ch 27 OB complications (HTN, endocrine) Flashcards
4 HTN disorders
-gestational HTN
-preeclampsia
-eclampsia
-chronic HTN
maternal consequences of HTN
-hepatic, renal, cardiac dysfunction/failure
-placental abruption
-coagulopathy/DIC
-cerebral hemorrhage
-pulmonary edema
-seizures
-stroke
-death
causes perinatal morbidity relating to HTN
-uteroplacental insufficiency
-premature birth
-death
UPI
uteroplacental insufficiency
Development of hypertension after week 20 of pregnancy in a previously normotensive woman
*without proteinuria or other systemic findings
gestational hypertension
what mmHg is considered HTN
> 140/>90
on 2 separate occasions atleast 4 hours apart
Development of hypertension and proteinuria in a previously normotensive woman after 20 weeks of gestation or in the early postpartum period
*with proteinuria or w/o proteinuria but other complications
preeclampsia
low platelets
thrombocytopenia
other complications with preeclampsia if woman doesn’t have proteinuria
-thrombocytopenia
-renal insufficiency
-impaired liver function
-pulmonary edema
-cerebral/visual symptoms
what are severe features of preeclampsia (7)
-BP >160/>110
-Plt < 100 K
-Impaired liver function
-Renal insufficiency
-Pulmonary edema
-New onset Headache unresponsive to med & not due to alternate dx
-Visual Disturbances
onset of seizure activity or coma in woman with preeclampsia
eclampsia
Hypertension in a pregnant woman present before pregnancy
chronic HTN
when does preeclampsia begin to resolve
after delivery of placenta
what doesn’t happen with woman with preeclampsia concerning spiral arteries
spiral arteries don’t dilate and straighten
less blood flow to placenta
risk of UPI
consequences at the cellular level of preeclampsia
-increased endothelial cell permeability (proteins and fluid go to ECF)
-increased blood concentration (increased RBCs and Hct)
-affects kidneys ability to reabsorb (causing proteinuria)
-nondependent edema (possibility for every organ swells)
-vasospasm
-decreased organ perfusion
-thrombocytopenia (platelet buildup in cells)
-*oliguria
-retinal arteriospasms (visual disturbances)
-DIC (micro-clots everywhere)
preeclampsia:
-what could cause increased RBC/Hct?
-what could cause decreased RBC/Hct?
-increased: increased blood concentration due to fluids going to ECF
-decreased: platelet buildup in cells tears up RBCs
DIC
disseminated intravascular coagulation
(body uses up all of clotting factors to patch up leaky blood vessels)
variant of severe preeclampsia
HELLP syndrome
what is included in HELLP syndrome for preeclampsia
-H: Hemolysis (decreased Hct)
-EL: elevated liver enzymes (hepatic dysfunction)
-LP: low platelets (<100,000)
variant of preeclampsia that may not have increased bp
HELLP syndrome
S+S HELLP syndrome (not labs)
-malaise
-epigastric/RUQ pain
-N/V
Tx HELLP syndrome
magnesium sulfate therapy
high risk factors preeclampsia (6)
-Hx preeclampsia
-multifetal pregnancy
-chronic HTN
-pregestational diabete (T1 or T2)
-renal disease
-autoimmune disease
moderate risk factors preeclampsia (6)
-primigravida
-maternal age >35 yo (previously included <19 yo)
-BMI >30 yo
-family h/o preeclampsia
-socio-demographic characteristics (non-white)
-personal history factors
other risk factors preeclampsia (not included in high risk or moderate) (4)
-gestational diabetes
- preexisting thrombophilia
-assisted reproductive technology (IVF)
-obstructive sleep apnea
subjective (CNS) S+S preeclampsia
-visual disturbances
-headaches
-N/V
subjective (hepatic) S+S preeclampsia
-epigastric
-RUQ pain
subjective (renal) S+S preeclampsia
oliguria
subjective (fetal) S+S preeclampsia
-decreased fetal movement
