Gestational Hypertensive Disorders

Pregnancy Induced hypertension or PIH

  • Mom is not hypertensive before pregnancy
  • Hypertension and other symptoms that occur due to pregnancy
  • Disappear with birth of fetus and placenta

 

High risk factors

  • Chronic renal disease
  • Chronic hypertension
  • Family history
  • Primagravidas (a woman who is pregnant for the 1st time)
  • Twins
  • Mom <19 and >40
  • Diabetes
  • Rh incompatibility
  • Obesity
  • Hydatidiform mole

 

Pathophysiology

  • Can progress from mild to severe
  • Aterial venospasms decrease diameter of blood flow, which results in:
    • Decreased blood flow
    • Increased BP

 

Classifications

  • Transcient Hypertension
  • Preeclampsia
    • Mild
    • severe
  • Eclampsia
  • HELLP syndrome

 

Transcient Hypertension

  • BP > 140/90
  • Develops during pregnancy
  • No proteinuria
  • No edema (other than “normal” places like ankles)
  • BP returns to normal by 10th day postpartum

 

Mild Preeclampsia

  • BP > 140/90 x 2 at least 4-6 hours apart
  • Weight gain (due to 3rd spacing)
    • +2 pounds/wk in 2nd trimester, or
    • +1 pound/wk in 3rd trimester, or
    • sudden weight gain of 4 pounds/week anytime
      • Norms –
        • 1st trimester: 1 lb/month
        • 2nd and 3rd trimester: 1 lb/week
  • Dependant edema
    • Eyes, face, fingers (above the waist)
  • Proteinuria
  • Urine output > 30ml/hr

 

 

Nursing care for Mild Preeclampsia

  • Patient at home
  • Bedrest (with BR privileges); side-lying position
  • Mom and family will be taught to monitor:
    • Daily weight
    • Urine dipstick
    • BP
    • Fetal movements
  • Diet: Regular with no salt restrictions
  • If symptoms progress to severe Preeclampsia à Hospital!

 

Severe Preeclampsia

  • Presence of any of the following in a woman diagnosed with Preeclampsia:
    • BP > 160/110 (x2) 4-6 hours apart
    • Proteinuria > 2+ dipstick x2 4 hrs apart
    • Urine output < 500ml/24 hr
      • Pulmonary edema (Crackles heard in lungs)
      • Cerebral changes
        • Headache (Tylenol will not alleviate)
        • visual changes (blurred vision or scotomata [blind spot or tunnel vision])
        • Decreased LOC
        • Liver involvement (epigastric pain)
          • May develop into HELLP
        • Thrombocytopenia, platelet count < 100,000/mm3
        • Hyperreflexia >3+
          • clonis, DTR [deep tendon reflex] – biceps and patellar
        • Fetus growth severely shunted [IUGR]
          • Due to decrease placental profusion

 

Care of patient with severe Preeclampsia

  • Hospitalized until baby is delivered
  • Bedrest on side
  • Bed near nurse’s station with code cart nearby
  • Quiet, calm, low light environment
  • Siderails up, padded
  • Frequent assessments to include:
    • BP, P, R q 5/10 min
    • Daily weight
    • Assess edema
    • Deep tendon reflexes
    • Assess for headache, visual disturbances,
    • Epigastric pain (liver is getting involved)
    • Insert foley (to best assess for oliguria)
    • Strict I and O
    • Evaluate urine for protein
    • Monitor fetal well-being
    • Assess labs; platelets, liver enzymes

 

Medical management

  • Prevent seizuresà MAGNESIUM SULFATE
    • Decreases neuromuscular irritability
    • Decreases CNS irritability (anticonvulsant effect)
    • Promotes maternal vasodilation, better tissue perfusion
    • Watch for magnesium toxicity
      • Loss of knee-jerk reflexes
      • Respirations <12 p/min
      • Urine output <30ml/hr
      • Cardiac or respiratory arrest
      • Toxic serum levels >9.6mg/dl
      • Sign of fetal distress
      • Calcium Gluconate is the antidote
  • Control hypertension
    • BP meds via IV
    • Continue observations 24-48 hrs after birth
    • Symptoms usually resolve within 48 hours after birth

 

Eclampsia

  • Onset of seizure activity or coma in person with PIH
  • Assessment findings
    • Increased hypertension precedes seizures followed by hypotension and collapse
    • Coma may occur
    • Labor may begin, putting fetus in great jeopardy
  • Treat with magnesium sulfate and above measures for severe Preeclampsia

 

HELLP syndrome

  • Hemolysis (destruction of RBC’s) H
  • Elevated liver enzymes EL
  • Low platelets LP
  • Occurs in 4-12% of patients with PIH; life-threatening situation to mom and/or baby. No known cause.
  • Treatment:
    • Give platelets
    • Deliver infant ASAP
    • All usually returns to normal after the delivery

 

DIC Disseminated Intravascular Coagulopathy

  • A complication of preeclampsia
  • Can occur with or without HELLP
  • Occurs in other conditions as well
    • Abruption placentae, stillbirth, amniotic fluid embolus syndrome, c-section, miscarriage
    • Sepsis, metastic carcinoma, transfusion reactions, hemolytic conditions, malignant hypertension, snake bite
  • Pathophysiology
    • Overreaction of clotting cascade
    • Overreaction of fibrinolytic (clot break down) system
    • Resulting in bleeding and clotting at the same time
    • Microclots form and go everywhere including microcirculation
    • Resulting in decrease profusion
  • Physical findings
    • Bleeding of gums, nose, puncture sites
    • Hematuria (may bleed at foley insertion site)
    • Petechiae or eccymosis at B/P cuff and monitor placement
    • Gastrointestinal bleeding
    • Tachycardia
    • Diaphoresis
    • s/s of shock
      • bleeding, light-headed, nausea, ashen or grayish skin, cool and clammy skin, pulse increases, BP decreases
  • Lab findings
    • Fibrinogen less than 100
    • Platelets less than 50,000
    • Fibrin split products greater than 40
    • PT decreased – 11 seconds
    • PTT decreased – 26-39 sec
    • Clotting time increased 4-12 minutes

 

Normal labs – nonpregnant

Hemoglobin                            12-16 g/dl

Hematocrit                              37-47%

Platelets                       150,000-400,000/mm3

PT                                            12-14 sec

PTT                                         60-70 sec

Fibrinogen                               200-400 mg/dl

Fibrin split products                < 10 mcg/ml

BUN                                       10-20 mg/dl

Creatinine                                .5 to 1.1 mg/dl

Lactate dehydrogenase LDT         45-40 units/l

Aspertate aminotransferase AST    4-20 units/l

Alanine aminotransferase ALT      3-21 units/l

Creatinine clearance                80-125 ml/min

Burr cells                                 0

Uric acid                                 2-6.6 mg/dl

Bilirubin (total)                       0.1-1 mg/dl

2 Responses to Gestational Hypertensive Disorders

  1. toya says:

    just need some more notes on pathophysiology

  2. Elwood says:

    I’m curious to find out what blog platform you are working with?
    I’m experiencing some small security problems with my latest blog
    and I’d like to find something more safe. Do you have any suggestions?

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