Pregnancy

Complications
PREGNANCY –INDUCED HYPERTENSION
 Definition of Terms:
Hypertension: a blood pressure reading in two occasions of at least 140/90 or a
rise of 30mm/hg systolic and 15 mm/hg diastolic. BP should be taken in two
occasions 4 to 6 hours apart
Gestational Hypertension: BP 140/90 mm/Hg develops for the first time during
pregnancy, but there is no proteinuria and within 12 weeks postpartum the BP is
normal.
Pregnancy Induced Hypertension: Hypertension that develops after the 20th
week of gestation to a previously normotensive woman. PIH include
preeclampsia, eclampsia and gestational hypertension.
Preeclampsia: Hypertension of BP 140/90, that develops after 20 weeks
gestation accompanied by proteinuria (300 mg/24Hours) and edema.
Eclampsia: all the signs and symptoms of preeclampsia accompanied by
convulsions or coma that is not caused by any other conditions.
 Definition of Terms:

Superimposed Eclampsia and Preeclampsia: Occurs when a

woman having chronic hypertension develops preeclampsia or
eclampsia during pregnancy
 
Chronic Hypertension: The presence of hypertension before
pregnancy or hypertension that develops before 20 weeks gestation in
the absence of H-mole that persists after 12th week postpartum
 PREDISPOSING FACTORS
1. Said to be a disease of primiparas – higher incidence in primiparas below 20 and
above 40 years
2. Preexisting disease – diabetes, collagen vascular disease, chronic hypertension or
chronic renal disease
3. Low socioeconomic status and inadequate prenatal care
4. Poor nutrition
5. Pregnancy complications – H-mole, DM, multiple pregnancy, polyhydramnios, Rh
incompatibility, renal disease, heart disease
6. Hereditary 9. Multiparity
7. Black race
8. Multigravida
 CAUSES OF PREGNANCY INDUCED HYPERTENSION

1. No definite cause known

2. highly correlated with the antiphospholipid syndrome or the
presence of antiphospholipid antibodies
3. protein deficiency theory and dietary deficiencies
4. endothelin theory – Endothelin are potent vasoconstrictors
produced by the endothelin
 PATHOPHYSIOLOGIC CHANGES

In normal pregnancy, plasma volume increases but systemic vascular

resistance decreases resulting in normal blood pressure .
Presence of overabundance of chorionic villi with or without fetus is
associated with vasospasm – the cause of arterial hypertension. This is
seen in multiple fetuses and H-mole. Vasospasm is the underlying cause
of preeclampsia’s insidious disease process.
PREECLAMPSIA EFFECT

The amount of circulating plasma volume falls, resulting Rise in hemoglobin and hematocrit
in hemoconcetration

Decreased blood supply to kidney and Sodium retention leading to edema

hemoconcentration stimulates release of aldosterone, Vasospasm and hypertension
ADH and angiotensin

Vasospasm cause damage to the endothelium, the cells Elevated platelets

that line the blood vessels – damaged endothelium  
promotes coagulation and increases sensitivity to pressor  
agents.  
After 20 weeks, there is decrease in synthesis of potent Further contributing to vasospasms and
vasodilators such as prostaglandin PGE2 and prostacyclin vascular changes that cause the end-organ
PG2 disturbances seen in severe preeclampsia
PREECLAMPSIA EFFECT
The patient’s renal perfusion is also affected. Decreased Serum levels of blood urea nitrogen (BUN),
blood supply to kidney resulting in decreased glomerular creatinine, and uric acid rise leading to
filtration rate (GFR) and efficiency of kidney to remove acidosis and decreased urinary output
metabolic waste products from the blood and decrease urine  
formation. Decreased renal perfusion results in damage to  
kidney structures allowing passage of large molecules such as Proteinuria
protein
Vasospasms decreases blood supply to the brain resulting in Hyperreflexia
cerebral ischemia
Vasogenic edema Convulsions

Decrease blood supply to the uterus and placenta IUGR

Fetal Hypoxia and distress

Continuous vasospasm cause diminished blood supply Abruption placenta

resulting in damage to blood vessels and tissues in the
placenta and decidua
 SIGNS AND SYMPTOMS
Preeclampsia :
SIGNS & SYMPTOMS MILD PREECLAMPSIA SEVERE PREECLAMPSIA

BLOOD PRESSURE 140/90 160/110

Systolic blood pressure greater than 30 diastolic pressure is 30 mm Hg above her
mm Hg and a diastolic prepregnancy level
pressure greater than 15 mm Hg above
prepregnancy values
PROTEINURIA +1 to +2 by dipsticks Marked proteinuria, 3+ or 4+
300 mg/24 hour urine collection on a random urine sample or more than 5
g in a 24-hour sample
LIVER ENZYMES Slightly elevated Markedly elevated

