MODULE 9: Hypertensive Disorders in Pregnancy Flashcards
Pregnancy - Induced Hypertension
A disorder during pregnancy after 20th week of gestation and
occurs in 5% to 10% of all pregnancies
Gestational Hypertension
a. Elevated blood pressure (140/90 mmHg)
o Systolic > 30 mmHg
o Diastolic >15 mmHg above pre-pregnancy levels
b. No proteinuria or edema
c. Blood pressure returns to normal after birth
Pre - Eclampsia with No Severe Features ( Mild - Pre - Eclampsia )
a. Blood pressure is 140/90 mmHg
b. Proteinuria of 1+ or 2+ on random sample
c. Mild edema in upper extremities and face
Pre - Eclampsia with Severe Features (Severe Pre-Eclampsia)
a. Blood pressure is 160/110 mmHg
b. Proteinuria is 3+ to 4+
c. Oliguria
d. Increased serum creatinine, cerebral or virtual disturbances,
extensive peripheral edema hepatic dysfunction,
thrombocytopenia, epigastric pain
Eclampsia
Seizure or coma accompanied by signs and symptoms of
preeclampsia are present
Risk Factors of Eclampsia
a. Women of color (common in Black)
b. Multiple pregnancy
o Multipara (>5 pregnancy)
c. Primipara (<20 y/o)
d. Maternal age > 35 y/o
e. Women with low socioeconomic status
f. Women with polyhydramnios
g. Type 1 or type 2 diabetes before pregnancy
h. History or essential hypertension
i. History of heart disease
j. History of renal disease
k. Pre-eclampsia in previous pregnancy
Pathophysiology of Eclampsia
a. Early pregnancy
o Villous cytotrophoblast invades the myometrium and
spiral arteries
o Spiral arteries lose the endothelium and most of its muscle fibers
o Dilatation of the lumen, Invasion of the trophoblast into
the vessel wall, replacement of muscular and elastic
tissue by a fibrinoid material.
▪ Lumen will become wider → decreased
responsiveness to the vasoconstrictor agents
(prostaglandin and angiotensin II)
b. Increased circulating blood volume during pregnancy
c. Decreases the action of prostacyclin, increases thromboxane
production
o Prostacyclin – a vasodilator that produced by endothelial
cells
o Thromboxane is produced by platelets
▪ It causes platelet aggregation → vessel constriction
d. Endothelial dysfunction (endothelial cell injury)
o Imbalance in prostacyclin and thromboxane results in
massive vasoconstriction
e. Vasoconstriction
o Increase production of angiotensin and norepinephrine
o Increases peripheral resistance
▪ Increased blood pressure
▪ Decrease perfusion or blood flow to body systems
Kidney Effects
a. Increased blood flow resistance
b. Decreased glomerular filtration rate and increased
permeability of glomerular membranes
o Albumin and globulins escape into the urine
▪ Proteinuria
o Decrease urine output (oliguria), creatinine clearance
▪ Increased kidney tubular reabsorption
* Increase retention of sodium
* Increase retention of fluid
* Diffusion of fluid from bloodstream to the
interstitial tissues
* Edema formation
Pancreas Effects
a. Increased blood flow resistance
b. Decreased blood flow to the pancreas
c. Ischemia to the pancreas
d. Epigastric Pain
Placenta Effects
a. Increased blood flow resistance
b. Decreased utero-placental transfusion
c. Decreased nutrient to fetus and oxygen supply
o Increased uterine growth restriction
o Fetal injury
Retina Effects
a. Increased blood flow resistance
b. Decreased blood flow to the eyes
c. Spasm to arteries of the retina
o Retinal hemorrhages and blindness
o Blurry vision
o Scotoma (blind spots in the visual field)
Assessment
a. Hypertension
b. Proteinuria
c. Edema (upper extremities, face)
Mild Pre - Eclampsia
a. BP of 140/90 mmHg into 2 occasions taken 6 hours apart
o Systolic pressure >30 mmHg
o Diastolic pressure >15 mmHg above pre-pregnancy
values
b. Proteinuria (1+ to 2+ on a urine dip) or 300mg in a 24-hour
urine specimen collection, or 0.3 higher on a urine proteincreatinine ratio
c. Edema in the upper part of body
d. Weight gain of more than 2-lb per week during 2nd trimester,
1-lb per week in the 3rd trimester
Severe Pre - Eclampsia
a. BP of 160/110 mmHg or above into 2 occasions taken 6
hours apart at bed rest
o Diastolic pressure >30 mmHg above pre-pregnancy
values
b. Marked proteinuria (3+ to 4+ on a urine dip) or more than 5g
in a 24-hour urine specimen collection
c. Extreme edema over bony surfaces
o Anterior surface, tibia, cheekbone
o Ask any observed edema in other body parts
d. Decreased urine output (400-600 ml per 24 hours)
e. Severe epigastric pain, nausea and vomiting
f. May report shortness of breath, visual changes
o SOB – suspect pulmonary edema
o Visual changes – scotoma; possible cerebral edema
g. Headache and marked hyperreflexia, ankle clonus
o Hyperreflexia – deep tendon reflexes is
hyperactive/overactive
h. Normal DTR: 2+
i. Hyperreflexia: 4+
o Ankle clonus – involuntary movement
Eclampsia
a. Gran Mal (Tonic-clonic) seizure
b. Coma
c. Acute cerebral edema
Gran Mal (Tonic-Clonic) seizure)
Characterized by a sudden loss of consciousness, followed by muscle stiffening and rhythmic convulsions
Eclampsia: Diagnostic Tests and Laboratory Procedures
a. Complete CBC
b. Serum ALT and AST levels
o Monitor: HELLP Syndrome
▪ Hemolysis
▪ Elevated liver enzymes
▪ Low platelet count
c. Serum creatinine
d. Uric acid test
e. 24-hour urine collection for protein and creatinine
f. Coagulation profile (PT, PTT, Fibrinogen)
g. Peripheral blood smear
h. Serum LDH levels
i. Head CT scan
o To check presence of intracranial hemorrhage
j. Transabdominal UTZ
k. Doppler UTZ
l. Cardiotocography
HELLP syndrome symptoms
a. right upper quadrant pain
b. nausea and vomiting
c. headache
d. hypertension
e. proteinuria
HELLP syndrome
A severe complication of eclampsia that involves hemolysis, elevated liver enzymes, and low platelet count, and it can occur with or without eclampsia. If untreated, it may lead to life-threatening complications such as liver rupture, stroke, disseminated intravascular coagulation (DIC), and multi-organ failure
Why liver enzymes would be elevated
Result from liver cell damage due to endothelial injury and fibrin deposition
Eclampsia: Nursing Diagnosis
a. Ineffective tissue perfusion related to vasoconstriction of
blood vessels
b. Deficient fluid volume related to fluid loss to interstitial
tissues
c. Risk for fetal injury related to reduced placental perfusion
secondary to vasoconstriction
d. Social isolation related to prescribed bed rest
