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OB > ch 27 OB complications (HTN, endocrine) > Flashcards

ch 27 OB complications (HTN, endocrine) Flashcards

1
Q

4 HTN disorders

A

-gestational HTN
-preeclampsia
-eclampsia
-chronic HTN

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2
Q

maternal consequences of HTN

A

-hepatic, renal, cardiac dysfunction/failure
-placental abruption
-coagulopathy/DIC
-cerebral hemorrhage
-pulmonary edema
-seizures
-stroke
-death

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3
Q

causes perinatal morbidity relating to HTN

A

-uteroplacental insufficiency
-premature birth
-death

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4
Q

UPI

A

uteroplacental insufficiency

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5
Q

Development of hypertension after week 20 of pregnancy in a previously normotensive woman
*without proteinuria or other systemic findings

A

gestational hypertension

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6
Q

what mmHg is considered HTN

A

> 140/>90
on 2 separate occasions atleast 4 hours apart

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7
Q

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

A

preeclampsia

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8
Q

low platelets

A

thrombocytopenia

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9
Q

other complications with preeclampsia if woman doesn’t have proteinuria

A

-thrombocytopenia
-renal insufficiency
-impaired liver function
-pulmonary edema
-cerebral/visual symptoms

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10
Q

what are severe features of preeclampsia (7)

A

-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

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11
Q

onset of seizure activity or coma in woman with preeclampsia

A

eclampsia

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12
Q

Hypertension in a pregnant woman present before pregnancy

A

chronic HTN

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13
Q

when does preeclampsia begin to resolve

A

after delivery of placenta

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14
Q

what doesn’t happen with woman with preeclampsia concerning spiral arteries

A

spiral arteries don’t dilate and straighten
less blood flow to placenta
risk of UPI

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15
Q

consequences at the cellular level of preeclampsia

A

-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)

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16
Q

preeclampsia:
-what could cause increased RBC/Hct?
-what could cause decreased RBC/Hct?

A

-increased: increased blood concentration due to fluids going to ECF
-decreased: platelet buildup in cells tears up RBCs

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17
Q

DIC

A

disseminated intravascular coagulation
(body uses up all of clotting factors to patch up leaky blood vessels)

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18
Q

variant of severe preeclampsia

A

HELLP syndrome

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19
Q

what is included in HELLP syndrome for preeclampsia

A

-H: Hemolysis (decreased Hct)
-EL: elevated liver enzymes (hepatic dysfunction)
-LP: low platelets (<100,000)

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20
Q

variant of preeclampsia that may not have increased bp

A

HELLP syndrome

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21
Q

S+S HELLP syndrome (not labs)

A

-malaise
-epigastric/RUQ pain
-N/V

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22
Q

Tx HELLP syndrome

A

magnesium sulfate therapy

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23
Q

high risk factors preeclampsia (6)

A

-Hx preeclampsia
-multifetal pregnancy
-chronic HTN
-pregestational diabete (T1 or T2)
-renal disease
-autoimmune disease

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24
Q

moderate risk factors preeclampsia (6)

A

-primigravida
-maternal age >35 yo (previously included <19 yo)
-BMI >30 yo
-family h/o preeclampsia
-socio-demographic characteristics (non-white)
-personal history factors

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25
Q

other risk factors preeclampsia (not included in high risk or moderate) (4)

A

-gestational diabetes
- preexisting thrombophilia
-assisted reproductive technology (IVF)
-obstructive sleep apnea

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26
Q

subjective (CNS) S+S preeclampsia

A

-visual disturbances
-headaches
-N/V

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27
Q

subjective (hepatic) S+S preeclampsia

A

-epigastric
-RUQ pain

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28
Q

subjective (renal) S+S preeclampsia

A

oliguria

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29
Q

subjective (fetal) S+S preeclampsia

A

-decreased fetal movement
-unusual/extreme activity

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30
Q

subjective (placental) S+S preeclampsia

A

-vaginal bleeding
-rigid abdomen
-abdominal pain

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31
Q

objective S+S preeclampsia

A

-BP
-edema (distribution, degree, pitting)
-DTRs and ankle clonus
-blood (CBC, clotting, liver enzymes, chemistry panel)
-urine (dipstick 2+ protein)

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32
Q

where do you check DTR in woman with epidural

A

upper extremity

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33
Q

what happens to BUN and creatinine in preeclampsia

A

increased BUN and creatinine
(decreased renal function)

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34
Q

when do you do a 24 hour urine protein test preeclampsia

A

2+ protein on dipstick screening

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35
Q

what indicates positive result in 24 hour urine protein test for preeclampsia

A

-protein >300 mg
-protein creatinine ration >0.3

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36
Q

assessment of fetal status in preeclampsia (4)

