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TOPICS: • Endothelin theory

• Pregnancy-Induced Hypertension
• Eclampsia CONDITIONS THAT ARE PRONE TO DEVELOP PIH
• Pre-eclampsia
• HELLP Syndrome • black race
• multiple pregnancy
PREGNANCY INDUCED HYPERTENSION • young primigravid ( 20 yo )
• old primigravid ( older than 40 yo )
th
• poor socioeconomic condition that may lead to
• Hypertension that develops after the 20 week of
history of malnutrition
gestation to a previously normotensive woman.
• experiencing polyhydramnious
• It includes preeclampsia, eclampsia and gestational
• cardio , renal and dm complications
hypertension
PATHOPHYSIOLOGIC CHANGES
Definition of Terms

HYPERTENSION

• A blood pressure reading in two occasions of a at

least 140/90 or a rise of 30 mmHg and 15 mmHg
diastolic.
• Blood pressure should be taken on two occasions 4
to 6 hours apart
GESTATIONAL HYPERTENSION

• BP of 140/90 mmHg develops for the first time

Pre-Eclampsia
during pregnancy, but there is no proteinuria and
within 12 weeks postpartum the BP is normal
• is a hypertension disorder of pregnancy developing
PREECLAMPSIA
after 20-week gestation and characterized by
• BP OF 140/90 that develops after 20 weeks of edema, hypertension and proteinuria
gestation accompanied by proteinuria (300 mg/24
hours) and with edema
ECLAMPSIA

• All the signs and symptoms of preeclampsia

accompanied by convulsions or coma that is not
caused by other conditions
SUPERIMPOSED PREECLAMPSIA & ECLAMPSIA
• Occurs when a woman having chronic hypertension
develops preeclampsia or eclampsia during
pregnancy •

Pregnancy induced hypertension ASSESSMENT FINDINGS

• Predisposing Factors: • Clinical manifestations of Mild preeclampsia:

• Disease of primiparas • BP exceeding 140/90 mmHg
• Preexisting diseases • excess above baseline of 30mmHg in
• Low socioecono`mic status systolic pressure or 15 mmHg in diastolic
• Pregnancy complications pressure on 2 readings taken 6 hours apart
• Hereditary • Generalized edema of the face, hands and ankles
• Black Race • Wt. gain of about 1.5kg (3.3 lbs) per month
• Lifestyle in the 2nd trimester or more than 1.3 to 2.3
• Poor nutrition kg (3-5lbs) in the 3rd trimester
CAUSES OF PIH • Proteinuria 1+ to 2+ or 300 mg/dl in a 24-
hour sample
• Unknown
• Genetic Predisposition
• Autoimmune reaction WARNING SIGNS OF WORSENING PRE-ECLAMPSIA
• Protein and Dietary deficiencies
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• rapid rise in BP • exist once the patient has experienced a grand mal
• rapid weight gain seizure
• generalized edema
• Increased proteinuria EFFECTS OF PREECLAMPSIA AND ECLAMPSIA
• epigastric pain
• severe headache • Cardiovascular changes:
• visual disturbances • Decreased cardiac output,
• oliguria (<120 ml in 4 hrs) Hemoconcentration, Thrombocytopenia,
• severe nausea and vomiting Prolonged thrombin time, Abnormal
formation of red blood cells
Clinical manifestations of severe Preeclampsia • Endocrine and Metabolic changes:
• Increased levels of the hormones such as
• BP exceeding 160/110 mmHg on two readings Renin, Angiotension II, Aldosterone, ADH
taken 6 hours apart with the client on bed • Increased extracellular fluid volume
• Proteinuria exceeding 5g/24 hrs. • Renal Changes
• Oliguria <than 400ml in 24 hours • Reduced renal perfusion and glomerular
• headache filtration rate
• blurred vision, spots before the eyes • Elevated creatinine, uric acid, and urea
• pitting edema of the sacrum, face, upper extremities • Decreased excretion of calcium in the urine
• dyspnea, nausea and vomiting • Decreased urine output
• epigastric pain • Proteinuria
COMPLICATIONS
Signs & Symptoms
• Abruptio Placenta
• Cerebral Hemorrhage
• Hepatic Failure
• Acute Renal Failure
• Prematurity
• Perinatal death
• Maternal death

MANAGEMENT CRITERIA

` HOME MANAGEMENT

• BP is 140/90 below
• There is low proteinuria
• There is no fetal growth retardation
• Fetal well being is assured; good fetal movement
PREECLAMPSIA

• Edema HOSPITAL MANAGEMENT

• Where?
• BP is equal to or greater than 160/100 mmHg
• Hypertension
• Proteinuria of 3+ or 4+
• BP?
• Rapid weight gain
• Proteinuria
• Oliguria
• How much?
• Visual disturbances
• Abnormal fetal movement
ECLAMPSIA Initial Hospitalization

