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NURS 4500: Midterm Material > Class 3: Hypertensive Disorders of Pregnancy > Flashcards

Class 3: Hypertensive Disorders of Pregnancy Flashcards

1
Q

what is the leading cause of maternal and perinatal morbidity and mortality worldwide?

A
  • hypertension
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2
Q

what is considered HTN in pregnancy (3)

A
  • SBP >140
  • and/or DBP >90
  • requires at least 2 measurements, taken 15 min apart, and using same arm
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3
Q

what is considered severe HTN in any setting?

A
  • SBP > 160
  • DBP >110
  • based on average of at least 2 measurements, taken at least 15 min apart
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4
Q

what is required to take accurate measurement of BP (4)

A
  • 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
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5
Q

what are 3 categories of classification of HTN in pregnancy

A
  • pre-existing HTN
  • gestational HTN
  • other hypertensive effects
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6
Q

what are 3 types of other hypertensive effects

A
  • transient HTN
  • white coat HTN
  • masked HTN
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7
Q

what is considered pre-existing HTN

A
  • HTN pre-pregnancy or diagnosis before 20 weeks gestation
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8
Q

what impact does pre-existing HTN usually have on pregnancy (2)

A
  • pregnancy usually uncomplicated
  • ~25% develop pre-eclampsia or eclampsia
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9
Q

pre-existing HTN causes an increased risk of: (2)

A
  • poor fetal growth
  • fetal stillbirth
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10
Q

what are 2 subgroups of pre-existing HTN

A
  1. with super-imposed pre-eclampsia
  2. with comorbid conditions (Type l and ll diabetes or kidney disease)
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11
Q

what is considered pre-existing HTN w superimposed pre-eclampsia (4)

A

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

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12
Q

what timing is considered gestational HTN

A
  • detected at or after 20 weeks gestation
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13
Q

describe symptoms of gestational HTN (2)

A
  • no proteinuria
  • no S&S of pre-eclampsia
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14
Q

what are the subgroups of gestational HTN (2)

A
  • with super-imposed pre-eclampsia
  • with comorbid conditions (Type l or ll diabetes or kidney disease)
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15
Q

gestational HTN w preeclampsia will include one or more of the following: (3)

A
  • new proteinuria
  • one or more adverse conditions
  • one or more severe complications
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16
Q

what are the 2 key components of pre-eclampia

A
  • HTN
  • new or worsening proteinuria
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17
Q

what is pre-eclampsia? when does it occur?

A
  • pregnancy-specific syndrome
  • multisystem, vasospastic disease process (=decreased perfusion to all systems)
  • occurs after 20 weeks gestation
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18
Q

what does pre-eclampsia result in

A
  • vasospastic –> reduced tissue perfusion to the major organs
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19
Q

pre-eclampsia may or may not have evidence of….

A
  • organ dysfunction
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20
Q

what is severe preeclampsia defined as?

A
  • preeclampsia with one or more severe complications –> both maternal and fetal complications exist
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21
Q

what is considered proteinuria in a 24-hr urine specimen? random urine specimens?

A
  • 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
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22
Q

when should significant proteinuria be suspected?

A
  • when urinary dipstick proteinuria is >1+ (anything over trace protein)
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23
Q

what systems are at risk w pre-eclampsia

A

all systems at risk for ischemic damage :
- hematologic
- CVS
- renal
- CNS
- pulmonary
- hepatic
- uteroplacental

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24
Q

what is defined as an adverse condition

A
  • those that we wait for and respond to (ex. low O2 sat) in order to avoid the severe complications (ex. pulmonary edema)
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25
Q

adverse conditions consist of… (3)

A
  • maternal symptoms, signs, and abnormal lab results
  • and abnormal fetal monitoring results that may herald…
  • severe maternal or fetal complications (that warrant delivery)
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26
Q

what adverse conditions might pre-eclampsia have on CNS (4)

A
  • HA
  • visual disturbance
  • hyper-reflexic (deep tendon relfexes +3/+4 = abnormal)
  • clonus –> assessed in ankles for number of beats
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27
Q

what severe complications might pre-eclampsia have on CNS (4)

