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What Is Pregnancy-Induced Hypertension?

Pregnancy-Induced Hypertension (PIH) is a condition in which vasospasm occurs during pregnancy in both small and large arteries. It is
unique to pregnancy and occurs in 5% to 7% of pregnancies ( Bailis & Witter,2007). Despite the years of research, the cause of the disorder is
still unknown it is highly correlated with the antiphospholipid syndrome or the presence of antiphospholipid antibodies (Clark, Silver &
Branch, 2007). 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.
Occurs mostly in women with:
Multiple pregnancy
Primiparas younger than 20 years or older than 40 years
Women fromm low socioeconomic backgrounds(perhaps because of poor nutrition)
Who have had five or more pregnancies
Who have had hydramnios (overproduction of amniotic fluid)
Or those who have an underlying disease ( diabetes, diabetes with vessel or renal involvement, essential hypertension)
ASSESSMENT:
CLASSIC SIGNS OF PIH:
Hypertension
Proteinuria
Edema
**some experienced vision changes
Of the three, HTN 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
CLASSIFICATION OF PIH:

Gestational Hypertension
Mild pre eclampsia
Severe pre eclampsia
Eclmapsia
TYPES AND SYMPTOMS OF PREGNANCY-INDUCED HYPERTENSION

HYPERTENSION TYPE SYMPTOMS


Blood pressure 140/90mmHg or systolic blood
GESTATIONAL HYPERTENSION pressure elevated to 30mmHg or diastolic
pressure elevated 15mmHg above prepregnancy
level
NO PROTEINURIA OR EDEMA
Blood pressure returns to normal after birth
Blood pressure 140/90mmHg or systolic pressure
MILD PRE-ECLAMPSIA elevated 30mmHg or diastolic pressure elevated
15mmHg above prepregnancy level
(+)PROTEINURIA of 1-2+ on a random sample
Weight gain over 2 lbs per week in second
trimester and 1 lb per week in third trimester
(+) MILD EDEMA IN UPPER EXTREMITIES OR FACE
Blood pressure 160/110mmHg
SEVERE PRE-ECLAMPSIA (+)PROTEINURIA of 3-4+ on a random sample
and 5g on 24 hour sample
(+) OLIGURIA (500ml or less in 24hours or altered
renal function tests
ELEVATED SERUM CREATININE more than 1.2
mg/dl
CEREBRAL OR VISUAL DISTURBANCES (headache
or blurring of vision)
PULMONARY OR CARDIAC INVOLVEMENT
EXTENSIVE PERIPHERAL EDEMA
HEPATIC DYSFUNCTION; THROMBOCYTOPENIA
EPIGASTRIC PAIN
Seizure or COMA accompanied by signs and
ECLAMPSIA symptoms of pre-eclampsia
NURSING INTERVERNTIONS FOR A WOMAN WITH MILD PIH

Clients with mild pre-eclampsia can be managed at home with frequent follow-up care. Regardless of the setting, the care is similar.

Monitor Antiplatelet therapy


Because of the increased tendency for platelets to cluster along arteria walls, a mild antiplatelet agent, such as lowdose
aspirin may prevent or delay development of pre-eclampsia (Duley, et al., 2009).

Promote Bed Rest


When the body is in a recumbent position, sodium tends to be excreted at a faster rate than during activity. Bed rest, therefore,
is the best method of aiding increased evacuation of sodium and encouraging diuresis. Rest should always be in a lateral
recumbent position to avoid uterine pressure on the vena cava and prevent supine hypotension syndrome.

Promote Good Nutrition


A woman needs to continue her usual pregnancy nutrition. At one time, stringent restriction of salt was advised to reduce
edema. This is no longer true because stringent sodium restriction may activate the renin-angiotensin-aldosterone system and
result in increased blood pressure, compounding the problem.

Provide Emotional Support


It is difficult for a woman with pre-eclampsia to appreciate the potential seriousness of symptoms because they are so vague.
Neither high blood pressure nor protein in urine is something she can see or feel. She may be aware that edema is present, but
it seems unrelated to the pregnancy: it is her hands that are swollen, not a body area near her growing child.
Women with beginning signs of hypertension will be seen approximately weekly or more frequently for the remainder of
pregnancy. Be certain a woman understands that if symptoms worsen before her next health care visit, she should call and
report them immediately. Because there is no cure for pre-eclampsia, adherence to bed rest and attempts to reduce symptoms
early are crucial.
NURSING INTERVENTIONS FOR A WOMAN WITH SEVERE PIH

If the pre-eclampsia is severe(systolic blood pressure of more than 160mmHg, diastolic blood pressure of more than 110mmHg after a
woman has been on bed rest; extensive edema; marked proteinuria [3+ to 4+]; cerebral or visual disturbances; marked hyperreflexia; or
oliguria [500ml per 24 hours or less), a woman may be admitted to a health care facility.
If the pregnancy is 36 weeks or further along or fetal lung maturity can be confirmed by amniocentesis, labor can be induced or a
cesarean birth performed to end the pregnancy at this point.
If the pregnancy is less than 36 weeks or amniocentesis reveals immature lung function, interventions will be instituted to attempt to
alleviate the severe symptoms and allow the fetus to come to term.
Support Bed Rest
With severe pre-eclampsia, most women are hospitalized so that bed rest can be enforced and a woman can be observed more
closely that she can be on home care.
Stress is another stimulus capable of increasing blood pressure and evoking seizures in a woman with severe pre-eclampsia. Be
certain the woman receives clear explanations of what is happening and what is planned. Clear explanations help her accept the
need for visitor restrictions and not to cheat on bed rest. Allow her opportunities to express her feelings about what is
happening or how bewildered he is because the few simple symptoms he noticed 2weeks ago have now developed into a
syndrome that may be lethal to her baby and possibly to herself

