•Pregnancy-induced Hypertension (PIH)

•Risk Factors•Symptoms of PIH

•Pharmacologic Nursing Management

•Medical-Surgical Intervention•Nursing Care Plan

Pregnancy-induced Hypertension (PIH)

• It is a condition in which vasospasm occurs during pregnancy in both small and large arteries. Despite years of research, the cause of disorder is still unknown. This condition is also called as “Toxemia” in which some kind of toxin is produced by a woman in response to the foreign protein of the growing fetus which leads to typical symptoms. PIH is classified as gestational hypertension, mild preeclampsia, severe preeclampsia and eclampsia. The classic sign of PIH are proteinuria, hypertension and edema.

• Pregnancy-induced hypertension (PIH) is the most common serious complication of pregnancy which can have devastating maternal and fetal effects. The condition is most often observed after 20 weeks gestation intra-partum and during the first 72 hours postpartum. A severe sequela of PIH is known as HELLP syndrome (defined by Hemolysis, Elevated Liver enzymes, and Low Platelet Count), which occurs in about 2% to 12% of clients with PIH.

• Primary treatment goals in PIH– delivery of an uncompromised fetus– psychological support for the client and

her family– reduction of vasospasm– prevention of seizures

• Cure for PIH– Delivery of the infant and placenta

(products of conception)• Labor induction via cervical ripening may be

initiated to facilitate labor. In contrast, with worsening PIH or fetal distress may be delivered via cesarean section.

• Clients with HELLP syndrome may have their labor induced for a vaginal delivery at 32 or more week’s gestation.– For clients with HELLP syndrome who are

at less than 32 weeks gestation, a cesarean delivery may be considered.

– If a client’s disease progresses to the point of eclampsia (maternal seizure), delivery is generally postponed for 1 to 3 hours if fetal status allows.

– Ideally, once vital signs are stabilized with improved urinary output and decreased acidosis/hypoxia, delivery is pursued.

• Potential non-medication treatments for pre-eclampsia – activity reduction,– lying on the left side– increased dietary protein (supplemental 90

g/day),– psychosocial therapy– and biofeedback.

∆But drug therapy is commonly used for treatment.

Risk Factors:

women with multiple pregnancyprimiparas younger than 20 years old

or older than 35 years oldwomen from low socio-economic

statuswomen who have underlying heart

disease, diabetes with renal involvement, and essential hypertension.

Symptoms of PIH

• Gestational Hypertension (GH)

• Mild Preeclampsia • Severe Preeclampsia • Eclampsia

Gestational Hypertension (GH)

• BP of 140/90 mmHg or systolic pressure elevated 30mmHg or diastolic pressure elevated 15mmHg above pre-pregnancy level

• no proteinuria or edema;

• BP retuns to normal after birth.

Mild Preeclampsia

• Symptoms of GH;

• proteinuria;

• weight gain of 2 lbs/week in 2nd trimester and 1lb/week in 3rd trimester;

• mild edema in upper extremities or face.

Severe Preeclampsia • BP of 160/110 mmHg;• proteinuria;• oliguria;• cerebral or visual disturbances

(headache, blurred vision);• extensive peripheral edema;• thrombocytopenia;• epigastric pain.

Eclampsia

• Seizures• signs and symptoms of

preeclampsia.

Pharmacologic Nursing Management

• Magnesium Sulfate• Hydralazine (Apresoline)• Diazepam (Valium)• Methyldopa (Aldomet)• Calcium gluconate

Magnesium Sulfate

• Muscle relaxant; prevents seizures. • Loading dose (4-6g): Maintenance dose(1-2

g/h) I.V.• Infuse loading dose slowly over 15-30

minutes.• Always administer as a piggyback infusion.• Assess RR, urine output, deep tendon

reflexes, clonus every hour.• Monitor serum Mg level of 5 to 8 mg/100mL.• Observe for CNS depression and hypotonia

in infant at birth.

Hydralazine (Apresoline)

• Antihypertensive (peripheral vasodilator); used to decrease hypertension.

• IV: 10 to 20mg; IM: 10 to 50mg; PO: 10mg q.i.d.

• Administer slowly to avoid sudden fall in blood pressure.

• Maintain diastolic pressure over 90 mm Hg to ensure adequate placental filling.

Methyldopa (Aldomet) • Antihypertensive (peripheral vasodilator)• Used to treat mild to severe hypertension• IV: 250-1000 mg q6-8h; max: 1g q6h• PO: 25mg b.i.d.,max: 4g/day • If GI upset occurs, take with food.• If through IV administration, infuse slowly

over 30-60 minutes.• Tell patient that drug may cause orthostatic

hypotension, to avoid, rise slowly and avoid sudden change of position.

Diazepam (Valium) • Halt seizures

• Tablets (2,5,10mg); Cap (15mg); Inj (5mg/mL)

• Administer slowly. Dose may be repeated q 5-10 min (up to 30 mg/hour).

• Observe for respiratory depression or hypotension in mother and respiratory depression and hypotonia in infant at birth.

Calcium gluconate

• Antidote for magnesium intoxication

• 1 g/IV (10 ml of a 10% solution)

• Have prepared at bedside when administering magnesium sulfate.

