Nursing management of PIH through case scenario

1. NURSING MANAGEMENT OF PREGNANCY
INDUCED HYPERTENSION (PIH)
PRESENTED BY:
LAMNUNNEM HAOKIP
MSC (N) 2ND YEAR
SNSR,SU

2. DISORDERS SYMPTOMS ONSET
Gestational
hypertension
Blood pressure elevated > 140/90 mm
Hg
After 20 weeks gestation
Preeclampsia
Blood pressure elevated >140/90
mmHg and +1 or greater proteinuria on
dipstick
After 20 weeks pregnancy
Eclampsia
Preeclampsia with neurologic
symptoms/seizures
After 20 weeks pregnancy
Chronic
hypertension
Pre-existing hypertension Exists prior to pregnancy
Preeclampsia/eclam
psia superimposed
on chronic
hypertension
Blood pressure increases >30 mm Hg
systolic or >15 mm Hg diastolic from
baseline with onset of significant
proteinuria
>20 weeks pregnancy
CLASSIFICATIONS OF PIH

3. ETIOLOGY
• Nulliparity
• Pre-eclampsia in a previous pregnancy
• Maternal age >35 years or<18 years
• Family history of PIH
• Chronic HTN
• Chronic Renal Disease
• Inherited Thrombophilia
• DM

4. CLINICAL
SCENARIO
Q. A 29-year old primigravida at 28 weeks of gestational age has a blood
pressure reading of 150/100 mm Hg obtained during a routine visit. Her
baseline blood pressure during the pregnancy was 120/70 mm Hg. The
patient denies having headache, blurry vision, nausea, vomiting or
abdominal pain. Her repeat BP is 160/100 mm Hg and urinalysis is 1+ for
protein by dipstick.
What is the most likely diagnosis?
PRE-ECLAMPSIA

5. Identification of Pre-eclampsia:
 BP measurement
 Peripheral Edema
 Excessive weight gain
 High risk history
 Urine protein analysis
Evaluation of severity
• Headache
• Blurring vision
• Epigastric pain
• Decreased urine output
• Breathlessness
• Assess the fetal well being

6. Investigations done to look for end organ
changes
• CBC – Platelet count < 1 lac/mm3
• LFT – elevated SGOT and SGPT (2 times above normal)
• KFT – Serum Creatinine >1.1 mg/dl
If anytime, any end organ changes seen or the BP is shooting up
beyond 160/110 mm Hg. (sever PE)

7. The definitive management for Pre-eclampsia?
 Termination of pregnancy.(37 completed).
 Baseline workup and investigations.
 Watch for development of severe PE.
 Watch for fetal growth and well being.

8. Q. A 25-year old nulliparous woman at 30 weeks comes for ANC check-up
in OPD. Her BP is 170/110 mm Hg and urinalysis shows 2+ by dipstick.
There is no complaint of headache, vision change, pain or decreased urine
output. The FHS is 140 bpm.
What is the diagnosis?
SEVERE PRE-ECLAMPSIA

9. Management of severe
PE
• Admit the woman
• Baseline investigations and follow
• Control the BP and monitoring
• Watch for S/S of impending Eclampsia
• Evaluate the well being of the baby. (<34 weeks)
• Steroids for fetal lung maturity.(Inj. Betamethasone 2 doses of 12 mg IM 24
hours apart). Reassess on daily basis.
• If the gestation is >34 weeks, termination of pregnancy if no S/S of
impending eclampsia.

10. Q. A female with 35 week gestation, presents in emergency with
complaint of headache and blurring of vision since morning. Her BP is
170/120 mm Hg. Her urine analysis is 3+ by dipstick. How is the patient
managed?
 Admit and observe.
 Admit, control BP and continue pregnancy till term.
 Admit, start MgSO4 and antihypertensive and terminate the pregnancy.
 Start antihypertensive and follow in OPD.

11. MANAGEMEN
T
Management
Nursing
management
Medical
management

12. NURSING
MANAGEMENT
MILD PRE-ECLAMPSIA
Rest
Diet: no added salt
Monitoring of the mother and fetus: Monitor blood pressure twice daily every
4 – 6 hours and urine examination. Fetal growth and well being have to be
monitor.
If gestation <37 weeks: DBP settles and proteinuria becomes insignificant, the
patient may be allow to continue pregnancy.
If gestation >37 weeks, after ensuring fetal maturity, labour is induced.

