case presentation of pregnancy induced hypertension

Loading metrics

Open Access

Learning Forum

Learning Forum articles are commissioned by our educational advisors. The section provides a forum for learning about an important clinical problem that is relevant to a general medical audience.

See all article types »

A 21-Year-Old Pregnant Woman with Hypertension and Proteinuria

• Andrea Luk,

* To whom correspondence should be addressed. E-mail: [email protected]

• Ching Wan Lam,
• Wing Hung Tam,
• Anthony W. I Lo,
• Enders K. W Ng,
• Alice P. S Kong,
• Wing Yee So,
• Chun Chung Chow
• Andrea Luk, 
• Ronald C. W Ma, 
• Ching Wan Lam, 
• Wing Hung Tam, 
• Anthony W. I Lo, 
• Enders K. W Ng, 
• Alice P. S Kong, 
• Wing Yee So, 

Published: February 24, 2009

• https://doi.org/10.1371/journal.pmed.1000037
• Reader Comments

Citation: Luk A, Ma RCW, Lam CW, Tam WH, Lo AWI, Ng EKW, et al. (2009) A 21-Year-Old Pregnant Woman with Hypertension and Proteinuria. PLoS Med 6(2): e1000037. https://doi.org/10.1371/journal.pmed.1000037

Copyright: © 2009 Luk et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: The authors received no specific funding for this article.

Competing interests: RCWM is Section Editor of the Learning Forum. The remaining authors have declared that no competing interests exist.

Abbreviations: CT, computer tomography; I, iodine; MIBG, metaiodobenzylguanidine; MRI, magnetic resonance imaging; SDH, succinate dehydrogenase; SDHD, succinate dehydrogenase subunit D

Provenance: Commissioned; externally peer reviewed

Description of Case

A 21-year-old pregnant woman, gravida 2 para 1, presented with hypertension and proteinuria at 20 weeks of gestation. She had a history of pre-eclampsia in her first pregnancy one year ago. During that pregnancy, at 39 weeks of gestation, she developed high blood pressure, proteinuria, and deranged liver function. She eventually delivered by emergency caesarean section following failed induction of labour. Blood pressure returned to normal post-partum and she received no further medical follow-up. Family history was remarkable for her mother's diagnosis of hypertension in her fourth decade. Her father and five siblings, including a twin sister, were healthy. She did not smoke nor drink any alcohol. She was not taking any regular medications, health products, or herbs.

At 20 weeks of gestation, blood pressure was found to be elevated at 145/100 mmHg during a routine antenatal clinic visit. Aside from a mild headache, she reported no other symptoms. On physical examination, she was tachycardic with heart rate 100 beats per minute. Body mass index was 16.9 kg/m 2 and she had no cushingoid features. Heart sounds were normal, and there were no signs suggestive of congestive heart failure. Radial-femoral pulses were congruent, and there were no audible renal bruits.

Baseline laboratory investigations showed normal renal and liver function with normal serum urate concentration. Random glucose was 3.8 mmol/l. Complete blood count revealed microcytic anaemia with haemoglobin level 8.3 g/dl (normal range 11.5–14.3 g/dl) and a slightly raised platelet count of 446 × 10 9 /l (normal range 140–380 × 10 9 /l). Iron-deficient state was subsequently confirmed. Quantitation of urine protein indicated mild proteinuria with protein:creatinine ratio of 40.6 mg/mmol (normal range <30 mg/mmol in pregnancy).

What Were Our Differential Diagnoses?

An important cause of hypertension that occurs during pregnancy is pre-eclampsia. It is a condition unique to the gravid state and is characterised by the onset of raised blood pressure and proteinuria in late pregnancy, at or after 20 weeks of gestation [ 1 ]. Pre-eclampsia may be associated with hyperuricaemia, deranged liver function, and signs of neurologic irritability such as headaches, hyper-reflexia, and seizures. In our patient, hypertension developed at a relatively early stage of pregnancy than is customarily observed in pre-eclampsia. Although she had proteinuria, it should be remembered that this could also reflect underlying renal damage due to chronic untreated hypertension. Additionally, her electrocardiogram showed left ventricular hypertrophy, which was another indicator of chronicity.

While pre-eclampsia might still be a potential cause of hypertension in our case, the possibility of pre-existing hypertension needed to be considered. Box 1 shows the differential diagnoses of chronic hypertension, including essential hypertension, primary hyperaldosteronism related to Conn's adenoma or bilateral adrenal hyperplasia, Cushing's syndrome, phaeochromocytoma, renal artery stenosis, glomerulopathy, and coarctation of the aorta.

Box 1: Causes of Hypertension in Pregnancy

• Pre-eclampsia
• Essential hypertension
• Renal artery stenosis
• Glomerulopathy
• Renal parenchyma disease
• Primary hyperaldosteronism (Conn's adenoma or bilateral adrenal hyperplasia)
• Cushing's syndrome
• Phaeochromocytoma
• Coarctation of aorta
• Obstructive sleep apnoea

Renal causes of hypertension were excluded based on normal serum creatinine and a bland urinalysis. Serology for anti-nuclear antibodies was negative. Doppler ultrasonography of renal arteries showed normal flow and no evidence of stenosis. Cushing's syndrome was unlikely as she had no clinical features indicative of hypercortisolism, such as moon face, buffalo hump, violaceous striae, thin skin, proximal muscle weakness, or hyperglycaemia. Plasma potassium concentration was normal, although normokalaemia does not rule out primary hyperaldosteronism. Progesterone has anti-mineralocorticoid effects, and increased placental production of progesterone may mask hypokalaemia. Besides, measurements of renin activity and aldosterone concentration are difficult to interpret as the renin-angiotensin-aldosterone axis is typically stimulated in pregnancy. Phaeochromocytoma is a rare cause of hypertension in pregnancy that, if unrecognised, is associated with significant maternal and foetal morbidity and mortality. The diagnosis can be established by measuring levels of catecholamines (noradrenaline and adrenaline) and/or their metabolites (normetanephrine and metanephrine) in plasma or urine.

What Was the Diagnosis?

Catecholamine levels in 24-hour urine collections were found to be markedly raised. Urinary noradrenaline excretion was markedly elevated at 5,659 nmol, 8,225 nmol, and 9,601 nmol/day in repeated collections at 21 weeks of gestation (normal range 63–416 nmol/day). Urinary adrenaline excretion was normal. Pregnancy may induce mild elevation of catecholamine levels, but the marked elevation of urinary catecholamine observed was diagnostic of phaeochromocytoma. Conditions that are associated with false positive results, such as acute myocardial infarction, congestive heart failure, acute cerebrovascular event, withdrawal from alcohol, withdrawal from clonidine, and cocaine abuse, were not present in our patient.

The working diagnosis was therefore phaeochromocytoma complicating pregnancy. Magnetic resonance imaging (MRI) of neck to pelvis, without gadolinium enhancement, was performed at 24 weeks of gestation. It showed a 4.2 cm solid lesion in the mid-abdominal aorto-caval region, while both adrenals were unremarkable. There were no ectopic lesions seen in the rest of the examined areas. Based on existing investigation findings, it was concluded that she had extra-adrenal paraganglioma resulting in hypertension.

What Was the Next Step in Management?

At 22 weeks of gestation, the patient was started on phenoxybenzamine titrated to a dose of 30 mg in the morning and 10 mg in the evening. Propranolol was added several days after the commencement of phenoxybenzamine. Apart from mild postural dizziness, the medical therapy was well tolerated during the remainder of the pregnancy. In the third trimester, systolic and diastolic blood pressures were maintained to below 90 mmHg and 60 mmHg, respectively. During this period, she developed mild elevation of alkaline phosphatase ranging from 91 to 188 IU/l (reference 35–85 IU/l). However, liver transaminases were normal and the patient had no seizures. Repeated urinalysis showed resolution of proteinuria. At 38 weeks of gestation, the patient proceeded to elective caesarean section because of previous caesarean section, and a live female baby weighing 3.14 kg was delivered. The delivery was uncomplicated and blood pressure remained stable.

Following the delivery, computer tomography (CT) scan of neck, abdomen, and pelvis was performed as part of pre-operative planning to better delineate the relationship of the tumour to neighbouring structures. In addition to the previously identified extra-adrenal paraganglioma in the abdomen ( Figure 1 ), the CT revealed a 9 mm hypervascular nodule at the left carotid bifurcation, suggestive of a carotid body tumour ( Figure 2 ). The patient subsequently underwent an iodine (I) 131 metaiodobenzylguanidine (MIBG) scan, which demonstrated marked MIBG-avidity of the paraganglioma in the mid-abdomen. The reported left carotid body tumour, however, did not demonstrate any significant uptake. This could indicate either that the MIBG scan had poor sensitivity in detecting a small tumour, or that the carotid body tumour was not functional.

