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PREGNANCY-INDUCEDHYPERTENSION(PIH)by:Trixie Mariel E. ArauneJenn Christian C. Bonono
WHAT IS PIH?► a condition in in which vasospasmoccurs during pregnancy in both small &large arteries► originally called toxemia► occurs in 5% - 7% of pregnanciesSigns of PIH: edema (interstitial effect) hypertension (vascular effect) proteinuria (kidney effect)
CLASSIFICATION OF PIH1) Gestational HPN2) Mild pre-eclampsia3) Severe pre-eclampsia4) Eclampsia
ANATOMY & PHYSIOLOGY Internal anatomy of the heart
ANATOMY & PHYSIOLOGY Blood flow through the circulatory system
ANATOMY & PHYSIOLOGY Diagram of human circulation
PATHOPHYSIOLOGY Vasospasm Vascular effects Kidney effects Interstitial effects Vasoconstriction ↓ed glomeruli Diffusion of fluid filtration rate & from bloodstream ↑ed glomeruli into interstitial membrane Poor organ tissue permeability perfusion ↑ed serum BUN, ↑ed BP uric acid, & Edema creatinine ↓ed urine output & proteinuria
Excretory System Anatomy & Physiology “ without me in your body, you are nothing but - a waste…”
the functionsUrinary system, often called as ‘excretory system’, is a body system that separates wastes from the body – usually as urine or sweat.As a system, the kidneys, ureters, urinary bladder & the urethra works through: Maintaining body’s fluid & electrolyte balance. Collects water & filter body fluids. Removes excess, unnecessary or dangerous materials in the body to help maintain homeostasis.
the anatomy [the kidneys] Are dark-red, slightly flattened, beanshaped organs about 10 cm long, 5 cm wideand 4 cm thick weighing approximately 150grams. Kidneys weigh about 0.5 percent oftotal body weight. A mass of tiny tubes & each tube is a knotof capillaries.Each kidney is composed of numerousmicroscopic coiled tubules called nephron orrenal tubules or uriniferous tubules.The inner surface has a deep notch calledhilus. The ureters, renal artery, renal veinand the nerves enter the kidney through thehilus.The kidney is divided into 2 regions, anouter region called renal cortex and the innerregion termed renal medulla.
the anatomy [the ureters] About 28 cm long Carry the urine from the kidneys to the urinary bladder. Arise from the renal pelvis on the medial aspect of each kidney before descending towards the bladder on the front of the psoas major muscle. This "pelviureteric junction" is a common site for the impaction of kidney stones. In the female, the ureters pass through the mesometrium on the way to the urinary bladder.
the anatomy [the urinary bladder] It can store about 0.5 to 1 litre of urine The lower part or neck of the bladder is guarded by 2 rings of muscle fibres called sphincters. The act of voiding of urine is called micturition. Tips for a healthy bladder Here are some tips you can pass onto clients and patients to help them achieve a healthy bladder Drink plenty of water Limit caffeine alchohol and fizzy drinks Do pelvic floor exercises Dont go to the toilet just in case however also dont hold on too long Keep your weight under control Dont smoke Dont strain when going to the toilet
the anatomy [the urethra] Tube that passes urine fromthe urinary bladder to theoutside of the body. In females it is about 2 - 3 cmlong and carries only urine.In male, urethra is about 20cm long and carries urine aswell as the spermatic fluid.
Pre-eclampsia• Serious metabolic disturbance (toxemia) of pregnancy that occurs most often following the twentieth week of pregnancy.• Involves a systemic malfunction of the tissue lining the blood vessels (vascular endothelium) and is characterized by high blood pressure (hypertension), swelling (edema), and high amounts of protein in the urine (proteinuria)
• It is one of a group of disorders that appear to be progressive steps in a single process that includes gestational hypertension (blood pressure of 140/90 or greater)Gestational Hypertension - when women develops an elevated blood pressure (140/90mmHG) but has no proteinuria or edema.
Mild Pre-eclampsia This condition is characterized by:• Blood Pressure reading of 140 mm hg systolic, or an elevation of 30 mm hg or more systolic or 15 mm hg diastolic above the patients prepregnancy level.• Bp readings are taken on two occasions 6 hours apart, with special attention to the diastolic pressure, which reflects peripheral vascular spasm.