-unusual/extreme activity
subjective (placental) S+S preeclampsia
-vaginal bleeding
-rigid abdomen
-abdominal pain
objective S+S preeclampsia
-BP
-edema (distribution, degree, pitting)
-DTRs and ankle clonus
-blood (CBC, clotting, liver enzymes, chemistry panel)
-urine (dipstick 2+ protein)
where do you check DTR in woman with epidural
upper extremity
what happens to BUN and creatinine in preeclampsia
increased BUN and creatinine
(decreased renal function)
when do you do a 24 hour urine protein test preeclampsia
2+ protein on dipstick screening
what indicates positive result in 24 hour urine protein test for preeclampsia
-protein >300 mg
-protein creatinine ration >0.3
assessment of fetal status in preeclampsia (4)
-electronic monitoring
-biophysical profile
-serial sonograms (decreased growth, decreasing AFI)
-doppler blood flow
prevention (decrease risk in woman with 1 high or 2 moderate risk factors) preeclampsia
-81 mg/day aspirin
-begin at 12-28 weeks EGA through birth
when is the woman with preeclampsia (w/o severe features) usually induced to deliver
37 weeks
outpatient management for woman <37 EGA with preeclampsia
-home monitoring of BP and symptoms
-daily fetal movement
-1-2x/week: BP, NST, labs, urine protein
-ultrasound to monitor AFI and fetal growth
-activity restrictions
-diet (high protein, salt reduction)
plan of care for woman with preeclampsia w/ severe features at 34 weeks EGA
birth
plan of care for woman with preeclampsia w/ severe features <34 weeks
-corticosteroids
-possible birth
-inpatient care in tertiary care center
-oral antiHTN med
-continuous maternal and fetal assessments
-birth for any indication of worsening condition
corticosteroid given to mom to facilitate fetal lung maturity
betamethasone
(takes atleast 48 hours to reach max benefit)
assessments (and frequency) for woman in expectant management for preeclampsia w/ severe features
-daily assessment for signs of coagulopathy
-q shift: DTR, clonus, breath sounds
-q4h: LOC, BP, HR, RR
-q1h: I&O
-ongoing: vaginal bleeding, signs of abruption
-continuous EFM
-patent IV (16-18G)
-foley
signs of coagulopathy
-petechiae
-bruising
-oozing blood from puncture sites
-labs: platelet, fibrinogen
frequency of assessments during intrapartum for woman with preeclampsia w/ severe features
-q1h: BP and HR
-q1h: DTR, urine protein
-q4h: I&O, breath sounds, headache, visual disturbances, RUQ pain
-labs (renal function, liver enzymes, CBC, clotting studies)
how often is BP checked when magnesium sulfate therapy is started
q15 minutes
nursing interventions to promote safety during intrapartum period for woman with preeclampsia w/ severe features
-decrease stimulation (dark, quiet room)
-emergency meds and suction checked and available (every shift)
-call button in reach
-emergency birth pack checked and available
-maintain total fluid take <125 mL/hr
meds given during intrapartum period for woman with preeclampsia w/ severe features (3)
-magnesium sulfate for seizure prevention
-corticosteroids for fetal lung development
-antiHTN med for bp control
what are anesthesiologists concerned about when placing epidural for woman with preeclampsia w/ severe features during intrapartum
won’t place when platelets under 100k
worried about subdural hematoma
3 reasons for giving magnesium sulfate
-preeclampsia/eclampsia, HELLP
-preterm labor
-fetal neuroprotection (preterm)
how is magnesium sulfate administered
-IVPB through infusion pump
-DEEP IM (alternating buttock)
what is loading dose for mag sulfate IVPB? maintenance dose?
loading: 4-6 g in 100 mL over 15-30 min
maintenance: 1-4 g/hr
what is loading dose for mag sulfate IM? maintenance dose?
