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OB > Exam Three: HTN > Flashcards

Exam Three: HTN Flashcards

1
Q

Types of HTN disorders

A
  • chronic HTN (pre existing)
  • Gestational HTN
  • Pre-eclampsia
  • Acute onset of severe HTN
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2
Q

types of pre-eclampsia

A
  • Without severe features
  • With severe features
  • Chronic hypertension with superimposed pre-eclampsia
  • HELLP
  • Eclampsia
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3
Q

Any type of hypertension, no matter the origin…

A

can lead to stroke and death for the pregnant individual and the fetus

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4
Q

Adverse affects for babies of HTN

A
  • Fetal growth restriction
  • Preterm birth
  • Placental abruption: can cause preterm birth
  • Death
  • Adverse effects of medications (Magnesium sulfate)- issues of resp. depression
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5
Q

what are the adverse effects for babies due to

A

due to direct and indirect consequences of the maternal disease process or from what we are doing to treat the patient

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6
Q

Significance of HTN with pre e/ eclampsia

A
  • Significant adverse effects for patient: Seizures, PE, stroke, renal failure, hepatic failure, retinal detachment, DIC
  • Long-term at increased risk for cardiovascular, renal, chronic hypertensive disease
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7
Q

what causes the fetal growth restriction

A
  • blood vessels in the placenta vasoconstrict leading to poor perfusion
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8
Q

why is preterm birth a risk for babies with moms who have HTN

A
  • may need to deliver @ 34 weeks to prevent issues
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9
Q

Measurement Accuracy

A
  1. Home/ambulatory BP monitoring compared to Office-Based monitoring
    -Routine office measurements are approximately 5 -10 mmHg higher
    -13 to 30% of patients with HTN in the clinician’s office are normotensive outside of the office, “white coat” or isolated office hypertension
    -A BP taken in a cool room (54 F) or while the patient is talking can raise BP by as much as 8 to 15 mmHg
    -Smoking, drinking caffeine, eating, strenuous exercise within 30 minutes can all transiently elevate the BP
    -Certain medications and drugs can also affect the BP
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10
Q

Measurement Technique- cuff size

A
  • Bladder width = 40% of circumference and encircle 80% of the upper arm
  • Too small raises rate as much as 10 to 20 mmHg (higher result)
  • too big= lower result
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11
Q

Measurement Technique- Patient position:

A
  • Seated with back supported
  • not talking
  • Legs uncrossed, feet on the ground
  • Arm supported at the level of the heart, supported
  • Rest for 5-10 minutes prior: Poor position can raise rate as much as 6-8 mmHg
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12
Q

Chronic Hypertension (HTN) in Adult Population (non pregnant): normal blood pressure

A
  • Normal blood pressure – Systolic <120 mmHg AND diastolic <80 mmHg
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13
Q

Chronic Hypertension (HTN) in Adult Population (non pregnant): elevated blood pressure

A

Systolic 120 to 129 mmHg AND diastolic <80 mmHg

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14
Q

Chronic Hypertension (HTN) in Adult Population (non pregnant): HTN stage one

A

Systolic 130 to 139 mmHg OR diastolic 80 to 89 mmHg

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15
Q

Chronic Hypertension (HTN) in Adult Population (non pregnant): HTN stage 2

A

Systolic at least 140 mmHg OR diastolic at least 90 mmHg

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16
Q

Chronic Hypertension (HTN) in Adult Population (non pregnant): HTN crisis

A

Systolic >180 and/or diastolic >120

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17
Q

Chronic HTN in Pregnancy

A
  1. HTN prior to pregnancy (pre-existing)
    OR
  2. HTN developing prior to 20 weeks:
    -BP > 140 and/or > 90 on at least 2 separate occasions > 4 hours apart
    -Persists longer than 12-weeks PP

*need 2 values of HTN at least 4 hours apart

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18
Q

why is chronic HTN in pregnancy if you get diagnosed before 20 weeks

A
  • most patients would have a drop in BP from progesterone increasing in the first few weeks of pregnancy
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19
Q

