Description about pregnancy Induced hypertension, types, management and nursing care. Good for student nurses as well as nurse practitioners. Simple terms, complete theoretical aspect covered in small points.
2. PATIENT PARTICULARS
• NAME : Mrs Guddan
• AGE : 34 yrs
• HUSBAND'S NAME : Hav Nawab Ali
• ADDRESS : Village- Gheja, Uttar Pradesh
• DATE OF ADMISSION : 02/11/2019
• LMP : 19/02/2019
• EDD : 26/11/2019
• OBSTETRIC SCORE : G3P2L2
• GESTATIONAL SCORE : 36 Weeks 05 Days
• DIAGNOSIS : ANC With Pre-eclampsia with GDM
3. PRESENTING COMPLAINTS
• Mrs Guddan, a 34 yr old multigravida, known case
of GDM and pre-eclampsia was admitted at 36
weeks 05 days period of gestation for safe
confinement and early termination of pregnancy with
induction of labour planned after completion of 37
weeks period of gestation
4. PRESENT HISTORY OF ILLNESS
• Known case of GDM and pre-eclampsia, was started of OHA's and insulin therapy
and oral antihypertensives at 31 weeks POG
• Mrs Guddan got admitted to maternity ward on 02/11/2019 for safe confinement and
BP monitoring and early termination of pregnancy after completion of 37 weeks
POG
• Blood sugar and BP monitored throughout her stay- within normal limit
• Induction done at 37 weeks 02 days POG with cerviprime on 07/11/2019 .
5. PAST MEDICAL/SURGICAL HISTORY OF
ILLNESS
• No known significant medical history
• Fracture humerus(left) operated in 2016
FAMILY HISTORY OF ILLNESS
• No significant medical or surgical history of illness
6. PERSONAL HISTORY
• NUTRITION
Dietary Habits : Non Vegetarian
Meal Pattern : 3 meal pattern
Smoking : Non Smoker
Alcohol : Non Alcoholic
• HYGIENE
Patient performs all activities of daily living herself and
was well groomed
7. PERSONAL HISTORY
• SLEEPING PATTERN
Normal sleeping pattern, slept 1-2 hours in the afternoon and around 6-7
hours at night everyday
• ELIMINATION
No history of constipation. No history of urinary retention or incontinence
8. PERSONAL HISTORY
• ALLERGIC REACTION
No known history of any allergic reactions
• CONTRACEPTIVE HISTORY
No contraceptives used post marriage
9. MENSTRUAL HISTORY
• Menarche : 15 years
• Cycle : 28-30 days/ 4-5 days and regular
• LMP :19/02/2019
• EDD :26/11/2019
MARITAL HISTORY
• Patient married at the age of 19 years
• Married since past 12 years
• Had a non consanguineous marriage
10. OBSTETRIC HISTORY
• PAST OBSTETRIC HISTORY
• PRESENT OBSTETRIC HISTORY
1. 1st TRIMISTER
Booked case, her first visit at MH Jalandhar was on 13/06/19 at 16 wks 04
days POG
Vomiting and nausea present during first trimester
SL NO YEAR CONCEPTION PREGANCY OUTCOME PUERPARIUM DETAILS OF
CHILD
1. 2011 Spontaneous Normal Vaginal Delivery Uneventful Male
3.5kg
2. 2012 Spontaneous Normal Vaginal Delivery Uneventful Female
3.5kg
3. 2019 Spontaneous Present Pregnancy
11. OBSTETRIC HISTORY
2. 2nd TRIMESTER
Quickening felt at 19 weeks POG
Two doses of Inj TT taken
3. 3rd TRIMESTER: Presence of GDM and PIH detected
30 weeks: Derranged blood sugar level, started on OHAs
31 weeks 02 days: Had raised Blood pressure, admitted for BP and Blood
sugar monitoring to Maternity ward. Started on antihypertensives