• PPT PowerPoint slide
• PNG larger image
• TIFF original image

https://doi.org/10.1371/journal.pmed.1000037.g001

https://doi.org/10.1371/journal.pmed.1000037.g002

In June 2008, four months after the delivery, the patient had a laparotomy with removal of the abdominal paraganglioma. The operation was uncomplicated. There was no wide fluctuation of blood pressures intra- and postoperatively. Phenoxybenzamine and propranolol were stopped after the operation. Histology of the excised tumour was consistent with paraganglioma with cells staining positive for chromogranin ( Figures 3 and 4 ) and synaptophysin. Adrenal tissues were notably absent.

The tumour is a well-circumscribed fleshy yellowish mass with maximal dimension of 5.5 cm.

https://doi.org/10.1371/journal.pmed.1000037.g003

The tumour cells are polygonal with bland nuclei. The cells are arranged in nests and are immunoreactive to chromogranin (shown here) and synaptophysin.

https://doi.org/10.1371/journal.pmed.1000037.g004

The patient was counselled for genetic testing for hereditary phaeochromocytoma/paraganglioma. She was found to be heterozygous for c.449_453dup mutation of the succinate dehydrogenase subunit D (SDHD) gene ( Figure 5 ). This mutation is a novel frameshift mutation, and leads to SDHD deficiency (GenBank accession number: 1162563). At the latest clinic visit in August 2008, she was asymptomatic and normotensive. Measurements of catecholamine in 24-hour urine collections had normalised. Resection of the left carotid body tumour was planned for a later date. She was to be followed up indefinitely to monitor for recurrences. She was also advised to contact family members for genetic testing. Our patient gave written consent for this case to be published.

https://doi.org/10.1371/journal.pmed.1000037.g005

Phaeochromocytoma in Pregnancy

Hypertension during pregnancy is a frequently encountered obstetric complication that occurs in 6%–8% of pregnancies [ 2 ]. Phaeochromocytoma presenting for the first time in pregnancy is rare, and only several hundred cases have been reported in the English literature. In a recent review of 41 cases that presented during 1988 to 1997, maternal mortality was 4% while the rate of foetal loss was 11% [ 3 ]. Antenatal diagnosis was associated with substantial reduction in maternal mortality but had little impact on foetal mortality. Further, chronic hypertension, regardless of aetiology, increases the risk of pre-eclampsia by 10-fold [ 1 ].

Classically, patients with phaeochromocytoma present with spells of palpitation, headaches, and diaphoresis [ 4 ]. Hypertension may be sustained or sporadic, and is associated with orthostatic blood pressure drop because of hypovolaemia and impaired vasoconstricting response to posture change. During pregnancy, catecholamine surge may be triggered by pressure from the enlarging uterus and foetal movements. In the majority of cases, catecholamine-secreting tumours develop in the adrenal medulla and are termed phaeochromocytoma. Ten percent of tumours arise from extra-adrenal chromaffin tissues located in the abdomen, pelvis, or thorax to form paraganglioma that may or may not be biochemically active. The malignant potential of phaeochromocytoma or paraganglioma cannot be determined from histology and is inferred by finding tumours in areas of the body not known to contain chromaffin tissues. The risk of malignancy is higher in extra-adrenal tumours and in tumours that secrete dopamine.

Making the Correct Diagnosis

The diagnosis of phaeochromocytoma requires a combination of biochemical and anatomical confirmation. Catecholamines and their metabolites, metanephrines, can be easily measured in urine or plasma samples. Day collection of urinary fractionated metanephrine is considered the most sensitive in detecting phaeochromocytoma [ 5 ]. In contrast to sporadic release of catecholamine, secretion of metanephrine is continuous and is less subjective to momentary stress. Localisation of tumour can be accomplished by either CT or MRI of the abdomen [ 6 ]. Sensitivities are comparable, although MRI is preferable in pregnancy because of minimal radiation exposure. Once a tumour is identified, nuclear medicine imaging should be performed to determine its activity, as well as to search for extra-adrenal diseases. I 131 or I 123 MIBG scan is the imaging modality of choice. Metaiodobenzylguanidine structurally resembles noradrenaline and is concentrated in chromaffin cells of phaeochromocytoma or paraganglioma that express noradrenaline transporters. Radionucleotide imaging is contraindicated in pregnancy and should be deferred until after the delivery.

Treatment Approach

Upon confirming the diagnosis, medical therapy should be initiated promptly to block the cardiovascular effects of catecholamine release. Phenoxybenzamine is a long-acting non-selective alpha-blocker commonly used in phaeochromocytoma to control blood pressure and prevent cardiovascular complications [ 7 ]. The main side-effects of phenoxybenzamine are postural hypotension and reflex tachycardia. The latter can be circumvented by the addition of a beta-blocker. It is important to note that beta-blockers should not be used in isolation, since blockade of ß2-adrenoceptors, which have a vasodilatory effect, can cause unopposed vasoconstriction by a1-adrenoceptor stimulation and precipitate severe hypertension. There is little data on the safety of use of phenoxybenzamine in pregnancy, although its use is deemed necessary and probably life-saving in this precarious situation.

The definitive treatment of phaeochromocytoma or paraganglioma is surgical excision. The timing of surgery is critical, and the decision must take into consideration risks to the foetus, technical difficulty regarding access to the tumour in the presence of a gravid uterus, and whether the patient's symptoms can be satisfactorily controlled with medical therapy [ 8 , 9 ]. It has been suggested that surgical resection is reasonable if the diagnosis is confirmed and the tumour identified before 24 weeks of gestation. Otherwise, it may be preferable to allow the pregnancy to progress under adequate alpha- and beta-blockade until foetal maturity is reached. Unprepared delivery is associated with a high risk of phaeochromocytoma crisis, characterised by labile blood pressure, tachycardia, fever, myocardial ischaemia, congestive heart failure, and intracerebral bleeding.

Patients with phaeochromocytoma or paraganglioma should be followed up for life. The rate of recurrence is estimated to be 2%–4% at five years [ 10 ]. Assessment for recurrent disease can be accomplished by periodic blood pressure monitoring and 24-hour urine catecholamine and/or metanephrine measurements.

Genetics of Phaeochromocytoma

Approximately one quarter of patients presenting with phaeochromocytoma may carry germline mutations, even in the absence of apparent family history [ 11 ]. The common syndromes of hereditary phaeochromocytoma/paraganglioma are listed in Box 2 . These include Von Hippel-Lindau syndrome, multiple endocrine neoplasia type 2, neurofibromatosis type 1, and succinate dehydrogenase (SDH) gene mutations. Our patient has a novel frameshift mutation in the SDHD gene located at Chromosome 11q. SDH is a mitochondrial enzyme that is involved in oxidative phosphorylation. Characteristically, SDHD mutation is associated with head or neck non-functional paraganglioma, and infrequently, sympathetic paraganglioma or phaeochromocytoma [ 12 ]. Tumours associated with SDHD mutation are rarely malignant, in contrast to those arisen from mutation of the SDHB gene. Like all other syndromes of hereditary phaeochromocytoma, SDHD mutation is transmitted in an autosomal dominant fashion. However, not all carriers of the SDHD mutation develop tumours, and inheritance is further complicated by maternal imprinting in gene expression. While it may not be practical to screen for genetic alterations in all cases of phaeochromocytoma, most authorities advocate genetic screening for patients with positive family history, young age of tumour onset, co-existence with other neoplasms, bilateral phaeochromocytoma, and extra-adrenal paraganglioma. The confirmation of genetic mutation should prompt evaluation of other family members.

Box 2: Hereditary Phaeochromocytoma/Paraganglioma Syndromes

• Von Hippel-Lindau syndrome
• Multiple endocrine neoplasia type 2A and type 2B
• Neurofibromatosis type 1
• Mutation of SDHB , SDHC , SDHD
• Ataxia-telangiectasia
• Tuberous sclerosis
• Sturge-Weber syndrome

Key Learning Points

• Hypertension complicating pregnancy is a commonly encountered medical condition.
• Pre-existing chronic hypertension must be considered in patients with hypertension presenting in pregnancy, particularly if elevation of blood pressure is detected early during pregnancy or if persists post-partum.
• Secondary causes of chronic hypertension include renal artery stenosis, renal parenchyma disease, primary hyperaldosteronism, phaeochromocytoma, Cushing's syndrome, coarctation of the aorta, and obstructive sleep apnoea.
• Phaeochromocytoma presenting during pregnancy is rare but carries high rates of maternal and foetal morbidity and mortality if unrecognised.
• Successful outcomes depend on early disease identification, prompt initiation of alpha- and beta-blockers, carefully planned delivery, and timely resection of the tumour.