Antepartum Management of Patients with Chronic Hypertension

A
  1. Baseline *HELLP labs at initial visit (NOB) or when diagnosed
  2. Home blood pressures–call with increasing BP or severe range
  3. If uncontrolled, may need more frequent prenatal visits
  4. Treat chronic HTN if systolic BP > 140 OR diastolic > 90)
  5. ACE inhibitors & angiotensin II receptor blockers are contraindicated in pregnancy
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20
Q

what do you treat chronic HTN in pregnancy with

A
  • if systolic BP > 140 OR diastolic > 90)
    1. With continuous beta or calcium channel blockers:
    -Labetalol, extended release Nifedipine, or Methyldopa
    -Avoid labetalol in patients with asthma to avoid bronchospasm/vasoconstriction or patients with a HR < 60
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21
Q

why do HELLP labs on pregnant person with chronic HTN

A
  • can develop Pre-eclampsia and HELLP syndrome later on in the pregnancy so we want to see what their values are now to have something to compare it to
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22
Q

HELLP labs

A
  • cbc (platelets)
  • CMP (ast,alt, serum creatinine)
  • 24-hur urine
  • P:C ratio
  • Urine dip (use only if the other quantitative testing is not available)
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23
Q

CBC platelets normal and concerning

A

-N: 150,000-400,000
-C: < 100,000

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24
Q

AST normal and concerning

A

N: 4-20 units/L
C: 2 times normal range

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25
Q

ALT normal and concerning

A

N: 3-21 units/L
C: 2 times normal range

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26
Q

Serum creatinine normal and concerning

A

N: 0.4 to 0.8 mg/dl
C: > 1.1 mg/dL

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27
Q

24- hour urine normal and concerning

A

N: < 300 mg/24 hours
C: ≥ 300 mg/24 hours

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28
Q

P:C ratio normal and concerning

A

N: < 0.2
C: >/= 0.3

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29
Q

Urine dip normal and concerning

A

N: none to trace
C: >/= 2 +
* GFR is not very good in pregnancy so it is normal to have some protein and glucose in urine

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30
Q

Chronic HTN management if it is well controlled without meds

A

-watch closely
-Expectant Management until you induce between 38-39 weeks
-Baseline HELLP labs at NOB
-No antenatal screening/growth US

31
Q

Chronic HTN management if it is well controlled with meds

A

-watch closely
-Expectant Management until IOL* at 38 weeks
-Baseline HELLP labs at NOB
-Weekly NST/MVP starting at 32 weeks
-Growth US at 28-32 wks, 34-36 wks to see if the HTN is affecting the growth

32
Q

Management of chronic HTN with superimposed pre-e without severe features or with severe features

A
  • Follow management guidelines for pre-E with or without severe features
33
Q

what is the point of induction (IOL) in HTN

A
  • to prevent seizure, stroke, hematologic complications, renal or hepatic disease
34
Q

Gestational Hypertension

A
  • New onset HTN after 20 weeks of pregnancy and resolves by the 12th week PP
    1. Elevated systolic BP of > 140 or diastolic BP > 90 on two separate occasions > 4 hours apart
    AND
    2. NO S/S of pre-eclampsia, abnormal labs, or proteinuria

-May convert to diagnosis of preeclampsia

35
Q

management of gestational HTN

A

-Do weekly HELLP labs to r/o pre-E
-Induction of labor at 37 weeks if have not developed pre-eclampsia

36
Q

Pre-Eclampsia

A

A multisystem progressive disorder that can manifest in many ways with multiple severities

37
Q

patho of pre-eclampsia

A
  • Multifactorial
  • Exact mechanism of the pathogenesis is unknown
  • Caused by placental and maternal vascular dysfunction and resolves after delivery
  • Placenta is key:
    1. Failure of uterine spiral arteries to expand
    2. Exaggerated inflammatory response
    3. Inappropriate endothelial-cell activation/endothelial damage
38
Q

risk factors for pre eclampsia

A
  • Pre-eclampsia in a previous pregnancy
  • Maternal medical history: DM, HTN, renal disease, SLE (lupus), hypercoagulability
  • First pregnancy
  • < 18 and > 35 y.o.
  • Obesity
  • Multiple gestation: twins, triplets, ect (bigger or more placentas = more issues)
  • Pre-E in 1st degree relative
  • IVF/infertility
  • Race: especially african american or black
  • New paternity (first pregnancy with new father)
39
Q

