Pregnancy-induced hypertension is a condition in which vasospasm occurs during pregnancy in

both small and large arteries. Signs of hypertension, proteinuria and edema develop. It is unique to
pregnancy and occurs in 5% to 7% of pregnancies. Despite years of research, the cause of the disorder is
still unknown although it is highly correlated with the antiphospholipid syndrome or the presence of
antiphospholipid antibodies. Originally it was called toxemia because researchers pictured a toxin of some
kind being produced by a woman in response to the foreign protein of the growing fetus, the toxin leading
to the typical symptoms.
The symptoms of PIH affect almost all organs. The vascular spasm may be caused by the
increased cardiac output that occurs with pregnancy and injures the endothelial cells of the arteries or the
action of prostaglandins (notably decreased prostacyclin, a vasodilator, and excessive production of
thromboxane, a vasoconstrictor and stimulant of platelet aggregation). Normally, blood vessels during
pregnancy are resistant to the effects of pressor substances such as angiotensin and norepinephrine, so
blood pressure remains normal during pregnancy. With PIH, this reduced responsiveness to blood
pressure changes appears to be lost. Vasoconstriction occurs and blood pressure increases dramatically.
With hypertension, the cardiac system can become overwhelmed because the heart is forced to
pump against rising peripheral resistance. This reduces the blood supply to organs, most markedly the
kidney, pancreas, liver, brain and placenta. Poor placental perfusion my reduce the fetal nutrient and
oxygen supply. Ischemia in the pancreas may result in epigastric pain and an elevated amylase-creatinine
ratio. Spasm of the arteries in the retina leads to vision changes. If retinal hemorrhages occur, blindness
can result.
PIH is classified as gestational hypertension, mild pre-eclampsia, severe pre-eclampsia, and
eclampsia, depending on how far development of the syndrome has advanced. Any woman with a high
risk for PIH should be observed carefully for symptoms at prenatal visits. She needs instructions about
what further symptoms to watch for so she can alert her clinician if additional symptoms occur between
visits.
Vasospasm in the kidney increases blood flow resistance. Degenerative changes develop in
kidney glomeruli because of back-pressure. This leads to increased permeability of the glomerular
membrane, allowing the serum proteins albumin and globulin to escape into the urine (proteinuria). The
degenerative changes also result in decreased glomerular filtration so there is lowered urine output and
clearance of creatinine. Increased kidney tubylar reabsorption of sodium occurs. Because sodium retains
fluid, edema results. Edema is further increased because as more protein is lost, the osmotic presure of
the circulating blood falls and fluid diffuses from the circulatory system into the denser interstitial spaces to
equalizethe pressure. Extreme edema can lead to cerebral and pulmonary edema and seizures
(eclampsia).
Yet another effect is that arterial spasm causes the bulk of the blood volume in the maternal
circulation to be pooled in the venous circulation, so a woman has a deceptively low arterial intravascular

volume. In addition, thrombocytopenia or a lowered platelet count occurs as platelets cluster at the sites of
endothelial damage. Measuring hematocrit levels helps to assess the extent of plasma loss to the
interstitial space or the extent of the edema (the higher the hematocrit the more is being lost). A
hematocrit level above 40% suggests significant fluid loss into interstitial spaces.
Although women may have additional symptoms such as vision changes, typically hypertension,
proteinuria, and edema are considered the classic signs of PIH. Of the three, hypertension and proteinuria
are the most significant as extensive edema occurs only after the other two are present. Symptoms rarely
occur before 20 weeks of pregnancy.
Symptoms of pregnancy-Induced hypertension
Gestational hypertension
Blood pressure 140/90 mmHg or systolic pressure elevated 30mmHg or diastolic pressure
elevated 15 mmHg above prepregnancy level, no proteinuria or edema, blood pressure returns to normal
after birth
Mild pre-eclampsia

Blood pressure 140/90 mmHg or systolic pressure elevated 30 mmHg or diastolic pressure
elevated 15 mmHg above prepregnancy level, proteinuria of 1-2+ on a random sample, weight gain over
2lb per wk in second trimester and 1 lb per wk in third trimester, mild edema in upper extremities or face.
Sever pre-eclampsia
Blood pressure of 160/110 mmHg, proteinuria 3-4+ on a random sample and 5 g on a 24 hour
sample, oliguria (500ml or less in 24 hours or altered renal function tests, elevated serum creatinine more
than 1.2 mg/dL) cerebral or visual disturbances (headache, blurred vision), pulmonary or cardiac
involvement, extensive peripheral edema, hepatic dysfunction thrombocytopenia, epigastric pain
Eclampsia
Seizure or coma accompanied by signs and symptoms of pre-eclampsia
Medical Management
Magnesium sulfate
Pregnancy risk Category B
Muscle relaxant prevents seizure
Loading dose 4-6 g Maintenance dose 1-2 g/h IV

Infuse loading dose slowly over 15-30 min. Always administer as a piggyback infusion. Assess respiratory
rate, urine output, deep tendon reflexes, and clonus every hour. Urine output should be over 30mL/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 and calcium deficit in the mother.
Hydralazine (Apresoline)
Pregnancy risk Category C
Antihypertensive
(peripheral vasodilator) used to decrease hypertension
5-10 mg/IV
Administer slowly to avoid sudden fall in blood pressure. Maintain diastolic pressure over 90 mmHg to
ensure adequate placental filling.
Diazepam (Valium)
Pregnancy risk Category D
Halt seizures
5-10 mg/IV
Administer slowly. Dose may be repeated q 5-10 min (up to 30mg/hour. Observe for respiratory
depression or hypotension in mother and respiratory depression and hypotonia in infant at birth.
Calcium gluconate
Pregnancy risk Category C
Antidote for magnesium intoxication
1 g/IV (10 mL of a 10% solution)
Have prepared at bedside when administering magnesium sulfate. Administer at 5 mL/min.
Nursing Interventions
Mild PIH
Monitor Antiplatelet Therapy. Because of the increased tendency for platelets to cluster along arterial
walls, a mild antiplatelet agent, such as low-dose aspirin, may prevent or delay development of preeclampsia.
Promote Bed Rest.
Promote Good Nutrition
Provide Emotional Support
Severe PIH

Support Bed Rest.