• All signs and symptoms of eclampsia • Evaluate laboratory status such as BUN, creatinine,
• Convulsion followed by coma liver enzymes and 24-hour uric acid levels
• Oliguria • Monitor daily weight
• Pulmonary edema • Monitor fetal well-being
• Deep tendon reflexes
• After evaluation:
ECLAMPSIA • Severe preeclampsia remain for
hospitalization.
• is an extension of preeclampsia and is characterized
by the client experiencing seizures
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• Mild preeclampsia discharged for home • Monitor for impending signs of convulsions
treatment. • Monitor urinary output accurately
Ambulatory Management • Weigh daily
• Check laboratory tests
• Bed rest should be emphasized • Initiate safety precautions
• Position? • Raise side rails
• Diet modification • Put bed at lowest position
• Low? High? • Have emergency equipment's
• Teach on how to self monitor available
• BP, weight, S&S, count fetal movements, • Manage during convulsions
urine specimen • Always monitor for impending
• Report any worsening of condition such as signs of convulsions
increasing BP. • Maintain patent airway and protect patient
from self injury
• Turn patient to side
• Place pillow under patients head
• Do not restrict movements

NURSING MANAGEMENT POSTPARTUM CARE

• Monitor for, and promote the resolution of • The danger of convulsions exist until 24 hour after
complications delivery, therefore MgSO4 therapy is continued until
• Monitor vital signs and FHR the immediate 24 hour postpartum.
• Minimize external stimuli, promote rest and • Hydralazine may be given depending on BP.
relaxation • Watch out for uterine relaxation and increased
• Measure and record I&O, protein level and spec lochia flow
gravity • Watch out for respiratory depression, hypocalcemia
• Assess for edema of the face, lower and upper and hypotonia in the infant
extremities • Continue to monitor I&O, vital signs, hematocrit,
• Weigh the client daily platelet count and liver enzymes
• Assess deep tendon reflexes every 4 hrs. • Advise to avoid becoming pregnant until 2 years
• Assess for separation of placenta, headache and
visual disturbance and altered level of
consciousness ANTIHYPERTENSIVE DRUGS
• Provide treatment as prescribed
• Mild preeclampsia – bed rest, balanced • Used when diastole is 110 mmHg
diet, Mg S04 • Apresoline-drug of choice
• Severe preeclampsia – CBR, balanced diet, • Side effects – tachycardia, dizziness, faintness,
Mg S04, fluid and electrolyte replacement, headache and palpations
sedative antihypertensive drug,
anticonvulsive drug MEDICATIONS
• Eclampsia – Mg S04 IV • Magnesium Sulfate
• Institute seizure precautions • Used to prevent and treat convulsions;
• Address emotional and psychosocial needs • its primary action is to lower the blood pressure
• decreases neuromuscular irritability and depress the
HOSPITAL MANAGEMENT nervous system
• is irritating to veins, so the infusion site must be
• The only cure for preeclampsia is delivery monitored
• Check for viability of fetus • is excreted through the kidneys, urine output should
• Fluid therapy - Crystalloid infusion be monitored to prevent toxicity
• Medications • is a central nervous depressant, respiratory status
• Magnesium Sulfate must be monitored
• Antihypertensives • Depresses deep tendon reflexes
• Emphasize bed rest to reduce BP and promote
diuresis. Signs of Magnesium sulfate toxicity
• Monitor patient closely.
• Take vital signs and fetal heart tome • Absence of deep tendon reflex
continuously. • Respiratory depression
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• Oliguria Note:
• Antidote for Mg S04 toxicity – Calcium Gluconate
- fat cell is resistant to insulin..
HELLP SYNDROME - Elevated maternal glucose results in elevated fetal
glucose., this stimulates fetal pancreatic production
• Hemolysis, Elevated Liver Enzyme and Low Platelet of insulin which increase fetal hyperinsulemia
• A variation of PIH resulting into increase growth and fat deposition
• A serious condition that cause 24 % maternal - Hyperglycemia is considered teratogenic that
mortality rate and infant mortality rate of 35 % directly affect the yolk sac development.

CLINICAL MANIFESTATIONS DIAGNOSIS

• Nausea /vomiting
50 g oral glucose challenge test:
• Epigastric pain
• General malaise
• Right upper quadrant pain
If, after I hr result
• Lab result –hemolysis of RBC
• thrombocytopenia(<100,000/cu.mm > 130-140mg/ dL ( >7.2 to 7.8mmol/ L) =
• elevated liver enzyme level scheduled for a 100g, 3 hour fasting glucose
• Hemorrhage and liver necrosis tolerance test.

COMPLICATIONS OF HELLP Note:

• Liver hematoma - Diagnosis is probably be made based on a
• Hyponatremia fasting plasma glucose or ramdom paslame
• Renal failure
glucose or non fasting ...
• Hypoglycemia
- But the recommended screening method has
MANAGEMENT
two steps
- 1. 50 g oral glucose load
• Improve platelet count –transfusion of fresh-frozen - this is usually done using a 50 g oral glucose
plasma or platelets challenge test
• If hypoglycemia is present, this is corrected by an
- After the oral 50 g glucose load, a venous
intravenous glucose infusion.
blood blood sample is taken for glucose
• The infant is born as soon as feasible by either
vaginal or cesarean birth. determination 60 mins later. If the serum
• Be alert that maternal hemorrhage may occur at glucose level at 1 hr is more than 140mg/ dl,
birth because of poor clotting ability. the woman is scheduled for....
• Epidural anesthesia may not be possible because of - 3. 3 hr test
the low platelet count and the high possibility of - If two of the four blood samples collected for
bleeding at the epidural site. this test are abnormal or the fasting value is
above 95mg/ dl, a diagnosis of diabetes is
GESTATIONAL DIABETES MELLITUS made.

