Best doc

1. 10/05/2025 1
PREGNANCY INDUCED
HYPERTENSION
Prepaired by: ABIE ASCHALE
Modulator : Ephrem. (BSC, ECCN)
BY ABIE ASCHALE
DEPARTMENT OF EMERGENCY AND CRITICAL
CARE NURSING

2. 10/05/2025
BY ABIE ASCHALE 2
CONTENT
Introduction
Risk factors
Pathophysiology
Classification
Diagnosis
Management
Complications
ICU admission criteria and management

3. 10/05/2025
BY ABIE ASCHALE 3
OBJECTIVES Define hypertension and PIH
 state Risk factors for PIH
Diagnosis of PIH
Classification
Discuss Diagnosis
Discuss Management option for PIH
List the Complications of PIH
Identify ICU admission criteria and
management for PIH
At the end of this session students are expected
to:

4. 10/05/2025
BY ABIE ASCHALE 4
INTRODUCTION
What is hypertension ?
Stages of hypertension ?
Types of hypertension?

5. 10/05/2025
BY ABIE ASCHALE 5
INTRODUCTION CONTI………
(ACC/AHA) ; 2017
Normal blood pressure Systolic <120 mmHg and diastolic <80 mmHg
Elevated blood pressure – Systolic 120 to 129 mmHg and diastolic <80 mmHg
Hypertension:
•Stage 1 – Systolic 130 to 139 mmHg or diastolic 80 to 89 mmHg
•Stage 2 – Systolic at least 140 mmHg or diastolic at least 90 mmHg
If there is a disparity in category between the systolic and diastolic pressures,
the higher value determines the stage.

6. 10/05/2025
BY ABIE ASCHALE 6
Isolated systolic hypertension vs Isolated diastolic hypertension
 White-coat hypertension - office/clinic BP (≥140/90 mmHg), but
normal at home or work.
 Masked hypertension - BP is normal at a clinic or office visit but
elevated at other times,
 more difficult to diagnose- WHY
 most typically diagnosed by 24-hour ABPM or automated home
BP monitoring
INTRODUCTION CONTI………

7. 10/05/2025
BY ABIE ASCHALE 7
PIH
Pregnancy induced hypertension is defined as a rise in BP> 140/90 mmHg
after the 20th week of gestation measured twice at least six hours apart or a
single measurement of diastolic BP>110mmHg.
Exception
Gestational Trophoblastic diseases (GTD) and multiple pregnancy. Why ?

8. 10/05/2025
BY ABIE ASCHALE 8
 unique to human pregnancy(PE)
 Complicates 7-10% of pregnancies
 70% Preeclampsia-eclampsia
 30% Chronic hypertension
 Eclampsia 0.05% incidence
 20% of Maternal Deaths
 Cause of 10% of Preterm birth
 Etiology unknown
INTRODUCTION CONTI………

9. 10/05/2025
BY ABIE ASCHALE 9
RISK FACTORS
A past history of preeclampsia
Multifetal pregnancy - 20 percent
Nulliparity –
family history
Advanced maternal age < 18 or < 35 yrs.
Pre- existing medical conditions:
 Pregestational diabetes
 underlying kidney or vascular
disease
 Obesity
 abnormal lipid metabolism
 Chronic hypertension

10. 10/05/2025
BY ABIE ASCHALE 10
PATHOPHYSIOLOGY
The pathophysiology of preeclampsia likely involves both maternal and
fetal/placental factors
 Abnormal development of the placenta
 Immunologic factors
 Genetic factors
 Environmental and maternal susceptibility factors
 Preexisting maternal vascular/metabolic/kidney/autoimmune disease

11. 11
Anormal invasion of the spiral arterioles by the cytotrophoblast cells reduced
uteroplacental perfusion  placental ischemia (lack of oxygen and nutrients) release
of placental factors  endothelial dysfunction in the maternal circulation
Endothelial dysfunction  inner lining of the blood vessels becomes impaired and unable to
produce enough vasodilators (substances that relax the blood vessels) such as nitric
oxide and prostacyclin.  This results in increased vascular resistanceandhypertension
Endothelial dysfunction  to increased production of vasoconstrictors (substances that
narrow the blood vessels) such as endothelin and thromboxane  increase the sensitivity of
the blood vessels to angiotensin II, a hormone that regulates blood pressure and fluid
balance