Monitor Maternal Well-being


Take blood pressure frequently (at least every 4 hours) or with a continuous monitoring device to detect any increase, which is
a warning that a womans condition is worsening. Obtain blood studies such as complete blood count, platelet count, liver
function, blood urea nitrogen, and creatinine and fibrin degradation products as ordered to assess renal and liver function and
the development of DIC, which often accompanies severe vasospasm. Because a woman is at high risk for premature
separation of the placenta and resulting hemorrhage, a blood sample for type and cross-match is usually also obtained.
Daily hematocrit levels are used to monitor blood concentration. This level will rise if increased fluid is leaving the
bloodstream for interstitial tissue(edema).
Obtain daily weights at the same time each day as another evaluation of fluid retention.
An indwelling catheter may be inserted to allow accurate recording of output and comparison with intake. Urinary output
should be more than 600ml per 24 hours; an output lower than this suggests oliguria.
Monitor Fetal Well-being
Generally, single Doppler auscultation at approximately 4 hour intervals is sufficient at this stage of management. However,
the fetal heart rate may be assessed continuously with an external fetal monitor. Oxygen administration to the mother may be
necessary to maintain adequate fetal oxygenation and prevent fetal bradycardia.

Support a Nutritious Diet


A diet moderate in high protein and moderate in sodium to compensate for the protein she is losing in urine. An intravenous
fluid line is usually initiated and maintained to serve as to administer fluid to reduce hemoconcentration and hypovolemia.

Administer Medications to Prevent Eclampsia


A hypotensive drug such as hydralazine (Apresoline) , labetalol(Normodyne) , or nifedipine may be prescribed to reduce
hypertension. They can also cause maternal tachycardia. Therefore, assess pulse before and after administration. Diastolic
pressure should not be lowered below 80 to 90mmHg or inadequate placental perfusion could occur.
To achieve immediate reduction of the blood pressure, magnesium sulfate is first given intravenously in a loading or bolus
dose. Given intravenously over 15 minutes, the drug acts almost immediately; unfortunately, the effect last only 30 to 60
minutes, so administration must be continuous.
Magnesium overdose most evident symptoms are, decreased urine output, depressed respirations, reduced consciousness and
decreased deep tendon reflexes(Subramanian, 2008).
NURSING INTERVENTIONS FOR A WOMAN WITH ECLAMPSIA

Tonic-Clonic Seizures
An eclamptic seizure is a tonic-clonic type that occurs in stages. After the preliminary signal or aura that something is
happening, all the muscles of the womans body contract. It lasts approximately 20 seconds. It may seem longer because a
woman may grow slightly cyanotic from the cessation of respirations.
During the second(clonic) stage, the womans bladder and bowel muscles contract and relax; incontinence of urine and
feces may occur. Although a woman begins to breathe during this stage, the breathing is not entirely effective. She may remain
cyanotic. The clonic stage of a seizure lasts up to 1 minute.
The priority for a woman with a tonic-clonic seizure is to maintain a patent airway. Administer oxygen by face mask to
protect the fetus. To prevent aspirations, turn the woman on her side to allow secretions to drain from her mouth.
The third stage of the seizure is the postictal state. During this stage, the woman is semicomatose and cannot be roused
except by painful stimuli for 1 to 4 hours. Extremely close observation is as important during the postictal stage as it was
during the first two stages, because if the seizure caused premature separation of the placenta, labor may begin during this
period but a woman will be unable to report the sensation of contractions. Also, the panful stimulus of contractions may initiate
another seizure. Keep a woman on her side so secretions can drain from her mouth. Give her nothing to eat nor drink.
Remember that with coma, hearing is the last sense lost and the first one regained, so limit conversation as she may be
able to hear even though she does not respond. Continuously assess fetal heart sounds and uterine contractions. Continue to
check for vaginal bleeding every 15 minutes.

BIRTH
If the pregnancy is more than 24 weeks along, a decision about birth will be made as soon as a womans condition stabilizes. Usually
12 to 24hours after the seizure. There is some evidence that a fetus does not continue to grow after eclampsia occurs, so terminating the
pregnancy at this point is appropriate for both mother and child.
Cesarean birth is always more hazardous for the fetus because of the association of retained lung fluid. Further, a woman with eclampsia is
not a good candidate for surgery. Because her vascular system is low in volume, she may become hypotensive with regional anesthesia, such
as an epidural block. The preferred method for birth therefore is vaginal.
NURSING INTERVENTIONS DURING THE POSTPARTUM PERIOD
Postpartum hypertension may occur up to 10 to 14days after birth, although it usually occurs no more than 48hours after birth.
Monitoring blood pressure and being alert that eclampsia can occur as late as 2 to 3 weeks post birth is essential to detect residual
hypertensive or renal disease (Cantey et al.,2007). Urge women who had an elevation of blood pressure during pregnancy to return for a
postpartum check-up to have their blood pressure evaluated to be certain it has returned to normal.