35 weeks : Started on Lispro and Glargin and added Tab Labetatol, due
to persisteantly raised Blood sugars and BP
13. CONTINUED
Pallor : Not present
Icterus : Not present
Breast : Enlarged in size, primary and secondary areola
present, montgomery tubercles prominent, no colostrum seen
Thyroid : Not enlarged
Pedal edema : Present
Varicose vein : Not present
Heart, liver & spleen: NAD
Lungs : No signs of breathlessness, normal lung sounds
14. ABDOMINAL EXAMINATION
INSPECTION
• Size : Appropriate for period of gestation
• Shape : Ovoid
• Contour : Even
• Fetal movements : Visible fetal movements
• Skin : Linea niagra and straie gravidarum
present
• Umbilicus : Slightly protruded
15. CONTINUED
PALPATION
• Lie : Longitudinal
• Presentation : Cephalic
• Position : LOA
• Engagement : Not Engaged
• Abdominal Girth : 88 cm
• Fundal Height : 36 cm
AUSCULTATION
• FSH : 144/min
16. INVESTIGATIONS
SL NO INVESTIGATIONS PATEINT VALUE NORMAL VALUE REMARKS
1. Hb 11.2 12-16 mg/dl Normal
2. TLC 7600 4000-11000 cumm Normal
3. PLATELET 1,53,000 1.5-3 lakh/cumm Normal
4. S.Bil 0.3 0.1-1 mg/dl Normal
5. SGOT 25 upto 40 Normal
6. SGPT Kit NA upto 40 -
7. Urea 22 10-50 mg/dl Normal
8. Creatinine Kit NA 0.5- 1.4 mg/dl -
9. Uric acid 5.4 <4.5 mg/dl >4.5 indicative of pre-
eclampsia
10. 24 Hours urine protein 325 <300mg Proteinurea
11. PBS for hemolysis NAD No hemolysis Normal
12. LDH 552 200-400 s/o hemolysis
13. Urine for ketones Negative Negative Normal
17. INVESIGATIONS
SUGAR PROFILE 21/09/19 23/09/19 22/10/19 31/10/19
FASTING
PP
BL
AL
BD
AD
3AM
HBA1C
99mg/dl
115mg/dl
93mg/dl
126mg/dl
156mg/dl
142mg/dl
-
8% (4.5-6.3%)
120mg/dl
111mg/dl
148mg/dl
132mg/dl
143mg/dl
166mg/dl
-
112mg/dl
155mg/dl
93mg/dl
103mg/dl
116mg/dl
158mg/dl
-
90mg/dl
100mg/dl
88mg/dl
104mg/dl
110mg/dl
102mg/dl
95mg/dl
USG at 31 weeks: Gravid uterus showing single live fetus,
Adequate amniotic flow
Placenta posterior, away from the internal os
Normal flow in umbilical artery and maternal uterine arteries
18. TREATMENT
SNO3. NAME OF DRUG DOSE FREQUENCY TIME
1. TAB METFORMIN 1g BD 7-7
2. TAB LABETALOL 100mg TDS 10-2-10
3. TAB ECOSPRIN 75mg OD 2pm
4. TAB CALCIUM 1 BD 10-10
5. TAB AUTRIN 1 OD 10am
6. INJ LISPRO 6U-6U-6U TDS With meals
7. INJ GLARGIN 6U HS 10pm
19. INTRAPARTUM MANAGEMENT
• Induction done at 37 weeks 02 days POG with cerviprime on 07/11/2019
cervix- 2cm, Effacement- 20% Head station- -3 , Membranes intact
• Augmented labor with ARM and inj pitocin infusion
• Sugar and BP monitored throughout the period of labour
• Patient gave complaint of uneasiness, BP recorded 150/98mmHg
• At 1730 hours patient had an episode of seizures (GTCS), Inj MgSO4 4g IV stat
administered over 3-5 min and infusion started @1g/hr and oxygen supplemented
via nasal prongs and shifted to OT for emergency LSCS
20. POST OPERATIVE MANAGEMENT
• Extracted a healthy alive baby
TOB- 1836 HOURS
DOB- 07/11/2019
SEX - Male
B.wt - 3kg
• Observed closely at ICU for 24 hours, continued on MgSO4 infusion
• Monitored hourly- BP, knee jerk, respiration and urine output
• Started on IV antibiotics
• Shifted to maternity ward after 24 hours
22. INCIDENCE
• 3.7% of pregnancies
• 16% of pregnancy related death