Phaeochromocytoma complicating pregnancy is uncommon. Nonetheless, in view of the potential for catastrophic consequences if unrecognised, a high index of suspicion and careful evaluation for secondary causes of hypertension is of utmost importance. Blood pressure should be monitored in the post-partum period and persistence of hypertension must be thoroughly investigated.

Author Contributions

All authors participated in the management of the patient or writing of the article. AL and RCWM wrote the article, with contributions from all the authors.

• View Article
• Google Scholar

Effects of a Case Management Program for Women With Pregnancy-Induced Hypertension

Affiliations.

• 1 PhD, RN, Assistant Professor, Institute of Community Health Care, College of Nursing, National Yang Ming Chiao Tung University, Taipei, Taiwan.
• 2 PhD, RN, Professor, School of Nursing, National Defense Medical Center, Taipei, Taiwan.
• 3 BSN, RN, Case Manager, Department of Nursing, National Cheng Kung University Hospital, Tainan, Taiwan.
• 4 PhD, RN, Distinguished Professor, Institute of Community Health Care, College of Nursing, National Yang Ming Chiao Tung University, Taipei, Taiwan.
• 5 PhD, RN, Associate Professor, Department of Nursing, College of Medicine, National Cheng Kung University, and National Cheng Kung University Hospital, Tainan, Taiwan.
• PMID: 34432727
• DOI: 10.1097/jnr.0000000000000450

Background: Pregnancy-induced hypertension (PIH) is a leading cause of maternal and fetal morbidity and mortality. Although case management programs have been proposed to improve maternal and fetal outcomes in high-risk pregnancies, limited data are available regarding the effect of case management on women with PIH.

Purpose: The aim of this study was to evaluate the effect of an antepartum case management program on stress, anxiety, and pregnancy outcomes in women with PIH.

Methods: A quasi-experimental research design was employed. A convenience sample of women diagnosed with PIH, including preeclampsia, was recruited from outpatient clinics at a medical center in southern Taiwan. Sixty-two women were assigned randomly to either the experimental group (n = 31) or the control group (n = 31). The experimental group received case management for 8 weeks, and the control group received routine clinical care. Descriptive statistics, independent t or Mann-Whitney U tests, chi-square or Fisher's exact tests, paired t test, and generalized estimating equations were used to analyze the data.

Results: The average age of the participants was 35.1 years (SD = 4.5). No significant demographic or clinical differences were found between the control and experimental groups. The results of the generalized estimating equations showed significantly larger decreases in stress and anxiety in the experimental group than in the control group. No significant differences were identified between the two groups with respect to infant birth weeks, infant birth weight, average number of medical visits, or frequency of hospitalization.

Conclusions/implications for practice: The nurse-led case management program was shown to have short-term positive effects on the psychosocial outcomes of a population of Taiwanese patients with PIH. These results have important clinical implications for the healthcare administered to pregnant women, particularly in terms of improving the outcomes in those with PIH.

Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc.

Publication types

• Randomized Controlled Trial
• Case Management
• Hypertension, Pregnancy-Induced* / therapy
• Pre-Eclampsia* / therapy
• Pregnancy Outcome
• Prenatal Care

Academia.edu no longer supports Internet Explorer.

To browse Academia.edu and the wider internet faster and more securely, please take a few seconds to  upgrade your browser .

Enter the email address you signed up with and we'll email you a reset link.

• We're Hiring!
• Help Center

A CASE STUDY ON LIFE-THREATENING PREGNANCY-INDUCED HYPERTENSION IN PRETERM PREGNANCY AND MANAGEMENT CHALLENGES

Related Papers

Introduction: Hypertensive disorders of pregnancy are the most common causes of adverse maternal & perinatal outcomes. Such investigations in resource limited settings would help to have great design strategies in preventing maternal and perinatal morbidity and mortality. All women who presented with hypertensive disorders of pregnancy and delivered in the hospital and whose records were complete, were included in the study and divided into 5 groups namely, Gestational hypertension (GH), Mild pre-eclampsia (PE), Severe pre-eclampsia, Eclampsia and Chronic hypertension with superimposed pre-eclampsia (CHPE) based on their clinical presentation at admission. After excluding all incomplete data entries, the sample size was finalized at 200. Results: In this study, records of 2,989 women who delivered in our tertiary hospital were reviewed and of these, 256 women had hypertensive disorders of pregnancy. Fifty six of these women had either left the hospital against medical advice or their records were incomplete so their outcome could not be followed and hence were excluded from the study. Conclusion: Pre-eclampsia and Eclampsia still remains a major problem in developing countries. Pregnancy induced hypertension is one of the most extensively researched subjects in obstetrics. Still the etiology remains an enigma to us. Though the incidence of pre-eclampsia and eclampsia is on the decline, still it remains the major contributor to poor maternal and foetal outcome. The fact that pre-eclampsia, eclampsia is largely a preventable disease is established by the negligible incidence of pre-eclampsia and eclampsia with proper antenatal care and prompt treatment of pre-eclampsia. In preclampsia and eclampsia, pathology should be understood and that i-involves multiorgan dysfunction should be taken into account. The early use of antihypertensive drugs, optimum timing of delivery and strict fluid balance, anticonvulsants in cases of eclampsia will help to achieve successful outcome. Early transfer to specialist centre is important and the referral the referral centers should be well equipped to treat such critically ill patients.

IOSR Journals

Back Ground: Aim: The Aim of the study was to find out the incidence of PIH & Preeclampsia and to evaluate the risk factors, predictors of severity and obstetrical and perinatal outcome in severe preeclampsia and Eclampsia.. Place and duration Methodology: Out of total 8800 deliveries 880 were diagnosed to have pregnancy induced hypertension. Out of these 580 (66%) had gestational hypertension. 80(0.9%) cases had preeclampsia without severe features, 220(2.5%) cases had preeclampsia with severe features. The present study was conducted in 200 cases of preeclampsia with severe features. The cases were evaluated and managed as per the existing protocol in the department and Obstetrical and perinatal outcome were recorded and analyzed. Results: The incidence of pregnancy induced hypertension was 10% and preeclampsia 3.5% in our study. 50% had anemia and 30% had obesity as risk factors. Materanl mortality was seen in 12cases of severe preeclamsia, accounting to 50% of total maternal deaths in our centre. Other maternal complications were seen in 60% of cases.Most common was Eclamsia in 30% of cases followed by Abruption in 20% & DIC in 18% and 20% of cases required transfusion of blood & Blood components for thrombocytopenia and coagulation failure. 10% cases required ventilator support for dyspneoa. Perinatal mortality was seen in 16% of cases. Perinatal morality is due to premaurity, low birth weight and abruption. NICU admissions were required in 20% of cases because of severe birth Asphyxia. Conclusion: Regular antenatal checkup and regular blood pressure measurement will help in early detection of hypertensive cases. Treating anemia and educating women on significance of alarming symptoms will improve maternal and perinatal outcome. Hospitalisation, regular BP monitoring, investigations and timely delivery will improve significantly the maternal and perinatal outcome. A good maternal intensive care unit and neonatal intensive care unit will help to improve obstetrical and perinatal outcome in hypertensive disorders of pregnancy.

Hypertension in Pregnancy

Altaf shaikh

Corine Koopmans

https://www.ijhsr.org/IJHSR_Vol.11_Issue.1_Jan2021/IJHSR_Abstract.041.html

International Journal of Health Sciences and Research (IJHSR)

Background: Hypertension is one of the common medical complications of pregnancy & contributes significantly to maternal & perinatal morbidity & mortality. The World Health Organization estimates that at least one woman dies every seven minutes from complications of hypertensive disorders of pregnancy. Hence a study was undertaken to assess the impact of Pregnancy Induced Hypertension on fetal outcomes among mothers with PIH who delivered at tertiary care hospital, Dadra & Nagar Haveli. Method: It was a cross sectional study conducted at Shri Vinoba Bhave Civil Hospital, Silvassa, Dadra & Nagar Haveli from September to November 2020.The sample size of the study was 32. The data regarding demographic variables, obstetric history, clinical details & examinations, investigations & fetal outcomes was collected using Structured Interview Schedule. Result: In the present study, Gestational Hypertension was found to be 65.62%, Pre eclampsia was 28.12% and Eclampsia was found to be 6.25%. It was more prevalent among multipara mothers. The clinical representation of PIH showed that 71.87% mothers had pain in lower abdomen, 37.3% had pedal edema followed by 15.62% headache & 9.37% blurring of vision. Antihypertensive drugs (93.75%) were given to almost all the mothers whereas 9.37% were treated with anticonvulsant medicines. The most common fetal complications found were preterm births (43.75%) & LBW (37.5%). 28.12% babies required NICU admission due to various reasons whereas 6.25% neonatal deaths were reported. Conclusion: Pregnancy-related hypertensive disorders are common and adversely impact perinatal outcomes. Efforts should be made at both the community and hospital levels to increase awareness regarding hypertensive disorder of pregnancy and reduce its associated morbidity and mortality.