loading: 5 G in each buttock
maintenance: 5 G q4h (alternating buttocks)
when would IM injection be used for magnesium sulfate
-no IV access and seizure is imminent/present
-transport to other care center
mag sulfate level for therapeutic range
5-9 mg/dL
mag sulfate level that results in loss of patellar reflex
> 9 mg/dL
mag sulfate level that results in respiratory paralysis
> 12 mg/dL
mag sulfate level that results in cardiac arrest
> 30 mg/dL
normal magnesium blood level (mg/dL) in non-pregnant woman
1.7-2.2 mg/dL
side effects mag sulfate therapy
-flushing: warm sensation
-diaphoresis
-N/V
-dry mouth
-lethargy and generalized weakness
-burning at IV site
S+S magnesium toxicity (4)
-absent DTRs
-lowered resps (<12)
-decreased LOC
-slurred speech
antidote for mag toxicity
1 gm calcium gluconate IV SLOW push
ongoing assessments for mom receiving mag therapy
-DTR, RR, BP, HR, LOC
-lab values
-urinary output
-watching for S+S toxicity
nursing consideration with calcium gluconate antidote for mag toxicity
-connect EKG (can cause heart arrhythmia)
effects of mag therapy on fetus/neonate
-decreased fetal HR variability
-rarely toxic in term normal weight neonate
S+S toxic levels in neonate with mag therapy (2)
-marked slowing of resps
-hyporeflexia
indication (mmHg) of antiHTN meds for woman with HTN condition in pregnancy
systolic >160
diastolic >110
bp goals of Tx with antiHTN med
*slowly decrease bp (maintain good cardiac output)
bp systolic 140-150
bp diastolic 90-100
antiHTN meds
-hydralazine
-labetalol
-methyldopa
-nefedipine (CCB)
what antiHTN med category is contraindicated in pregnancy
ACE inhibitor
contraindications to using labetalol
-asthma
-heart disease
-CHF
contraindications to using nefedipine
concurrent use with mag therapy
how long is mag therapy continued postpartum
24 hours
frequency of assessment postpartum for woman who received mag therapy
-q1h while on mag, then q4h for 48 hours: BP, RR, DTR, I&O
-q4h for 48 hours: LOC, breath sounds, headache, vision, RUQ pain, uterine tone, fundal height
how do you know woman with preeclampsia is improving
lots of diuresis
when is risk for pulmonary edema highest (for woman with or without preeclampsia)
postpartum
why is uterine monitoring postpartum extremely important for mom who received mag
mag = muscle relaxant
increased risk uterine atony, PPH
warning signs eclampsia
-persistent headache
-blurred vision
-photophobia
-RUQ pain
-altered mental status
-seizure (tonic clonic) without warning
S+S tonic clonic seizure
-no resps
-hypoTN and coma
-nystagmus and muscular twitching
-incontinent or urine and stool
-disorientation and amnesia
-oliguria/anuria
nursing care during seizure
-patent airway: turn head to side, place pillow under one shoulder or back
-call for assistance
-side rails up (pad if possible)
-observe and record time
nursing care after seizure
-assess: ABC
-turn on side
-suction
-O2
-check IV
-mag sulfate IVPB: initiate or increase
-foley
-assess fetus, uterus, cervix
-notify NICU of pt status/plans for birth
-expedite labs
-hygiene and quiet environment
antiHTN therapy for woman with chronic HTN and high risk for complications
-labetalol (contraindicated with asthma, HF)
-methyldopa (drug of choice)
-nefedipine (CCB, can’t be given with mag)
what to assess in postpartum mom with chronic HTN
-renal failure: decreased urine output, labs
-pulmonary edema: crackles, SOB, pink frothy sputum
-heart failure: edema, pulmonary edema S+S
-encephalopathy
4 endocrine and metabolic disorders in pregnancy
-diabetes mellitus
-hyperemesis gravidarm
-hyper/hypothryoidism
-phenylketonuria
type 1 or type 2 DM that existed prior to 2nd trimester pregnancy
pregestational diabetes
DM that is diagnosed during 2nd/3rd trimester of pregnancy
gestational diabetes
normal changes (endocrine) during first half pregnancy
-increased estrogen and progesterone
-increased insulin production
-extra storage energy
-decreased blood sugar (risk hypoglycemia)
normal changes (endocrine) during second half pregnancy
-increased estrogen, progesterone, prolactin, cortisol, insulinase (all from placenta)
-insulin resistance
-decreased maternal use glucose
-increased glucose available to fetus
risks and complications for women with pregestational DM
-miscarriage/congenital malformations
-fetal macrosomia (w/ shoulder dystocia): C/S, operative vaginal birth, traumatic birth
-HTN disorders
-preterm labor/birth
-polyhydramnios
-infections
-hyperglycemia/ketoacidosis
-hypoglycemia
-newborn RDS (decreased surfactant), polycythemia (made more RBCs because more O2 was needed)
does woman with pregestational diabetes need more/less insulin during 1st half pregnancy?