• Eclampsia 1 in 2000 deliveries
23. CLASSIFICATION OF HYPERTENSION IN
PREGNANCY
DISORDER DEFINITION
1. HYPERTENSION
2. GESTATIONAL
HYPERTENSION
3.PRE-ECLAMPSIA
4. ECLAMPSIA
5. CHRONIC
HYPERTENSION
6. SUPERIMPOSED PRE
ECLAMPSIA/ECLAMPSIA
BP ≥ 140/90 mmhg measured 2 times with atleast a 6 hr interval
BP ≥ 140/90 mmhg for the first time in pregnancy after 20 weeks,
without proteinuria
Gestational Hypertension with proteinuria
Women with pre-eclampsia complicated with convulsions
Known hypertension before pregnancy or hypertension diagnosed first time
before 20 weeks of pregnancy
Occurence of new onset of proteinuria in women with chronic hypertension
24. PRE-ECLAMPSIA
• Multisystem disorder of unknown etiology characteristized by development
of hypertension to the extent of 140/90 mmHg or more with protienuria
after 20 week in a previously normotensive and nonproteinuric women
DIAGNOSTIC CRITERIA
• Hypertension
• Oedema: Pitting edema over the ankles over 12 hours bed rest or rapid
weight gain 0.5 kg a week
• Proteinuria: Presence of total protein in 24 hours urine of more than 0.3g
or ≥ 2+ (1g/L) on atleast two random clean catch urine samples tested ≥ 4
hours apart in the absence of any UTIs
25. CLINICAL TYPES
• MILD PRE-ECLAMPSIA
BP ≥ 140/90 mmHg but less than
160/110mmHg without significant
proteinuria
• SEVERE PRE-ECLAMPSIA
Persistent BP ≥ 160/110 mmHg
Protein excretion > 5g/24 hrs
Oliguria <400ml/24 hours
Platelet < 100,000/mm3
Cerebral or visual disturbances
26. ECLAMPSIA
• Pre-eclampsia when complicated with generalized tonic-clonic
convulsions and or coma is called eclampsia
• May appear before, during or after labor
27. RISK FACTORS
• Primigravida: Young or elderly
• Family history
• Placental abnormalities: excessive
exposure to chorionic villi- molar
pregnancy, multiple pregnancy,
diabetes
• Obesity
• Pre-existing vascular diseases
• Thrombophilias
31. CLINICAL FEATURES
Mild symptoms:
• Slight swelling over the ankles
• Gradually extending to the face, abdominal
wall, vulva and even the whole body
Alarming symptoms:
• Headache
• Disturbed sleep
• Oliguria
• Epigastric pain
• Blurring/dimness of vision
32. SIGNS
• Weight gain
• Persistent rise of BP > 140/90mmHg
• Edema over ankles
• Pulmonary edema
• Abdominal examination: scanty liqour or IUGR (chronic placental
insufficiency)
• Eclamptic Fit or Convulsions
PREMONITORY STAGE
TONIC STAGE
CLONIC STAGE
STAGE OF COMA
33. INVESTIGATIONS
• Urine: Proteinuria is the last feature of pre-eclampsia to
occur
• Ophthalmic examination: Retinal edema, constriction of
the arterioles,hemorrhage etc
• Blood values: Serum uric acid >4.5 mg/dL
Serum creatinine maybe >1mg/dL,
Urea normal to slightly raised,
Thrombocytopenia,
Abnormal coagulation profile and
Hepatic enzymes maybe elevated
34. COMPLICATIONS
• IMMEDIATE: MATERNAL
• ECLAMPSIA: Injuries, pulmonary failure, neurological deficits, cardiac and renal
shutdown, coagulopathies, postpartum psychosis
DURING PREGNANCY DURING LABOR PUERPERIUM
a. Eclampsia
b. Antepartum hemorrhage
c. Acute renal failure
d. Cardiac failure
e. Dimness of vision or even
blindness
f. Preterm labor
g. HELLP Syndrome
h. ARDS
a. Eclampsia