LABORATORY STUDIES Normal hematocrit, uric acid, creatinine Increased hematocrit, creatinine, and uric
acid; liver enzymes are markedly elevated
& thrombocytopenia maybe present
FETUS No IUGR IUGR present
 SIGNS AND SYMPTOMS
Preeclampsia :
SIGNS & SYMPTOMS MILD PREECLAMPSIA SEVERE PREECLAMPSIA

EDEMA Digital edema Pitting edema (4+)

Dependent edema Generalized edema

WEIGHT GAIN 2 lb/week More rapid weight gain

URINARY OUTPUT Not less than 400 ml/24 hours Less than 400 ml/24 hours

CEREBRAL DISUTRBANCES Occasional headache Severe frontal headache,

photophobia, blurring, spots
before the eyes, nausea, vomiting

REFLEXES Normal to 3+ Hyperreflexia, 4+

EPIGASTRIC PAIN Absent RUQ pain (aura to convulsion dur
to swelling of hepatic capsule
 MANAGEMENT:
Screening and early diagnosis
1. Roll-over Test: or supine-pressor test. Given between 28 and 32 weeks gestation. BP is taken at the
brachial artery in the lateral recumbent position, the woman then rolls over to the supine position
and pressure id measured immediately and again after 5 minutes. An increase of 20mmHg or
greater in diastolic pressure is a positive indicator that the woman is likely to develop PIH.
Initial Hospitalization
1. Patients who show signs of preeclampsia are initially hospitalized for further evaluation and
stabilization
a. CBC with platelet, BUN, creatinine, uric acid levels
b. Liver function test
c. A 24-hour urine for total protein and creatinine clearance
d. Daily weights
e. UTZ for fetal size, amniotic fluid volume and fetal well being
f. Ongoing (monitoring) assessment
 Initial Hospitalization
g. Deep tendon reflexes (DTR’s) at the patellar site are recorded on a scale of 0 to 4:
 0: no response
 1+: diminished
 2+: normal
 3+: brisker than average, possibly developing disease
 4+: very brisk, hyperactive, associated with clonus and developing disease
2. To assess the clonus at the ankle joint, the nurse should dorsiflex the foot and observes for movement
when it is released. Clonus is evidenced by a rhythmic jerking indicating hyperreflexes.
1. After evaluation:
a. Severe preeclampsia: woman remains hospitalized for treatment
b. Mild preeclampsia with normal laboratory values: woman is discharged for home treatment
 