more/less insulin during 2nd half pregnancy?
-1st half: less because increased insulin production
-2nd half: more because increased insulin resistance
increased risks of complications due to polyhydramnios
-supine hypoTN
-dysnpea
-PPROM, preterm labor
-PPH
-abruption
-uterine dysfunction
consequence polycythemia for neonate at birth
hyperbilirubinemia
care management of woman with pregestational diabetes: preconception
-strict glucose control
-A1C <6-6.5
-assess vasculopathy, neuropathy, nephropathy, retinopathy
target glucose levels for woman with pregestational diabetes antepartum
-fasting: 60-105
-postmeal 1 hr: <140
-postmeal 2 hr: <120
-2 am to 6 am: >60
med of choice for managing pregestational diabetes
insulin
(not oral hypoglycemics)
why do women with pregestational diabetes need to test blood glucose and not urine
pregnancy causes trace amounts of glucose in urine
possible complications antepartum for woman with pregestational diabetes
-preeclampsia
-polyhydramnios
-preterm labor
-infection
most common fetal anomalies in woman with pregestational DM
-neural tube defect (test MSAFP)
-heart (fetal echocardiogram)
when is fetal echocardiogram performed for mom with pregestational DM
20-22 weeks
when do kick counts start for mom with pregestational DM
28 weeks
when does NST/BPP start for mom with pregestational DM
28-32 weeks
2x/week
intrapartum care for moms with pregestational DM
-mainline IV with NS or RL
-IVPB with D5W
-IVPB insulin
-glucose monitor q1h (90-110)
-continuous EFM
-epidural (in case of stat C/S or shoulder dystocia)
-lateral positioning
-monitor for FTP/CPD
-monitor for ketonuria
FTP
failure to progress
CPD
cephalopelvic disproportion (associated with failure to progress)
nursing considerations postpartum care for mom with pregestational DM
-insulin requirements drop quickly in first 24 hrs PP (DC IV insulin)
-risk PPH (due to uterine distention)
-risk infection
-delayed lactogenesis
benefit of breastfeeding for pregestational DM mom (+baby)
-decreases fetal risk for DM
-lowers mom’s blood sugar with breastfeeding
risk factors gestational DM
-maternal age >25 yo
-obesity
-HTN
-family h/o T2DM
-race (non-white)
-OB history (large baby, unexplained miscarriages, infant w/ congenital anomaly)
*many don’t have any risk factors
moms with gestational DM are at higher risk for developing what in later life
type 2 diabetes
why does gestational DM have reduced risk miscarriage/fetal anomalies (as opposed to pregestational DM)
gestational DM develops in 2nd half of pregnancy
fetus is already well developed
when are women screened for gestational DM
at first prenatal visit (if have risk factors for T2DM)
repeated at 24-28 weeks
what happens in 2 step method for gestational DM
-1 hour 50 g oral glucose screen (have light, high protein breakfast before)
-if positive: 3 hour 100 g oral glucose tolerance test (NPO for 8-12 hrs before test)
OGTT
oral glucose tolerance test
what blood glucose values are positive for gestational DM
if 2 or more values are met/exceeded:
-fasting: 95
-1 hr: 180
-2 h: 155
-3 h: 140
instructions for woman coming in for oral glucose test
1 hr test: can eat before (light, high protein breakfast recommended)
3 hr test: NPO for 8-12 hrs before, no smoking or caffeine. blood glucose tested at 1 hr, 2 hr, 3 hr
