1. Hypertension during pregnancy can be classified into five main categories: preeclampsia, eclampsia, gestational hypertension, chronic hypertension, and preeclampsia superimposed on chronic hypertension. 2. Gestational hypertension involves new onset high blood pressure after 20 weeks without proteinuria, while preeclampsia includes high blood pressure accompanied by proteinuria. 3. Eclampsia is a complication of preeclampsia involving seizures not caused by other conditions.

1. 1
Hypertension During
Pregnancy
Chapter 25

2. CLASSIFICATION OF HYPERTENSION DURING
PREGNANCY
First four are the main categories of hypertension
During Pregnancy
1. Preeclampsia
2. Eclampsia
3. Gestational hypertension
4. Chronic hypertension
5. Preeclampsia superimposed on chronic
hypertension
See table 25-1 (classification of hypertension in
pregnancy), page 591
2

3. GESTATIONAL HYPERTENSION
 Blood pressure elevation (Systolic ≥ 140 mmHg
or diastolic ≥ 90 mmHg) after 20 weeks of
pregnancy, that is not accompanied by
proteinurea and returns to normal within 6
weeks postpartum.
 proteinuria is not present (negative or trace)
3

4. PREECLAMPSIA
Systolic blood pressure of 140
mmHg or more and diastolic
blood pressure of 90 mmHg or
more after 20 weeks of
pregnancy that is accompanied
by proteinurea more or equal
0.3 g in a 24 hour collection or
1+ or more in random urine
dipstick 4

5. ECLAMPSIA
Progression of
preeclampsia to generalized
seizures that cannot be
attributed to other causes
5

6. CHRONIC HYPERTENSION
Elevated blood pressure that
was known to exist before
pregnancy or develops before
20 weeks of pregnancy or
hypertension that is not
resolved during postpartum
period
6

7. PREECLAMPSIA SUPERIMPOSED ON CHRONIC
HYPERTENSION
 Development of new onset proteinurea more or equal
0.3 g in a 24 hour collection or 1+ or more in random
urine dipstick in a woman who has chronic
hypertension. In a woman who had proteinuria before
20 weeks of gestation,
 Preeclampsia should be suspected if woman has
sudden increase in proteinuria from baseline levels, a
sudden increase in blood pressure when it had been
previously well controlled.
 Development of thrombocytopenia (Platelets
<100,000/mm³) , or abnormal elevations of liver
enzymes (Aspartate aminotransferase (AST, (SGOT) )
or Alanine aminotransferase (ALT (SGPT))
7

8. RISK FACTORS
1.First pregnancy
2.Women older than 35 years.
3.Ethnicity (African- American)
4.Positive family history
5.Women who have chronic
hypertension or renal disease.
Cont. 8

9. RISK FACTORS CONT.
6. Overweight
7. Women with DM
8. Multifetal gestations
9. Presence of immunologic disorders.
10.Women married from fathers who has
previously fathered a pregnancy in
another woman that was complicated
with preeclampsia.
9

10. PATHOPHYSIOLOGY
Preeclampsia is a result of
generalized vasospasm
Vasoconstriction results in the
impeded blood flow and elevated
blood pressure. As a result,
circulation to all body organs,
including the kidneys, liver, brain
and placenta is decreased.
10

11. The most significant changes
 Decrease Renal Perfusion lead
to
 Decreased GFR
 Increased (BUN, Createnine, uric
acid)
 Proteinurea
 Generalized edema +4
 Increased blood viscosity (elevated
hematocrite)
 Water and sodium retention, rapid
weight gain 11

12. Decreased liver Perfusion
lead to
Impaired liver function
Hepatic edema and
subscapular hemorrhage
Elevated liver enzymes
Epigastric pain
12

13. VASOCONSTRICTION OF CEREBRAL VESSELS
LEAD TO
Cerebral hemorrhage
Headache
visual disturbances (blurred
vision and spot before eyes)
Hyperreflexia
13

14. DECREASED PLACENTAL PERFUSION
LEAD TO
Intra uterine growth restriction
Persistent fetal hypoxemia
Abruptio placenta and HELLP
syndrome(H:Hemolysis, EL: Elevated
liver Enzymes (AST and ALT), LP: Low
platelets counts <100,000/mm³)
 May results in DIC
Lung
Pulmonary edema ( symptoms
include dyspnea
14

15. Preventive measures:
1. Early and regular prenatal care
2. Monitor Weight gain
3. Monitor blood pressure
4. Monitoring of urinary protein
5. Anti oxidants therapy:
6. Recent researches assessed the benefit
of 1000mg of Vit C and 400 IU of Vit E
starting at 22 weeks.
7. Attempts of prevention in woman of
high risks. Cont.
15

16. ATTEMPTS OF PREVENTION IN WOMAN OF
HIGH RISKS INCLUDES
a) low dose aspirin
b) Calcium and
magnesium supplement
c) Fish oil supplements
16