b. Postpartum hemorrhage
a. Eclampsia
b. Shock
c. Sepsis
35. COMPLICATIONS
• IMMEDIATE: FETAL
a. Intrauterine fetal death
b. Intrauterine growth retardation
c. Asphyxia
d. Prematurity
• REMOTE: MATERNAL
a. Residual hypertendion
b. Recurrent pre-eclampsia
c. Chronic renal disease
d. Risk of palental abruption
36. PREVENTION
• Regular antenatal checkup
• Antithrombotic agents: Tab Ecosprin 75mg daily in
potentially high risk patients
• Heparin or Low Molecular Weight Heparin is useful in
women with thrombophilia and with high risk
pregnancy
• Calcium supplementation 2gm per day
• Antioxidants: Vitamin E and C
• Balanced diet rich in protein
37. MANAGEMENT
• HOSPITAL MANAGEMENT
i. Rest
ii. Continuous BP monitoring - every 4 Hourly
iii. Blood investigations: Platelet, coagulation profile, uric acid, creatinine,
LFT and 24 hour urine protein
iv. Daily urine dipstick
v. Ophthalmoscopy
vi. Fetal well being assessment: DFMC, NST, CTG, Biophysical profile and
USG-Doppler
vii. Antihypertensives: Diastolic BP over 110mmHg
38. MANAGEMENT
ANTIHYPERTENSIVES
DRUG DOSE SCHEDULE MAXIMUM DOSE
Tab Labetalol
Tab Nifedipine
Tab Methydopa
Tab Hydralazine
100mg qid
10-20 mg bd
250-500mg tds or qid
10-25 mg bd
HYPERTENSIVE CRISIS- BP ≥160/110 mmHg or MAP ≥ 125 mmHg
Inj Labetalol
Inj Hydralazine
Tab Nifedipine
Inj NTG
Inj Sodium nitropruside
10-20 mg IV/10 min
5mg/30 min
10-20 mg oral, can be repeated
in 30 min
5µg/min IV
0.25-5µg/kg/min IV
300mg
30 mg
240 mg/24 hrs
} Only used when other drugs
have failed
39. MANAGEMENT
COMPLETE CONTROL BP PERSISTENTLY
HIGH
PERSISTENTLY ↑BP
EVEN WITH ANTI-
HYPERTENSIVES
ADDITIONAL
OMNIOUS SYMPTOMS
• PRETERM: Discharge
and attend ANC Clinic
• TERM: Hospitalization
≥ 37 weeks then
deliver
Try to continue
pregnancy till 37 weeks
or atleast 34 weeks then
deliver
• Couple counseling
• Transfer to tertiary care center
• Prophylactic anticonvulsant therapy
• Delivery, irrespective of POG
• Steroid if < 34 weeks
METHOD OF DELIVERY
Induction of labour
Cesarean
40. MANAGMENT: ECLAMPSIA
• Maintain: airway, breathing and
circulation
• Oxygen administration 8-10 l/min
• Arrest convulsions
• Ventilatory support (if needed)
• Prevention of injuries
• Hemodynamic stabilization
• Organize investigations
• Deliver by 6-8 hours
• Prevention of complications
• Postpartum care
41. MANAGMENT: ECLAMPSIA
FIRST AID OUTSIDE THE HOSPITAL MEDICAL and NURSING MANAGEMENT
• Shift to tertiary cary hospital immediately
• All maternal documents
• Stabilize BP, arrest convulsions
• MgSO4 : Pritchard/Zuspan
• Inj Labetalol 20 mg IV
• Diuretics: Pulmonary edema
• Diazepam 5 mg: Avoid apnoe or cardiac
arrest
• Trained medical personnel or a midwife
• Supportive care: Management during fits
• Detailed history
• Examination: General, abdominal and vaginal
examination
• Monitoring: Half hourly-pulse, respiration and
BP
hourly- Urine output
• Fluid balance: Total fluid previous UO +
1000ml (RL)
• Antibiotics: In Ceftriaxone 1g BD
42. MANAGMENT: ECLAMPSIA
• MANAGEMENT DURING FITS:
Placed in a railed cot, mouth gag to be placed in premonitory stage
Lateral decubitus position
Clear air passage to avoid aspiration
Oxygen 8-10 l/min