what blood glucose value means woman passed 1 hr oral glucose screen
<130-140
glucose control goals antepartum for women with gestational DM (fasting, 1 hr, 2 hr)
-fasting: <95
-1 hr: <140
-2 hr: <120
antepartum fetal surveillance for mom with gestational DM
-non stress test 2x/week starting at 32 weeks
-monitor for polyhydramnios
intrapartum blood glucose assessment frequency for mom with gestational DM
-hourly blood glucose: maintain 80-110
what test do women with gestational DM need after they’re done breastfeeding or 4-12 weeks PP
-CHO intolerance test (for T2DM)
-repeat q1-3years
-must be tested before another pregnancy
IDM
infant of diabetic mom
what type DM is higher risk for SGA
-type 1 pregestational DM because vasculopathy (+nephropathy) results in placenta insufficiency
possible complications for infant of diabetic mom
-hypoglycemia
-birth trauma/shoulder dystocia/asphyxia
-congenital anomalies (cardiac, neuro, musculoskeletal)
-polycythemia
-hyperbilirubinemia
-hypocalcemia
-hypomagnesemia
-resp distress/premature birth
what level is considered neonatal hypoglycemia
<40
risk factors neonatal hypoglycemia
-prematurity
-SGA/IUGR
-LGA
-discordant twin (twin to twin transfusion)
-polycythemia
-intrapartum asphyxia
-cold stress/hypothermia
-resp distress syndrome
-sepsis
-maternal meds (corticosteroids, terbutaline, propranolol, oral hypoglycemics)
maternal meds that could cause neonatal hypoglycemia
-corticosteroids
-terbutaline
-propranalol
-oral hypoglycemics
when should LGA and IDM babies be fed after birth
within 1 hr
excessive vomiting (inability to keep down fluids and solid foods for 24 hours)
hyperemesis gravidarum
what mom cannot receive mag sulfate therapy (contraindicated)
and would receive -pam drug instead
myasthenia gravis
S+S that accompany hyperemesis gravidarum
-weight loss (5% of prepregnancy weight)
-electrolyte imbalance
-nutritional deficiency
-ketonuria
risk factors hyperemesis gravidarum
-hyperthyroidism
-h/x of with previous pregnancy
-BMI <18.5 or >25
-prepregnancy psychiatric diagnosis
-molar pregnancy
-multiple gestation
-family h/x of
medical management hyperemesis gravidarum
-IV fluids
-pyridoxine w/ or w/o doxylamine succinate
-diclegis/bonjesta
-promethazine (phenergan)
-metoclopramide (reglan)
-corticosteroids : CAUTION
-antacids, Hblockers, PPI
-enteral/parenteral nutrition prn
fetal effects phenylketonuria
-intellectual disability
-microcephaly
-seizures
-growth impairment
-cardiac abnormalities
Tx pregnant woman with phenylketonuria
strict compliance with phenylalanine diet before conception and throughout pregnancy
can women with phenylketonuria breastfeed
yes,
can combine with medical phenylalanine free formula
S+S graves disease (thyroid disorder) in pregnancy
-heat intolerance
-sweating
-fatigue
-anxiety
-emotional lability
-tachycardia
-weight loss
-goiter
Tx graves disease during pregnancy
-drug therapy
(potentially dangerous maternal side effects of meds)
S+S thyroid storm during pregnancy
-fever
-restlessness
-tachycardia
-vomiting
-stupor
Tx thyroid storm
STAT EMERGENCY
-IV fluids
-oxygen
-meds: PTU, iodide, antipyretic, dexamethasone, b blocker
potential consequences of severe hypothyroidism
-infertility
-increased risk miscarriage
S+S hypothyroidism during pregnancy
-weight gain
-lethargy
-decrease in exercise capacity
-cold intolerance
