twin Subtypes


  • If twinning occurred within 72 hours after fertilization, there will be two amnions (diamnionic) , two chorions (dichorionic) and two embryos
  • If twinning occurred between the fourth and eight day after fertilization, there will be two amnions, one chorion (monochorionic) and two embryos
  • If twinning occurred after eight days, there will be one amnion (monoamnionic), one chorion and 2 embryos
  • If twinning occurred after the embryonic disc is formed, conjoined twins will develop. Conjoined twins are classified according to the part of the body where they are attached: Anterior – thoracopagus, Posterior – pyopagus, Cephalic – craniopagus, Caudal - ischiopagus
• Dizygotic or Fraternal Twins

  Develop from two or more ova and sperm cells that were fertilized at the same time. They have different genetic traits, may or may not be of the same sex, and always have separate placentas, chorions and amnions.
• Predisposing Factors for Dizygotic Twins

  • Race: highest among blacks
  • Heredity: more common in women with family history of twinning
  • Age and parity: increased incidence in high parity and advance maternal age
  • Higher incidence in women taking fertility drugs that promotes ovulation and release of several ova at the same time
  • Higher incidence in tall and large framed women
  • Endogenous gonadotrophin: higher incidence within the first months after stopping oral contraceptives
  • In vitro fertilization: stimulation of formation of numerous follicles, harvesting them in the ovary and fertilizing them in vitro