Ambulatory Management
1. Home management is allowed only if:
 BP is 140/90 or below
 There is low proteinuria
 There is no fetal growth retardation
 Fetal well being is assured: good fetal movement
2. Bed rest: woman must be free from physical and emotional stress. When lying down, they
assume a left lateral position to shift the weight off the vena cava, maximize uteroplacental flow
and increase diuresis to lower BP. Include diversional activities and gentle exercise to decrease
setback brought about by prolong bedrest
3. Consult the clinic regularly, usually every two weeks
4. Regular phone calls and home visit by the nurse to check signs and symptoms of worsening
conditions
5. Diet is high protein and high carbohydrates with moderate sodium restriction
6. Hospitalization if condition worsens
Ambulatory Management:
7. Provide detailed instruction about:
a. Dietary modifications
• High protein – at least 1.5 g/kg of body weight per day
• Moderate sodium restriction to less than 2 g/day ●Avoid alcohol
 Eat a balanced diet that includes 1200 mg calcium ●Measure I and O
 During 8-10 glasses of water per day
b. Monitor her own health condition:
 Take and record her BP twice a day
 Count fetal movement per hour (3/h)
 Void into specimen pan and check for protein
 Take and record weight daily
● s/s of preeclampsia
Ambulatory Management:
c. She must report to health care provider immediately if the following occur:
 Increasing BP
 Epigastric pain
 Visual disturbances
 Severe headache
 Nausea and vomiting
 Weight gain more than 1 lb a week
 Abnormal fetal movement
 Abdominal pain
Hospital Management
1. Hospitalization maybe required in the following conditions:
 BP is equal or greater than 160/100 mmHg
 Proteinuria of 3+ or 4+
 Rapid weight gain
 Oliguria
 Visual disturbances
 Abnormal fetal movement
2. Expectant management: the only cure for preeclampsia is delivery. Because of
this, it is important to know the age of the fetus to determine viability if maternal
condition worsens and necessitated immediate delivery.
 Bethamethasone to promote lung maturity
Hospital Management
3. Fluid therapy: a crystalloid infusion is preferred, usually lactated Ringers solution or
normal saline at a rate of 100 to 125 ml/hour
 Fluid imbalances can exist leading to oliguria because of contracted plasma volume.
However, because the essence of disease process is capillary endothelial damage, fluid
therapy must be expertly monitored as fluid overload could quickly lead to pulmonary
edema
4. Medications
a. Magnesium sulfate: drug of choice to treat and prevent convulsions. (CNS Depressant)
Actions :
 Prevent convulsion by depressing CNS & preventing seizures by blocking the release
of acetylcholine at the myoneural junctions
 Reduce edema
 Reduce BP by reducing muscle excitability
MAGNESIUM SULFATE
Nursing Considerations:
 Dose: the American College of Obstetricians & Gynecologists recommends a
loading dose of 4 g infused over 20 minutes, followed by a continuous infusion of 2
g to 3 g per hour
 Check the following first before administering the drug:
 Respiration should be above 14 CPM
 Urine output should be at least 100 ml/hour
 Deep tendon reflexes are present (knee-jerk or patellar reflex) loss of DTR is often
the first sign of toxicity or hypermagnesemia
 Serum magnesium levels are evaluated periodically: 7-8 mg/dl is therapeutic ; 9-12
mg/dl indicates developing toxicity
MAGNESIUM SULFATE:
 Antidote for magnesium toxicity is Calcium gluconate IV over two minutes and notify
physician
 Magnesium sulfate is given up to 24 hours after delivery or from the last convulsion if it
happened during the postpartum period
 If given during postpartum, monitor for uterine atony as it can cause uterine relaxation
and increase the risk for postpartum hemorrhage
 Side effects of MgSO4:
 Maternal –CNS depression, hyporeflexia, flushing , confusion
 Fetal – tachycardia, hypoglycemia, hypocalcemia, hypomagnesemia
B. Antihypertensive

