BRIEF DESCRIPTION

PREGNANCY-INDUCED HYPERTENSION
-condition in which vasospasm occurs during pregnancy in both small and large arteries.

-“Toxemia”, or “Pregnancy-Induce Hypertension (PIH)”

o Originally it was called toxemia because researchers pictured a toxin of some

kind being produced by a woman in response to the foreign protein of the
growing fetus, the toxin leading to the typical symptoms.

GESTATIONAL HYPERTENSION

 140/90 mmHg but has no proteinuria, or edema.

 No drug is necessary.

PRE ECLAMPSIA

 It is diagnosed by the elevation of the expectant mother’s blood pressure usually after
the 20th week of pregnancy.
 the most common form of high blood pressure (BP) that complicates pregnancy, is
primarily defined by the occurrence of new-onset hypertension plus new-onset
proteinuria.
o Evidence shows organ problems with the kidneys and liver can occur without
signs of protein, and that the amount of protein in the urine does not predict how
severely the disease will progress.1

Types of Pre-Eclampsia:

1. Mild Pre-Eclampsia
a. BP: 140/90mmHg
b. Positive Proteinuria (1+, or 2+)
c. Weight gain of more than 2lb/wk in the second trimester, or 1lb/wk in third
trimester

2. Severe Pre-Eclampsia
a. BP: 160/
110 mmHg or above
b. Proteinuria (3+, or 4+)
c. Extreme edema
i. Cerebral edema: visual disturbance, severe headache, ankle clonus

If not properly recognized, and managed…

ECLAMPSIA

 Most severe classification of PIH.

 Grand-mal seizure (tonic-clonic), or coma occurs.

1
Pre-eclampsia.org
HELLP Syndrome
H: Hemolysis

EL: Elevated liver enzymes

LP: Low platelet count

• was coined by Louis Weinstein of the University of Arizona.

• is a rare manifestation of hypertensive diseases of pregnancy, and represents the most
severe end of pre-eclampsia spectrum. (British Journal of Anesthesia, 1991)
o About 4-12% of women with diagnosed pre-eclampsia will develop HELLP
syndrome.2
• This condition usually occur during the later stages of pregnancy, or sometimes after
childbirth.
• This syndrome usually develops suddenly between 28-36 week gestation. (The Journal of
Obstetrics and Gynecology of India, 2009)
o It is believed that HELLP syndrome affects about 0.2-0.6% of all pregnancies and
a mortality rate: 7.7-60% %3

ETIOLOGY:
• Unknown

RISK FACTORS:
• Caucasian (14.6%), or African-American (15%)4
• Mothers aged 25 or 35 y/o and above
• Family history of pre-eclampsia
• History of pre-eclampsia, or HELLP Syndrome
- 2-19% recurrence in each pregnancy5
• Primigravidas, or Mulitgravidas
• Multiple Gestation
• History of hypertension, or Diabetes Mellitus
• Obesity
• Poor prenatal check-up

CLASSIFICATION:
• Partial HELLP –one, or two abnormalities
• Complete/Full HELLP –all three abnormalities
-high risk for complication

2
Americanpregnancy.org, 2018
3
Americanpregnancy.org, 2018 and Pre-eclampsia.org
4 The Role Of Ethnicity In The Development Of Pre-Eclampsia, 1998 and Pre-eclampsia.org, 2018
5
pre-eclampsia.org, 2019
The Mississippi classification.6

• Class I (severe thrombocytopenia): platelets under 50,000/mm3

• Class II (moderate thrombocytopenia): platelets between 50,000 and 100,000/mm3

• Class III (AST > 40 IU/L, mild thrombocytopenia): platelets between 100,000 and
150,000/mm3

SIGNS AND SYMPTOMS

• General Malaise
• Headache
• Nape Pain
• Dizziness
• Nausea and vomiting
• RUQ pain
• Changes in vision
–most serious symptoms of pre-eclampsia
–flashing lights, auras, light sensitivity, or blurry vision or spots.
• High blood pressure
• Proteinuria
• Bleeding

DIAGNOSTIC TEST:

• Complete Blood Count with APC

- blood test used to evaluate your overall health and detect a wide range of disorders,
including anemia, infection and leukemia.

• Peripheral Blood Smear

-primarily ordered as a follow-up test when a CBC with differential, performed with an
automated blood cell counter, indicates the presence of atypical, abnormal, or immature
cells.