• Proteinuria of 1+ or 2+ on a reagent test strip or 500 mg/24 hours or more.• Swelling in the upper part of her body rather than the usual ankle edema associated with pregnancy.• Weight gain of more than 1 kg (2 pounds) a week in the second trimester and 0.5 kg (1 pound) a week in the third trimester.
Management:• Bed rest to facilitate sodium excretion• Some physicians also prescribe a high- protein diet to compensate for the protein lost in the urine and, perhaps, mild restriction of sodium intake. Diuretics are not used for control of edema because they can only aggravate the condition by increasing glomerular vessel permeability and stimulating angiotension activity.
Symptoms Blood pressure: 160/110 mmhg Proteinuria: 3–4+ on a random sample and 5 g on a 24-hour sample Oliguria: (500 mL or less in 24 hours or altered renal function tests; elevated more than 1.2 mg/ dL) Cerebral or visual disturbances (headache, blurred vision) Thrombocytopenia
Hepatic dysfunction Elevated serum creatinine more than 1.2 mg/dL Extensive peripheral edema Pulmonary edema Epigastric pain
NURSING INTERVENTIONSa. Support bed restb. Monitor maternal well- beingc. Monitor fetal well- beingd. Support nutritious diete. Administer medications to prevent eclampsia
NURSING INTERVENTIONS•Woman may be admitted to health care facility•If pregnancy is 36 WEEKS or further along or FETALLUNG MATURITY can be confirmed by amniocentesis labor can be induced to end pregnancy•If pregnancy is LESS THAN 36 WEEKS or IMMATURELUNG FUNCTION can be revealed by amniocentesis interventions will be instituted to attempt to alleviate thesever symptoms and allow fetus to come in term.
Support bed rest•woman should be admitted to aPRIVATE ROOM so she can restundisturbed as possible•raise side rails•darken the room•stress can trigger an INCREASEin BP and can evoke seizures•make sure a woman receivesclear explanations and allowopportunities to EXPRESS HERFEELINGS
Monitor maternal well- being•Take BP every 4HOURS or w/continuous monitoring device•Obtain blood studies asordered(complete blood count,platelet count, liver function,blood urea nitrogen, and creatineand fibrin degradation products•Type and cross-matching
Monitor maternal well- being•Obtain daily hematocritlevels as ordered•Assess optic fundus•Obtain daily weights at thesame time each day NORMAL:more than 600mL per 24 hours(>•Indwelling catheter may be 30mL/hr), output lower than this suggestsinserted OLIGURIA
Monitor maternal well- being•Urinary protein & specificgravity recorded & measuredwith voiding or if with indwellingcatheter, HOURLY•24-hour urine sample may becollected for protein andcreatinine clearancedeterminations to evaluatekidney function
SEVERE PREECLAMPSIA MILD PREECLAMPSIA 5g per 24 hours(3+ or 4+ on bet 0.5 and 1g of proteinindividual specimen) every 24 hours(1+ on sample)
. Monitor fetal well-being•single Doppler auscultation at approximately 4-hourintervals(FHR may be assessed by an external fetalmonitor)•Nonstress test or biophysical profile to assessuteroplacental sufficiency•O2 administration to maintain adequate fetaloxygenation and prevent fetal bradycardia
MEDICATIONSDRUG INDICATION DOSAGE COMMENTMagnesium Muscle Loading dose Infuse loading dose slowly oversulfate relaxant; 4–6 g 15–30 min.Pregnancy prevents Maintenance Always administer as arisk category seizures dose 1–2 g/h IV piggyback infusionB Assess respiratory rate, urine output, deep tendon reflexes, and clonus every hour. Keep in mind that urine output should be over 30 mL/hour and respiratory rate over 12/min. Serum magnesium level should remain below 7.5 mEq/L. Observe for CNS depression and hypotonia in infant at birth
MEDICATIONSDRUG INDICATION DOSAGE COMMENTHydralazine Antihypertensiv 5–10 mg/IV Administer slowly to avoid sudden(Apresoline) e fall in blood pressure.Pregnancy risk Maintain diastolic pressure overcategory C 90 mm Hg to ensure adequate placental filling. Administer slowly. Dose may be repeated q 5–10 min (up to 30 mg/ hour). Observe for respiratory depression or hypotension in mother and respiratory depression and hypotonia in infant at birth.Calcium Antidote for 1 g/IV (10 mL of Have prepared at bedside whengluconate magnesium a 10% solution) administering magnesium sulfate.Pregnancy risk intoxication Administer at 5 mL/min.category C
Eliciting A Patellar Reflexand Ankle ClonusPATELLAR REFLEX RESULTS: 0 = No response; hypoactive; abnormal 1+ = Somewhat diminished response but not abnormal 2+ = Average response 3+ = Brisker than average but not abnormal 4+ = Hyperactive; very brisk; abnormal
PROGNOSISSign and symptoms of preeclampsia usually go away within 6weeks after delivery. However, the high blood pressuresometimes get worse the first few days after delivery.If you have had preeclampsia, you are more likely to develop itagain in another pregnancy. However, it is not usually as severeas the first time.If you have have high blood pressure during more than onepregnancy, you are more likely to have high blood pressurewhen you get older. The infants risk of death depends on the severity of thecondition and how early the baby is born.
