exam 2 hypertensive disorders

Question 1

What are the potentially lethal complications of HTN in pregnancy?

Answer 1

Pre-eclampsia -> Eclampsia
Abruptio Placentae: placenta has pulled away from uterine wall, painful bleeding, or no bleeding
Disseminated intravascular Coagulation (DIC): DIC = DEAD, IV in both arms, bleeding out of nose, vagina, eyes, IV holes are bleeding, etc.
Acute Renal Failure
Hepatic Failure
Adult Respiratory Distress Syndrome (ARDS)
Cerebral Hemorrhage
HELLP Syndrome: syndrome not a diagnoses, have to be diagnoses with preelampsia, HTN, etc.

Question 2

what are the common types or classifications of HTN?

Answer 2

Gestational Hypertension
Preeclampsia
Eclampsia
Chronic Hypertension
Preeclampsia superimposed on Chronic Hypertension

Question 3

what is HTN?

Answer 3

Systolic BP > 140 mm Hg
Diastolic > 90 mm Hg
Mean Arterial Pressure (MAP) > 105 mm Hg

Question 4

what is gestational HTN?

Answer 4

Hypertension WITHOUT proteinuria after 20 weeks gestation
Recorded at least 2 separate occasions at least 4-6 hours apart but within 1 week.
Primigravidas 6% to 17% = pregnancy
Mulitparous 2% to 4% = multiple pregnancies, more frequent w/ more babies  takes 12 wks for BP to go back to norm.
More frequently in multifetal pregnancies
Usually develops at or after 37 weeks with no preexisting HTN
BPs return to normal within 1-12 weeks after delivery  continuously watch the pts BP, Memphis has A LOT of undiagnosed HTN patients come in!

Question 5

what is preeclampsia?

Answer 5

Hypertension AND Proteinuria developed after 20 weeks

Question 6

what is mild preeclampsia?

Answer 6

BP 140/90mm Hg x2 > 4-6hrs apart
MAP > 105
24hr urine protein > 0.3g  300 mg of protein in urine; +1 or higher on the dipstick, make sure the pts BP doesn’t get worse

Question 7

what is severe preeclampsia?

Answer 7

BP > 160/110mm Hg on 2 occasions at least 4 hours apart
MAP >105
24hr urine protein >2g

Question 8

what is the etiology of preeclampsia?

Answer 8

Disruption in placental perfusions and endothelial cell dysfunction

Question 9

what is the consequences of endothelial cell dysfunctions?

Answer 9

Vasospasms & decreased organ perfusion
HTN, Uteroplacental spasms, headaches, blurred vision, hyperreflexia, elevated liver enzymes, N&V, epigastric pain

Intravascular coagulation: 50% more blood vol.
Hemolysis or red blood cells, low platelet counts, DIC, Increased Factor VIII antigen

Increased permeability and capillary leakage
Proteinuria, generalized edema, pulmonary edema (Dyspnea), Hemoconcentration (Increased hematocrit)

Question 10

what is the cause of preeclampsia?

Answer 10

Cause of preeclampsia is unknown, however, it is a condition unique to pregnancy and the only cure is delivery of the infant

Question 11

What are the effects of preeclampsia?

Answer 11

The major pathological factor in preeclampsia is NOT elevated blood pressure. It is poor perfusion as a result of vasospasm.
-Vasoconstriction results from sensitivity to vasopressors (like angiotensin II)
-Arteriolar vasospasm diminishes the diameter of blood vessels, which impedes blood flow to all organs and increases BP
-Endothelial cell dysfunction as a result of vasospasm

Question 12

what is the immunologic theory of preeclampsia?

Answer 12

This is possibly the result of an immunologic response or faulty implantation of the placenta
Immunologic factors as a result of foreign protein, the placenta, or the fetus
Supported by increased incidence in nulliparas and multipara mothers with a new partner
Maternal antibody system overwhelmed from excessive fetal antigens in the maternal circulation
Supported by the high incidence of women exposed to a large mass of trophoblastic tissue as seen in twins and Hydatiform mole

Question 13

what are the placenta effect of preeclampsia?

Answer 13

Impaired perfusion leads to early aging of the placenta and IUGR of the fetus

Question 14

what are the renal effects of preeclampsia?

Answer 14

Decreased glomerular filtration rate (GFR) results in oliguria, increased excretion of protein (mainly albumin) decreased uric acid clearance. Sodium and water retention

Question 15

what are the hepatic effects of preeclampsia?

Answer 15

Hepatic-Decreased perfusion can result in hepatic edema and sub-capsular hemorrhage as evidenced by the complaint of epigastric pain or right upper quadrant pain- A sign of impending eclampsia

Liver enzymes become elevated (AST, ALT, and LDH).

Question 16

what are the neuro effects of preeclampsia?