A

-electronic monitoring
-biophysical profile
-serial sonograms (decreased growth, decreasing AFI)
-doppler blood flow

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37
Q

prevention (decrease risk in woman with 1 high or 2 moderate risk factors) preeclampsia

A

-81 mg/day aspirin
-begin at 12-28 weeks EGA through birth

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38
Q

when is the woman with preeclampsia (w/o severe features) usually induced to deliver

A

37 weeks

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39
Q

outpatient management for woman <37 EGA with preeclampsia

A

-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)

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40
Q

plan of care for woman with preeclampsia w/ severe features at 34 weeks EGA

A

birth

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41
Q

plan of care for woman with preeclampsia w/ severe features <34 weeks

A

-corticosteroids
-possible birth
-inpatient care in tertiary care center
-oral antiHTN med
-continuous maternal and fetal assessments
-birth for any indication of worsening condition

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42
Q

corticosteroid given to mom to facilitate fetal lung maturity

A

betamethasone
(takes atleast 48 hours to reach max benefit)

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43
Q

assessments (and frequency) for woman in expectant management for preeclampsia w/ severe features

A

-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

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44
Q

signs of coagulopathy

A

-petechiae
-bruising
-oozing blood from puncture sites
-labs: platelet, fibrinogen

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45
Q

frequency of assessments during intrapartum for woman with preeclampsia w/ severe features

A

-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)

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46
Q

how often is BP checked when magnesium sulfate therapy is started

A

q15 minutes

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47
Q

nursing interventions to promote safety during intrapartum period for woman with preeclampsia w/ severe features

A

-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

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48
Q

meds given during intrapartum period for woman with preeclampsia w/ severe features (3)

A

-magnesium sulfate for seizure prevention
-corticosteroids for fetal lung development
-antiHTN med for bp control

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49
Q

what are anesthesiologists concerned about when placing epidural for woman with preeclampsia w/ severe features during intrapartum

A

won’t place when platelets under 100k
worried about subdural hematoma

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50
Q

3 reasons for giving magnesium sulfate

A

-preeclampsia/eclampsia, HELLP
-preterm labor
-fetal neuroprotection (preterm)

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51
Q

how is magnesium sulfate administered

A

-IVPB through infusion pump
-DEEP IM (alternating buttock)

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52
Q

what is loading dose for mag sulfate IVPB? maintenance dose?

A

loading: 4-6 g in 100 mL over 15-30 min
maintenance: 1-4 g/hr

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53
Q

what is loading dose for mag sulfate IM? maintenance dose?

A

loading: 5 G in each buttock
maintenance: 5 G q4h (alternating buttocks)

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54
Q

when would IM injection be used for magnesium sulfate

A

-no IV access and seizure is imminent/present
-transport to other care center

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55
Q

mag sulfate level for therapeutic range

A

5-9 mg/dL

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56
Q

mag sulfate level that results in loss of patellar reflex

A

> 9 mg/dL

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57
Q

mag sulfate level that results in respiratory paralysis

A

> 12 mg/dL

58
Q

mag sulfate level that results in cardiac arrest

A

> 30 mg/dL

59
Q

normal magnesium blood level (mg/dL) in non-pregnant woman

A

1.7-2.2 mg/dL

60
Q

side effects mag sulfate therapy

A

-flushing: warm sensation
-diaphoresis
-N/V
-dry mouth
-lethargy and generalized weakness
-burning at IV site

61
Q

S+S magnesium toxicity (4)

A

-absent DTRs
-lowered resps (<12)
-decreased LOC
-slurred speech

62
Q

antidote for mag toxicity

A

1 gm calcium gluconate IV SLOW push

63
Q

ongoing assessments for mom receiving mag therapy

A

-DTR, RR, BP, HR, LOC
-lab values
-urinary output
-watching for S+S toxicity

64
Q

nursing consideration with calcium gluconate antidote for mag toxicity

A

-connect EKG (can cause heart arrhythmia)

65
Q

effects of mag therapy on fetus/neonate

A

-decreased fetal HR variability
-rarely toxic in term normal weight neonate

66
Q

S+S toxic levels in neonate with mag therapy (2)

A

-marked slowing of resps
-hyporeflexia

67
Q

indication (mmHg) of antiHTN meds for woman with HTN condition in pregnancy

A

systolic >160
diastolic >110

68
Q

bp goals of Tx with antiHTN med

A

*slowly decrease bp (maintain good cardiac output)
bp systolic 140-150
bp diastolic 90-100

69
Q

antiHTN meds

A

-hydralazine
-labetalol
-methyldopa
-nefedipine (CCB)