Support a Nutritious DietA woman needs a diet:•moderate to high in protein•moderate in sodium tocompensate for the protein sheis losing in her urine, An intravenous fluid line should be initiated and maintained to serve as an emergency route for drug administration as well as to administer fluid to reduce hemoconcentration and hypovolemia.
Administer Medications to Prevent EclampsiaA hypotensive drug such as hydralazine(Apresoline) or labetalol (Normodyne) may beprescribed to reduce hypertension.- Assess pulse and blood pressure afteradministration. Diastolic pressure should not belowered below 80 to 90 mm Hg or inadequateplacental perfusion could occur.
Magnesium Sulfate – drug of choice to preventeclampsia - classified as a cathartic - reduces edema by causing a shift in fluidfrom the extracellular spaces into the intestine - also has a central nervous systemdepressant action which lessens the possibilityof seizures
• For magnesium sulfate to act as an anticonvulsant, blood serum levels must be maintained at 5 to 8 mg/100 mL. If the blood serum level rises above this, respiratory depression, cardiac arrhythmias, and cardiac arrest can occur.
The most evident symptoms of overdosefrom magnesium sulfate administrationinclude:• decreased urine output• depressed respirations• reduced consciousness• decreased deep tendon reflexes
• Because magnesium is excreted from the body almost entirely through the urine, urine output must be monitored closely to ensure adequate elimination.• If severe oliguria should occur (less than 100 mL in 4 hours), excessively high serum levels of magnesium can result.
Before you administer further magnesiumsulfate, assess the following:• ensure that urine output is above 25 to 30 mL/hour, with a specific gravity of 1.010 or lower• respirations should be above 12 per minute• a woman should be able to answer questions asked of her• ankle clonus (a continued motion of the foot) should be minimal• deep tendon reflexes should be present Make these assessments every hour if a continuous intravenous infusion is being used.
• a solution of 10 mL of a 10% calcium gluconate solution (1 g) should be kept ready nearby for immediate intravenous administration should a woman develop signs and symptoms of magnesium toxicity, as calcium is the specific antidote for magnesium toxicity
Severe oliguria may be treated by theintravenous infusion of salt-poor albumin. High colloid solution (salt-poor albumin)call fluid into the bloodstream from interstitial tissue by osmotic pressure the kidneys will then excrete the extra fluid along with magnesium sulfate levels
TABLE 15.7 Drugs Used in Pregnancy-Induced HypertensionDrug Indication DosageMagnesium sulfate Muscle relaxant; Loading dose 4–6 g Maintenance dose 1–2Pregnancy risk prevents seizures g/h IVcategory B
Is a grand mal seizure Symptoms: which passes the -Seizure or coma stages of: accompanied by signs A) Tonic-Clonic and symptoms of pre- B) Coma eclampsia Usually happens in late pregnancy But can happen up to 48 hrs after birth
Causes of poor fetal If premature prognosis: separation of the Hypoxia placenta from Consequent fetal vasospasm occurs, the acidosis fetal prognosis is graver. If a fetus must be born before term, all the risks of immaturity will be faced.
A woman’s blood pressure Reflexes become rises suddenly from hyperactive additional vasospasm May experience a Temperature rises sharply premonition that to 103 to 104 degrees “something is happening” Fahrenheit Vascular congestion of the Blurring of vision or severe liver and pancreas can lead headache to severe epigastric pain and nausea Urinary output may decrease abruptly to less than 30 mL/hr.