12. 10/05/2025
BY ABIE ASCHALE 12

13. 10/05/2025
BY ABIE ASCHALE 13
• The increased vascular resistance and hypertension affect the renal
function and cause proteinuria (protein in the urine), edema (swelling),
and reduced glomerular filtration rate (GFR).
• The increased blood pressure and endothelial dysfunction also affect
the brain, the liver, and the coagulation system.
• The placental ischemia and the maternal hypertension also affect the fetal
growth and development. The reduced blood flow and oxygen delivery to the
placenta can cause intrauterine growth restriction (IUGR), fetal distress,
and premature birth image

14. 10/05/2025
BY ABIE ASCHALE 14
PRE ECLAPSIA
GESTATION AL HTN
MILD
Pre existing HTN
ECLAPSIA
SEVER

15. 10/05/2025
BY ABIE ASCHALE 15
CLASSIFICATION

16. 10/05/2025
BY ABIE ASCHALE 16
1. GESTATIONAL HYPERTENSION
BP > 140/90 or more after the 20th week of gestation
without significant proteinuria.
Gestational hypertension may represent pre-eclampsia prior to
proteinuria or chronic hypertension previously unrecognized

17. 10/05/2025
BY ABIE ASCHALE 17
2. PRE-ECLAMPSIA
Pre-eclampsia BP > 140/90mmHg
Presence of significant proteinuria of > 300 mg/24 hours urine
specimen OR > 1+ protein (equivalent to approximately 100mg/dl)
on dipstick in at least two randomly collected urine specimen at least 6
hours apart
Based on degree of hypertension or proteinuria and involvement of
other organ systems

18. 10/05/2025
BY ABIE ASCHALE 18
1. Mild pre-eclampsia
The mild form of pre-eclampsia is diagnosed when the Systolic and
diastolic blood pressure is between 140-160 and 90-110mmHg respectively
without signs of severity.

19. 10/05/2025
BY ABIE ASCHALE 19
2. Severe pre-eclampsia
Severe blood pressure elevation: BP > 110 ∕160mmHg measured twice at
least six hours apart OR A single measurement of diastolic BP
>120mmHg
Proteinuria > 5gm/24 hours or >3+ in randomly collected urine
Pulmonary edema
• Kidney function impairment- Serum creatinine >1.1 mg/Dl
• HELLP syndrome

20. 10/05/2025
BY ABIE ASCHALE 20

21. 10/05/2025
BY ABIE ASCHALE 21
Elevated Liver Enzymes (HELLP syndrome)
- Disseminated intravascular coagulation (DIC)
- Headache, visual disturbance and right upper abdominal pain
- Oliguria (<400ml in 24hours or 30ml/hour)
- Intrauterine growth restriction (IUGR)
- Cardiac decompensation, Pulmonary edema, cyanosis

22. 10/05/2025
BY ABIE ASCHALE 22
3. ECLAMPSIA
 Eclampsia is the development of new-onset seizures (generalized tonic clonic type),
superimposed upon
 Preeclampsia, in a woman between 20 weeks of gestation and 4 weeks postpartum.
Eclampsia is the convulsive manifestation of preeclampsia
absence of other causative conditions (eg, epilepsy, cerebral arterial ischemia and
infarction, intracranial hemorrhage, drug use
Any convulsion occurring during pregnancy is eclampsia unless proven otherwise
.

23. 10/05/2025
BY ABIE ASCHALE 23
DIAGNOSIS
History
Physical examination
laboratory

24. 10/05/2025
BY ABIE ASCHALE 24
MANAGEMENT
objectives
1. Control hypertension
2. Prevent convulsion
3. Prevent complication
4. Deliver viable fetus

25. 10/05/2025
BY ABIE ASCHALE 25
GENERAL PRENCIPLES
Stabilization of air way, breathing and circulation is the initial step.
Always anticipate difficult airway in pregnant patients.
Two large-bore intravenous cannula (14G or 16G) should be placed to
administer fluids.
The Foley catheter should be placed to monitor urine output.
Nurse in the left lateral position (30° wedge to the right hip) to prevent supine
hypotension syndrome

26. 10/05/2025
BY ABIE ASCHALE 26
Non pharmacologic
- Bed rest at home in the lateral decubitus position.
- Frequent evaluation of fetal well being
- Maternal well being i.e. BP, laboratory
- Advise patient to immediately report whenever they develop symptoms of severity such as
headache, epigastric pain, blurring of vision etc
- Plan termination of pregnancy at term.
- If the disease progresses to severe range, manage as severe case.
Management of mild pre-
eclampsia
Most patients are asymptomatic and can be managed conservatively. Such patients are
not candidates for urgent delivery.

