1. Complication of pregnancy Pregnancy Induced Pregnancy(PIH)

2. Hypertensive Disorders of Pregnancy 1. Chronic Hypertension (before pregnancy) 2. Gestational (in pregnancy) Hypertension -Pre-eclampsia Severe pre-eclampsia Eclampsia HELLP syndrome 3. Hypertensive Disorders of Pregnancy Most commonly reported disorder of pregnancy May occur in 20% of all pregnancies One of the leading causes of maternal morbidity and mortality worldwide 4. Pathophysiology/Etiology 1. Actual cause is unknown. 2. Theories of the etiology include the exposure to chorionic villi for the first time, or in large amounts, along with immunologic, genetic, and endocrine factors. 3. The disease is primarily seen in primagravidas. 4. Chronic hypertension, hydatidiform mole, multiple gestation, polyhydramnios, and diabetes mellitus may predispose to PIH. 5. Adolescents and women over 35 years of age are at higher risk. 6. Approximately 6% to 8% of pregnancies may be affected. 7. Vasospasms occur and result in increased resistance in vascular flow, increasing the arterial blood pressure. 8. Increased sensitivity to angiotensin II occurs before the onset of hypertension. 9. Hemoconcentration occurs due to the vasoconstriction or as a result of increased vascular permeability or a combination of both. 5. Characteristics PIH Three typical Symptoms: Hypertension(high blood pressure) Edema Protein urine 6. Pathophysiology: 1. Vasoconstriction 2. Vasospasm 3. Endothelial damage 7. Pathophysiology: Damage to blood vessels causes increased capillary permeability and decreased organ perfusion. 8. Clinical Manifestations 1. Hypertension, which is defined as a blood pressure of 140/90 mm Hg or greater on two occasions at least 6 hours apart 2. Proteinuria , +, ++, +++, ++++ 3. Edema, nondependent, present after 8 to 12 hours of bed rest , 4. Frequently, a sudden weight gain will occur, of 2 lb or more in 1 week, or 6 lb or more in 1 month. This often occurs before the edema is present. 5. Altered level of consciousness, visual changes, headache 6. Oliguria 7. Epigastric pain, chest pressure 8. Hyperreflexia with or without clonus 9. Hypertensive Disorders of PregnancyPreeclampsia Gestational Hypertension PLUS Protein in the urine PLUS Edema 10. Hypertensive Disorders of Pregnancy Pre-eclampsiaSevere PreeclampsiaPLUS one of the following: 1. Systolic BP > 160 mmHg 2. Diastolic BP > 110mmHg 3. Persistent headache, visual changes or epigastric pain 4. Creatinine > 1.2 mg/dL 5. Platelets < 100,000 6. Increase liver function tests 11. eclampsia Gestational Hypertension PLUS Protein in the urine PLUS Edema PLUS Convulsion 12. Hypertensive Disorders of Pregnancy H = HemolysisHELLP SyndromeEL = Elevated Liver EnzymesLP = Low Platelets 13. Hypertensive Disorders of Pregnancy Risk factors 1. 2. 3. 4. 5. 6.First pregnancy More than one fetus Pre-existing disease (diabetes, hypertension) Obesity Maternal age (< 20 years, > 40 years) Family history 14. Diagnostic Evaluation 1. A 24-hour urine for protein of 300 mg or greater 2. Serum BUN and creatine to evaluate renal function 3. Sonogram, nonstress testing to evaluate placenta and fetus 15. Management 1. Directed toward decreasing the maternal blood pressure through the use of bed rest and antihypertensive medications along with increase in dietary protein 2. Hospitalization and seizure 3. Medication a. Magnesium sulfate (MgS04) may be given either IV or IM Side effect, loss of knee reflex, should be given calcium gluconate b. Antihypertensive drug; Hydralazine (Apresoline) * Side effects include tachycardia, palpitations, dizziness, faintness, headache. c. Diazepam (Valium) and amobarbital sodium (Amytal Sodium) may be used if convulsions occur that respond to MgS04. 4. If symptoms are uncontrollable, delivery is planned. 16. Complications 1. Abruptio placentae 2. DIC 3. HELLP syndrome 4. Prematurity 5. Intrauterine growth retardation (IUGR) from decreased placental perfusion 6. Maternal/fetal death 17. Nursing Assessment Assessment of mother 1. Blood pressure 2. Protein in the urine3. Complaints of headache, liver pain, or strange bruises or bleeding 18. Nursing Diagnoses A. Fluid Volume Excess related to IV fluid overload(edema) B. Altered Tissue Perfusion, Fetal Cardiac and Cerebral, related to altered placental blood flow(fetal distress) C. Risk for Injury related to convulsions D. Anxiety related to concern for self and fetus 19. A. Maintaining Fluid Balance 1. Control IV fluid intake using a continuous infusion pump. 2. Monitor intake and output strictly; notify health care provider if urine output is less than 30 mL/h. 4. Monitor hematocrit levels to evaluate intravascular fluid status. 5. Monitor vital signs every hour. 6. Auscultate breath sounds every 2 hours and report signs of pulmonary edema (wheezing, crackles, shortness of breath, increased pulse rate, increased respiratory rate). 20. B. Promoting Adequate Tissue Perfusion 1. Position on side, preferably the left side to promote placental perfusion. 2. Monitor fetal activity. 3. Evaluate nonstress tests to determine fetal status. 4. Increase protein intake to replace protein lost through kidneys. 21. C. Preventing Injury 1. Instruct on the importance of reporting headaches, visual changes, dizziness, and epigastric pain. 2. Instruct to lie down on left side if symptoms are present. 3. Keep the environment quiet and as calm as possible. 4. If hospitalized, side rails should be padded and remain up to prevent injury if seizure occurs. 5. If hospitalized, have oxygen and suction setup, along with a tongue blade and emergency medications immediately available for treatment of seizures. 22. D. Decreasing Anxiety 1. Explain the disease process and treatment plan. 2. Explain that PIH does not lead to chronic hypertension. 3. Explain that PIH usually does not occur with subsequent pregnancies. 4. Discuss the effects of all medications on the mother and fetus. 5. Allow time to ask questions and discuss feelings regarding the diagnosis and treatment plan. 23. Patient Education/Health Maintenance 1. Teach the woman the importance of bed rest in helping to control symptoms. 2. Encourage the support of family and friends while on bed rest. 3. Provide and suggest diversional activities while on bed rest. 4. Provide information on tests and procedures to evaluate maternal-fetal status, such as laboratory tests, sonogram, nonstress tests. 5. Include support of the neonatal team for discussion of fetal prognosis with the woman and her family. 24. Evaluation A. No evidence of pulmonary edema; urine output adequate B. Fetal heart rate within normal range; reactivity present C. No seizure activity D. Expresses concern for self and the fetus