Class 3: Hypertensive Disorders of Pregnancy Flashcards
what is the leading cause of maternal and perinatal morbidity and mortality worldwide?
- hypertension
what is considered HTN in pregnancy (3)
- SBP >140
- and/or DBP >90
- requires at least 2 measurements, taken 15 min apart, and using same arm
what is considered severe HTN in any setting?
- SBP > 160
- DBP >110
- based on average of at least 2 measurements, taken at least 15 min apart
what is required to take accurate measurement of BP (4)
- person in sitting position w arm at level of heart
- an appropriately sized cuff
- arm w higher values
- manual BP should be used, or automated BP has been validated for use of pre-clampsia
what are 3 categories of classification of HTN in pregnancy
- pre-existing HTN
- gestational HTN
- other hypertensive effects
what are 3 types of other hypertensive effects
- transient HTN
- white coat HTN
- masked HTN
what is considered pre-existing HTN
- HTN pre-pregnancy or diagnosis before 20 weeks gestation
what impact does pre-existing HTN usually have on pregnancy (2)
- pregnancy usually uncomplicated
- ~25% develop pre-eclampsia or eclampsia
pre-existing HTN causes an increased risk of: (2)
- poor fetal growth
- fetal stillbirth
what are 2 subgroups of pre-existing HTN
- with super-imposed pre-eclampsia
- with comorbid conditions (Type l and ll diabetes or kidney disease)
what is considered pre-existing HTN w superimposed pre-eclampsia (4)
one or more of the follow at >20 weeks gestation:
- resistant HTN
- new or worsening proteinuria
- one or more adverse conditions
- one or more severe complications
what timing is considered gestational HTN
- detected at or after 20 weeks gestation
describe symptoms of gestational HTN (2)
- no proteinuria
- no S&S of pre-eclampsia
what are the subgroups of gestational HTN (2)
- with super-imposed pre-eclampsia
- with comorbid conditions (Type l or ll diabetes or kidney disease)
gestational HTN w preeclampsia will include one or more of the following: (3)
- new proteinuria
- one or more adverse conditions
- one or more severe complications
what are the 2 key components of pre-eclampia
- HTN
- new or worsening proteinuria
what is pre-eclampsia? when does it occur?
- pregnancy-specific syndrome
- multisystem, vasospastic disease process (=decreased perfusion to all systems)
- occurs after 20 weeks gestation
what does pre-eclampsia result in
- vasospastic –> reduced tissue perfusion to the major organs
pre-eclampsia may or may not have evidence of….
- organ dysfunction
what is severe preeclampsia defined as?
- preeclampsia with one or more severe complications –> both maternal and fetal complications exist
what is considered proteinuria in a 24-hr urine specimen? random urine specimens?
- 24-hr urine specimen: conc of greater than 0.3g/L per 24 hrs
- a conc of 0.03g/L or more in at least two random urine specimens collected at least 6 hrs apart where there is no evidence of UTI
when should significant proteinuria be suspected?
- when urinary dipstick proteinuria is >1+ (anything over trace protein)
what systems are at risk w pre-eclampsia
all systems at risk for ischemic damage :
- hematologic
- CVS
- renal
- CNS
- pulmonary
- hepatic
- uteroplacental
what is defined as an adverse condition
- those that we wait for and respond to (ex. low O2 sat) in order to avoid the severe complications (ex. pulmonary edema)
adverse conditions consist of… (3)
- maternal symptoms, signs, and abnormal lab results
- and abnormal fetal monitoring results that may herald…
- severe maternal or fetal complications (that warrant delivery)
what adverse conditions might pre-eclampsia have on CNS (4)
- HA
- visual disturbance
- hyper-reflexic (deep tendon relfexes +3/+4 = abnormal)
- clonus –> assessed in ankles for number of beats
what severe complications might pre-eclampsia have on CNS (4)
- eclampsia
- cortical blindness or retinal detachment
- stroke or TIA
- GCS <13
what adverse conditions might pre-eclampsia have on cardiorespiratory system (2)
- chest pain/dyspnea
- O2 sats <97%
what severe complications might pre-eclampsia have on cardioresp system (4)
- uncontrolled severe HTN >12 hrs, despite use of 2 antihypertensive agents
- O2 sat <90%, need for 50% O2 for >1hr, intubation
- pulmonary edema
- myocardial ischemia or infarctation
what adverse conditions might pre-eclampsia have on hematological system (2)
- elevated INR or aPTT
- low plt count (<100 x 10^9/L)
what severe complications might pre-eclampsia have on hematological system (2)
- plt count <50 x 10^9/L
- transfusion of blood products