70
Q

what antiHTN med category is contraindicated in pregnancy

A

ACE inhibitor

71
Q

contraindications to using labetalol

A

-asthma
-heart disease
-CHF

72
Q

contraindications to using nefedipine

A

concurrent use with mag therapy

73
Q

how long is mag therapy continued postpartum

A

24 hours

74
Q

frequency of assessment postpartum for woman who received mag therapy

A

-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

75
Q

how do you know woman with preeclampsia is improving

A

lots of diuresis

76
Q

when is risk for pulmonary edema highest (for woman with or without preeclampsia)

A

postpartum

77
Q

why is uterine monitoring postpartum extremely important for mom who received mag

A

mag = muscle relaxant
increased risk uterine atony, PPH

78
Q

warning signs eclampsia

A

-persistent headache
-blurred vision
-photophobia
-RUQ pain
-altered mental status
-seizure (tonic clonic) without warning

79
Q

S+S tonic clonic seizure

A

-no resps
-hypoTN and coma
-nystagmus and muscular twitching
-incontinent or urine and stool
-disorientation and amnesia
-oliguria/anuria

80
Q

nursing care during seizure

A

-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

81
Q

nursing care after seizure

A

-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

82
Q

antiHTN therapy for woman with chronic HTN and high risk for complications

A

-labetalol (contraindicated with asthma, HF)
-methyldopa (drug of choice)
-nefedipine (CCB, can’t be given with mag)

83
Q

what to assess in postpartum mom with chronic HTN

A

-renal failure: decreased urine output, labs
-pulmonary edema: crackles, SOB, pink frothy sputum
-heart failure: edema, pulmonary edema S+S
-encephalopathy

84
Q

4 endocrine and metabolic disorders in pregnancy

A

-diabetes mellitus
-hyperemesis gravidarm
-hyper/hypothryoidism
-phenylketonuria

85
Q

type 1 or type 2 DM that existed prior to 2nd trimester pregnancy

A

pregestational diabetes

86
Q

DM that is diagnosed during 2nd/3rd trimester of pregnancy

A

gestational diabetes

87
Q

normal changes (endocrine) during first half pregnancy

A

-increased estrogen and progesterone
-increased insulin production
-extra storage energy
-decreased blood sugar (risk hypoglycemia)

88
Q

normal changes (endocrine) during second half pregnancy

A

-increased estrogen, progesterone, prolactin, cortisol, insulinase (all from placenta)
-insulin resistance
-decreased maternal use glucose
-increased glucose available to fetus

89
Q

risks and complications for women with pregestational DM

A

-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)

90
Q

does woman with pregestational diabetes need more/less insulin during 1st half pregnancy?
more/less insulin during 2nd half pregnancy?

A

-1st half: less because increased insulin production
-2nd half: more because increased insulin resistance

91
Q

increased risks of complications due to polyhydramnios

A

-supine hypoTN
-dysnpea
-PPROM, preterm labor
-PPH
-abruption
-uterine dysfunction

92
Q

consequence polycythemia for neonate at birth

A

hyperbilirubinemia

93
Q

care management of woman with pregestational diabetes: preconception

A

-strict glucose control
-A1C <6-6.5
-assess vasculopathy, neuropathy, nephropathy, retinopathy

94
Q

target glucose levels for woman with pregestational diabetes antepartum

A

-fasting: 60-105
-postmeal 1 hr: <140
-postmeal 2 hr: <120
-2 am to 6 am: >60

95
Q

med of choice for managing pregestational diabetes

A

insulin
(not oral hypoglycemics)

96
Q

why do women with pregestational diabetes need to test blood glucose and not urine

A

pregnancy causes trace amounts of glucose in urine

97
Q

possible complications antepartum for woman with pregestational diabetes

A

-preeclampsia
-polyhydramnios
-preterm labor
-infection

98
Q

most common fetal anomalies in woman with pregestational DM

A

-neural tube defect (test MSAFP)
-heart (fetal echocardiogram)

99
Q

when is fetal echocardiogram performed for mom with pregestational DM

A

20-22 weeks

100
Q

when do kick counts start for mom with pregestational DM

A

28 weeks

101
Q

when does NST/BPP start for mom with pregestational DM

A

28-32 weeks
2x/week

102
Q

intrapartum care for moms with pregestational DM

A

-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

103
Q

FTP

A

failure to progress

104
Q

CPD

A

cephalopelvic disproportion (associated with failure to progress)

105
Q

nursing considerations postpartum care for mom with pregestational DM

A

-insulin requirements drop quickly in first 24 hrs PP (DC IV insulin)
-risk PPH (due to uterine distention)
-risk infection
-delayed lactogenesis

106
Q

benefit of breastfeeding for pregestational DM mom (+baby)