Risk factors: gestational diabetes- greater in nulliparous prepregnancy obesity compared to parous weight gain during women pregnancy- Being a young mother (<20 years) or an older mother (≥35 years) were each associated with elevated eclampsia risk
Nursing Interventions for a woman with Eclampsia
Tonic-Clonic SeizureTONIC PHASE- Last approximately 20 secs.• all the muscles of the woman’s body contract• Back arches• Arms and legs stiffen• Jaw closes abruptly• Respirations halt because her thoracic muscles are held in contraction
Nursing Interventions:• Priority Care: Maintain a patent airway• Do not put tongue blade• Administer oxygen by face mask• Assess oxygen saturation via a pulse oximeter• Apply an external fetal heart monitor
Clonic Phase-last up to 1 minute• Bladder and bowel muscles contract and relax• Incontinence of urine and feces may occur.• Remains cyanotic and may need continued oxygen therapy for the fetusNURSING INTERVENTIONMagnesium Sulfate or Diazepam (Valium) may be administered intravenously
Postictal State• A woman is semicomatose and cannot be roused except by painful stimuli for 1 to 4 hours• Part of the seizure that may cause premature separation of the placenta• Labor may begin during this period and a woman will be unable to report the sensation of contraction
Nursing Interventions:• Keep a woman on her side so secretions can drain• Nothing per Orem• Continuously assess fetal heart sounds and uterine contractions.• Check for vaginal bleeding every 15 minutes
BirthThere is evidences that the fetus does not continue to grow after eclampsia happens, so terminating the pregnancy at this point is appropriate for both mother and child.A woman with eclampsia is not a good candidate for surgery: she may become hypotensive with regional anesthesia.
HELLPSYNDROMEa variation of PIH named forthe common symptoms thatoccur: -hemolysis -elevated liver enzymes -low platelets.
HELLP SYNDROME Occurs in approximately 1 in every 150 births. Results in maternal mortality rate as high as 24% and an infant mortality rate as high as 35%.It occurs in: -primigravidas -multigrvidas -some women with pre-eclampsia
SYMPTOMS nausea Epigastric pain General malaise Right Upper Quadrant tenderness from liver inflammation.
SYMPTOMS Laboratorystudies reveals: 1. Hemolysis of RBCs-appears fragmented on peripheral blood smear 2.Thrombocytopenia- platelet count below 100,000/mm3 3. Elevated liver enzyme levels (alanine aminotransferase-ALT and serum aspartate aminotransferase-AST)
THERAPY Improve the platelet count by transfusion of fresh-frozen plasma or platelets.
The infant is delivered as soon as feasible by either vaginal or cesarean birth. Maternal hemorrhage may occur at birth because of poor clotting activity. Epidural anesthesia may not be possible because of the low platelet count and the high possibility of bleeding at the epidural site. Laboratory results return to normal after birth.
Decreased cardiac output related to hypovolemiaIt can also be related to decreased venous return.Possibly evidenced by:d. Edemae. Shortness of breathf. Change in mental statusg. Decreased urine output
Deficient Fluid Volume related to loss to subcutaneous tissueIt can also be related to a plasma protein loss.Possibly evidenced by:d. Edema formatione. Sudden weight gainf. Hemoconcentrationg. Nausea & vomitingh. Epigastric paini. Headachej. Visual changesk. Decreased urine output
Ineffective Tissue Perfusion related to vasoconstriction of blood vesselsIt could be related to vasospasm of spiral arteries & relative hypovolemia.Possibly evidenced by:e. Changes in Fetal heart ratef. Reduced weight gaing. Premature delivery
Nursing InterventionsWoman with MILD PIH: Monitor Antiplatelet Therapy Promote Bed Rest Promote Good Nutrition Provide Emotional SupportWoman with SEVERE PIH: Support bed rest Monitor maternal well-being Monitor fetal well-being Support a nutritious diet Administer medications to prevent Eclampsia
Woman with ECLAMPSIA:II. Patient that has tonic-clonic seizure: Maintain a patent airway Administer Oxygen face mask Turn the woman in her side to prevent aspirations Administer Magnesium Sulfate or diazepam via IV Assess oxygenation via pulse oximeter