Pregnancy Induced Hypertension (PIH)

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Pregnancy Induced Hypertension (PIH)
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• Pregnancy induced hypertension is still one of
  the most common causes of maternal and prenatal
  mortality and morbidity. It is characterized by
  vasospasm that leads to poor perfusion of many
  vital organs including the feto/placental unit.

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• Pre-eclampsia and eclampsia are two
  categories of pregnancy induced hypertension. The
  HELLP syndrome is a severe sequel of pregnancy
  induced hypertension.

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Classifications

• Pre-eclampsia.
• Severe pre-eclampsia.
• Eclampsia.

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Incidence

• 5-7 of all pregnancies. If a woman has
  chronic hypertension, she has a 25 to 35 risk of
  developing PIH

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Prenatal Factors Increasing the Risk of PIH

• Primigravida.
• Grand multigravidit.
• Essential hypertension
• Family history of hypertension or vascular
  disease.
• Diagnosis of PIH in previous pregnancy

• Low socioeconomic status.
• Diabetes mellitus.
• Obesity.
• Malnutrition.
• Age (under 17 or over 35 years old).
• Underweight or overweight.

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Factors that Develop During Pregnancy and
Increase the Risk of Developing PIH

• Diabetes mellitus.
• Multiple gestation.
• Gestational trophoplastic disease.
• Hydramnios.
• Renal infections

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Sequelae of PIH Representing Serious Threats to
Maternal and Fetal Wellbeing

• Abruptio placenta.
• Retinal detachment
• Acute renal failure.
• Cardiac failure.
• Cerebral hemorrhage.
• Maternal death.

• Fetal growth retardation, hypoxia and death.
• Preterm labor.
• Coagulation failure.
• Spontaneous abortion.
• Prematurity.

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Pre-eclampsia

• Hypertension 140/90
• Proteinuria 300mg or more in 24h
• Edema greater than I pitting edema after 12 hour
  bed rest or weight gain of 2.3kg or more in one
  week or both after 20 week of gestation

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Severe pre-eclampsia

• Blood pressure160/110
• Proteinuria 5 g in 24 hour urine collection
• Oliguria less than 700 to 800 ml in 24 hours or
  lt30 ml/hr.
• Hypereflexia
• Visual disturbances
• Headache, blurred vision
• Pulmonary edema or cyanosis.
• Epigastric pain

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Eclampsia

• Presence of seizures
• Eclamptic fit pass in the following stage
• 1- Premonitory stage (1-2 minute) eye rolled up
  with twitches of face and hands
• 2- Tonic stage (1-2minute) generalized tonic
  spasms ,patient is cyanosed ,the tongue may
  bitten
• 3- Clonic stage (1-2 minute) convulsion occur,
  face is red and cyanosed ,temperature rise and
  involuntary pass of urine
• 4- coma

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HELLP syndrome

• Occurs in 2-12 of cases
• H Hemolysis
• EL elevated liver enzymes
• LP low platelets

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Eclamptic fit may occur

• Ante partum (65) with best prognosis
• Intrapartum (20)
• Postpartum (15)with bad prognosis which
  indicated excessive pathological damage

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Criteria for severity of eclampsia

• Coma more than 6 hours.
• Temperature more than 39c.(indicate pneumonia
• Systolic blood pressure more than 200mmhg.(risk
  for cerebral he)
• Pulse more than 120/m(acute heart failure) .
• Anuria or oliguria( indicate renal failure)
• Respiratory rate more 40/m (indicate pneumonia(?
• More than 10 fit.

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Complications of the Epileptic Fit

• Biting of the tongue.
• Suffocation.
• Heart failure.
• Cerebral hemorrhage.
• Accidental hemorrhage.
• Bronchopneumonia

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Investigations

• Urine 24h urine , protinuria
• Kidney function (serum creatinine, urea, uric
  acid
• Liver function bilirubin and enzymes
• Blood picture, hematoicreate
• Coagulation profile (bleeding and clotting time

• Fundus examination (retinal or hemorrhage
• CT to detect cerebral hemorrhage
• Ultrasound (gestational age ,fetal life, IUGR
  ,IUFD, retroplacenta hematoma

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Nursing Management of Pregnancy Induced
Hypertension (PIH)

• Preventive measure
• Counsel all women prior to conception regarding
  health behaviors that minimize risk of
  hypertension, e.g.
• Correct dietary deficiencies.
• Attain ideal pre-pregnancy weight.
• Stop smoking.
• Manage stress positively.
• Alter coping style.