A

-decreases fetal risk for DM
-lowers mom’s blood sugar with breastfeeding

107
Q

risk factors gestational DM

A

-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

108
Q

moms with gestational DM are at higher risk for developing what in later life

A

type 2 diabetes

109
Q

why does gestational DM have reduced risk miscarriage/fetal anomalies (as opposed to pregestational DM)

A

gestational DM develops in 2nd half of pregnancy
fetus is already well developed

110
Q

when are women screened for gestational DM

A

at first prenatal visit (if have risk factors for T2DM)
repeated at 24-28 weeks

111
Q

what happens in 2 step method for gestational DM

A

-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)

112
Q

OGTT

A

oral glucose tolerance test

113
Q

what blood glucose values are positive for gestational DM

A

if 2 or more values are met/exceeded:
-fasting: 95
-1 hr: 180
-2 h: 155
-3 h: 140

114
Q

instructions for woman coming in for oral glucose test

A

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

115
Q

what blood glucose value means woman passed 1 hr oral glucose screen

A

<130-140

116
Q

glucose control goals antepartum for women with gestational DM (fasting, 1 hr, 2 hr)

A

-fasting: <95
-1 hr: <140
-2 hr: <120

117
Q

antepartum fetal surveillance for mom with gestational DM

A

-non stress test 2x/week starting at 32 weeks
-monitor for polyhydramnios

118
Q

intrapartum blood glucose assessment frequency for mom with gestational DM

A

-hourly blood glucose: maintain 80-110

119
Q

what test do women with gestational DM need after they’re done breastfeeding or 4-12 weeks PP

A

-CHO intolerance test (for T2DM)
-repeat q1-3years
-must be tested before another pregnancy

120
Q

IDM

A

infant of diabetic mom

121
Q

what type DM is higher risk for SGA

A

-type 1 pregestational DM because vasculopathy (+nephropathy) results in placenta insufficiency

122
Q

possible complications for infant of diabetic mom

A

-hypoglycemia
-birth trauma/shoulder dystocia/asphyxia
-congenital anomalies (cardiac, neuro, musculoskeletal)
-polycythemia
-hyperbilirubinemia
-hypocalcemia
-hypomagnesemia
-resp distress/premature birth

123
Q

what level is considered neonatal hypoglycemia

A

<40

124
Q

risk factors neonatal hypoglycemia

A

-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)

125
Q

maternal meds that could cause neonatal hypoglycemia

A

-corticosteroids
-terbutaline
-propranalol
-oral hypoglycemics

126
Q

when should LGA and IDM babies be fed after birth

A

within 1 hr

127
Q

excessive vomiting (inability to keep down fluids and solid foods for 24 hours)

A

hyperemesis gravidarum

128
Q

what mom cannot receive mag sulfate therapy (contraindicated)
and would receive -pam drug instead

A

myasthenia gravis

129
Q

S+S that accompany hyperemesis gravidarum

A

-weight loss (5% of prepregnancy weight)
-electrolyte imbalance
-nutritional deficiency
-ketonuria

130
Q

risk factors hyperemesis gravidarum

A

-hyperthyroidism
-h/x of with previous pregnancy
-BMI <18.5 or >25
-prepregnancy psychiatric diagnosis
-molar pregnancy
-multiple gestation
-family h/x of

131
Q

medical management hyperemesis gravidarum

A

-IV fluids
-pyridoxine w/ or w/o doxylamine succinate
-diclegis/bonjesta
-promethazine (phenergan)
-metoclopramide (reglan)
-corticosteroids : CAUTION
-antacids, Hblockers, PPI
-enteral/parenteral nutrition prn

132
Q

fetal effects phenylketonuria

A

-intellectual disability
-microcephaly
-seizures
-growth impairment
-cardiac abnormalities

133
Q

Tx pregnant woman with phenylketonuria

A

strict compliance with phenylalanine diet before conception and throughout pregnancy

134
Q

can women with phenylketonuria breastfeed

A

yes,
can combine with medical phenylalanine free formula

135
Q

S+S graves disease (thyroid disorder) in pregnancy

A

-heat intolerance
-sweating
-fatigue
-anxiety
-emotional lability
-tachycardia
-weight loss
-goiter

136
Q

Tx graves disease during pregnancy

A

-drug therapy
(potentially dangerous maternal side effects of meds)

137
Q

S+S thyroid storm during pregnancy

A

-fever
-restlessness
-tachycardia
-vomiting
-stupor

138
Q

Tx thyroid storm

A

STAT EMERGENCY
-IV fluids
-oxygen
-meds: PTU, iodide, antipyretic, dexamethasone, b blocker

139
Q

potential consequences of severe hypothyroidism

A

-infertility
-increased risk miscarriage

140
Q

S+S hypothyroidism during pregnancy

A

-weight gain
-lethargy
-decrease in exercise capacity
-cold intolerance

OB (21 decks)

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