 Hydralazine (Apresoline) is the medication of choice because it reduces BP

effectively and safely. An initial 5 mg bolus is followed by 5 mg to 10 mg
every 20 minutes until a mildly hypertensive pressure is achieved, that is
diastolic pressure between 90 mmHg and 100 mmHg
 A 20 mg dose of IV labetolol (Normodyne) may also be given every 10
minutes to a maximum dose of 300 mg
5. Bedrest is one of the most important principles of care because it reduces BP
and promote diuresis
a. Rest in left lateral recumbent position
b. Room should be dim, quiet, away from areas of activity. Avoid bright lights
such as flashlights
c. Restrict visitors to allow patient to rest
d. Leave BP cuff on patient’s arm so as not to disturb the patient when placing it
everytime BP is checked
6. Monitor patient closely
a. Take v/s and fht continuously
b. Monitor for impending signs of convulsion. Blurring of vision, severe headache and
epigastric pain
c. Weigh daily at the same time each day using the same weighing scale
d. Laboratory tests for proteinuria, creatinine, hematocrit
7. Fetal Monitoring:
e. Fetal movement counting
f. Nonstress testing
g. Biophysical profile
d. Doppler flow studies
8. Safety measures
a. Raise padded side rails at all times to keep the woman from falling if convulsion occurs
b. Put bed at lowest position
c. Have emergency equipments available for use: suction apparatus, MgSO4, Calcium gluconate, Oxygen etc
9. Care for the woman during convulsion – Eclamptic convulsions occur in about 2% of all pregnancies
Stages of Convulsion:
 Stage of Invasion or Aura: Facial twitching, rolling of the eyes to one side, staring fixedly in space, sudden
severe headache, screaming and epigastric pain
 Tonic phase: Body becomes rigid as all muscles go into violent spasms or contractions, eyes protrude, arms are
flexed with legs inverted, hands are clenched, woman stops breathing. Last for 15 to 20 seconds
 Clonic phase: Jaws and eyelids close and open violently, foaming of the mouth; face becomes congested and
purple, muscles of the body contract and relaxes alternately. The contractions are so violent that the woman may
throw herself out of bed. Lasts for about one minute
 Postictal state: contractions cease and woman enters a semicomatose state. The patient will not remember the
convulsion and the event immediately before and after the event
 Nursing Responsibilities during Convulsion:
a. Always monitor patient for impending signs of convulsion
b. The two main responsibilities of the nurse during convulsion are: maintaining of patient
airway and protection of patient from self-injury
c. Turn patient on her side to allow drainage of saliva and prevent aspiration
d. Place pillow under the patient’s head to prevent injury
e. Never leave an eclamptic patient alone
f. Do not restrict movement during convulsion as this could result to fracture
g. After convulsion:
 Watch for the signs of abruption placenta: vaginal bleeding, abdominal pain, decreased
fetal activity
 Take v/s and FHT
 Suction nasopharynx as necessary and administer oxygen
 If nor infusing prophylactically, infuse 4 g MgSO4 over 20 minutes, followed by a
maintenance dose of 2 g/hr. an IV bolus of 2 g is infused for recurrent seizures
 Sedatives such as Diazepam (Valium) are only used if MgSO4 cannot control the convulsions
 Do not give anything by mouth unless the woman is fully awake after convulsion
h. Electronic fetal monitoring of the fetus is continued
i. Take v/s every 5 minutes and then every 15 minutes when the patient stabilizes
j. Auscultate the patient lungs for possible pulmonary edema
k. Output will need careful monitoring via a urinary catheter
l. Physician may order arterial blood gas to assess maternal oxygenation (acidosis is very
common after convulsion) and chest x-ray to rule out aspiration
m. Once the patient is stabilized, delivery should commence within 3 to 6 hours
10. Delivery:
a. The preferred method is vaginal delivery. Labor is induced by amniotomy or oxytocin
administration when the condition of the woman is stable. Local or pudendal anesthesia is
used. Prostaglandin E2 gel is often used to ripen the cervix. Pitocin and magnesium can
be given simultaneously
b. However, cesarean delivery is an excellent option for the seriously ill patient who might
not tolerate induction or if labor induction is unsuccessful and fetal distress is severe that
the fetus needs to be delivered immediately.
11. Postpartum care
c. The danger of convulsion exist until 24 hours after delivery, MgSO4 therapy is continued.
Hydralazine maybe given depending upon the BP
d. Watch for uterine relaxation and increase lochial flow if the woman is receiving MgSO4
C.If the mother received large doses of MgSO4 before delivery, the newborn may have
high serum magnesium level, therefore watch for respiratory depression, hypocalcemia,
hypotonia in these infants. Newborn toxicity is treated with levallorphan( Lorfan)
d. Continue to monitor the patient during the postpartum period:
 I and O: diuresis is a positive sign that signals resolution of the disease process
 BP and pulse are checked at least every 4 hours for 48 hours
 Hematocrit is checked daily
 Platelet count and liver enzymes are monitored for risk for HELLP syndrome
e. Ergot products such as methergine, are contraindicated because they are
hypertensive
f. Two years should elapse before another pregnancy is attempted to decrease the
likelihood that PIH will recur on the subsequent pregnancy.
HELLP SYNDROME
 HELLP SYNDROME

It is a variation of PIH named for the common symptoms that occur:

H - emolysis that leads to anemia

E - levated

L - iver enzymes that lead to epigastric pain, and

L – ow

P - latelets that lead to abnormal bleeding/clotting and petechia

 
 HELLP SYNDROME
Incidence:
The syndrome occurs in 4% to 12% of patients with PIH. It is a serious syndrome because it results
in a maternal mortality rate as high as 24% and an infant mortality rate as high as 35%.

CAUSE/PREDISPOSING FACTORS

1. Unknown
2. associated with antiphospholipid syndrome or the presence of antiphospholipid antibodies

 
 HELLP SYNDROME
SIGNS AND SYMPTOMS

1. proteinuria
2. edema
3. increased blood pressure
4. nausea,
5. epigastric pain
6. general malaise
7. right upper quadrant tenderness from liver inflammation
 HELLP SYNDROME
LABORATORY STUDIES

1. hemolysis of red blood cells (they appear fragmented on a peripheral blood

smear),
2. thrombocytopenia (a platelet count of 100,000/mm)
3. elevated liver enzyme levels (alanine aminotransferase [ALT) and serum
aspartate aminotransferase [AST]). The liver enzyme levels are elevated from
hemorrhage and necrosis of the liver
 HELLP SYNDROME
COMPLICATIONS

1. Subcapsular liver hematoma

2. Hyponatremia
3. renal failure
4. hypoglycemia from poor liver function.
 HELLP SYNDROME
COMPLICATIONS
5. Mothers complications include:
 cerebral hemorrhages
 aspiration pneumonia
 hypoxic encephalopathy
6. Fetal complications can include
 growth restriction
 preterm birth
 HELLP SYNDROME
MANAGEMENT

1. transfusion of fresh-frozen plasma or platelets.

