Hypertensive disorders
of pregnancy
PRIYANKA GEHLOT
M.Sc . NSG.FINAL YEAR
BATCH-2019
INTRODUCTION
Hypertension is one of the common medical
complications of pregnancy and contributes
significantly to maternal and prenatal
morbidity and mortality. Intrauterine growth
restriction, preterm delivery.
DEFINITION OF HYPERTENSIVE
DISORDERS IN PREGNANCY
Hypertensive disorders of Pregnancy also known
as maternal Hypertensive disorders is a group of
disease that includes:-
Pre-eclampsia , Eclampsia, Gestational
Hypertension and Chronic Hypertension.
CLASSIFICATION OF
HYPERTENSION IN
PREGNANCY
1. Gestational Hypertension
2. Pre-Eclampsia
3. Eclampsia
4. Chronic Hypertension
PRE-ECLAMPSIA –
PREGNANCY
INDUCED
HYPERTENSION
PRE-ECLAMPSIA /PREGNANCY
INDUCED HYPERTENSION
Definition:
A multisystem disorder of unknown
etiology 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.
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%)
CLASSIFICATION BASED ON
SEVERITY
1. Mild Pre-Eclampsia
2. Moderate Pre-eclampsia
3. Severe Pre-eclampsia
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
RISK FACTORS
• Primigravidae(Young or elderly).
• Family history of hypertension, pre-
eclampsia.
• Placental abnormalities
– (molar pregnancy twins, diabetes)
– Placental ischemia.
• Genetic disorders.
• Immunological phenomenon.
ETIOLOGY OF
PRE-ECLAMPSIA
• Placental implantation with abnormal
trophoblastic invasion of uterine vessels.
• Maternal maladaptation to cardiovascular or
inflammatory changes of normal pregnancy.
• Genetic factors.
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.
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
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.
INVESTIGATIONS
• Urine-proteinuria.
• Opthalmoscopic examination-retinal edema.
• Blood values
– BUN
– Serum creatinine
– Thrombocytopenia
– Liver function test
• Antenatal fetal monitoring
– USG
– Cardio tocography
MATERNAL COMPLICATIONS-
IMMEDIATE
• Antenatal
– Eclampsia(2%)
– Accidental haemorrhage
– Oliguria and anuria
– Dimness of vision and even blindness
– Preterm labor
– HELLP syndrome
MATERNAL COMPLICATIONS-
IMMEDIATE
During labour
– Eclampsia
– Post partum haemorrhage
During Puerperium:
– Eclampsia (usually within 48 hrs)
– Shock.
– Sepsis
FETAL COMPLICATIONS
• Intrauterine deaths.
• Intrauterine growth restriction.
• Asphyxia.
• Prematurity.
REMOTE COMPLICATIONS
• Residual hypertension.
• Recurrent preeclampsia.
• Chronic renal disease.
• Risk of placental abruption.
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.
MANAGEMENT OF PRE-
ECLAMPSIA OBJECTIVES
1. To stabilise hypertension and to
prevent its progression to severe pre
eclampsia.
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.
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.
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.
SEDATIVES
• To cut down emotional factor, mild sedative
may be given orally (phenobarbitone 60mg
or diazepam 5mg at bedtime is given).
DIURETICS
• Indications for diuretics use are:
– Cardiac failure
– Pulmonary oedema
– Along with selective antihypertensive
drug therapy
– Massive oedema
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
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.
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
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.
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.
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.
DEFINITION OF ECLAMPSIA
Pre-eclampsia when complicated with
generalized tonic clonic seizures &/ or coma
is called eclampsia.
STAGES OF ECLAMPTIC
nCONVULSIONS
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.
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.
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.
4.STAGE OF COMA
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
MANAGEMENT- 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.
• Prevention of life threatening
situation.
• Postpartum care
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.
SPECIFIC MANAGEMENT OF
ECLAMPSIA:-
Magnesium sulfate is drug of choice
The therapeutic level of serum magnesium is 4-7 mEq/L.
PRITCHARD REGIMEN
Loading dose Maintenance dose
5g (50%) IM 4 hourly
4g(20% solution) IV
over 3-5 minute in alternate buttock
followed by
10g(50%), deep IM
(5g in each buttocks)
ZUSPAN REGIMEN
Loading dose Maintenace dose
4-6 g IV slow over 15- 1-2 g/h IV infusion
20 minute
Magnesium sulfate is
drug of choice:-
Mechanism of action.
Detection of magnesium
toxicity.
Management of magnesium
sulfate toxicity.
ANTIHYERTENSIVE AND DIURETICS
DRUGS IN ECLAMPSIA:-
INJECTION
INJECTION
FRUSEMIDE IV
LABETATOL IV
TAB NIFEDIPINE
It decrease BP and relaxation of the uterine
smooth muscle.
OBSTETRICAL MANAGEMENT
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.