Continous monitoring
ABG if oxygen saturation < 92%
STATUS EPILEPTICUS: Inj Thiopentone sodium 0.5 g dissolved in 20
ml 5%D IV slow
Anesthesia, muscle relaxants and assisted ventilation
43. ANTICONVULSANT AND SEDATIVE
REGIMEN LOADING DOSE MAINTENANCE DOSE
INTRAMUSCULAR
(PRITCHARD)
4g IV, over 3-5 min followed by
10g deep IM (5g in each buttock)
5g IM 4 hours in alt buttock
INTRAVENOUS (ZUSPAN OR
SIBAI)
4-6g IV over 15-20 min 1-2g/hr IV infusion
Recurret fits: 2g repeat IV bolus over 5 min in the above regimen
44. MANAGEMENT: ECLAMSIA
ECLAMPSIA : IN LABOR
• ARM: Forceps, ventose
• Cesarean: Uncontrolled fits, unconscious patient with poor prospect of
vaginal delivery, malpresentations
• ECLAMPSIA: NOT IN LABOR
FITS CONTROLLED FITS NOT CONTROLLED (6-8 HOURS)
• Term: Deliver- Induce or CS
• Preterm: Steroid then deliver
• Dead: Induce and deliver
Deliver
• Favourable vaginal findings: ARM, oxytocin
• Unfavourable finding: CS
45. NURSING MANAGEMENT: ASSESSMENT
• Early prediction and prevention: Look for
omnious signs and symptoms
• Intensive monitoring of the patient
i. Continuous fetal monitoring
ii.Assess vital signs
• Ask patient to tell if she develops a
headache, blurred vision, dizziness or
epigastric pain
• Age and parity
• Predisposing factors
46. NURSING DIAGNOSIS
• Altered tissue perfusion related to decreased uteroplacental perfusion,
maternal hypovolemia
• Fluid volume deficit related to decreasing plasma colloid and ongoing
renal shutdown
• Decreased cardiac output related to hpovolemis/decreased venous return
and increased systemic vascular resistenace
• Ineffective airway clearance related to possible chances of aspiration due
to convulsions
• Risk for maternal injury related to tonic clonic convulsions
• Impaired physical mobility related to decreased muscle strength
• Risk for fetal injury
• Risk for infections
47. NURSING INTERVENTION
• Faciliate early prenatal care
• Assess physical parameters
• Provide diet instructions
• Instruct regarding medications
• Anticipate seizure:Prompt seizure prophylaxsis
• Maintain IV assess, catheterize the patient
• Special considerations during MgSO4 infusion: Continue infusion only if
Knee jerks are present, Urine output is >30ml/hr and RR is >12/min
• Therapeutic serum magnesium level is 4-7mEQ/L
• Administer Inj calcium gluconate for MgSO4 toxicity
• Prepare for labour induction or cesarean
• Continue MgSO4 for 24 hours after delivery
48. HEALTH EDUCATION
• Regular antenatal checkup
• Drug compliance
• Dietary changes: High protein diet
• Teach and patient about the alarming signs of PIH
• Seek care immediately
• Counselling: Possible early termination of pregnancy, premature new born
• Family support
49. SUMMARY
• Mrs Guddan, 34 year old multigravida, known case of pre-
eclampsia with GDM got admitted to MH JRC at 36 weeks 06
days POG for safe confinement and induction of labor at 37
weeks POG. During labor after induction as planned, she
developed eclampsia, immediate care was given and shifted
for emergency LSCS. Postpartum continued to have ↑BP.
She was diagnosed as a case of Chronic Hypertension and
was diacharged after 10 days on Tab Amlodipine 5mg OD