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 1^st 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 10^th day postpartum

 

Mild Preeclampsia

• BP > 140/90 x 2 at least 4-6 hours apart
• Weight gain (due to 3^rd spacing)
  • +2 pounds/wk in 2^nd trimester, or
  • +1 pound/wk in 3^rd trimester, or
  • sudden weight gain of 4 pounds/week anytime
    • Norms –
      • 1^st trimester: 1 lb/month
      • 2^nd and 3^rd 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