17. MANIFESTATIONS:CLASSIC SIGNS:
HYPERTENSION & PROTEINUREA
17
 Systolic BP≥140 but
< 160 mm Hg
 Diastolic BP ≥ 90
but < 110 mm Hg
 Proteinuria ≥0.3g
but <2g in 24hr
collection
 1+ or higher on
random dipstick
sample
 Systolic BP ≥160
mm Hg
 Diastolic BP ≥110
mm Hg
 Proteinuria ≥5g in
24hr collection
 3+ or higher on
random dipstick
sample
Mild preeclampsia Severe preeclampsia

18. Additional Signs: (severe preeclampsia)
Retinal vasoconstriction
Hyperreflexia
Generalized edema +4
Impaired coagulation (decrease platelets
<100,000/mm³)
Lab test indicate liver and renal
dysfunction (creatinine >1.2mg/dL)
18

19. Symptoms: (severe preeclampsia)
 Continuous headache
 Drowsiness
 Mental confusion
 Convulsion (Eclampsia)
 Visual disturbances
 Epigastric pain
 Decreased urinary output < 500ml/
day or 30 ml/hr.(oligurea)
See table 25-3 (mild vs. severe
preeclampsia) page 594
19

20. Therapeutic Management:
Delivery is the only definitive
treatment but it may not be
practical if preeclampsia is mild
and the fetus is premature.
If the fetus less than 34 wks,
steroids to accelerate fetal lung
maturity will be given and delay
birth for 48 hrs.
20

21. If the maternal or fetal
condition deteriorates, the
woman will be delivered
regardless the fetal age or
administration of steroids.
Vaginal birth is preferred
because of the multisystem
impairments.
21

22. Home care for mild preeclampsia:
Home management is possible if
1.Preeclampsia is mild
2.The woman and the fetus in
stable condition
3.The woman can adhere to the
treatment plan
4.The woman make a follow up
visit every 3-4 days
22

23. CARE AT HOME
 Activity restriction; side lying
at least one and half hour a
day
 Fetal activity (kick count)
should report if no movement
noticed in a 4 hour period
 Weight daily each morning 23

24.  Urinanalysis for proteinurea
daily
 Diet, regular balance nutrition
without salt or fluid
restrictions
 Blood pressure checked 2 to 4
times daily
24

25. Inpatient management for
severe Preeclampsia:
Severe preeclampsia is diagnosed
if systolic Bp ≥ 160 or diastolic
≥110mmHg or multisystem
involvement
Delivery is necessary even if GW
less than 34
25

26. MANAGEMENT FOR SEVERE
PREECLAMPSIA
Bed rest on quiet environment
 Reduce external stimuli that precipitate convulsion
(noise, light)
Anticonvulsant medications (MgSo4)
Antihypertensive medications: If BP
≥ 160/110 Hydralazine is given.
26

27. S/S OF MAGNESIUM SULFATE TOXICITY
Respiratory rate < 12 per minute
Maternal pulse oximetre <95%
Hyporeflexia (absence DTR)
Sweating, flushing
Altered sensory (confusion and
drowsiness
Hypotension
Sudden decrease in FHR
Serum MgSo4 level >8 mg/dl
Urine output<30 ml /hour 27

28. Intrapartum Management:
 Monitor the mother to prevent
convulsions
 Keep woman on lateral position
 Vaginal births is usually the first choice
 Give oxytocin to stimulate birth
 Continuous fetal monitoring
 Pain control (narcotic or epidural)
 Mgso4 to prevent convulsion
28

29. Postpartum management:
Careful assessment of the mother’s
blood loss and signs of shock
Assessment of s/s of preeclampsia is
continuous for at least 48 hrs
Continue giving magnesium to
prevent seizures
29

30. Signs of recovering:
Urinary output 4-6 L/day
Decrease protein in urine
Return BP to normal within 2 weeks.
Gradual improvement in serum
laboratory values
30

31. Nursing care
1. Assessment:
 Weight daily
 Vital signs every 4 hour
 Ascultate the chest for moist breath sounds
(pulmonary edema)
 Assess edema every 4 hours
 Measure urine output hourly
 Check urine for protein every 4 hours
31

32. ASSESSMENT OF EDEMA
(+1) Minimal edema of lower
extremities
(+2) Marked edema of lower extremities
(+3) Edema of lower extremities, face,
hands and sacral area
(+4) Generalized massive edema that
include ascites (accumulation of fluid in
peritoneal cavity)
32

33. 33

34. Fetal monitoring
Check brachial, radial and patellar
reflexes for hyperreflexia, or
hyporeflexia which indicate
magnesium excess
Ask woman about symptoms e.g.
headache, visual disturbances
epigastric pain, nausea vomiting and
increased edema.
34

35. Management of Eclampsia:
Maintain patent airway
Adequate oxygenation
Put the patient on lateral position to
prevent aspiration
After convulsion suction of food and
fluids
Administer anticonvulsant
Monitor fetal status
Blood specimen for type and Rh
Accurate assessment of urine output.
35

36. HELLP SYNDROME
H: Hemolysis
EL: Elevated liver Enzymes (AST and
ALT)
LP: Low platelets counts <100,000/mm³
The Prominent Symptoms:
Pain in the right upper quadrant, the
lower chest or epigastric area
Nausea, vomiting and severe edema
Treatment in intensive care unit
36