Hypertensive disorders of pregnancy

1. Hypertensive disorders of
pregnancy
Mrs.Jagadeeswari.J
M.Sc Nursing

2. DEFINITION OF HYPERTENSION
DISORDERS IN PREGNANCY
Hypertension disorders of
Pregnancy also known as maternal
Hypertensive disorders is a group
of disease that includes
Pre-eclampsia , Eclampsia,
Gestational Hypertension and
Chronic Hypertension.
A.V.Raman

3. CLASSIFICATION OF HYPERTENSION IN
PREGNANCY
1. Gestational Hypertension
2. Pre-Eclampsia
3. Eclampsia
4. Chronic Hypertension
5. Pre-Eclampsia or Eclampsia super imposed
on Chronic Hypertension

4. PRE-ECLAMPSIA –
PREGNANCY INDUCED
HYPERTENSION

5. PRE-ECLAMPSIA –PREGNANCY INDUCED
HYPERTENSION
Definition:
A multisystem disorder of unknown
aetiology characterized by development of
Hypertension to the extent of 140/90 mm hg
or more with proteinuria after the 20th week
in a previously normotensive and
nonproteinuric woman.
-D.C.Dutta

6. CLASSIFICATION OF PRE-ECLAMPSIA
The Pre-Eclampsia is classified as
A. Primary -70%
• Pre-eclampsia
• Eclampsia
B . Secondary -30%
• Pre-eclampsia-eclampsia
superimposed on chronic
hypertension (25%)
• Pre-Eclampsia-Eclampsia
superimposed on Chronic renal
disease (5%)

7. CLASSIFICATION BASED ON SEVERITY
1. Mild Pre-Eclampsia
2. Moderate Pre-eclampsia
3. Severe Pre-eclampsia

8. MILD-MODERATE PRE-ECLAMPSIA
• Systolic B.P 140-160 mmhg
• Diastolic B.P 90-100 mmhg
• Proteinuria upto ++
SEVERE PRE-ECLAMPSIA
• Systolic B.P >160 mmhg
• Diastolic B.P >110 mmhg
• Proteinuria upto +++ or more
• Epigastric pain

9. RISK FACTORS
• Primigravidae(Young or elderly)
• Family history of hypertension, pre-
eclampsia
• Placental abnormalities
– Hyperplacentosis: (molar pregnancy
twins, diabetes)
– Poor placentation
– Placental ischemia.
– Molar pregnancy
• Genetic disorders
• Immunological phenomenon
• Pre-existing vascular disease
• New paternity
• Thrombophilias

10. ETIOLOGY OF PRE-ECLAMPSIA
• Placental implantation with
abnormal trophoblastic invasion of
uterine vessels
• Immunological maladaptive
tolerance between maternal,
paternal (placental),and fetal tissues
• Maternal maladaptation to
cardiovascular or inflammatory
changes of normal pregnancy
• Genetic factors

12. CLINICAL FEATURES OF PRE-
ECLAMPSIA SIGNS:
• Abnormal weight gain-
>5lb/month or 1lb/week in
later months
• Rise in blood pressure
• Edema- ankles, then
spread all over the body
• Pulmonary edema
• Abdominal examination-
chronic placental
insufficiency (scanty liquor
or IUGR)

13. MILD SYMPTOMS
• Slight swelling over the ankles which
persists on rising from the bed in the
morning or tightness of the ring on the
finger is the early manifestation of pre-
eclampsia oedema.
• Gradually, the swelling may extend to
the face, abdominal wall, vulva and
even the whole body

14. ALARMING SYMPTOMS
• Headache —occipital or frontal region
• Disturbed sleep
• Diminished urinary output—Urinary
output of less than 400 ml in 24 hours,
• Epigastric pain
• Eye symptoms—blurring, dimness of
vision or complete blindness.