Clinical &amp; Biomedical Research

Francisco Maximiliano Pancich Gallarreta

Scholar Science Journals

Background: Preeclampsia and eclampsia have been recognized as clinical entities since the times of Hippocrates. Pregnancy induced hypertension (PIH) is one of the commonest disorders associated with the increased risk of maternal and fetal complications. It is reported in the world literature that the incidence of eclampsia is on the decline, but still a menace in developing countries. Objectives: To study the maternal and foetal outcome in pregnancy induced hypertension. Material and Methods: A prospective randomized study was carried out A total of 100 pregnant women with PIH were enrolled in the study. A pre-tested interview tool was used to collect necessary information such as detailed history, clinical examination findings and investigations performed. Results were analysed using SPSS 13.0 Results: In the present study, the overall incidence of PIH was 8.96%, which includes preeclampsia in 7.26% and eclampsia in 1.70%. Preterm labour was the commonest maternal obstetrical complication observed in 18% of mild PIH and 48% of severe PIH cases. Prematurity was the commonest foetal complication seen in 17.99%, 47.62% and 52.63% of mild PIH, severe PIH and Eclampsia cases respectively. Conclusion: Pregnancy induced hypertension is a common medical disorder seen associated with pregnancy in the rural population, especially among young primigravidas, who remain unregistered during pregnancy. Maternal and fetal morbidity and mortality can be reduced by early recognition and institutional management.

American Journal of Pediatrics

Mustafa Captain

Archives of Gynecology and Obstetrics

Eray Çalışkan

Objective: The aim of the study was to determine the risk factors, prevalance, epidemiological parameters and maternal-perinatal outcome in pregnant women with hypertensive disorder. Materials and methods: A retrospective analysis was undertaken on 255 consecutive cases of hypertensive disorder in pregnancy who were managed at Kocaeli University, School of Medicine, Department of Obstetrics and Gynecology from June 1997 to November 2004. Demographic data involving age, parity, gestational week, clinical and laboratory findings were recorded from the medical files. Additionally delivery route, indications of cesarean section, fetal and maternal complications were determined. Statistical analysis was performed by SPSS programme using Kruskal Wallis nonparametric test, ANOVA (Analysis of variance) and chi-square tests. Results: Of 5,155 deliveries in our clinic during the defined period, 438 cases (8.49%) were managed as hypertensive disorder of pregnancy. Medical records of 255 cases could be avaliable. Of 255 cases, 138 patients (54.11%) were found to have severe preeclampsia while 88 cases (34.50%) were diagnosed as mild preeclampsia. Twenty-nine patients (11.37%) were suffering from chronic hypertension. Of 138 severely preeclamptic cases, 28 cases (11%) had eclamptic convulsion and another 28 patients (11%) were demonstrated to have HELLP syndrome. Intrauterine growth restriction, oligohydramnios, placental ablation were the obstetric complications in 75 (29.4%), 49 (19.2%), 19 (7.5%) cases, respectively. Additionally multiple pregnancy and gestational diabetes mellitus were noted in 5.9% (n:15) and 3.9% (n:10) of the patients. Delivery route was vaginal in 105 patients (41.2%) while 150 patients (58.8%) underwent cesarean section with the most frequent indication to be fetal distress in 69 cases (46%). Cesarean section rate seemed to be the lowest (48.3%) in chronic hypertensive women while the highest (63.8%) in severe preeclamptic patients. Maternal mortality occured in 3 cases (1.2%) and all of those cases were complicated with HELLP syndrome. Intracranial bleeding was the cause of maternal death in one case while the other two cases were lost due to acute renal failure and disseminated intravascular coagulation, respectively. Intrauterine fetal demise was recorded in 24 cases on admission. Ten fetuses died during the intrapartum period. Mean gestational age and birth weight were 28±3.5 and 1000±416 g, respectively in this group. In these ten women, five cases were diagnosed as HELLP syndrome, two were severely preeclamptic and three were eclamptic. Perinatal mortality rate was found to be 144/1,000 births Conclusion: Hypertensive disorder of pregnancy is associated with increased risk of maternal-perinatal adverse outcome. The complications of severe preeclampsia and eclampsia could be prevented by more widespread use of prenatal care, education of primary medical care personnel, prompt diagnosis of high-risk patients and timely referral to tertiary medical centers.

South African Family Practice

Nnabuike Chibuoke Ngene

RELATED PAPERS

Canadian Journal of Fisheries and Aquatic Sciences

Alfonso Mucci

Portal de la Ciencia

Nitzia Vásquez

Élvia Fadul

Anais do 5. Congresso Brasileiro de Redes Neurais

Dilson Espenchitt

alfauzan amin

Procedia - Social and Behavioral Sciences

Mehmet Kurt

Atividades cartográficas - v. 3

Adriano Picarelli

Frontiers in Environmental Science

Ashraf Zaied

Emily Rundlet

monika lestari

International Journal of Fracture Fatigue & Wear: Proc. 4th Int. Conf. Fracture Fatigue & Wear, Ghent, Belgium,

Libardo V Vanegas-Useche

Journal of Non-Crystalline Solids

Yanfei ZHANG

Journal of Virological Methods

Adama Diallo

Analytical Biochemistry, Volume 231, Issue 1, Pages 230-236

Tamotsu Hashimoto-Gotoh

Journal of International Medical Research

Baris Zulfikaroglu

Qualitative Inquiry

Evance Mwathunga

Current Journal of Applied Science and Technology

Sidpouita Mathilde Koudougou

Armando Delgado Hernández

Diversity and Distributions

Kimmo Saarinen

Benefit: Jurnal Manajemen dan Bisnis

Bayu Wijayantini A20E0067F

Toxicology Letters

Frederico Pereira

Critical Care

Alain Duhamel

Bioscience, Biotechnology, and Biochemistry

Laura Yolanda Pagola López

national seminar

Dr.sudarshan Aher

hbgjfgf hyetgwerf

•   We're Hiring!
•   Help Center
• Find new research papers in:
• Health Sciences
• Earth Sciences
• Cognitive Science
• Mathematics
• Computer Science
• Academia ©2024

• Practice Test
• Fundamentals of Nursing
• Anatomy and Physiology
• Medical and Surgical Nursing
• Perioperative Nursing
• Psychiatric Mental Health Nursing
• Maternal & Child Nursing
• Community Health Nursing
• Pathophysiology
• Nursing Research
• Study Guide and Strategies
• Nursing Videos
• Work for Us!
• Privacy Policy

Pregnacy Induced Hypertension (PIH) Case Study

Pregnancy-induced hypertension (PIH) is one of the most common complications of pregnancy. This occurs during the 20 th week of gestation or late in the second trimester of pregnancy. This is a health condition wherein there is a rise in the blood pressure and disappears after the termination of pregnancy or delivery. PIH was formerly called toxaemia or the presence of toxins in the blood. This is because its occurrence was not well understood in the clinical field. Its common manifestations are hypertension, proteinuria (presence of protein in the urine), and edema. There are 2 main types of pregnancy-induced hypertension namely: pre-eclampsia and eclampsia.

• Pre-eclampsia— this is the non-convulsive form of PIH. This affects 7% of all pregnant women. Its incidence is higher in lower socio-economic groups. It may be classified either mild or severe.
• Eclampsia— this is the convulsive form of PIH. It occurs with 5% of all pre-eclampsia cases. The mortality rate among mothers is nearly 20% and fetal mortality is also high due to premature delivery.

NORMAL ANATOMY AND PHYSIOLOGY

There are a lot of bodily changes that happen during a normal pregnancy. There are external changes that are noticeable, and there are internal changes that can only be appreciated through thorough clinical examinations. Most of the changes are the body’s response to the changes in levels of hormones and the growing demands of the fetus.

The two dominant female hormones, estrogen and progesterone , change in a normal level. Along with this, a significant rise/appearance of 4 more major hormones take place; these are 1. human chorionic gonadotropin (HCG), 2. human placental lactogen, 3. prolactin, and 4. oxytocin. All these 6 hormones interact with each other simultaneously to maintain a normal pregnancy as it progresses.

The following are the major effects of these hormones in the body:

The exact cause of pregnancy-induced hypertension is unknown; however, it is highly linked to angiotensin gene T235 and the existence of other risk factors. Malnutrition and inadequate prenatal care are the greatest risk factors. The history and presence of diabetes mellitus (DM), multifetal gestation (twin pregnancies), polyhydramnios (excessive amniotic fluid), and renal diseases are also among the major contributory factors in the development of PIH. In the past, the mystery revolving around PIH postulated a lot of theories on its true origin, most of them were believed to be of toxic nature. Among these are placental infarcts, autointoxication, uremia, pyelonephritis, and maternal sensitization to total proteins.

