PIH

General

This case presentation aims to identify and determine the general health problems and needs of the patient with an admitting diagnosis of Pregnancy Induced Hypertension. This presentation also intends to help patient promote health and medical understanding of such condition through the application of the nursing skills.

Specific

• To raise the level of awareness of patient on health problems that she may encounter.
• To facilitate patient in taking necessary actions to solve and prevent the identified problems on her own.
• To help patient in motivating her to continue the health care provided by the health workers.
• To render nursing care and information to patient through the application of the nursing skills.

INTRODUCTION

Blood pressure is the force of the blood pushing against the walls of the arteries (blood vessels that carry oxygen-rich blood to all parts of the body). When the pressure in the arteries becomes too high, it is called hypertension.

Up to 5 percent of women have hypertension before they become pregnant .  This is called chronic hypertension. Another 5 to 8 percent develop hypertension during pregnancy. This is referred to as gestational hypertension. Gestational hypertension generally goes away soon after delivery: however, women who develop it may be at increased risk of developing hypertension later in life.

High blood pressure usually causes no noticeable symptoms, whether or not a woman is pregnant. However, hypertension during pregnancy can cause serious complications for mother and baby. Fortunately, serious problems usually can be prevented with proper prenatal care.

Anatomy and Physiology:

When most people hear the term cardiovascular system, they immediately think of the heart. We have all felt our own heart "pound" from time to time, and we tend to get a bit nervous when this happens. The crucial importance of the heart has been recognized for a long time. However, the cardiovascular system is much more than just the heart, and from a scientific and medical standpoint, it is important to understand why this system is so vital to life.

Most simply stated, the major function of the cardiovascular system is transportation. Using blood as the transport vehicle, the system carries oxygen, nutrients, cell wastes, hormones, and many other substances vital for body homeostasis to and from the cells. The force to move the blood around the body is provided by the beating heart. The cardiovascular system can be compared to a muscular pump equipped with one-way valves and a system of large and small plumbing tubes within which the blood travels.

HEART:

The heart is a muscular organ found in all vertebrates that is responsible for pumping blood throughout the blood vessels by repeated, rhythmic contractions.
The heart is enclosed in a double-walled sac called the pericardium. The superficial part of this sac is called the fibrous pericardium. This sac protects the heart, anchors its surrounding structures, and prevents overfilling of the heart with blood. It is located anterior to the vertebral column and posterior to the sternum. The size of the heart is about the size of a fist and has a mass of between 250 grams and 350 grams. The heart is composed of three layers, all of which are rich with blood vessels. The superficial layer, called the visceral layer, the middle layer, called the myocardium, and the third layer which is called the endocardium. The heart has four chambers, two superior atria and two inferior ventricles. The atria are the receiving chambers and the ventricles are the discharging chambers. The pathway of blood through the heart consists of a pulmonary circuit and a systemic circuit. Blood flows through the heart in one direction, from the atrias to the ventricles, and out of the great arteries, or the aorta for example. This is done by four valves which are the tricuspid atrioventicular valve, the mitral atrioventicular valve, the aortic semilunar valve, and the pulmonary semilunar valve.
Systemic circulation is the portion of the cardiovascular system which carries oxygenated blood away from the heart, to the body, and returns deoxygenated blood back to the heart. The term is contrasted with pulmonary circulation.

Pulmonary circulation is the portion of the cardiovascular system which carries oxygen-depleted blood away from the heart, to the lungs, and returns oxygenated blood back to the heart. The term is contrasted with systemic circulation. A separate system known as the bronchial circulation supplies blood to the tissue of the larger airways of the lung.

Arteries are blood vessels that carry blood away from the heart. All arteries, with the exception of the pulmonary and umbilical arteries, carry oxygenated blood.

Pulmonary arteries
The pulmonary arteries carry deoxygenated blood that has just returned from the body to the heart towards the lungs, where carbon dioxide is exchanged for oxygen.

Systemic arteries
Systemic arteries can be subdivided into two types – muscular and elastic – according to the relative compositions of elastic and muscle tissue in their tunica media as well as their size and the makeup of the internal and external elastic lamina. The larger arteries (>10mm diameter) are generally elastic and the smaller ones (0.1-10mm) tend to be muscular. Systemic arteries deliver blood to the arterioles, and then to the capillaries, where nutrients and gasses are exchanged.

The Aorta
The aorta is the root systemic artery. It receives blood directly from the left ventricle of the heart via the aortic valve. As the aorta branches, and these arteries branch in turn, they become successively smaller in diameter, down to the arteriole. The arterioles supply capillaries which in turn empty into venules. The very first branches off of the aorta are the coronary arteries, which supply blood to the heart muscle itself. These are followed by the branches off the aortic arch, namely the brachiocephalic artery, the left common carotid and the left subclavian arteries.