A
  • eclampsia
  • cortical blindness or retinal detachment
  • stroke or TIA
  • GCS <13
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28
Q

what adverse conditions might pre-eclampsia have on cardiorespiratory system (2)

A
  • chest pain/dyspnea
  • O2 sats <97%
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29
Q

what severe complications might pre-eclampsia have on cardioresp system (4)

A
  • 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
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30
Q

what adverse conditions might pre-eclampsia have on hematological system (2)

A
  • elevated INR or aPTT
  • low plt count (<100 x 10^9/L)
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31
Q

what severe complications might pre-eclampsia have on hematological system (2)

A
  • plt count <50 x 10^9/L
  • transfusion of blood products
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32
Q

what adverse conditions might pre-eclampsia have on renal system (3)

A
  • elevated serum creatinine
  • elevated serum uric acid
  • proteinuria
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33
Q

what severe complications might pre-eclampsia have on renal system (3)

A
  • acute kidney injury
  • kidney failure
  • oliguria
34
Q

what adverse conditions might pre-eclampsia cause in the hepatic system (3)

A
  • NV
  • RUQ or epigastric pain
  • elevated serum AST/ALT
35
Q

what severe complication might pre-eclampsia cause in the hepatic system (2)

A
  • hepatic dysfunction
  • hepatic hematoma or rupture
36
Q

what adverse conditions might pre-eclampsia cause in the fetoplacental system (4)

A
  • abnormal FHR
  • absent or reversed end diastolic flow by Doppler –> umbilical artery
  • placental insufficiency –> IUGR, oligohydramnios
37
Q

what severe complications might pre-eclampsia cause in the fetoplacental system (2)

A
  • abruption w evidence of maternal or fetal compromise
  • stilbirth
38
Q

what is included in mngmt of HTN disorders of pregnancy (4)

A
  • monitoring for maternal complications
  • monitoring for fetal complications
  • delivery as needed
  • balance of gains in fetal maturity vs risks of fetal & maternal compromise
39
Q

what is included in monitoring for maternal complications in mngmt of HTN disorders of pregnancy (2)

A
  • maintaining BP control
  • adverse reactions/severe complications
40
Q

what is included in monitoring for fetal complications in mngmt of HTN disorders of pregnancy

A
  • adverse reactions/severe complications
41
Q

describe what subjective data should be assessed when monitoring for maternal complications r/t HTN disorders (4)

A
  • visual disturbances (blurred vision, spots, stars)
  • headaches
  • epigastric/RUQ pain
  • NV
42
Q

describe what physical data should be assessed when monitoring for maternal complications r/t HTN disorders (5)

A
  • VS –> BP, O2 sat, RR
  • deep tendon reflexes (+3/+4)
  • clonus
  • resp assess (O2 sat, auscultation)
  • intake and output (urine output)
43
Q

what lab tests are done for HTN disorders of pregnancy (4)

A
  • CBC
  • serum creatinine/uric acid (kidney fnxn)
  • ASL or ALT (liver function)
  • INR/aPTT
44
Q

what is assessed r/t urine for HTN disorders of pregnancy

A
  • proteinuria
45
Q

what is included in fetal health surveilance for HTN disorders of pregnancy (4)

A
  • 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)
46
Q

what is included in pharmacological control of HTN in pregnancy (4)

A
  • labetolol
  • hydralazine
  • nifefipine
  • methyldopa
47
Q

what is the BP parameters for antihypertensive pharmacology for non-severe HTN without comorbid conditions

A
  • maintain SBP at 130-155
  • DBP at 80-105
48
Q

what is the BP parameters for antihypertensive pharma therapy for severe HTN

A
  • maintain SBP <160
  • DBP <110
49
Q

for mngmt of HTN disorders of pregnancy at home thru the antenatal home care program, education should be provided regarding: (6)

A
  • 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
50
Q

what clinical signs should you provide education on for mngmt of HTN disorders at home (5)