2. If hypoglycemia is present, this is corrected by an intravenous glucosinfusion.
3. The infant is born as soon as feasible by either vaginal or cesarean birth.
MULTIPLE PREGNANCY
 MULTIPLE PREGNANCY
When two, three, four or even five fetuses are conceived , grow and develop in the uterus at the same time,
it is called multiple pregnancy or multifetal pregnancy .

 Twins – 2 fetuses

 Triplets – 3 fetuses

 Quadruplets – 4 fetuses

 Quintuplets – 5 fetuses

 Sextuplets – 6 fetuses

 Septuplets – 7 fetuses
 MULTIPLE PREGNANCY
TYPES OF TWINNING

1. Monozygotic or identical twin. Identical twins develop from one ovum and one sperm cell that undergo too
rapid cell division after fertilization resulting in the formation of two or more fetuses. Since the fetus came
from the same sperm cell and egg cell, they naturally possess the same genetic traits and are always of the
same sex

a. if twinning occurred within 72 hours after fertilization, there will be two amnions (diamnionic) , two

chorions (dichorionic) and two embryos (monozygotic)

b. if twinning occurred between the fourth and eight day after fertilization, there will be two amnions, one
chorion (monochorionic) and two embryos

c. If twinning occurred after eight days, there will be one amnion (monoamnionic), one chorion and 2 embryos
 MULTIPLE PREGNANCY
TYPES OF TWINNING (CONTINUED)
d. If twinning occurred after the embryonic disc is formed, conjoined twins will develop. Conjoined twins
are classified according to the part of the body where they are attached:
 Anterior – thoracopagus (common)
 Posterior – pyopagus
 Cephalic – craniopagus
 Caudal - ischiopagus

2. Dizygotic or Fraternal twin: this develop from two or more ova and sperm cells that were fertilized at the
same time. They have different genetic traits; they may or may not be of the same sex and always have
separate placentas, chorions and amnions

 
MULTIPLE PREGNANCY
 Predisposing Factors for Dizygotic Twinning:

 Race : highest among blacks

 Heredity : more common in women with family history of twinning

 Age and parity: increased incidence in high parity and advance maternal age

 Higher incidence in women taking fertility drugs that promotes ovulation and release of several ova
at the same time

 Higher incidence in tall and large framed women

 Endogenous gonadotrophin: higher incidence within the first months after stopping oral
contraceptives because of the sudden and greater amount of pituitary gonadotrophins released at
this time

 In vitro fertilization: stimulation of formation of numerous follicles, harvesting them in the ovary
and fertilizing them in vitro. All zygotes that were fertilized are returned to the uterus to grow and
develop
 MULTIPLE PREGNANCY

SEX RATIO: There are more females than males as the number of fetuses
increase in every pregnancy because

 Female zygote has higher tendency to divide into twins

 Female zygotes have higher rate of survival than male zygotes
SIGNS AND SYMPTOMS

1. uterus begins to increase in size at a rate faster than usual.

2. Alpha-fetoprotein levels are elevated.
3. At the time of quickening, a woman may report flurries of action at different
portions of her abdomen rather than at one consistent spot(where the feet are
located).
4. On auscultation of the abdomen, multiple sets of fetal heart sounds are heard, but if
one or more fetus has his or her back positioned toward a woman’s back, only one
fetal heart sound may be heard.
5. An ultrasound can reveal multiple gestation sacs early in pregnancy
 
COMPLICATIONS

1. Abortion
2. Preterm labor or birth 8. Postpartum hemorrhage
3. Pregnancy-induced hypertension 9. Hydramnios
4. Anemia 10. Low birth weight
5. Birth defects 11. Placenta previa
6. Twin-to-twin transfusion syndrome 12. Intrauterine growth retardation
7. Cesarean delivery 13. Cord entanglement, prolapse and
compression
 MANAGEMENT:

1. Prenatal care

a. Clinic visit is more frequent than usual

 First trimester: every month

 Second trimester: every 2 weeks

 Third trimester: every week

a. Nutrition

 Caloric requirement: additional 300 kcal to the normal pregnancy requirement

 Iron 60-100 mg

 Vitamin supplements to meet increased demand

 Six small meals rather then 3 large meals to decrease the discomfort of large uterus compressing a full
stomach

 Gain at least 35-45 pounds

Management (continued)
a. Rest and ambulation
 More bed rest during the 3rd trimester to avoid premature labor
 Rest in LLP
 Higher order multiple pregnancies often require bed rest beginning in the
middle of the 2nd trimester
a. Occurrence of discomforts of pregnancy might come earlier so give advise of
the relief measures
b. Monitoring of maternal and fetal health
Thank you