-a blood smear is a blood test used to look for abnormalities in blood cells. The three
main blood cells that the test focuses on are: red cells, which carry oxygen throughout
your body. white cells, which help your body fight infections and other inflammatory
diseases. platelets, which are important for blood clotting.7

• Liver Function Test

-Liver function tests are blood tests used to help diagnose and monitor liver disease or
damage. The tests measure the levels of certain enzymes and proteins in your blood.8

Alanine transaminase (ALT). ALT is an enzyme found in the liver that helps your body
metabolize protein. When the liver is damaged, ALT is released into the bloodstream and
levels increase.

6
The Journal of Obstetrics and Gynecology of India, 2009
7 https://www.healthline.com/health/blood-smear
8
https://www.mayoclinic.org/tests-procedures/liver-function-tests/about/pac-20394595
 Aspartate transaminase (AST). AST is an enzyme that helps metabolize alanine, an amino
acid. Like ALT, AST is normally present in blood at low levels. An increase in AST levels
may indicate liver damage or disease or muscle damage.

Bilirubin. Bilirubin is a substance produced during the normal breakdown of red blood cells.
Bilirubin passes through the liver and is excreted in stool. Elevated levels of bilirubin
(jaundice) might indicate liver damage or disease or certain types of anemia.

• Kidney Function Test

-are simple blood and urine test that can help identify problems with your kidneys.

GFR (Glomerular Filtration Rate) is a measure of kidney function and is performed through
a blood test. Your GFR will determine what stage of kidney disease.

ACR (Albumin to Creatinine Ratio) is a urine test to see how much albumin (a type of
protein) is in your urine. Too much albumin in your urine is an early sign of kidney
damage.9

-Your doctor will ask you to collect your urine for 24 hours, for measurement of the amount
of protein in your urine.

• Fetal ultrasound
-Doctor may also recommend close monitoring of your baby's growth, typically through
ultrasound. The images of your baby created during the ultrasound exam allow your doctor
to estimate fetal weight and the amount of fluid in the uterus (amniotic fluid)

• Ultrasound, MRI, CT scan

-can detect liver damage
-these tests do not involve exposure to x-rays.

• Non-stress test or biophysical profile

-A non-stress test is a simple procedure that checks how your baby's heart rate reacts
when your baby moves. A biophysical profile uses an ultrasound to measure your baby's
breathing, muscle tone, movement and the volume of amniotic fluid in your uterus.

MEDICAL MANAGEMENT:10
• Magnesium Sulfate (anti-convulsant)
-muscle relaxant
-should be administered intrapartum and early postpartum for seizure prophylaxis
regardless of blood pressure. It is started at the beginning of the observation period,
continued through the intrapartum period, and then for 24-48 hours postpartum.
-assess for respiratory rate, deep tendon reflex, and clonus q hour.
-Calcium gluconate is an antidote for magnesium intoxication.

• Anti-hypertensive
-are used for systolic blood pressures above 160, and or diastolic pressures of more
than 105 to avoid intracerebral bleeding.
 Hydralazine

9
https://www.kidney.org/atoz/content/know-your-kidney-numbers-two-simple-tests
10 The Journal of Obstetrics and Gynecology of India, 2009
 • Corticosteroid
-Dexamethasone
-Promotion of fetal lung maturation in threatening preterm delivery

TREATMENT:11
1. Strict Bed Rest

-due to potential for sudden deterioration of maternal, or fetal condition.

2. Delivery

-best treatment, but not cure.

Cesarean Delivery

-HELLP syndrome is not an indication for cesarean delivery.

-Vaginal delivery is attempted in patients in gestations beyond 32 weeks, or in the presence of
active labor or membrane rupture.
-CS is performed if the pregnancy is less than 30 weeks with an unfavorable cervix, and
absence of active labor.

NURSING MANAGEMENT
Mild Pre-eclampsia
- Promoting bed rest
- Promote good nutrition
- Provide emotional support
- Monitoring and managing potential complications

Severe Pre-Eclampsia

- Support bed rest

- Monitor Maternal, and fetal well-being
- Support a nutritious diet

Eclampsia

- Promote safety
- Maintain patent airway
o Priority

After delivery:

- Monitoring for Complication

- Maintaining fluid and electrolyte Imbalance
- Relieving pain

11 The Journal of Obstetrics and Gynecology of India, 2009

PROGNOSIS:12
• The long-term outlook (prognosis) for mothers with HELLP syndrome varies from woman
to woman, but HELLP syndrome is rarely fatal.
• The prognosis for a fetus or newborn of a mother with HELLP syndrome is thought to
largely depend on the gestational age at delivery and birth weight.

COMPLICATION:
• DIC
• Abruptio Placenta
• Pulmonary Edema
• Pleural Effusions
• Acute Renal Failure
• Stroke

12
https://rarediseases.info.nih.gov/diseases/8528/hellp-syndrome#diseasePrognosisSection