The i ncidence of PIH among pregnant women is very high (8%), costing hundreds and thousands of lives of both mothers and fetus around the world. This commonly affects first-time pregnancies due to the presence of functioning tropoblasts (develops after the 20 th week of gestation and stays evident until after 48 hours after delivery. Age is also an important indicator in the development of PIH. Too early, as in teenage pregnancies and old primigravidas (first-time pregnancy) as in over 35 years of age put a woman higher chances of having pregnancy-induced hypertension . 

PATHOPHYSIOLOGY

SIGNS AND SYMPTOMS

The signs and symptoms of the type of PIH present in a pregnant woman are based on the presentation of evident clinical manifestations. These are shown in the table below:

COMPLICATIONS

Based on the severity of the PIH present to a person or the extent of damage left/occurred, a list of possible complications can be drawn.

• Abruption placenta
• Disseminated intravascular coagulation (DIC)
• Prematurity
• Intrauterine growth retardation (IUGR)
• HELLP syndrome
• Maternal and/or fetal death  

The changes of the mother and/or fetus to survive after an episode of convulsion or until delivery depends on the threshold on the effects of PIH and its complications. This can be:

• Good— if the symptoms are mild or those that are with mild pre-eclampsia and is responding well to the treatment regimen
•   Poor— if there are multiple and long episodes of convulsions that are associated or lead to the development of persistent coma, hyperthermia, cyanosis, tachycardia, and liver damage.
• Congestive heart failure (CHF)
• Pulmonary edema
• Cerebral hemorrhage
• Renal failure

DIAGNOSTIC EVALUATIONS

            Diagnostic evaluations are performed after episodes of convulsions or after the client has been rushed to a health care facility. These are routinely done to assess the damages and will serve as the basis for the plan of treatment.

• 24-hour urine-protein— health problem through protein determination from the involvement of the renal system.
• Serum BUN and creatinine— to evaluate renal functioning.
• Ophthalmic examination— to assess spasm, papilledema, retinal edema/detachment, and/or hemorrhages.
• Ultrasonography with stress and non- stress test— to evaluate fetal well-being after.
• Stress test —fetalheart tone (FHT) and fetal activity are electronically monitored after oxytocin induction which causes uterine contraction.
• Non-stress test —fetal heart tone (FHT) and fetal activity are electronically monitored during fetal activity (no oxytocin induction).  

NURSING DIAGNOSES

• Fluid volume excess related to altered blood osmolarity and sodium/water retention.
• Altered nutrition, less than body requirements related to loss through damaged renal membrane.
• Altered tissue perfusion related to increased peripheral resistance and vasospasm in renal and cardiovascular system.
• Altered urinary elimination related to hypovolemia.
• Sensory/perceptual alterations: visual related to cerebral edema and decreased oxygenation of the brain.
• Diversional activity deficit related to decreased time for rest and sleep from stimulating environment.
• Risk for injury related to seizure episodes.
• Anxiety-related to fear of the unknown.    

            The overall goal of management in pregnancy-induced hypertension is directed towards the control of hypertension and the correction of developed health problems that might leadto other serious complications. Among the specially-designed treatment course for PIH are the following:

• Use of antihypertensive drugs (hydralazine-drug of choice)
• Diet-high protein, high calories
•   Magnesium sulphate (MgSO4) treatment
• Diazepam and amobarbital sodium (if convulsions don’t respond to MgSO4)
• Beta-adrenergic blockers (used for acute hypertension)
• Delivery (if all treatment regimen don’t work)

NURSING MANAGEMENT

A.   Assessment

•   Monitor blood pressure in sitting or side-lying position.
• Monitor fetal heart tone (FHT) and fetal heart rate (FHR).
• Check for deep tendon reflexes (DTR) and clonus.
•   Monitor intake and output (I&O) and proteinuria.
• Monitor daily weight and edema.
• Assess for signs of labor (possibility of abruption placenta).
• Assess for emotional status.

B.  Interventions

1.  Fluid balance

• Maintain patent and regulated IVF
• Strict I&O monitoring
• Monitor hematocrit level
• Vital signs monitoring every hour
• Assess breath sounds for signs of pulmonary edema

  2.  Tissue perfusion

•  Position on left-lateral position
• Monitor fetal activity (stress and fetal activity)

3.   Preventing injury

• Monitor cerebral signs and symptoms (headache, visual disturbances, and dizziness)
• Lie on left-lateral position if cerebral symptoms are present
• Secure padded side rails
• Keep oxygen suction set, tongue blade, and emergency medications (diazepam and magnesium sulphate) at all times
• Never leave an unstable patient

4.   Anxiety

 Discuss the health condition and planned treatment

• PIH is not lifetime
• PIH is only for the first pregnancy
• All medications and its maternal and fetal effects

Allow to ask questions and answer it truthfully

Provide emotional support to the client and family

C.   Educative

• Reinforce the importance of rest and sleep
• Encourage family cooperation with the treatment course
• Discuss the laboratory procedures and alternative managements
• Include medical team, client, and significant others in the discussion
• Be realistic in discussing the possibilities of premature delivery  
• No sign of pulmonary edema
• Adequate urine output
• No episode of seizure
• Stable and normal heart rate

RELATED ARTICLES MORE FROM AUTHOR

Anaphylactic shock case study -the impending doom, ectopic pregnancy case study, chronic suppurative otitis media case study, gestational diabetes mellitus case study, leave a reply cancel reply.

Save my name, email, and website in this browser for the next time I comment.

• International

Trump hush money trial

SCOTUS hears Trump immunity case

University protests

Supreme Court hears case about emergency abortion care

By CNN's Tierney Sneed, John Fritze, Hannah Rabinowitz, Jen Christensen and Holmes Lybrand

Idaho’s attorney tells Supreme Court that state law controls medicine

From CNN's John Fritze

Joshua Turner, arguing on behalf of Idaho, told the Supreme Court in opening remarks Wednesday that nothing in the Emergency Medical Treatment and Labor Act preempts the state’s traditional power to regulate medicine.

The administration’s reading, Turner said, is “wholly untenable.”

“Licensing laws limit medical practice, that’s why a nurse isn’t able to perform open heart surgery,” he said. “The answer doesn’t change just because we’re talking about abortion.”

You will hear the acronym EMTALA mentioned a lot in today's arguments. Here's what it means 

From CNN’s Jen Christensen

A law called the Emergency Medical Treatment and Active Labor Act, also known as EMTALA, is at the heart of a Supreme Court case that is before justices on Wednesday. It became law in 1986 after studies showed that  many hospitals were trying to save money by engaging in “patient dumping” or transferring a patient — often uninsured or a member of a minority community — to a public hospital without first providing appropriate care to stabilize them. 

A study at  Cook County Hospital at the time the law passed found that “dumped” patients were twice as likely to die as those who were treated at the hospital where they initially sought care. About a quarter of patients were transferred in what was considered an unstable condition. 

EMTALA required all US hospitals that received Medicare money — essentially nearly all of them — to screen everyone who came to their emergency rooms to determine whether the person had an emergency medical condition. The law then requires hospitals, to the best of their ability, to stabilize anyone with an emergency medical condition or transfer them to another facility that has that capacity. The hospitals must also treat these patients   “until the emergency medical condition is resolved or stabilized.” 

Why this matters to the Idaho case: In 1989 , after reports that some hospitals were refusing to care for uninsured women in labor, Congress expanded EMTALA to specifically say how it included people who were pregnant and having contractions. In 2021, the Biden administration released the  Reinforcement of EMTALA Obligation , which says the doctor’s duty to provide stabilizing treatment “preempts any directly conflicting state law or mandated that might otherwise prohibit or prevent such treatment” although it did not specify whether an abortion has to be provided.

In July 2022, the Biden administration’s  guidance  clarified that EMTALA includes the need to perform stabilization abortion care if it is medically necessary to treat an emergency medical condition.

Here's a look at where abortion access stands in Idaho and across other states:

Supreme Court arguments in major abortion case are underway

The Supreme Court’s arguments in what has the potential to be the most significant abortion case since the high court overturned Roe v. Wade two years ago are now underway.

First up is Josh Turner, the chief of constitutional litigation and policy of the Idaho attorney general’s office.

Turner is expected to argue that the federal government cannot supplant the state’s strict ban on abortion by relying on a Reagan-era federal law that requires hospitals to “stabilize” patients who need emergency care.