- Usually occur at the midpoint of pregnancy when The values are conformed Diabetes are shown below
insulin resistance is noticeable.

RISK FACTORS

• Obesity
• History of large babies Monitoring woman with GDM
• History of unexplained fetal loss
• History of congenital anomalies in previous - glygocylated hgb- is used to detect the degree of
pregnancy hyperglycemia present.
- This is a measure of the amount of glucose attached
• Family history of diabetes
to hgb
• Population group
• (Native American, Hispanic and Asian)
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( as glucose circulates in the bloodstreams, it binds to a — Intermediate insulin - given before breakfast- peak
portion of the total hgb in the blood. The amount of glucose action is after lunch or late in the afternoon just
that attaches to hgb will be high if the hgb has been exposed before dinner.
to a greater level of glucose than normally present. — Regular insulin- given before breakfast - peak action
is just after breakfast.
- measuring glygocylated hgb is advantageous
because it reflects the average blood glucose level Note:
over the past 4to 6 weeks ( the time the red blood
cells were picking up the glucose). Not just the level — to prevent hypoglycemia
on the day of testing. The upper normal level of - Bcoz, they cross the placenta and are potentially
HbA1c is 6% of the total hgb. teratogenic to a fetus.
- Knowing when insulin reachers its peak level makes
2. Ophthalmic- done once during pregnancy for a woman serum glucose monitoring meaningful and alerts
with GDM and at each trimester for women with known woman to the time of the day when they are most
diabetes.( background retinal changes such as increased apt to be hypoglycemic.
exudate, dot hemorrhage, and macular edema can progress
during pregnancy. If proliferation retinopathy was present If hypoglycemia is present
before pregnancy, this also progresses and can lead to
blindness. — Common time for hypoglycemia
— 2nd and 3rd months before insulin resistance peak
- laser- to halt these changes can be done during
pregnancy with risk to the fetus. Note:

- She should ingest some form of sustained

3. Urine culture may be done each trimester to detect
carbohydrate such as a glass of milk and some
asymptomatic UTI . increased glucose concentration in urine
crackers
leads to increased infection.
- Taking a less concentrated fluid such as milk rather
orange juice and including a complex carbohydrate
THERAPEUTIC MANAGEMENT helps prevent rebound phenomenon in which a high
glucose level is created that produces even more
— Early in pregnancy- less insulin need than before pronounced hypoglycemia.
pregnancy.
— Later in pregnancy- need an increased in insulin 2. Insulin pump therapy ( continuous subcutaneous
— Short acting insulin( regular insulin) combined with insulin)
an intermediate type.
— Give 30 mins before breakfast and 30 mins before Because some woman will have some periods of hypo and
dinner. hyper no matter how carefully she maintains her diet and
balances her exercise..
Note: - the most effective method to keep serum glucose
1. Insulin- early in pregnancy, less insulin because the constant during pregnancy.
fetus is using so much glucose for rapid cell growth. - An insulin pump is an automatic pump about the
Later in pregnancy- bcoz her metabolic rate and need size of an MP3 player. A syringe of regular insulin is
increase. placed in the pump chamber and a small gauge
Short acting insulin or regular insulin combined with an needle is attached to a length of thin polyethylene
intermideate type. tubing and implanted into the subcutaneous tissue
Regular insulin is clear like humulin r and novolin r. of a woman abdomen or thigh.
Intermediate insulin is cloudy like humulin n and novolin n. - Day and night, at a continuous rate of about 1 unit
- self administered per hour, infusing insulin continually into the
- Women should eat almost immediately after subcutaneous tissue.
injecting these short acting insulin to prevent - depending on individual prescription
hypoglycemia before mealtimes. - Before a snack or before a meal, a woman can dial
or press a button on the pump, the pump then
Oral hypoglycemic agent is not given because they cross the pushes the syringe barrel forward to administer the
placenta and are potentially teratogenic to a fetus. bulos.
- The site of the pump is cleaned daily and covered
— After administration of insulin, eat your meal. with sterile gauze, the site is changed every 24 or 48
— Oral hypoglycemia agents are not used for hours to ensure that absorption remains optimal.
regulation during pregnancy. - Not allowed to become wet
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- Remove the pump when showering or remove the

complete apparatus to bathe or swim ( not to leave it
disconnected for more one hour)
- To assess whether the pump is delivering insulin at
the designated rate, a woman must do blood
glucose determinations about four times throughout
the day( fasting and 1 hour after each meal)

Preterm Labor Nursing Management

Pathophysiology of PIH