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• Receive regular antenatal care
• Screen all patients for PIH each prenatal visit
  by evaluating blood pressure, edema, proteinuria
• Low dose of asprine
• Calcium supplementation
• Magnesium supplementation
• Antioxidants as vitamin C and E
• Salt restriction

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Treatment

• Expectant treatment
• Control hypertension
• Prevent and control convulsion
• Treatment of eclampsia
• Termination of pregnancy

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General and first aid measures

• Isolation in single ,quite ,semi dark room
• An efficient nurse should be present
• The following equipment must be present
• Airway, oxygen source ,suction apparatus
• Bed with side ray
• Put pt in trendlenburg position
• Insert a catheter ,nothing by moth and fluid
  chart
• Observation
• 1- Vital signs
• 2- Level of consciousness and duration of coma
• 3- Urine out put and albumineuria
• 4- Number of convulsion

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Expectant treatment

• Rest
• Diet increase protein and carbohydrate and low
  salt
• Sedation
• Observation
• Mother (BP, pulse, respiration ,protein urea
• Investigation
• Fetus , fetal well being as fetal movement NST
  ,Us

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Prevent and control convulsion

• Magnesium sulfate (Mgso4) it is drug of choice it
  cause CNS depression ,it can given IV or IM
• Antidote 10ml of 10 calcium gluconate

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Diabetes Mellitus

• Definition
• Diabetes mellitus is a chronic disease
  resulting from a relative or absolute lack of
  insulin, which is required for carbohydrate
  metabolism.
• In diabetes mellitus, the pancreas does not
  produce sufficient amounts of insulin to allow
  necessary carbohydrate metabolism. With
  inadequate amounts of insulin, glucose cannot
  enter the cells and remains in the blood.

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Etiology

• Insulin deficiency may be caused by
• ? Damage to beta cells in the pancreas.
• ? Increased insulin ruirement as in obesity and
  pregnancy

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Women at risk

• Obstetric history
• Previous macrosomia.
• Previous unexplained still birth.
• Poor obstetric outcome.
• Polyhydramnios.
• Excessive weight gain.
• Hypertension.
• Recurrent infection as monilial infections.
• Present pregnancy
• Abnormal fasting blood sugar.
• Glucosuria.
• Unexplained polyhydramnios.

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Symptoms of Diabetes Mellitus

• Excessive thirst and hunger.
• Frequent urination.
• Blurred vision.
• Weight loss.
• Recurrent infections

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Influence of Diabetes on Pregnancy Outcome

• During pregnancy
• Mother
• ? Abortion.
• ? Pre-eclampsia.
• ? Polyhydramnios.
• ? Incidence of cesarean section.

• Fetus
• ? IUGR.
• ? IUFD.
• ? Congenital anomalies.
• ? Abnormal presentation.

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Postpartum Infection. Postpartum hemorrhage.

• During labor
• Mother
• ? Obstructed labor.
• Fetus
• ? Prematurity.
• ? Neonatal hypoglycemia.
• ? Respiratory distress.
• ? Macrosomia.

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Nursing Intervention for Gestational Diabetes

• Controlling serum glucose
• Dietary adjustment
• Insulin
• Prevent, recognize and treat hypo- or
  hyperglycemia
• Ultrasound assessment at 20 week of gestation.
• Non - stress test.
• Educate the patient regarding self-care measures
• Activity and exercise
• Hospitalization
• ?From 32 week till delivery for patient with
  vascular changes.

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Hyperemesis Gravidarum

• Persistent and excessive vomiting in early
  pregnancy

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Signs and symptoms

• Dehydration ( eye appear dry , sunken).
• Weight loss- signs of anemia.
• Dryness or inelastic of the skin.
• Jaundice may apparent denoting liver damage.
• Mother breath will smell of acetone.
• Urine will smell of acetone .bescant and dark in
  olor

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Causes

• Unknown .
• May be associated with multiple pregnancy and
  hydatoform mole.

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Role of Nurse

• Preventive
• Provide ante natal care and manage nausea and
  vomiting
• Management
• Hospitalization
• Monitor mother and fetus
• Record intake and output, weight and vital signs
• Oral hygiene and Reassurance