Chapter 25 Complications of Pregnancy Continued
Hypertensive disorders of pregnancy. Please see table 25-1 for comments on each of these.
We will discuss each of them. Gestational hypertension. The key issue is
they will have high blood pressure without proteinuria. The proteinuria is associated
with preeclampsia. it may progress to preeclampsia during the
pregnancy. If gestational hypertension persists after birth then they will be diagnosed with
chronic hypertension. Risk Factors include: first pregnancy, over
35 years of age, Family or personal history of pregnancy induced hypertension, obesity,
diabetes and mulitfetal pregnancy are some risk factors. Will be treated with an antihypertensive
and monitored closely for signs of preeclampsia.
Preeclampsia is a condition in which hypertension develops during the last half of pregnancy
in a woman who previously had normal blood pressure. In addition to hypertension, renal
involvement may cause proteinuria. Many women also experience generalized edema. The only
known cure is birth of the fetus. Preeclampsia is relatively common, affecting
5% to 10% of all pregnancies. the cause of preeclampsia is not understood,
several factors are known to increase a woman’s risk (Box 25-2)
Preeclampsia is a result of generalized vasospasm. In preeclampsia, peripheral vascular resistance
increases because some women are sensitive to angiotensin II. Vasoconstriction results
in impeded blood flow and elevated blood pressure. As a result, circulation to all body organs,
including the kidneys, liver, brain, and placenta, is decreased.
Early and regular prenatal care with attention to pattern of weight gain and monitoring of
blood pressure and urinary protein level may minimize maternal and fetal morbidity and
mortality by allowing early detection of the problem.
The first indication of preeclampsia is usually hypertension. Proteinuria can be identified
by using a clean-catch specimen of urine to prevent contamination of the specimen by vaginal
secretions or blood. DTRs may be very brisk (hyperreflexia), suggesting cerebral irritability
secondary to decreased brain circulation and edema.
Laboratory studies may identify liver, renal, and hepatic dysfunction if preeclampsia is
severe. Coagulation may be impaired, as evidenced by a decrease in the number of platelets,
which are often in the high-normal range in a woman without preeclampsia. See also the
earlier discussion of DIC (p. 507). Although it is a nonspecific sign that may
have many causes, generalized edema often occurs with preeclampsia, and it may be severe.
Edema may first manifest as a rapid weight gain caused by fluid retention. Edema may
be present in the lower legs, which is common in pregnancy, and in the hands and face (Figure
25-8). Edema may be so massive that the woman’s appearance is distorted. Edema may not, however,
be present in all women who develop preeclampsia, and it may be severe in women who do not have
the disorder. HA, blurred vision, epigastric discomfort,
tingling or numbness in hands and feet The only cure for preeclampsia is delivery
of the baby. However, the decision about delivery will be based on the severity of the hypertensive
disorder and the degree of fetal maturity. If the fetus is less than 34 weeks of gestation,
steroids to accelerate fetal lung maturity will be given and an attempt made to delay
birth for 48 hours. However, if the maternal or fetal condition deteriorates, the infant
must be delivered, regardless of fetal age or administration of steroids. Vaginal birth
is preferred because of the multisystem impairments. If mild may be treated at home. The mother
should rest frequently, although full bed rest is not required for mild preeclampsia.
A lateral position for at least 1 ½ hours a day decreases pressure on the vena cava,
thereby increasing cardiac return and circulatory volume and improving perfusion of the woman’s
vital organs and the placenta. Monitor B/P daily, weight daily, diet of ample protein.
Many times salt and fluid restrictions are not given. Urine checks for protein, may need
to do a 24 hour urine test. Fetal assessment (kicks, or monitor Doppler from home care
nurse) See Table 25-2 for difference between mild
and severe. Care for severe, bed rest, antihypertensives
(hydralazine according to book but labatolol is more common now), Anticonvulsant (Mag sulfate).
