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 seizures 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


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