001hypertensive disorders in pregnancy.pdf
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Hypertensive Disorders
in
Pregnancy
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Pregnancy Induced Hypertension
Terms :
PIH development of HPN ( BP> 140 /90 duringsecond half of pregnancy, occurs in previouslynormotensive woman.
Pre-eclampsia renal involvement leads toproteinuria
Eclampsia CNS involvement leads to seizures
HELLP clinical picture dominated by
hematologic and hepatic signs and symptoms. Chronic HPN elevation of BP occurs before 20
weeks gestation.
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Hypertensive Disorders of Pregnancy
a potentially life-threatening disorder
that usually develops after 20 week
of pregnancy
most common in nulliparous women cause is unknown.
systemic vasospasm occur, affecting
every organ system
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Two categories ofPIH
1 .Preeclampsia Mild / Severe
- non convulsive form of disorder
- maybe mild or severe
- occurs after 20 weeks gestation
- higher incidence in the low
socioeconomic group
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Factors that increases the risk for developing
Pre-eclampsia
1- Primigravidas age 40 yrs and above
2- Women with chronic hypertension /
Renal disease
3- Low socioeconomic status
4- Young maternal age > less than 17 yrs.
5- Women with DM or Multiple pregnancies
6- Dietary deficiencies
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2. Eclampsia -
- convulsive form of the disorder
- occurs between 24 weeks gestation and
the end of the first post partum week
- higher incidence with first pregnancies,
multiple gestations and history of vascular
disease
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Assessment Findings:
1. BP over 140/90 mmHg or an increaseof 30 mmHg systolic and 15mmHgdiastolic over baseline taken on 2
occasions 4-6 hrs. apart. 2. Increase in generalized edema
associated with a sudden weight gain ofmore than 5lbs.( 2.3 Kg) per week
3. Proteinuria
4. Convulsion and or coma
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SIGNIFICANT CHANGES IN PIH
Decreased renal perfusion reducesGFR( Glomerular Filtration Rate)
Reduced blood flow to kidneys
causing glomerular damage Loss of PRO from kidneys reduces
colloid osmotic pressure and allowsfluid to shift from vascular to interstitial
spaces Hypovolemia additional angiotensin II
and aldosterone (retention of Na andwater)
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Decreased circulation to the liver impaired liver function (hepatic edema
and subscapular hemorrhage) Vasoconstriction of cerebral vessels -
small cerebral hemorrhages ( spotsbefore eyes, blurred vision)
Decreased colloid oncotic pressure pulmonary capillary leak ( pulmonaryedema)
Decreased placental circulation infarctions (abruptio placenta)
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Changes Associated with PIH
Effects on the
Interstitial
History of Systematic Vasospasm
Effects on the
Vascular system
Vasoconstriction
Impaired organ
Perfusion
Hypertension
Effects on the
renal system
Reduced glomerularFiltraction rate: Increased
Glomercular membrance
permeability
Increased serum bloodUrea nitrogen and
creatinine
Oliguria and protelnuria
Fluid diffusion from
Vascular space into
Interstitial space
Effects on the
Interstitial
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Preventive Measures for PIH:
1. Adequate prenatal care close attentionto weight gain, monitoring BP and urinary
protein.
2. Low dose aspirin (6080 mg /day) per
doctors order suppresses synthesis of
thromboxane that causes vasoconstrictionand platelet aggregation.
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3. Calcium supplementation for less
sensitivity to the pressor effects of
angiotensin II and have a lower incidence ofHPN.
4. Sedatives ( Diazepam or Phenobarbital)given if MgSO4 fails in Eclampsia to bring
seizures under control.
5. Environment modification
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Manifestations / Classic Signs :
1. Generalized edema rapid weight gaindue to fluid retention , present in lower
legs, hands and face ( tightening ofwedding ring )
2. Hypertension BP 140/90;30 mmHgsystolic and 15mmHg diastolic
3. Proteinuria
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Symptoms :
Continuous headache, drowsiness, mentalconfusion ( poor cerebral perfusion )
Visual disturbances ( blurring of vision )
arterial spasms, edema of retina Numbness or tingling of hands and feet
compression of nerves by retained fluid
Epigastric pain or upset stomach distention of hepatic capsule
Decreased urinary output poor perfusion
of the kidneys > acute renal failure
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Nursing Considerations for Pre-eclampsia
1. Sedentary activity for most of the day or bedrest.
2. Keep record of fetal movements or kick
count 3. Check BP 2-4x a day ( same arm, same
position)
4. Weigh daily( same time, same scale)
5. Advice on dietary regulation - low or no salt,
protein rich foods
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6. Administration of anti-hypertensives and diureticsper doctors order Hydralazine, Nifedipine orLabetalol
7. Anticonvulsant Meds MgSO4 ( to preventconvulsions), Phenytoin , Nifedifine
- Check DTR before administration
- Keep CA Gluconate on standby ( antidote ) -Monitor urine output ( shd. be 30 ml/hr)
RR ( 12 BPM )
Side Effects: CNS depression, depression of
Respiratory Center 8. Environment should be kept quiet with dim lights
9. Seizure precautions and prevent injury foreclampsia
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General Nursing Measures:
1. High protein, low salt diet
2. Adequate fluid intake
3. Bed rest in lateral position
4. Antihypertensive methyldopa,hydralazine
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5. Magnesium sulfate have
antidote ready at bedside (Cagluconate)
6. Monitor VS, level of consciousness
and DTR
7. Maintain seizure precautions
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Symptoms of Magnesium Sulfate Toxicity
1. Decreased deep tendon reflexes or
absent
2. Muscle flaccidity
3. Central Nervous System depression /altered sensorium ( confusion, lethargy,
slurring speech, drowsiness, disorientation )
4. Decreased respiratory rate - < than 12
breaths per minute
5. Decreased renal function
6. Sweating and flushing sensations
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Severe Complications of Eclampsia:
1. Seizures ( eclampsia)
2. Cerebral edema
3. Stroke
4. Abruptio placenta
5. Fetal death
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Assessment of Edema
Characteristics
Minimal edema of lower extremities
Marked edema of lower extremities
Edema of lower extremities,face
hands and sacral area
Generalized massive edema that
include ascites
Grade
+ 1
+ 2
+ 3
+ 4
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Chronic Hypertensive Vascular Disease
(CHVD )
Persistent hypertension before pregnancybefore 20th week of gestation or beyond
42nd wk. postpartum.
Seen in older women who are obese and
those with DM.
Can be attributed to heredity, race
Can lead to pre-eclampsia , and seen onthe basis of rise in BP, sustained
proteinuria and generalized edema
Management :
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Management :
High protein diet with adequate salt
Advise woman to weigh herselfevery 3 days to detect abnormal
weight gain
Anti hypertensive drugs if diastolicis consistently higher than 90
mmHg. Anti-hypertensive drugsshould not be teratogenic.(methyldopa )