INTRODUCTION

Pregnancy induced Hypertension (PIH) is a condition in which vasospasm

occurs during pregnancy in both small and large arteries. Signs of hypertension,
proteinuria, and edema develop. It is unique to pregnancy and occurs in 5% to 7%
of pregnancies (Bails & Witter, 2007). The cause of disorder is still unknown
although it is highly correlated with the antiphospholipid syndrome or the presence
of antiphospholipid antibodies (Clark, Silver, & Branch, 2007). 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.

A condition separate from chronic hypertension, PIH tends to occur most frequently
in women of color or with a multiple pregnancy, primiparas younger than 20 years
or older than 40 years, women from low socioeconomic backgrounds (poor
nutrition), those who have had five or more pregnancies, those who have
hydramnios (over production of amniotic fluid), or those who have an underlying
disease such as heart disease, diabetes with vessel or renal involvement, and
essential hypertension.

Types of Hypertension:

Gestational Hypertension

A woman is said to have gestational hypertension when she develops an elevated

blood pressure (140/90 mm Hg) but has no proteinuria or edema. Perinatal mortality
is not increased which simple gestational hypertension, so no drug therapy is
necessary.

Mild Pre-eclampsia

If a seizure from PIH occurs, a woman has eclampsia, but any status above
gestational hypertension and below a point of seizures is pre-eclampsia. A woman is
said to be mildly pre-eclamptic when she has proteinuria and blood pressure rises to
140/90 mm Hg, taken on two occasions at least 6 hours apart. A second criterion for
evaluating blood pressure is a systolic blood pressure greater than 30 mm Hg and a
diastolic pressure greater than 15 mm Hg above prepregnancy values.

A woman younger than age 20 could have a blood pressure of 98/61 mm Hg and
still be within normal limits. If her blood pressure were elevated 30 mm Hg systolic
and 15 mm Hg diastolic, it would be only 128/76 mm Hg. This is well beneath the
traditional warning point of 140/90 but would represent hypertension for her.

With mild pre-eclampsia, in addition to the hypertension a woman has proteinuria

(1+ or 2+ on a reagent test strip on a random sample). Many women show a trace
of protein during pregnancy. Actual proteinuria is said to exist when it registers as
1+ or more (this represents a loss of 1 g/L).
Occasionally women have orthostatic proteinuria (on long periods of standing, they
excrete protein; at bed rest, they do not). Edema develops because of the protein
loss, sodium retention, and lowered glomerular filtration rate. The edema is not just
the typical ankle edema of pregnancy but begins to accumulate in the upper part of
the body. A weight gain of more than 2 lb/wk in the second trimester or 1 lb/wk in
the third trimester usually indicates abnormal tissue fluid retention. This is likely to
be the first symptom a woman notices, or it may be discovered when a woman is
weighed at prenatal visit. Noticeable edema may or may not be present when this
sudden increase in weight first occurs.

Severe Pre-eclampsia

A woman has passed from mild to severe pre-eclampsia when her blood pressure
rises to 160 mm Hg systolic and 110 mm Hg diastolic or above on at least two
occasions 6 hours apart at bed rest (the position in which blood pressure is lowest)
or her diastolic pressure is 30 mm Hg above her prepregnancy level. Marked
proteinuria, 3+ or 4+ on a random urine sample or more than 5 g in a 24-hour
sample, and extensive edema are also present.

With severe pre-eclampsia, the extreme edema in most readily palpated over bony
surfaces, such as over the tibia on the anterior leg, the ulnar surface of the forearm,
and the cheekbones, where the sponginess of fluid-filled tissue can be palpated
against bone. Most women at the end of pregnancy have edema of the feet at the
end of the day. They report this as difficulty fitting into their bedroom slippers, or
kicking off their shoes at dinner time and then not being able to put them back on
again. This is a normal discomfort of pregnancy. However, edema that has
progressed to the upper extremities or the face is abnormal. This accumulating
edema will reduce their urine output to approximately 400 to 600 mL per 24 hours.

Some women have severe epigastric pain and nausea and vomiting, possibly
because of abdominal edema or ischemia to the pancreas and liver. If pulmonary
edema develops, a woman may report feeling short of breath. If cerebral edema
occurs, reports may be voiced of visual disturbances such as blurred vision or
seeing spots before the eyes. Cerebral edema also produces symptoms of severe
headache and marked by perreflexia and perhaps ankle clonus (a continued motion
of the foot).

Eclampsia

This is the most severe classification of PIH. A woman has passed into this stage
when cerebral edema is so acute that a grand-mal seizure (tonic-clonic) or coma
occurs. With eclampsia, the maternal morality rate is as high as 20% from causes
such as cerebral hemorrhage, circulatory collapse, or renal failure.

The fetal prognosis with eclampsia is also poor because of hypoxia and consequent
fetal acidosis. If premature separation of the placenta from vasospasm occurs, the
fetal prognosis is even graver. If a fetus must be born before term, all the risks of
immaturity will be faced. In pre-eclampsia develops, the fetal morality rate is
approximately 10%. If eclampsia develops, the morality rate increases to as high as
20% (Bailis & Witter, 2007).