what adverse conditions might pre-eclampsia have on renal system (3)
- elevated serum creatinine
- elevated serum uric acid
- proteinuria
what severe complications might pre-eclampsia have on renal system (3)
- acute kidney injury
- kidney failure
- oliguria
what adverse conditions might pre-eclampsia cause in the hepatic system (3)
- NV
- RUQ or epigastric pain
- elevated serum AST/ALT
what severe complication might pre-eclampsia cause in the hepatic system (2)
- hepatic dysfunction
- hepatic hematoma or rupture
what adverse conditions might pre-eclampsia cause in the fetoplacental system (4)
- abnormal FHR
- absent or reversed end diastolic flow by Doppler –> umbilical artery
- placental insufficiency –> IUGR, oligohydramnios
what severe complications might pre-eclampsia cause in the fetoplacental system (2)
- abruption w evidence of maternal or fetal compromise
- stilbirth
what is included in mngmt of HTN disorders of pregnancy (4)
- monitoring for maternal complications
- monitoring for fetal complications
- delivery as needed
- balance of gains in fetal maturity vs risks of fetal & maternal compromise
what is included in monitoring for maternal complications in mngmt of HTN disorders of pregnancy (2)
- maintaining BP control
- adverse reactions/severe complications
what is included in monitoring for fetal complications in mngmt of HTN disorders of pregnancy
- adverse reactions/severe complications
describe what subjective data should be assessed when monitoring for maternal complications r/t HTN disorders (4)
- visual disturbances (blurred vision, spots, stars)
- headaches
- epigastric/RUQ pain
- NV
describe what physical data should be assessed when monitoring for maternal complications r/t HTN disorders (5)
- VS –> BP, O2 sat, RR
- deep tendon reflexes (+3/+4)
- clonus
- resp assess (O2 sat, auscultation)
- intake and output (urine output)
what lab tests are done for HTN disorders of pregnancy (4)
- CBC
- serum creatinine/uric acid (kidney fnxn)
- ASL or ALT (liver function)
- INR/aPTT
what is assessed r/t urine for HTN disorders of pregnancy
- proteinuria
what is included in fetal health surveilance for HTN disorders of pregnancy (4)
- daily fetal movement
- electronic fetal monitoring/NST
- US for assessment of fetal growth (IUGR) and deepest amniotic fluid pocket (oligohydramnios)
- umbilical artery doppler (to assess for increased resistance, absence, or reversed end-diastolic flow)
what is included in pharmacological control of HTN in pregnancy (4)
- labetolol
- hydralazine
- nifefipine
- methyldopa
what is the BP parameters for antihypertensive pharmacology for non-severe HTN without comorbid conditions
- maintain SBP at 130-155
- DBP at 80-105
what is the BP parameters for antihypertensive pharma therapy for severe HTN
- maintain SBP <160
- DBP <110
for mngmt of HTN disorders of pregnancy at home thru the antenatal home care program, education should be provided regarding: (6)
- ID of symptoms
- ID of clinical signs
- measurement of BP
- assess fetal activity daily
- regular prenatal appts, may have increased appts/specialized appts towards end of pregnancy or as needed
- when to come to hospital
what clinical signs should you provide education on for mngmt of HTN disorders at home (5)
- BP
- protein in urine
- decreased fetal movement
- parameters set by primary care providers
- report to clinical provider or present to triage
what education should be provided regarding measurement of BP in mngmt of HTN at home (3)
- taught to take BP on same arm
- sitting position
- well supported/position of the heart
what education should be provided regarding assessing daily fetal activity in mngmt of Htn at home
- decreased fetal activity can indicate fetal compromise –> report immediately
when is mngmt of HTN disorders done in hospital
- admitted for mngmt of severe pre-eclampsia or HELLP
what is included in mngmt of HTN disorders in hospital (12)
- frequent symptoms/physical assessment (usually hourly)
- IV access (2 18 G)
- antiHTN meds as ordered for BP control (assess effectiveness, oral or IV labetalol/hydralazine)
- frequent measurement of BPs, request parameters, observe trends
- assist w arterial line placement as needed
- lab work as ordered
- accurate I&O hourly –> foley w urometer
- confirm TFI with IV fluids
- prepare for birth/initiate induction as ordered
- electronic fetal monitoring
- provide calm, quiet enviro
- explain plans and interventions
what med might be used for mngmt of HTN disorders in the hospital if the gestational age is between 24 weeks and 34+6 weeks? why? when?