Aorta the largest artery in the body, originating from the left ventricle of the heart and extends down to the abdomen, where it branches off into two smaller arteries (the common iliacs). The aorta brings oxygenated blood to all parts of the body in the systemic circulation.

The aorta is usually divided into five segments/sections:

• Ascending aorta—the section between the heart and the arch of aorta
• Arch of aorta—the peak part that looks somewhat like an inverted "U"
• Descending aorta—the section from the arch of aorta to the point where it divides into the common iliac arteries
  o    Thoracic aorta—the half of the descending aorta above the diaphragm
  o    Abdominal aorta—the half of the descending aorta below the diaphragm

Arterioles
Arterioles, the smallest of the true arteries, help regulate blood pressure by the variable contraction of the smooth muscle of their walls, and deliver blood to the capillaries.
Veins are blood vessels that carry blood towards the heart. Most veins carry deoxygenated blood from the tissues back to the lungs; exceptions are the pulmonary and umbilical veins, both of which carry oxygenated blood. Veins differ from arteries in structure and function; for example, arteries are more muscular than veins and they carry blood away from the heart.
Veins are classified in a number of ways, including superficial vs. deep, pulmonary vs. systemic, and large vs. small.

Superficial veins
Superficial veins are those whose course is close to the surface of the body, and have no corresponding arteries.

Deep veins
Deep veins are deeper in the body and have corresponding arteries.

Pulmonary veins
The pulmonary veins are a set of veins that deliver oxygenated blood from the lungs to the heart.

Systemic veins
Systemic veins drain the tissues of the body and deliver deoxygenated blood to the heart.
Atrium sometimes called auricle, refers to a chamber or space. It may be the atrium of the lateral ventricle in the brain or the blood collection chamber of a heart. It has a thin-walled structure that allows blood to return to the heart. There is at least one atrium in animals with a closed circulatory system.

Right atrium is one of four chambers (two atria and two ventricles) in the human heart. It receives deoxygenated blood from the superior and inferior vena cava and the coronary sinus, and pumps it into the right ventricle through the tricuspid valve. Attached to the right atrium is the right auricular appendix.

Left atrium is one of the four chambers in the human heart. It receives oxygenated blood from the pulmonary veins, and pumps it into the left ventricle, via the atrioventricular valve.
Ventricle is a chamber which collects blood from an atrium (another heart chamber that is smaller than a ventricle) and pumps it out of the heart.
Right ventricle is one of four chambers (two atria and two ventricles) in the human heart. It receives deoxygenated blood from the right atrium via the tricuspid valve, and pumps it into the pulmonary artery via the pulmonary valve and pulmonary trunk.

Left ventricle is one of four chambers (two atria and two ventricles) in the human heart. It receives oxygenated blood from the left atrium via the mitral valve, and pumps it into the aorta via the aortic valve.

Pathophysiology of Pregnancy Induced Hypertension (PIH):

Clinical Manifestations:

A.  Mild Preeclampsia

• BP of 140/90
• 1+ to 2+ proteinuria on random
• weight gain of 2 lbs per week on the 2nd trimester and 1 lb per week on the 3rd trimester
• Slight edema in upper extremities and face

B. Severe Preeclampsia

• BP of 160/110
• 3-4+ protenuria on random
• Oliguria (less than 500 ml/24 hrs)
• Cerebral or visual disturbances
• Epigastric pain
• Pulmonary edema
• Peripheral edema
• Hepatic dysfunction

C. Eclampsia is an extension of preeclampsia and is characterized by the client experiencing seizures.

Diagnostic Evaluation:

1. Based on the presenting symptoms. Often the disease process has been developing and affecting the renal and vascular system
2. Frequently a sudden weight gain will occur, of 2 lb. or more in 1 week, or 6 lb. or more within 1 month. This often occurs before the edema is present.

DISEASE ENTITY

Pregnancy induced hypertension (PIH) is a condition of high blood pressure during pregnancy. Your blood pressure goes up, you retain water, and protein is found in your urine. It is also called toxemia or preeclampsia. The exact cause of PIH is unknown.

Pregnancy-induced hypertension (PIH) is a form of high blood pressure in pregnancy. It occurs in about 7 to 10 percent ofall pregnancies. Another type of high blood pressure is chronic hypertension - high blood pressure that is present before pregnancy begins.

With high blood pressure, there is an increase in the resistance of blood vessels. This may hinder blood flow in many different organ systems in the expectant mother including the liver, kidneys, brain, uterus, and placenta.