Reproductive rights and anti-abortion protesters clash in front of Supreme Court ahead of arguments

From CNN's Gabe Cohen and Aileen Graef

Reproductive rights and anti-abortion activists clashed in front of the Supreme Court on Wednesday just before arguments are slated to start in Moyle v. United States.

Justices are set to hear arguments regarding a law from the 1980s protecting a person’s right to an abortion if they have a life-threatening condition.

The two groups shouted phrases, including "abortion is health care" and "abortion is oppression," while standing shoulder-to-shoulder, highlighting the tense divisions surrounding the issue.

No significant physical altercation has been seen, but they were shouting in each others' faces at times.

The key players in today's oral arguments

From CNN staff

The Supreme Court will soon hear arguments on whether Idaho’s abortion ban can be enforced in medical emergencies. Here are the key players in court today:

The justices:

• Chief Justice  John Roberts   
• Justice  Clarence Thomas   
• Justice  Samuel Alito   
• Justice  Sonia Sotomayor   
• Justice  Elena Kagan   
• Justice  Neil Gorsuch   
• Justice  Brett Kavanaugh   
• Justice  Amy Coney Barrett   
• Justice  Ketanji Brown Jackson   

Arguing in defense of the state abortion ban:

• Joshua Turner , Idaho’s chief of constitutional litigation and policy

Arguing on behalf of the Biden administration: 

• US Solicitor General Elizabeth Prelogar

Order of proceedings: Turner, representing Idaho, is expected to be up first for arguments. Then, Prelogar will respond for the Biden administration in a presentation. Finally, Turner will return to the lectern for a five-minute rebuttal. 

Pregnancy complications are a common medical emergency and childbirth is riskier than abortion

From CNN’s Deidre McPhillips

Pregnancy complications are the fifth most common reason why women age 15 to 64 seek care at emergency departments in the United States, according to  data  published by the US Centers for Disease Control and Prevention’s National Center for Health Statistics. In 2021, pregnancy complications led to about two million emergency department visits, the CDC estimates.  

Warning signs of an emergency during pregnancy can include bleeding, chest pain and dizziness. There is not sufficient data to understand how many of these emergencies require an induced termination, or abortion.  

However, experts say that abortion bans may increase the number of pregnancy-related emergencies and that restricting the option to have an abortion in emergencies can threaten the health and livelihood of the pregnant person. 

“Abortion care is part of standard and proven medical practice to reduce risk and in some cases, save lives. Tying the hands of emergency medicine healthcare workers would pose a major threat to pregnant people and public health,” Dr. Ushma Upadhyay, a professor at the University of California, San Francisco’s Bixby Center for Global Reproductive Health, said in an email. 

“Abortion care is extremely safe, safer than continuing a pregnancy to term,” she said. 

More context: One  study  from 2015 found that only 0.23% of abortions — including medication and procedural cases — resulted in a major complication that required hospital admission, surgery or blood transfusion. Meanwhile, a 2012  study  found that childbirth caused severe complications five times more often, or 1.3% of the time.

Maternal mortality in the US has increased sharply in recent years, rising from about 20 deaths for every 100,000 live births in 2020 to nearly 33 deaths for every 100,000 live births, according to a CDC  report  published last year. The latest abortion surveillance  data  from the CDC suggests that there was less than one death for every 100,000 legal abortions in the US. 

On the political front, Biden attacks Trump for "nightmare" of Dobbs decision

From CNN's Priscilla Alvarez and Nikki Carvajal

President Joe Biden on Tuesday launched one of his most forceful attacks of the 2024 campaign against presumptive Republican nominee Donald Trump – who he said was responsible for the “nightmare” caused by the overturning of Roe v Wade .

“For 50 years the court ruled that it was a fundamental constitutional right to privacy,” Biden said at a campaign stop.

“There’s one person who’s responsible for this nightmare, and he's acknowledged, and he brags about it. That’s Donald Trump.”

Democrats have seized on abortion ahead of November , hoping it could spur moderate voters – particularly women – to turn out in droves against Trump by tying the abortion bans directly to him. Biden’s campaign often cites Democratic successes in the 2022 midterms and off-year elections since Roe was overturned as examples of the issue driving voters to the polls.

Biden also poked fun at the former president for describing “the Dobbs decision as a miracle.”

“Maybe it’s coming from that Bible he’s trying to sell,” Biden joked. “I almost wanted to buy one to see what the hell’s in it."

Biden added: "Folks, it was no miracle — it was a political deal to get rid of Roe – a deal, a political deal he made with the evangelical base of the Republican Party.”

Read more on Biden and presidential abortion politics.

Lawyer for Idaho is making his debut at the Supreme Court

Arguing for Idaho is Josh Turner, a lawyer with Attorney General Raúl Labrador’s office who is making his debut at the Supreme Court.

Turner, whose title is chief of constitutional litigation and policy, joined Labrador’s office last year during a shakeup that involved several senior attorneys . He was previously a business litigation attorney at Faegre Drinker Biddle & Reath .

Turner told Law360 recently that there was “a lot of clamoring” to represent the state before the Supreme Court but that he was “thankful that the attorney general has confidence in me to deliver the argument and represent the people of Idaho.”

What to know about Solicitor General Elizabeth Prelogar, who is arguing on behalf of the Biden administration

From CNN's Tierney Sneed

For the fourth time since she became the federal government’s top Supreme Court advocate, Solicitor General Elizabeth Prelogar is arguing an abortion-related case.

The  dispute before the high court on Wednesday , about whether federal mandates for hospitals override strict state abortion bans in medical emergencies, shows how legal fights over abortion rights did not cease when the conservative majority ended a constitutional right to an abortion in 2022.

In the first two abortion-related cases Prelogar argued, the conservative majority rejected her calls that abortion rights be protected.

But she has eked out wins on other issues where the Biden administration was seemingly at odds with the court’s conservative proclivities, including in tussles over immigration policy and voting rights.

Prelogar, born in 1980, is a former Supreme Court clerk herself, having worked for both the late Justice Ruth Bader Ginsburg and Justice Elena Kagan. The Senate’s 53-36 vote confirming her as solicitor general made her the second women ever to serve in the role, with Prelogar following in the footsteps of Kagan, the solicitor general during the Obama administration.

An Idaho native, Prelogar attended Emory University and then Harvard Law School. She also clerked for her current boss, Attorney General Merrick Garland, when he was a DC Circuit judge, before her Supreme Court clerkships. She went on to litigate Supreme Court cases for private firms and worked on special counsel Robert Mueller’s investigation.

Read more about Elizabeth Prelogar's career here.

Please enable JavaScript for a better experience.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Ethiop J Health Sci
• v.29(1); 2019 Jan

Pregnancy Induced Hypertension and Associated Factors among Women Attending Delivery Service at Mizan-Tepi University Teaching Hospital, Tepi General Hospital and Gebretsadik Shawo Hospital, Southwest, Ethiopia

Tesfaye abera gudeta.

1 MizanTepi University, College of Health science, Department of Nursing, Maternal Health Nursing Unit

Tilahun Mekonnen Regassa

2 MizanTepi University, College of Health Science, Department of Nursing, adult Health Hursing Unit

Disorders of pregnancy induced hypertensive are a major health problem in the obstetric population as they are one of the leading causes of maternal and perinatal morbidity and mortality. The World Health Organization estimates that at least one woman dies every seven minutes from complications of hypertensive disorders of pregnancy. The objective of this study is to assess pregnancy induced hypertension and its associated factors among women attending delivery service at Mizan-Tepi University Teaching Hospital, Gebretsadikshawo Hospital and Tepi General Hospital.

A health facility based cross-sectional study was carried out from October 01 to November 30/2016. The total sample size (422) was proportionally allocated to the three hospitals. Systematic sampling technique was used to select study participants. Variables with p-value of less than 0.25 in binary logistic regression were entered into the multivariable logistic regression to control cofounding. Odds ratio with 95% confidence interval was used. P-value less than 0.05 was considered as statistically significant.

The prevalence of pregnancy induced hypertension was 33(7.9%); of which 5(15.2%) were gestational hypertension, 12 (36.4%) were mild preeclampsia, 15(45.5%) were severe preeclampsia and 1 (3%) eclampsia. Positive family history of pregnancy induced hypertension [AOR5.25 (1.39–19.86)], kidney diseases (AOR 3.32(1.04–10.58)), having asthma [AOR 37.95(1.41–1021)] and gestational age (AOR 0.096(0.04-.23)) were predictors of pregnancy induced hypertension.

The prevalence of pregnancy induced hypertension among women attending delivery service was 7.9%. Having family history of pregnancy induced hypertension, chronic kidney diseases and gestational age were predictors of pregnancy induced hypertension.