27. 10/05/2025 27
Pharmacologic
BY ABIE ASCHALE
BP control
 Arterial pressure not greater than 160/110 mmHg in preeclampsia can increase
the risk of complication, and it should be controlled.
 Goal of BP control is 15–25% reduction in the mean arterial pressure, and
 Reduction of pressure to normal levels (<140/90 mmHg) should be avoided as
it may compromise placental perfusion.
Methyldopa, 250-500mg P.O., 8 to 12 hourly
Nifedipine, 10-40mg P.O., BID OR slow release 30-60mg daily
N.B. Advise patient

28. 10/05/2025
BY ABIE ASCHALE 28
PREECLAMPSIAAND ECLAMPSIA
B. BP CONTROL

29. 10/05/2025
BY ABIE ASCHALE 29
1. Labetalol
 Dosage
 20 mg IV gradually over 2 minutes.
• If BP remains above target level at 10 minutes, give 40 mg IV over 2 minutes.
• If BP remains above target level at 20 minutes, give 80 mg IV over 2 minutes.
 Cumulative maximum dose is 300 mg. If target BP is not achieved, switch
to another class of agent. Hold dose if heart rate <60 beats per minute.
 A continuous IV infusion of 1 to 2 mg/minute can be used instead of
intermittent therapy or started after 20 mg IV dose.

30. 10/05/2025
BY ABIE ASCHALE 30
2. HYDRALAZINE
Repeat BP measurement at 20-minute intervals:
•If BP remains above target level at 20 minutes, give 5 or 10 mg IV over 2
minutes, depending on the initial response.
Cumulative maximum dose is 20 to 30 mg per treatment event.
Initial dose - 5 mg IV gradually over 1 to 2 minutes.*
Less predictable than with IV labetalol.

31. 10/05/2025
BY ABIE ASCHALE 31
3. NIFEDIPINE*
Immediate release- 10 mg orally.
• Repeat BP measurement at 20-minute intervals:
• If BP remains above target at 20 minutes, give 10 or 20 mg orally,
depending on the initial response.
• If BP remains above target at 40 minutes, give 10 or 20 mg orally,
depending on the previous response.

32. 10/05/2025
BY ABIE ASCHALE 32
C. CONTROL SEIZURE

33. 33
FIRST LINE - Magnesium sulphate
A loading dose
 4gm as 20% solution IV over 10-15 minutes followed by
10gm as 50% IM injection divided on two sides of the buttock,
Maintenance dose
5gm every 4 hours as 50% concentration over 2minutes,
2gm IV as 50% solution over 2minutes if convulsion recurs.
Reduce the maintenance dose by half if there are signs of renal derangement
during labor and for the first 24 hours postpartum

34. 10/05/2025
BY ABIE ASCHALE 34
Monitor toxicity
 Loss of deep tendon reflexes
 Respiratory depression
 Loss of patellar reflex
If seizures recur while the patient is receiving magnesium, a repeat (2g)
bolus of magnesium may be given.
Infusion dose should be reduced in case of renal dysfunction.
Serum magnesium level should be monitored
Discontinue magnesium sulfate 24 h after delivery or after last seizer

35. 10/05/2025
BY ABIE ASCHALE 35
D. DELIVERY
The definitive treatment for eclampsia is prompt delivery;

36. 10/05/2025
BY ABIE ASCHALE 36

37. 10/05/2025
BY ABIE ASCHALE 37
Maternal Complications
 DIC(3%),
 Renal failure (4%)
 Adult respiratory distress syndrome (3%).
 HELLP syndrome3%,
 severe PE 4-12% with
 Uncontrolled Hypertension
 Risk of Cerebro-vascular Accident
 Liver failure (Liver rupture)