- antepartum steroids to promote fetal lung maturity if between 24+0 and 34+6 weeks gestation when delivery is expected within 7 days
- ideally would wait 48 hours after admin for birth
what is eclampsia
- seizures in a woman diagnosed w preeclampsia, with no other history that would explain the seizures
how does pre-eclampsia lead to eclampsia (seizures)
- pre-eclampsia = vasospastic process = damage vessels = increased permeability = cerebral edema
describe the onset of eclampsia
- may be suddenly or can be preceded by specific signs and symptoms
what signs and symptoms may preced eclampsia (3)
- HA
- severe epigastric pain
- hyperreflexia
what is a concern w eclampsia
- during the convulsion, both the pregnant person and the fetus are not recieving O2
describe mngmt of eclampsia pre-convulsion or seizures (8)
- call bell easily accessible
- O2 working and mask available
- suction available and working
- side rails raised
- IV inserted
- room organized
- quiet/non-stimulating enviro
- emergency medical tray
describe mngmt of eclampsia during convulsion/seizure (4)
- maintain pt airway –> turn head to side, place pillow under shoulder or back
- call for help –> do not leave bedside
- protect from injury if possible (padded rails, etc.)
- observe and record activity/timing
describe mngmt of eclampsia post-convulsion/seizure (14)
- do not leave unattended until fully alert
- observe for coma
- suction as needed
- O2 by face mask at 10L/min
- IV inserted if not already
- catheter inserted if not already
- magnesium sulphate ordered
- monitor BP
- electronic fetal mvmt
- lab work as ordered
- hygeine for incontinence
- prepare for birth as needed
- risk for placental abruption –> monitor
- chest x-ray and ABG to rule out aspiration
describe preparation for birth in mngmt of eclampsia (4)
- assess uterine activity and cervical change
- ROM
- dilation
- delivery is most definitieve cure –> decisions concerning timing of delivery once stable
what med plays a role in eclampsia prevention and treatment
- magnesium sulfate IV
what is the usualy dose mg sulfate
- 4g IV loading dose –> piggy back infusion
- followed by 1-2g/hour IV
describe the monitoring of a pt of Mg sulfate
- requires close monitoring –> should not be left alone
describe what assessments should be done for a pt on Mg sulfate (6)
- assess resp hourly
- assess deep tendon reflex hourly (can decrease them)
- LOC hourly
- urine output hourly –> excreted in urine
- continuous electronic FHR
- uterine contraction monitoring
what is the antidote for Mg toxicity
- calcium gluconate
what are signs of magnesium toxicity (8)
- lethargy
- resp distress
- decreased reflexes/muscle weakness
- hypotension
- feeling warm/flushing
- headache
- NV
- slurred speech
what does HELLP syndrome stand for
Hemolysis
Elevated Liver enzymes
Low Platelets
when does HELLP syndrome occur
- can occur during later stages of pregnancy or after child birth
HELLP syndrome is considered a variant or complication of..
- pre-eclampsia
what is used to diagnose HELLP syndrome
- plt count less than 100 x 10^9/L with elevated liver enzymes (AST or ALT)
the pathophysiological changes of HELLP syndrome occur as a result of… (6)
- arteriolar vasospasms
- endothelial cell dysfunction with fibrin deposits
- adherence of plts in blood vessels
- red cells are damaged as they pass thru narrowed blood vessels = hemolyzed = decreased RBC and plt count and hyperbilirubinemia
- endothelial damage and fibrin deposits in the liver lead to impaired liver fnxn and can cause hemorrhagic necrosis
- liver enzymes elevated when hepatic tissue is damaged
what is the most definitive care for HELLP? what concerns are there w this?
- delivery
- decisions concerning timing of delivery once stable
what is there a risk of post-partum if mg sulfate was administered? what indication does this have?
- postpartum hemorrhage
- ongoing monitoring thru postpartum period, anti-htn med may continue
what is DIC
- disseminated intravascular coagulation
- disorder of clotting and bleeding
what pregnancy related conditions may trgger DIC (5)
- placental abruption
- postpartum hemorrhage
- preeclampsia/eclampsia/HELLP syndrome
- amniotic fluid embolism
- pregnancy related sepsis
what is included in mngmt of DIC (6)
- correct underlying cause
- volume expansion
- rapid replacement of blood products and clotting factors
- optimization of O2
- achievement of normal body temp
- continued reassessment of lab parameters
what does each grade of deep tendon reflexes mean? (0, +1, +2, +3, +4)
0: no response
1: sluggish or diminished
2: active or expected response
3: more brisk than expected, slightly hyperactive
4: brisk, hyperactive, intermittent or transient clonus