Answer 16

vasospasms and decreased perfusion can result in:
- Cerebral edema- change in emotion, mood, and LOC
- CNS irritability-manifested as headache, hyperreflexia, positive ankle clonus, and occasionally eclampsia
- Visual disturbances- scotomata and blurring

Question 17

what are the lab value effects of preeclampsia?

Answer 17

-↓ serum albumin-Results in ↓ plasma colloid osmotic pressure therefore, fluid moves out of the intravascular resulting in hemoconcentration, ↑ blood viscosity, and tissue edema.
-↑ Hct as a result of hemoconcentration
-↑BUN, serum creatinine, and serum uric acid as a result of degenerative glomerular change

Question 18

what is proteinuria?

Answer 18

Concentration at or above 300 mg/dl (> 1+ on dipstick

In at least 2 urine specimens; 1 isn’t enough (peanut butter can cause increase in protein)
At least 6 hours apart
OR
24-hour Specimen: 1st urination –> throw away, and then after the 1st void, the next voids for 24 H the patient must catch to monitor, can be done at home (urinate and poor into orange bucket) Ex: @ 14:30 start urination sample –> throw away urine … the next urinations till 14:29 (moms last urination will be done at 14:29 to complete 24 H specimen)

Concentration at or above 300mg/24 hours
Both in absence of UTI

Question 19

what is eclampsia?

Answer 19

Seizure activity or coma in a woman with preeclampsia with no history of preexisting pathology that can result in seizure activity.

Question 20

what do you need to remember with eclampsia?

Answer 20

Keep the patient safe

Turn onto side

Suction

Oxygen –> to help both mom and baby

IV Magnesium Sulfate: CNS depressant; monitor moms LOC; urine output less than 40/30 (make sure someone knows ab it) DTR, going to affect the baby –> watch the baby and might want to give the mom o2. the mom DOES GET HOT, get the fan in the room bc the mom WILL BE BURNING UP!!

Monitor fetus

Uterine & Cervical Assessment

Document

Question 21

what is the assessment for eclampsia?

Answer 21

History & S/SX: (ex: did her mom have pre-eclampsia or did she have pre-eclampsia with her last pregnancy?)
BP
Edema & breath sounds
DTRs/Clonus
Fetal status
Uterine tonicity
Other maternal indicators
Lab values?? Mg, platelets, H/H, liver enzymes, ALT, AST, Uric Acid

Question 22

what is the management for mild preeclampsia?

Answer 22

Bedrest – Home or Hospital
Monitoring of BP
Daily weights
Fetal surveillance
Monitor urine protein
Educate on signs to report
Healthy diet & adequate hydration
Emotional support

Question 23

what is the management for severe preeclampsia?

Answer 23

Hospital bed rest
Maternal & fetal surveillance
Possibly in an ICU setting
Quiet, non-stimulating environment & seizure precautions –> turn off phone, make room quite, one guest w/ mom (has to be quite and relax)
Pharmacological interventions
Delivery

Question 24

what do you need to look at on a NST for a baby?

Answer 24

non-stress test:
Baseline
Variability
Decelerations
Accelerations
Uterine activity

Question 25

what do you need to look at with a biophysical profile with doppler flow?

Answer 25

Fetal Movement/tone
Fetal Breathing
Amniotic fluid Index
Heart Rate
Reactive or nonreactive NST

Question 26

what is important to remember with postpartum?

Answer 26

Frequent BP & vital signs

Magnesium Sulfate (12-24 hrs): may not go to postpartum, may go to antepartum and stay there for 12-24 H, MAG slows everything down

Uterine tone and lochia, check where fundus is (envolushia, have to see how much it has gone down every day, have to see if it is hard or soft, etc.)

Family support & bonding

Question 27

what does HELLP syndrome stand?

Answer 27

(H) - hemolysis
(EL) - elevated liver enzymes
(LP) - low platelets

Question 28

what is hemolysis, with HELLP syndrome?

Answer 28

Breakdown of RBC as they pass through the small vessels with endothelial cell damage and fibrin deposit

Question 29

what is elevated liver enzymes, with HELLP syndrome?

Answer 29

A result of impaired hepatic blood flow and fibrin deposits

Watch for RUQ pain
Epigastric pain unresponsive to medication
Jaundice can occur in mom bc of decrease liver function

Question 30

what is low platelets, with HELLP syndrome?

Answer 30

(Thrombocytopenia – platelets less than 100,000)  less than 150 (platelets tell us how well a person will clot) –> dysfunction can lead to HELLP syndrome and that can lead to DIC, if those platelets are LOW the mom cannot CLOT!!

Question 31

what do you need to know about disseminated intravascular coagulation (DIC)?

Answer 31

Activation of coagulation sequence: thrombi
throughout microcirculation
Consumption of platelets and coagulation factors
to sub-hemostatic levels
Activation of fibrinolysis
Tissue hypoxia: micro-infarcts
Hemorrhage from (minor) trauma due to
consumption/depletion of clotting factors and fibrinolysis destroying clots