• Administer at 5mL/min.

Medical-Surgical Intervention

• Diagnostic Evaluation• Surgical Intervention• Nursing Intervention

Diagnostic Evaluation • Urinalysis

Laboratory analysis of urine, commonly used to aid in the diagnosis of disease or to detect the presence of a specific substance. It involves examination of the urine by physical or chemical means as well as microscopic examination that helps to screen for urinary tract infections, renal disease, and diseases of other organs, that result in abnormal metabolites (break-down products) appearing in the urine. Protein may be present.

Complete Blood Count - A test to check the number of red blood cells, white blood cells, and platelets in a sample of blood. Thrombocytopenia is seen in Severe Preeclampsia

Hematology – it evaluates blood loss, erythropoetic ability, anemia and response to therapy. Hgb is an component of RBC that carries O2 and CO2 and from tissues. Normally performed as a part of complete blood count.

Blood chemistry – it helps determine the exerts of damage to the liver, heart and musculoskeletal system.

Electrocardiogram – is an essential tool in evaluating the heart rhythm and signs of ischemia.

Liver function tests (LFTs or LFs), which include liver enzymes, are groups of clinical biochemistry laboratory blood assays designed to give information about the state of a patient's liver.

Levels of aspartate aminotransferase (AST or SGOT) and alanine aminotransferase (ALT or SGPT), are associated with inflammation and/or injury to liver cells. Damage to the liver typically results in a leak of AST and ALT into the bloodstream. A high level of AST does often indicates that there is a liver problem

Surgical Intervention

• A possible cesarean delivery may be required to address increasing maternal disease severity and minimize maternal and fetal – essential morbidity and mortality.

Nursing Intervention

• Mild PIH• Severe PIH• Eclampsia

Mild PIH• Promote bed rest- aid in increased

evaluations of Na and encouraging diuresis.– Rest should be always in a lateral

recumbent position to avoid uterine pressure on the vena cava and prevent supine hypotension syndrome.

• Promote good nutrition – restriction of salt to reduce edema.

• Provide emotional support – to reduce anxiety.

Severe PIH• Monitor maternal well being – continue

monitoring of BP to detect if the condition is worsening.– Obtain blood studies as ordered (CBC,

platelet count, liver function test) to assess liver and renal function.

– Obtain daily weights at the same time of each day to evaluate tissue fluid retention.

• Support bed rest – patient may need to be admitted to hospital.

• Monitor fetal well being – using doppler to assess the condition of the child.

• Support a nutritious diet – the mother may need high protein diet to compensate for the protein she is losing in urine.– An IVF line should be initiated and

maintained to serve as an emergency route for drug administration and to reduce hemoconcentration and hypovolemia.

• Administer medication to prevent eclampsia – a hypotensive drug such as hydralazine (Apresoline) may be prescribed to reduce hypertension. The drug acts to lower BP by peripheral dilatation and thus not interfere with placental circulation.– Administer magnesium sulfate as

ordered to achieve immediate reduction of BP via bolus dose.

Eclampsia

• Tonic-clonic seizures – administer diazepam to correct clonic stage of seizures.

• Prepare for an emergency caesarian – to minimize maternal and fetal essential morbidity.

Nursing Care Plan

• Nursing Diagnosis• Goal • Nursing Intervention and

Rationale • Evaluation

Nursing Diagnosis

• Decreased cardiac output related to decreased venous return as evidence by BP of 150/100mmHg, edema, prolonged capillary refill and as client verbalized: “Nakita ko nga gulpi lng ako nagtambok kag nagbug-at akon timbang”.

Goal

• Within 2 hours of nursing intervention, client blood pressure will decrease to 20mmHg in systole and 10mmHg in diastole.

Nursing Intervention and Rationale

• Monitor blood pressure of the patient.– Monitoring helps to identify whether the

patient is hypertensive, as well as to have a baseline data.

• Measure BP in both arms and thighs 3 times with 3-5 minutes apart while the patient is at rest, then sitting and standing for initial evaluation.

– Comparison of pressure provides a more comprehensive vascular involvement or scope of the problem.

• Observe skin color, moisture, temperature and capillary refill.

– Presence of pallor and delayed capillary refill may be due to peripheral vasoconstriction.

• Note and assess for edema. – Edema may indicate heart failure, renal or

vascular impairment.

• Provide rest full environment and minimize noise.

– It helps to reduce sympathetic stimulation and promotes relaxation.

• Maintain activity restrictions.– It reduces physical stress and tension

that affect blood pressure.

• Instruct relaxation techniques and guided imagery.

– It can reduce stressful stimuli and produces calming effect which resolve BP.

• Advise patient to avoid foods high in sodium, such as dried fish, sea foods and salt.

– High sodium intake may cause water retention which can lead to increase BP.

Dependent• Administer medications as prescribed,

such as Methyldopa (Aldomet) 25mg tablet 2x/day orally.– Methyldopa is an antihypertensive drug

which reduces BP.

Interdependent• Refer patient to dietician about dietary

plan. – Dietician is a person who finds alternative

food preparation to meet the patient needs.

Evaluation

• After 2 hours of nursing intervention, goal meet.