Eclampsia is a severe form of pregnancy-induced hypertension. Women with eclampsia have seizures resulting from the condition. Eclampsia occurs in about one in 1,600 pregnancies and develops near the end of pregnancy, in most cases.

Causes pregnancy-induced hypertension (PIH)?

The cause of PIH is unknown. Some conditions may increase the risk of developing PIH, including the following:

• pre-existing hypertension (high blood pressure).

• kidney disease.

• diabetes.

• PIH with a previous pregnancy.

• mother's age younger than 20 or older than 40.

• multiple fetuses (twins, triplets).

The following are the most common symptoms of high blood pressure in pregnancy. However, each woman may experience symptoms differently. Symptoms may include

• increased blood pressure.

• protein in the urine.

• edema (swelling).

• sudden weight gain.

• visual changes such as blurred or double vision.

• nausea, vomiting.

• right-sided upper abdominal pain or pain around the stomach.

• urinating small amounts.

• changes in liver or kidney function tests

How is pregnancy-induced hypertension diagnosed?

Diagnosis is often based on the increase in blood pressure levels, but other symptoms may help establish PIH as the diagnosis. Tests for pregnancy-induced hypertension may include the following:

• blood pressure measurement

• urine testing.

• assessment of edema.

• frequent weight measurements.

• eye examination to check for retinal changes.

• liver and kidney function tests.

Treatment for pregnancy-induced hypertension:

Specific treatment for pregnancy-induced hypertension will be determined by your physician based on:

• your pregnancy, overall health and medical history.

• extent of the disease.

• your tolerance for specific medications, procedures, or therapies

The goal of treatment is to prevent the condition from becoming worse and to prevent it from causing other complications.

Treatment for pregnancy-induced hypertension (PIH) may include:

• bedrest (either at home or in the hospital may be recommended).

• hospitalization (as specialized personnel and equipment may be necessary).

• magnesium sulfate (or other antihypertensive medications for PIH).

• fetal monitoring (to check the health of the fetus when the mother has PIH) may include:

• Doppler flow studies - type of ultrasound that uses sound waves to measure the flow of blood through a blood vessel.

• medications, called corticosteroids, that may help mature the lungs of the fetus (lung immaturity is a major problem of premature babies)
• delivery of the baby (if treatments do not control PIH or if the fetus or mother is in danger). Cesarean delivery may be recommended, in some cases

Medical Treatment and Evaluation:

1. Magnesium Sulfate (Pregnancy risk category B)
     muscle relaxant, prevent seizures
     loading dose 4-6g, maintenance dose 1-2g/h IV
     infuse IV dose slowly over 15-30 min.
      •Always administer as a piggy back infusion.
      •Assess PR, urine output, DTR, and clonus every hour.
      •Observe for CNS depression and hypotonia in infant at birth.
2. Hydrazaline (Apresoline) Pregnancy risk category C
     anti hypertensive (peripheral vasodilator) use to decrease hypertension
     5-10mg/IV
     Administer slowly to avoid sudden fall of BP
      •Maintain diastolic pressure over 90 mmHg to ensure adequate placental filling.
3. Diazepam (Valium) Pregnancy risk category D
     halt seizures
     5-10mg/IV
     administer slowly. Dose may be repeated every 10-15 min. (up to 30mg/hr)
      •Observe for respiratory depression for both mother and infant at birth.
4. Calcium Gluconate (Pregnancy risk category C)
     antidote for Magnesium Sulfate
     1g/IV (10 mL of a 10% solution)
     have prepared at bed side when administering Magnesium Sulfate
     administer at 5mL/min.

 Discharge Planning:

Exercise

1. encourage patient’s on deep breathing exercises.
2. move extremities when lying.
3. elevate the head part when sleeping, to promote increase peripheral circulation
4. encourage overall passive and active exercises program during pregnancy to prevent need for cesarean birth.
5. exercises like tailor sitting, squatting, kegel exercise, pelvic rocking, and abdominal muscle contraction will promote easy delivery. 

Treatment:

1. use of drugs
2. catheterization
3. obtaining labs. (CBC, platelets count, liver function, BUN and creatinine, and fibrin degregation)

Health Teaching:

1. Encourage patient foe sodium restriction.
2. Encourage to avoid foods rich in oil and fats.
3. Encourage patient to limit her daily activities and exercises.

Ongoing Assessment:

1. Observe carefully for symptoms at prenatal visit.
2. Give instruction about what symptoms to watch for so she can alert her clinician if additional symptoms occur between visits.

Diet:

1. low fats and sodium diet, restriction if possible.
2. high in protein, calcium and iron.
3. Adequate fluid intake

Sex:

1. limit sexual activity
2. sexual intercourse at 2nd trimester should be avoided.