15. INVESTIGATIONS
• Urine-proteinuria
• Opthalmoscopic examination-
retinal edema ,constriction of
arterioles
• Blood values
– BUN
– Serum creatinine
– Thrombocytopenia
– Coagulation profile
– Liver function test
• Antenatal fetal monitoring
– USG
– Fetal kick count
– Cardio tocography
– Umbilical artery flow velocimetry
– Biophysical profile

16. MATERNAL COMPLICATIONS-
IMMEDIATE
• Antenatal
– Eclampsia(2%)
– Accidental haemorrhage
– Oliguria and anuria
– Dimness of vision and even
blindness
– Preterm labor
– HELLP syndrome

17. MATERNAL COMPLICATIONS-
IMMEDIATE
During labour
– Eclampsia
– Post partum
haemorrhage
During Puerperium:
– Eclampsia (usually
within 48 hrs)
– Shock.
– Sepsis

18. FETAL COMPLICATIONS
• Intrauterine deaths
• Intrauterine growth
restriction
• Asphyxia
• Prematurity

19. REMOTE COMPLICATIONS
• Residual hypertension
• Recurrent preeclampsia
• Chronic renal disease
• Risk of placental abruption

20. PREVENTIVE MEASURES
• Regular antenatal check up
• Antithrombotic agents-low
dose aspirin 60 mg daily
• Calcium supplementation-
2gm/day to reduce risk of
pre eclampsia
• Anti oxidants-vitamin E & C
• Nutritional supplementation
with Magnesium,Zinc,Fish
oil, high protein and low
salt diet.

21. MANAGEMENT OF PRE-ECLAMPSIA
OBJECTIVES
1. To stabilise hypertension and to
prevent its progression to severe
preeclampsia.
2. To prevent the complications
3. To prevent eclampsia.
4. Delivery of a healthy baby in optimal
time.
5. Restoration of the health of the mother
in puerperium

22. TREATMENT MODALITIES
REST
• In left-lateral position as much as
possible.
• It lessen the effects of vena caval
compression.
• Increases the renal blood flow →
diuresis
• Increases the uterine blood flow →
improves the placental perfusion
• Reduces the blood pressure.

23. DIET
• Should contain adequate amount of
daily protein (about 100 gm).
• Total calorie approximate 1600 cal/day.
• Usual salt intake is permitted.
• Fluids need not be restricted.

24. SEDATIVES
• To cut down emotional factor, mild
sedative may be given orally
(phenobarbitone 60mg or
diazepam 5mg at bedtime is given)

25. DIURETICS
• Should not be used injudiciously as they
can harm to the baby by diminishing
placental perfusion and by electrolyte
imbalance.
• Indications for diuretics use are:
– Cardiac failure
– Pulmonary oedema
– Along with selective antihypertensive drug
therapy
– Massive oedema

26. ORAL ANTIHYPERTENSIVES DRUGS
• Methyl dopa-250-500mg TID/QID-central
& peripheral anti-adrenergic action.
• Labetalol 250 mg TID/QID- Adrenoceptor
antagonist
• Nifedipine 10-20mg BID –Calcium
channel blockers
• Hydralazine 10-25mg BID-vascular
smooth muscle relaxant

27. PROGRESS CHART
• Blood pressure Q6H
• State of Edema & daily weight
• Fluid intake & output
• Urine examination for protein/24 hrs
• Blood examination- Hematocrit ,platelet
count, uric acid, creatinine , LFT once a
week.

28. METHODS OF TERMINATION
INDUCTION OF LABOUR
• Aggravation of the pre-
Eclamptic features in spite
of medical treatment
and/or appearance of
newer symptoms
• Hypertension persists in
spite of medical treatment
with pregnancy reaching 37
weeks or more.
• Acute fulminating pre-
eclampsia irrespective of
the period of gestation
• Post term pregnancy

29. METHODS OF TERMINATION
CAESAREAN SECTION
• Urgent termination is indicated and the
cervix is unfavourable.
• Severe pre-eclampsia
• Associated complicating factors, such as
elderly primigravidae, contracted
pelvis, malpresentation, etc

30. MANAGEMENT DURING LABOUR
• Patient should be on bed
• Liberal sedatives
• Anti-Hypertensives drugs
• Blood pressure & urine output is monitored
• Care monitor of fetal well being
• Labour-ARM and deliver by forceps/ ventouse
• IV Ergometrine is contraindicated
• IM Oxytocin is given
• Sedation immediately-IM Morphine 15mg to
prevent postnatal Eclampsia