13. SEVERE PREECLAMPSIA:
Anti hypertensive drugs is to be given.
Tab. Labetalol – 100 mg orally BD per day.
Tab. Nifedipine 10 mg orally, can be titrated according to the BP level.
Tab. Hydralazine 10-25 mg bid, orally, Tab. Methyldopa 250 – 500 mg tid,
qid, Orally.
For quick control of HTN in severe pre-eclampsia, Inj. Labetalol 10 – 20 mg
can be given.

15. Q. 8 months pregnant woman is wheeled into the emergency with
seizures. Her relatives inform that she had been complaining of severe
headache and blurring of vision since morning.
What is the diagnosis? How will we managed?
 Stabilization
Airway
ECLAMPSIA
Termination of
pregnancy

16. Dangers of Eclampsia
• Aspiration pneumonia
• Pulmonary edema
• Placental abruption
• Cardiopulmonary arrest
• Renal failure
 Massive cerebral haemorrhage
Q. What is the most common cause of sudden death in a woman with
eclampsia?
Intracranial haemorrhage.

17. ECLAMPSIA CAN OCCUR DURING:
• Antepartum
• Intra-partum
• Postpartum
Q. Which is the most dangerous?

18. ECLAMPSIA
Magnesium Sulphate (MgSO4) is the drug of choice for treating
convulsions.
Pritchard regime (MgSO4)
Loading dose :
4g 20% MgSO4 should be given IV over 5 – 10 minutes (not less than 3
minutes.)
Maintenance dose :
10g of 50% MgSO4 solution deep IM injection into alternate buttocks(5g on
left and 5g on right buttock) every 4 hrs.

20. Zuspan regime
• Loading dose : 4 – 6 g diluted in 100 mL NS, slow IV infusion over 15 – 20
minutes.
• Maintenance dose: 1 – 2 gm / hour in 100 mL of IV infusion.
MONITORING DURING MgSO4 THERAPY:
 Respiratory rate
 Knee jerk
 Urine output
Antidote of MgSO4: Inj. Calcium Gluconate 10 mL. IV
Therapeutic MgSO4 levels: 4 – 7
mEq/L
Loss of knee jerk: 10 mEq/L
Respiratory paralysis: 12 mEq/L
Cardiac arrest: 15 mEq/L

21. OBSTETRIC
MEASURES
Timing of delivery
Method of delivery
Intra-partum care
Post – partum care

22. TIMING OF DELIVERY
Severe pre-eclampsia is usually treated consecutively till the end of the
36th weeks to ensure reasonable maturation of the fetus. Indications of
termination before 36th weeks include:
Aggravation of the pre-eclamptic feature.
HTN persists
Acute fulminating pre-eclampsia

23. METHOD OF DELIVERY:
Vaginal delivery may be commenced in vertex presentation by –
Amniotomy + Oxytocin
PGs, if cervix is not favourable.
Caesarean section is indicated in:
Oxytocin test fails
Failure of induction of labour
CPD

24. INTRAPARTUM CARE:
Close monitoring of the fetus and mother vitals
Proper analgesia
Anti-hypertensives may be given if needed
2nd stage of labour may be shortened by forceps delivery.
POST PARTUM CARE:
Continue observation of the mother for 48 hours
Drugs are continued in a small dose for 48 hours.

25. COMPLICATIONS
• Injuries
• Cerebral haemorrhage
• Hyperpyrexia
• Renal failure
• Pulmonary edema: Furosemide 40 mg IV followed by 20 mg of mannitol.
• Puerperal infection and puerperal psychosis.

26. NURSES
RESPONSIBILTIES
Patient
identification
Drug
Identification
Thorough
assessment
Right technique
Post
administration
evaluation
Education Documentation

28. BIBLIOGRAPHY/REFEREN
CE
• Annamma Jabob. A comprehensive textbook of Midwifery and Gynaecological
Nursing, Fourth edition.pp 724-741.
• Lily Podder. Fundamentals of Midwifery and Obstetrical Nursing. ELSEVIER.pp 374-
381.
• DC Dutta’s textbook of Obstetrics. Hiralal Konar 8th Edition.Jaypee The Health
Sciences Publisher.pp 573-585.
• DAVIS’S DRUG GUIDE for Nurses TWELFTH EDITION. Pp 806-808,869-870.
• Mosby’s 2020. Nursing Drug Reference. Skidmore, Third South Asia Edition. Pp
801-803,732-734.