Introduction

Hypertension in pregnancy is a systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg or both. Both systolic and diastolic blood pressure raises are important in the identification of Pregnancy induced hypertension ( 1 ). Pregnancy induced hypertension (PIH) is hypertension that occurs after 20 weeks of gestation in women with previously normal blood pressure. The broad classification of pregnancy-induced hypertension during pregnancy is gestational hypertension, pre-eclampsia and eclampsia ( 2 ).

Severe preeclampsia in pregnancy is a systolic blood pressure ≥160 mmHg or diastolic blood pressure ≥110 mmHg or both. Eclampsia is a severe type of pregnancy induced hypertension, and it happens in about one in 1,600 pregnancies and develops near the end of pregnancy ( 4 ). The three primary characteristics of pregnancy induced hypertension conditions are high blood pressure, protein in the urine and pathologic edema ( 3 – 5 ).

Pregnancy induced hypertension is a major contributors to maternal and perinatal morbidity and mortality. In the United States, about 15% of maternal deaths are attributable to hypertension, making it the second leading cause of maternal mortality. Severe hypertension increases the mother's risk of cardiac failure, heart attack, renal failure and cerebral vascular accidents. In addition, the fetus is at increased risk from complications like poor placental transfer of oxygen, growth restriction, preterm birth, placental abruption, stillbirth and neonatal death ( 2 ). Hypertensive disorders represent the most common medical complications of pregnancy with a reported incidence of 5–10% ( 6 , 7 ).

Globally, preeclampsia is a leading cause of maternal and neonatal mortality and morbidity, predominantly in developing countries. The disorder is usually diagnosed in late pregnancy by the presence of high blood pressure with proteinuria and/or edema. Prevention of any disease process needs awareness of its prevalence, etiology and pathogenesis ( 8 ). The World Health Organization estimates that at least one woman dies every seven minutes from complications of pregnancy induced hypertension disorders. Pregnancy complicated with hypertensive disorder is related with increased risk of adverse fetal, neonatal and maternal outcome ( 9 ).

Null parity, multiple pregnancies, history of chronic hypertension, gestational diabetes, fetal malformation , obesity, extreme maternal age (less than 20 or over 40 years), history of PIH in previous pregnancies and chronic diseases like renal disease, diabetes mellitus, cardiac disease, unrecognized chronic hypertension, positive family history of PIH which shows genetic susceptibility, psychological stress, alcohol use, rheumatic arthritis, extreme underweight and overweight, asthma and low level of socioeconomic status are the risk factors for PIH ( 5 , 10 , 11 ). According to a study in South Africa, the incidence of hypertensive disorders of pregnancy was 12%, and it was the commonest cause of maternal death which contributed 20.7% of maternal deaths ( 12 ).

As the Ethiopian Demographic Health survey (EDHS) 2016 reported, maternal mortality ratio is 412 deaths per 100,000 live births, and pregnancy induced hypertension has a countless role for this maternal death ( 13 ). A review study conducted on the causes of maternal mortality in Ethiopia indicated that the proportion of maternal mortality in Ethiopia due to hypertensive disorders between the year of 1980 and 2012 was in an increased trend from 4%–29% ( 14 ).

The Federal Ministry of Health has applied multi-pronged approaches to reducing maternal and newborn morbidity and mortality by improving access to and strengthening facility-based maternal and newborn services but the maternal morbidity and mortality due to pregnancy induced hypertension was in an increasing trend ( 15 ).

Despite the fact that pregnancy induced hypertension is a leading causes of maternal morbidity and mortality during pregnancy, little is known about the current magnitude of PIH, its associated factors among women attending delivery service in Ethiopia and specifically in study areas. Therefore, the objective of this study was to assess pregnancy induced hypertension and its associated factors among women attending delivery service at Mizan Tepi University Teaching Hospital, Gebretsadikshawo Hospital and Tepi General Hospital, Southwest Ethiopia.

Materials and Methods

Study area and period : The study was conducted in Mizan Tepi University Teaching Hospital, Tepi General Hospital and Gebretsadikshawo Hospital found in Benchi Maji, Sheka and Kefa zones from October 01-November 30/2016. Mizan Tepi University Teaching Hospital is located in Bench Maji Zone 560 kms far from Addis Ababa, and Gebretsadikshawo is found 441 kms from Addis Ababa in Kefa Zone and Tepi General Hospital is located in Sheka Zone 565 kms from the capital city of Ethiopia, Addis Ababa.

Study design: Health facility based cross-sectional study design with quantitative data collection method was used.

Source and study population : All women who attended delivery service in Mizan Tepi University teaching Hospital, Tepi General Hospital and Gebretsadikshawo Hospital were considered as source population whereas all sampled women were considered as study population.

Inclusion and exclusion criteria : All admitted women in delivery ward with gestational age greater than 28 weeks were included to the study whereas women with known chronic hypertension and those who were critically ill and unable to communicate after full course of treatment were excluded from the study. A woman who was critically ill due to PIH was waited until she recovered from her illness.

Sample size and sampling technique : The sample size was calculated by using a single population proportion sample size calculation formula by considering the following assumptions: d = margin of error of 5% with 95% confidence interval and P=50% in order to maximized the sample size. By considering 10% none response rate, the final sample size became 422.

The total sample size was proportionally allocated to the three public hospitals based on their source population from each hospital. The source population of each hospital was taken from six-month delivery reports. Then, the average was considered as source population (1030). Afterwards, the study participants were systematically selected from each hospital, and admitted mothers for delivery who were eligible to the study were included until the required sample size was obtained ( Figure 1 ).

Schematic presentation of sampling procedure

Pregnancy induced hypertension (PIH) : A pregnant women attending delivery service with high blood pressure (≥140/90mmHg) after 28 weeks of gestation was measured two times six hours apart by trained data collectors and with or without proteinuria. The diagnosis of PIH was confirmed by a physician working in labour ward. Pregnancy induced hypertension includes gestational hypertension, pre-eclampsia and eclampsia.

Psychological stress : A woman who scored greater than the mean score was considered as psychologically stressed.

Data collection instruments : The data was collected by using pre-tested structured questionnaire adapted from a validated questionnaire ( 16 , 17 ). The questionnaire was first adapted in English and translate into Amharic by an expert and translated back to English to see the consistency of the item. The questionnaire contains sections for assessing demographics and associated factors. The questions and statements were grouped and arranged according to the particular objectives that they were aimed to address. Six data collectors who were degree-holding midwives in qualification fluent in speaking, writing and reading Amharic language were recruited purposefully from their respective facilities to maintain the quality of the data. also Three supervisors were recruited for the same purpose.

Data collection procedure : Data was collected through face-to-face interview, measurements and reviewing of medical records of the mother using pretested structured questionnaire by trained data collectors. Data were collected day and night in order not to miss the cases. Blood pressure reading was taken while the woman was seated in the upright position and supine position using a mercury sphygmomanometer apparatus, and for referred women, BP and protein urea at time of diagnosis were taken from referral form.

Data processing and analysis : EPI data statistical software version 3.1 and Statistical Package for Social Sciences (SPSS) software version 21.0 were used for data entry and analysis. After organizing and cleaning the data, frequencies and percentages were calculated to all variables that were related to the objectives of the study. Variables with p-value less than 0.25 in binary logistic regression analysis were entered into the multivariable logistic regression analysis to control confounders. Odds ratio with 95% confidence interval was used to examine associations between dependent and independent variables. P-value less than 0.05 was considered significant. Finally, the result was presented by using tables and narrative forms.

Data quality control measures : The quality of the data was assured by using validated and pretested questionnaire. Prior to the actual data collection, pre-testing was done on 5% of the total study subjects at Chena Hospital which was not included in the actual study, and based on the findings necessary amendments were made. Reliability of the questions used to measure psychological stress of mothers was tested by Cronbach's alpha test (0.89). Data collectors were trained for one day intensively on the study instrument and data collection procedure that included the relevance of the study, the objective of the study, confidentiality of the information, informed consent and interview technique. The data collectors worked under close supervision of the supervisors to ensure adherence to correct data collection procedures. The supervisors reviewed the filled questionnaires at the end of data collection every day for completeness.

Every morning, the supervisors and the data collectors conducted a morning session to solve problem, if encountered, as early as possible and to take corrective measures accordingly. Moreover, the data was carefully entered and cleaned before the analysis.

Ethical considerations : The study did not involve any experiment, and no harm was expected on human subjects, exception of benefit. Ethical clearance from Mizan Tepi University and permission from respective authorities and written consent of respondents' were obtained before the data collection. To get full co-operation, respondents were reassured about the confidentiality of their responses. They were also informed their voluntarily participation and right to take part or terminate at any time they wanted. Since the subjects of the study could raise ethical issues, care was taken in the design of the questionnaire.