31. MANAGEMENT OF PUERPERIUM
• Close monitoring for at least 48 hours
• Tab.Phenbarbitone 60mg is repeated for
effective sedation
• Anti- Hypertensive drugs is given until
diastolic pressure is below 100mmhg
• Patient is hospitalized until B.P brought
down to safe level and proteinuria
disappears

33. DEFINITION OF ECLAMPSIA
Pre-eclampsia when complicated
with generalized tonic clonic
seizures &/ or coma is called
eclampsia.
D.C.DUTTA

34. PATHOPHYSIOLOGY OF ECLAMPSIA
Since Eclampsia is a severe form of
pre-eclampsia the histopathological and
biochemical changes are similar
although intensified than those of pre
eclampsia as already described.

35. STAGES OF ECLAMPTIC CONVULSIONS
• The Eclamptic fits are epileptiform
& consist of four stages , that are :
1).PREMONITORY STAGE :
*The patient becomes unconscious.
*There is twitching of muscles of face,
tongue & limbs.
*Eye balls or are turned to one side &
become fixed.
*This stage lasts for about 30 second.

36. 2.TONIC STAGE
*The whole body goes into a spam
called trunk opisthotonus.
*Limbs are flexed & hands
clenched.
*Respiration ceases & tongue
protrudes between the teeth.
*Cyanosis appears.
*Eyes balls become fixed.
*This stage lasts for about 30
seconds.

37. 3.CLONIC STAGE
*All the voluntary muscles undergo
alternate contraction & relaxation.
*The twitching starts in face then
involve one side of extremities &
ultimately the whole body is
involved in the convulsion.
*Biting of tongue occurs.
*Breathing is strenuous & blood
stained frothy secretions fill the
mouth.
*Cyanosis gradually disappears.
*This stage lasts for 1-4 minutes.

38. 4.STAGE OF COMA
*Following the fit , the patient
passes on the stage of coma.
*It may last for a brief period or in
others deep coma persists till
another convulsion.
*On occasion, the patient appears
to be in a confused state
following the fit & fails to
remember the happenings.
*Rarely, the coma occurs without
prior convulsion

39. MANAGEMENT OF ECLAMPSIA
PRINCIPLES
• Arrest convulsion.
• Maintenance of patent airway ,
breathing & circulation.
• Oxygen administration at the rate 8-
10 L/Min.
• Terminate pregnancy.
• Ventilatory support.
• Prevention of complication.
• Hemodynimical stable.
• Prevention of life threatening
situation.
• Postpartum care

40. FIRST AID TREATMENT
• The patient , either at
home or in the health
centres should be shifted
urgently to the tertiary
referral care hospitals ,
because there is no place
of continuing the treatment
in such place.
• Sedation
• Maintain airway

41. NURSING MANGEMENT
• Aim to prevent serious maternal
injury from fall , to prevent aspiration
, to maintain airway & to ensure
oxygenation.
• Patient is kept in railed cot & a
tongue depressor is inserted
between teeth.
• She is kept in the lateral position to
avoid aspiration.
• Collect detailed history from the
relatives, relevant diagnosis of
eclampsia, duration of pregnancy,
number of fits & nature of medication
administered outside.

42. Cont..
• Continuous Vital signs monitoring
• Hourly urine output monitoring
• Fetal heart rate monitoring
• Fluid balance
• Antibiotic therapy

43. SPECIFIC MANAGEMENT
ANTIHYPERTENSIVE AND SEDATIVE REGIME
1.Magnesium sulphate therapy-
IM/Prictchard Regimen-
Loading dose-4gm IV/3-5 min followed by
10gm deep IM (5gm in each buttock)
Maintenance dose-5gm IM Q4H in
alternate buttock

44. CONT..
• IV Zuspan or sibai regimen
Loading dose-4-6gm/15-20minutes
Maintenance dose -1-2 gm/hr IV
• Lytic cocktail regimen
• Diazepam
• Phenytoin therapy
• Antihypertensive and diuretics.

45. OBSTETRICAL MANAGEMENT