Monitor Maternal Well-being
Monitor Fetal Well-being.
Support a Nutritious Diet.
Administer Medications to Prevent Eclampsia

Pregnancy induced hypertension refers to a potentially severe and even fatal elevation of blood pressure
that occurs during pregnancy. Several symptoms signal that PIH is developing:
Rapid weight gain (over 2 lb per week in the second trimester, 1 lb per week in the third trimester) 2
swelling of the face or fingers 3 flashes of light or dots before the eyes 4dimness or blurring of vision 5
sever, continuos headache 6decreased urine output
One by one, these are vague symptoms so a woman may need some help appreciating that they are
important to report during pregnancy. Some edema of the ankles during pregnancy is normal, for
example, particularly if it occurs after a woman has been on her feet for a long period. Swelling of the
hands (ask if she has noticed if her rings are tight) or face (difficulty opening eyes in the morning because
of edeman of the eyelids), however indicated edema that is more extensive than usual. Visual
disturbances or a continuous headache may signal cerebral edema or acute hypertension. Be certain a
woman is not reporting symptoms she had before she became pregnant. If she had the same visual
difficulties and headaches before pregnancy as she is reporting now, she may need to see an
opthalmologist rather than her obstetrician for help with the problem.

What is blood pressure?

Blood pressure is the pressure in the blood vessels in your body. It is the force with
which the blood moves through the blood vessels. Doctors and nurses measure
blood pressure by putting a cuff around your upper arm. Then they listen to your
blood flow with a stethoscope. High blood pressure (also called hypertension) occurs
when your blood moves through your blood vessels at a higher pressure than
normal.
What are the different types of high blood pressure during pregnancy?
There are three types of high blood pressure in pregnant women:
Chronic hypertension: High blood pressure that develops before the 20th week of
pregnancy or is present before the woman becomes pregnant. Sometimes a woman
has high blood pressure for a long time before she gets pregnant, but she doesn't
know it until her first prenatal check-up.

Gestational hypertension: Some women just get high blood pressure near the end of
pregnancy. They don't have any other associated symptoms.
Pregnancy-induced hypertension (PIH), also called toxemia or preeclampsia: This
condition can cause serious problems for both the mother and the baby if left
untreated. PIH develops after the 20th weeks of pregnancy. Along with high blood
pressure, it causes protein in the urine, blood changes and other problems.
What are the risks of PIH to the baby and me?
PIH can prevent the placenta (which gives oxygen and food to your baby) from
getting enough blood. If the placenta doesn't get enough blood, your baby gets less
oxygen and food. This can cause low birth weight and other problems for the baby.
Most women who have PIH still deliver healthy babies. A few develop a condition
called eclampsia (PIH with seizures), which is very serious for the mother and baby,
or other serious problems. Fortunately, PIH is usually detected early in women who
get regular prenatal care, and most problems can be prevented.
What are the symptoms of PIH?
If you have any of the following symptoms of PIH, call your doctor right away:
Severe headaches
Vomiting blood
Excessive swelling of the feet and hands
Smaller amounts of urine or no urine
Blood in your urine
Rapid heartbeat
Dizziness
Excessive nausea
Ringing or buzzing sound in ears
Excessive vomiting
Drowsiness
Fever
Double vision
Blurred vision

Sudden blindness
Pain in the abdomen (tummy)
Who is at risk for PIH?
PIH is more common during a woman's first pregnancy and in women whose
mothers or sisters had PIH. The risk of PIH is higher in women carrying multiple
babies, in teenage mothers and in women older than 40 years of age. Other women
at risk include those who had high blood pressure or kidney disease before they
became pregnant. The cause of PIH isn't known.
PIH: How your doctor treats this condition depends on how close you are to your
due date and how you and your baby are doing. The only treatment that stops PIH is
to deliver the baby. If your baby is born very early, it may have serious health
problems. But your doctor may want your baby to be delivered early if you or the
baby are very sick. If your doctor thinks it is safe for the pregnancy to continue to
full term, he or she will monitor you and your baby very closely until delivery. You
will see your doctor often and get blood tests. Your baby will also get some tests to
make sure he or she is healthy. You might need to stay home from work and rest in
bed. In some cases, hospitalization may be necessary.
PIH: High blood pressure is not the main problem, but it is one of the main signs of
this health condition. PIH can cause headaches, blurred vision, vision loss,
abdominal pain and dizziness. It can cause slow growth of the baby, low birth
weight and premature delivery. If you get PIH with seizures (called eclampsia), you
and your baby are at risk of dying. Many doctors give magnesium sulfate to their
patients during labor and for a few days afterward to help prevent eclampsia. Talk to
your doctor about these things