Severe will typically remain in the hospital for close monitoring and many times need to
deliver prematurely. Preelampsia is the precursor to eclampsia.
Eclampsia is when severe preeclampsia advances and the woman has one or more generalized
seizures. This shows the facial edema that can occur
and the pitting edema in preeclampsia Applying the nursing process to your patient
with preeclampsia. You first assess your patient and collect data. There are different directions
you can use the info to determine appropriate nursing diagnosis. A few examples could be
enhanced readiness for knowledge related to her preeclampsia. You could use this if she
was asking questions and wanting to learn. An appropriate outcome would be she would
be able to verbalize 3 signs and symptoms that you teach her. Your interventions could
revolve around assessing her knowledge level, provider her with handouts and verbally teach
her. If she was very anxious you could focus your diagnosis on anxiety or ineffective coping
and outcome could relate to her stating two positive coping mechanisms or able to demonstrate
appropriate relaxation techniques within an hour of your teaching session. Your interventions
would revolve on how you could teach her and then evaluating if your outcome was met.
HELLP syndrome is a life-threatening occurrence, which complicates about 10% of pregnancies.
It stands for Hemolysis, elevated liver enzymes, low platelets. Half of the women affected
by HELLP also have severe preeclampsia, although hypertension may be absent. It is the result
of fragmentation and distortion of erythrocytes as they pass through small damaged blood vessels.
The liver enzymes increase due to the reduced hepatic blood flow due to fibrin deposits
impeding that blood flow. The prominent symptom of HELLP syndrome is
pain in the right upper quadrant , the lower right chest, or the mid-epigastric area. There
may also be tenderness because of liver distention. Additional signs and symptoms include nausea,
vomiting, and severe edema. Women with HELLP syndrome should be managed
in a setting with intensive care facilities. Treatment includes magnesium sulfate to control
seizures and hydralazine to control blood pressure.
This can occur during pregnancy or postpartum. It is preferred to have a vaginal delivery
because of the risk for bleeding with a c-section. Also anesthesia can be difficult if platelets
are low which puts her at risk for bleeding. Chronic hypertension is diagnosed when hypertension
preceded the pregnancy or diagnosed before she is 20 weeks gestation
Typically seen in older women, women who are obese, and those with diabetes
Since most women have a decrease in their blood pressure during pregnancy, she may see
hers be in the normal level during pregnancy. She will usually continue her medication unless
it does drop too low. She is at higher risk for developing preeclampsia so careful monitoring
is needed. Just like someone who is not pregnant, the effects of hypertension is the same. It
can decrease blood flow to vital organs and this can now include the placenta. Not all
antihypertensives can be used during pregnancy. Methyldopa(aldomet) is the drug of choice.
Normally diuretics are avoided. Meeting with the dietician also can help in making good
dietary choices. Rhesus (Rh) factor incompatibility during
pregnancy is possible only when two specific circumstances coexist: (1) the mother is Rh-negative
(D-negative), and (2) the fetus is Rh-positive. For such a circumstance to occur, the father
of the fetus must be Rh-positive. Rh incompatibility is a problem that affects the fetus; it causes
no harm to the mother. People who are Rh-positive have the Rh antigen
on their RBCs, whereas people who are Rh-negative do not have the antigen. When blood from a
person who is Rh-positive enters the bloodstream of a person who is Rh-negative, the body reacts
as it would to any foreign substance: It develops antibodies to destroy the invading antigen.
Most exposure of maternal blood to fetal blood occurs during the third stage of labor, when
active exchange of fetal and maternal blood may occur from damaged placental vessels.
ABO incompatibility usually occurs when the mother has type O blood and naturally occurring
anti-A and anti-B antibodies, which cause hemolysis if the fetus’s blood is not type
O. ABO incompatibility may result in hyperbilirubinemia of the infant, but it usually presents no
serious threat to the health of the child. This shows how Rh negative and Rh fetus effects