A
  • BP
  • protein in urine
  • decreased fetal movement
  • parameters set by primary care providers
  • report to clinical provider or present to triage
51
Q

what education should be provided regarding measurement of BP in mngmt of HTN at home (3)

A
  • taught to take BP on same arm
  • sitting position
  • well supported/position of the heart
52
Q

what education should be provided regarding assessing daily fetal activity in mngmt of Htn at home

A
  • decreased fetal activity can indicate fetal compromise –> report immediately
53
Q

when is mngmt of HTN disorders done in hospital

A
  • admitted for mngmt of severe pre-eclampsia or HELLP
54
Q

what is included in mngmt of HTN disorders in hospital (12)

A
  • 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
55
Q

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?

A
  • 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
56
Q

what is eclampsia

A
  • seizures in a woman diagnosed w preeclampsia, with no other history that would explain the seizures
57
Q

how does pre-eclampsia lead to eclampsia (seizures)

A
  • pre-eclampsia = vasospastic process = damage vessels = increased permeability = cerebral edema
58
Q

describe the onset of eclampsia

A
  • may be suddenly or can be preceded by specific signs and symptoms
59
Q

what signs and symptoms may preced eclampsia (3)

A
  • HA
  • severe epigastric pain
  • hyperreflexia
60
Q

what is a concern w eclampsia

A
  • during the convulsion, both the pregnant person and the fetus are not recieving O2
61
Q

describe mngmt of eclampsia pre-convulsion or seizures (8)

A
  • 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
62
Q

describe mngmt of eclampsia during convulsion/seizure (4)

A
  • 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
63
Q

describe mngmt of eclampsia post-convulsion/seizure (14)

A
  • 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
64
Q

describe preparation for birth in mngmt of eclampsia (4)

A
  • assess uterine activity and cervical change
  • ROM
  • dilation
  • delivery is most definitieve cure –> decisions concerning timing of delivery once stable
65
Q

what med plays a role in eclampsia prevention and treatment

A
  • magnesium sulfate IV
66
Q

what is the usualy dose mg sulfate

A
  • 4g IV loading dose –> piggy back infusion
  • followed by 1-2g/hour IV
67
Q

describe the monitoring of a pt of Mg sulfate

A
  • requires close monitoring –> should not be left alone
68
Q

describe what assessments should be done for a pt on Mg sulfate (6)

A
  • 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
69
Q

what is the antidote for Mg toxicity

A
  • calcium gluconate
70
Q

what are signs of magnesium toxicity (8)

A
  • lethargy
  • resp distress
  • decreased reflexes/muscle weakness
  • hypotension
  • feeling warm/flushing
  • headache
  • NV
  • slurred speech
71
Q

what does HELLP syndrome stand for

A

Hemolysis
Elevated Liver enzymes
Low Platelets

72
Q

when does HELLP syndrome occur

A
  • can occur during later stages of pregnancy or after child birth
73
Q

HELLP syndrome is considered a variant or complication of..

A
  • pre-eclampsia
74
Q

what is used to diagnose HELLP syndrome

A
  • plt count less than 100 x 10^9/L with elevated liver enzymes (AST or ALT)
75
Q

the pathophysiological changes of HELLP syndrome occur as a result of… (6)

A
  • 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
76
Q

what is the most definitive care for HELLP? what concerns are there w this?

A
  • delivery
  • decisions concerning timing of delivery once stable
77
Q

what is there a risk of post-partum if mg sulfate was administered? what indication does this have?

A
  • postpartum hemorrhage
  • ongoing monitoring thru postpartum period, anti-htn med may continue
78
Q

what is DIC

A
  • disseminated intravascular coagulation
  • disorder of clotting and bleeding
79
Q

what pregnancy related conditions may trgger DIC (5)

A
  • placental abruption
  • postpartum hemorrhage
  • preeclampsia/eclampsia/HELLP syndrome
  • amniotic fluid embolism
  • pregnancy related sepsis
80
Q

what is included in mngmt of DIC (6)

A
  • 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
81
Q

what does each grade of deep tendon reflexes mean? (0, +1, +2, +3, +4)

A

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

NURS 4500: Midterm Material (19 decks)

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