Socio-demographic characteristics : Among the total study participants, 155(37.3%) were aged between 20–24 years, more than half 236(56.7%)of the respondents were orthodox in religion, and 403(96.9%) were married. Almost half of the participants were from rural areas, 214(51.4%). Regarding their educational level, 150(36.1%) of the respondents attended primary school, the majority 276(66.3%) were housewives, and 230(55.3) of the family sizes of the participants were between 3–4 ( Table 1 ).

Distribution of the study participants by their socio- demographic characteristics at MTUTH, Tepi and Gebretsadikshawo hospitals, south west Ethiopia, Nov, 2016

Prevalence of pregnancy induced hypertension : The prevalence of pregnancy induced hypertension among women attending delivery service in the three hospitals of this study was 33(7.9%). The mean of systolic blood pressure was 110.72±15.315 with range of 90 mmHg to 210 mmHg, and the mean of diastolic blood pressure was 72.71±13.093 with range of 50 mmHg to160 mmHg. The result of proteinuria ranged from negative to 3+ in dipstick test. Out of the total of women who had pregnancy induced hypertension, 5(15.2%) were gestational hypertension, 12(36.4%) were mild preeclampsia, 15(45.5%) were severe preeclampsia and 1(3%) were eclampsia.

Variables related to obstetric conditions : Out of the pregnant women who participated in study, 408(98.1%) of the pregnancy were wanted, and 224(53.8%) of pregnancy were multigravida. Regarding parity of the women, 261(62.7%) had parity of 1–4, and the majority, 309(74.3%) of gestational ages were between 37 and 42 weeks. Only 5(1.3%) of the pregnant mothers who were admitted for delivery had previous history of PIH, only 3(0.8) of them had history of gestational diabetic mellitus while 20(4.8%) of the pregnancies were multiple ones ( Table 2 ).

Frequency distribution of variables related to obstetric conditions among women attending delivery service at MTUTH, Tepi and Gebretsadikshawo hospitals, southwest Ethiopia, 2016

NB : GDM=Gestational Diabetic Mellitus

Medical and family history related variables : Regarding medical and family histories of illness, out of the total, 43(10.3%) had family history of chronic hypertension, 16(3.8%) of them had family history of pregnancy induced hypertension commonly from their mothers, 11(84.6). Regarding kidney diseases, 32(7.7%) of the respondents had history of kidney diseases during the current pregnancy, and only 7(1.7%) of them had history of chronic diabetic mellitus. From the study participants, only 36(8.7%) of them had family history of diabetic mellitus and 2 (0.5%) of them had history of asthma ( Table 3 ).

Distributions of medical and family history risk factors among delivered women at MTUTH, Tepi and Gebretsadikshawo hospitals, South west Ethiopia, 2016

Variables related to personal risks : Among the respondents, 9(2.2%) had history of smoking cigarette, of which 2(0.5%) were current smokers while 23(5.5%) of the family members smoked cigarette, mostly the husbands, 20 (87%). From the total of the mothers attending delivery service, 350(84.1%) had mid upper arm circumference ≥21cm whereas 66(15.9%) them were <21cm.

Regarding sleeping pattern of women during current pregnancy, more than half, 250(60.1%), of them sleep ≥9 hours per night, and 164(39.4%) of women were doing scheduled regular physical exercise during their current pregnancy. Based on the nine items used to assess psychological stress, 171(41.1%) of the women had psychological stress during current pregnancy ( Table 4 ).

Distribution of the study subjects by their personal risk factors among women attending delivery service at MTUTH, Tepi and Gebretsadikshawo hospitals, Southwest Ethiopia, Nov, 2016

Variables related to health facility utilization : According to this study, 406(97.6%) of the pregnant mothers utilized health facility for ANC follow-up, of which 8(2%) attended first visit of their routine ANC follow-up and 398 (98%) attended ANC more than twice. Regarding utilization of health facilities for health problems other than the current pregnancy, only 132(31.7%) utilized health facilities for gynecology, surgical and medical problems.

Predictors of pregnancy induced hypertension : In the multivariable logistic regression analysis, factors contributing to pregnancy induced hypertension were identified: Positive family history of pregnancy induced hypertension, kidney diseases during pregnancy, asthma and gestational age had statistically significant associations with pregnancy induced hypertension ( Table 5 ).

Multivariable logistic regression analysis of pregnancy induced hypertension and associated factors among women attending delivery service at MTUTH, Tepi and Gebretsadikshawo hospital, Southwestern 11 Ethiopia, 2016

The pregnant women attending delivery service with family history of pregnancy induced hypertension were five times more likely to develop pregnancy induced hypertension than those who did not have family history of pregnancy induced hypertension (AOR=5.25 at 95%CI= (1.39–19.86).

As this study showed, having kidney diseases during pregnancy was 3.25 times more likely to develop pregnancy induced hypertension as compared to pregnant mothers who did not have kidney diseases during pregnancy (AOR=3.32 at 95%CI= (1.04–10.58). Women who had asthma more likely develop pregnancy induced hypertension by 38 times as compared with women those attending delivery service did not have asthma (at 95% CI, AOR=37.95(1.41–1021).

In this study, gestational was age identified as predictor, indicating that women with gestational age greater than or equal to 37 weeks were less likely to develop pregnancy induced hypertension by 9.6% as compared to women gestational age less than 37 weeks (AOR=0.096 at 95% CI(0.04–0.23) ( Table 5 ).

The prevalence of pregnancy induced hypertension among women attending delivery service in this study was 33(7.9%). This might increase the morbidity and mortality of the mother and the fetus. If appropriate preventive measures are not taken for the risk of pregnant women, in long term, it might be the first cause of maternal mortality. The prevalence of PIH in this study is similar with the study conducted in India which was 7.8 % ( 18 ). However, it is slightly lower than the findings of studies done in Iran 9.8% ( 19 ), in Jimma University Specialized Hospital (8.48%) and Dessie Referal Hospital, 8.4%( 20 , 21 ).

This difference might be attributed to differences in the study period and study design. The population might also be different in lifestyle and culture. However, the prevalence in this study is still greater than the study done in Ethiopia at Tikur Anbessa Hospital which was 5.3% and Mettu Karl Hospital, 2.4% ( 7 , 22 ).

This discrepancy might be because of differences in the study period, study design and health seeking behaviors of pregnant women. In addition, the gap might be due to current health policy which focuses on implementation of focused ANC and exempted service for maternal care which increases the health care seeking behavior of pregnant women and delivery at health facility which increases detection of the case.

In this study, some associated factors of pregnancy induced hypertension were also identified. Having family history of pregnancy induced hypertension had about five times greater odds of developing pregnancy induced hypertension. This is consistent with the study conducted in Ghana ( 23 ) and in the textbook of current diagnosis and treatment in obstetrics and gynecology ( 2 ). This might have occurred due to genetic factors that contribute to the physiologic predisposition of pregnancy induced hypertension.

This study revealed that having kidney diseases during pregnancy increases the likelyhood of pregnancy induced hypertension. This finding was similar with the study conducted in Public Health facility of Dirashe Woreda which showed that preexisting renal diseases had statistically significant associations with pregnancy induced hypertension ( 24 ). Other theories also support that renal physiological function had direct relationship with cardiovascular system ( 2 ).

This study also showed that women who had asthma are at more risk to develop pregnancy induced hypertension than those who did not have asthma. This is in line with the study conducted in New York and Canada ( 25 , 26 ). The other variable associated with PIH in this study was gestational age, which showed that women with gestational age greater than or equal to 37 weeks were less likely to develop pregnancy induced hypertension than women with gestational age less than 37 weeks. However this is inconsistent with the literature. This might be due to the fact that the population of this study was women attending delivery service so that more women with PIH might be delivered before and around 37 weeks of gestational age to reduce the risk of maternal and fetal complication.

As any other cross-sectional study, this study has strength and weakness. The possible limitations may arise from women's readiness and ability to provide every information about themselves and their family correctly based on which PIH was related and; recall and social desirability bias may be introduced during data collection from the pregnant women as they were self-referred. However, measure has been taken to minimize these limitations by using targeted questions.

The other limitation of this study was few variables have small observation which causes lower precision, so it was carefully interpreted. Inclusion of all hospitals from the three zones was strength of this study.

The prevalence of pregnancy induced hypertension among women attending delivery service was 7.9% which indicates that a significant number of women attending delivery services at Mizan Tepi Teaching Hospital, Gebretsadikshawo and Tepi Hospital developed pregnancy induced hypertension. Among pregnancy induced hypertensions, severe preeclampsia was the most common. Having family history of pregnancy induced hypertension, chronic renal diseases (kidney diseases) and gestational age were the factors associated with pregnancy induced hypertension.

Acknowledgment

We are extremely grateful to the Mizan Tepi University for grant fund, study subjects involved in the study, data collectors and supervisors.