38. 10/05/2025
BY ABIE ASCHALE 38
 Pulmonary oedema 2%(adult RDS)
 Pulmonary hemorrhage
 Placental abruption
 Eclampsia (risk of aspiration pneumonia)

39. 10/05/2025
BY ABIE ASCHALE 39
Prematurity
IUGR
Utero-placental insufficiency
Oligohydramnios
Respiratory distress syndrome
Placental abruption
 Acute fetal distress
 IUFD
 Caesarean section,
 Admission to SCUBU/NICU
Fetal complications

40. 10/05/2025
BY ABIE ASCHALE 40
ICU ADMISSION CRITERIA FOR SEVER CONDITIONS
The criteria for ICU admission for preeclampsia and depending on
 the severity of the condition,
 the availability of resources, and
 the clinical judgment of the obstetrician and the intensivist.

41. 10/05/2025
BY ABIE ASCHALE 41
some common indicators may warrant ICU admission are
BP > 160/110 mmHg or higher, despite adequate antihypertensive therapy.
Severe proteinuria (> 4+ on dipstick or 5 g in 24 hours).
Oliguria (UO < 20-30 ml/hr) or AKI (cr. >1.3 mg/dl).
Signs of HELLP syndrome
Epigastric pain, headache, visual disturbances, or altered mental status (signs of
cerebral edema or ischemia).
Seizures or coma (eclampsia).
Pulmonary edema, signs of fluid overload or cardiopulmonary dysfunction.
Fetal distress or IUGR (signs of placental insufficiency or abruption).

42. 10/05/2025
BY ABIE ASCHALE 42
GOAL OF ICU CARE AND ROLE OF NURSE
• Blood pressure control with intravenous antihypertensive a
• Magnesium sulfate infusion for seizure prophylaxis and treatment
• Fluid management with careful assessment of the fluid balance, urine
output, and hemodynamics.
• Fetal monitoring with continuous cardiotocography, ultrasound, and
biophysical profile
• Steroid administration for fetal lung maturation if the gestational age is
less than 34 weeks and delivery is anticipated within 7 days.

43. 10/05/2025 43
SUMMERY
PIH) a condition where a pregnant woman develops high blood pressure after 20 weeks of
pregnancy.
It can affect the mother’s organs and the baby’s growth and development.
PIH can also lead to serious complications such as pre-eclampsia, eclampsia, and HELLP
syndrome.
PIH is diagnosed by measuring blood pressure and checking for protein in the urine.
Treatment options depend on the severity of the condition and the stage of pregnancy. Some
common treatments include bed rest, medication, and early delivery.
PIH usually goes away after childbirth

44. 10/05/2025
BY ABIE ASCHALE 44
REFERENCES
Overview of pregnancy induced hypertension– UpToDate,2024
Protocol R. 3: Classification of hypertension in pregnancy. 2012;
Melkie DA, Internist, Teferra DE, Pediatrician, Assefa DM, Oncologist, et al. Food , Medicine and Healthcare Administration
and Control Authority of Ethiopia Standard Treatment Guidelines For General Hospital Diseases Investigations Good
Prescribing & Dispensing Practices for Better Health Outcomes. Fmhaca Addis Ababa. 2014;(3):360.
Brown MA, Magee LA, Kenny LC, Karumanchi SA, McCarthy FP, Saito S, et al. Hypertensive disorders of pregnancy: ISSHP
classification, diagnosis, and management recommendations for international practice. Hypertension. 2018;72(1):24–43.
Braunthal S, Brateanu A. Hypertension in pregnancy: Pathophysiology and treatment. SAGE Open Med. 2019;7.
 Gouveia, I., Costa, C., Cunha, P. et al. Pre-eclampsia in the intensive care unit: indicators of severity and hospital
outcome. Crit Care 9 (Suppl 1), P216 (2005). https://doi.org/10.1186/cc3279

45. 10/05/2025
BY ABIE ASCHALE 45

46. 10/05/2025
BY ABIE ASCHALE 46

47. 10/05/2025
BY ABIE ASCHALE 47
አመሰግናለሁ