Prevention of pre eclampsia

A
  • Low dose Aspirin based on level of risk (moderate to high risk)
  • 81 mg aspirin daily initiated between 12 and 28 weeks, preferably before 16 weeks continue until delivery
  • decreases chance of developing pre-e
40
Q

high risk for pre eclampsia

A
  • HX of pre-e
  • multifetal gestation
  • chronic HTN
  • diabetes
  • renal disease
  • autoimmune

*low does ASA

41
Q

moderate risk for Pre-e

A
  • need to have two or more
  • nulliparity
  • BMI>30
  • fam hisotry of pre e
  • socioeconomic (AA, low socioeconomic)

*low dose ASA

42
Q

low risk for pre-e

A
  • previous uncomplicated full term birth

*NO ASA

43
Q

Fluid Status in Patient’s with Pre-Eclampsia

A
  • Persons with preeclampsia are in a state of total volume overload AND have depleted intravascular volume.
    -Limit total IV fluids (typically to 125mL/hr) To avoid fluid overload because both preeclampsia and Magnesium Sulfate increase the risk for fluid overload related complications such as pulmonary edema
44
Q

why is someone with pre-e in a state of total volume overload AND have depleted intravascular volume.

A

-Fluid leaks out of intravascular space and collects in the intervillous space (edema) = less circulating volume
-Vasospasm and limited intravascular volume causes diminished flow to organs (IUGR, Oliguria).
-The patient is at risk for hypotension and inadequate perfusion with an epidural.

45
Q

Pre-E: without Severe Features

A
  1. New onset hypertension after 20 weeks or occurring postpartum
    -Elevated systolic BP of > 140 or diastolic BP > 90 on two separate occasions >4 hours apart

AND

  1. New onset proteinuria
    - > 300 mg/24-hour urine or a p:c ratio > 0.3, or a dipstick reading of > 2+
46
Q

Proteinuria Defined:

A
  • ≥ 300mg/dL on a 24-hour urine
    OR
  • Urine Protein/Creatinine (P:C ratio) of ≥ 0.3
    OR
  • Urine dipstick of ≥ 2+ (use only if quantitative measurement is not available)

*Proteinuria is required for diagnosis of “preeclampsia WITHOUT severe features”
*It is NOT required for diagnosis of “preeclampsia WITH severe features”– evidence of end organ damage

47
Q

Pre-Eclampsia Patient Presentation

A
  1. Many patients do not have symptoms, even though they have elevated BP, protein in the urine
  2. When they do have symptoms, they include
    -RUQ or epigastric abdominal pain
    -Severe headache not relieved by Tylenol, rest
    -Visual changes (persistent scotomata)
48
Q

Pre-E with Severe Features

A
  • Definition: HTN after 20 weeks AND one or more of the following: (all signs telling us there is end organ damage)
    1. Severe range HTN: Systolic BP > 160 or diastolic BP > 110: At least two BPs repeated within 15 minutes
  1. Symptoms of central nervous system dysfunction:
    New onset severe HA/visual disturbances**
  2. Hepatic abnormality:
    Impaired liver function (LFTs 2 x normal) **
    Severe persistent RUQ/epigastric pain**
  3. Thrombocytopenia: platelets < 100,000 microliter**
  4. Renal insufficiency
    Serum creatinine > 1.1 mg/dl or doubling **
  5. Pulmonary edema**
49
Q

PRE-E management without severe features but < 37 weeks

A
  • Expectant Management until planned delivery at 37 weeks*
  • Biweekly NSTs
  • Weekly Maximum vertical pocket (amniotic fluid assessment)
  • Serial US for growth
50
Q

PRE-E management without severe features but >/= 37 weeks

A
  • deliver/ induce
51
Q

PRE-E management with severe features but >/= 34 weeks

A
  • Initiate Magnesium Sulfate
  • Deliver/
    Induction
52
Q

PRE-E management with severe features but < 34 weeks

A
  • Give corticosteroids (lung surfactant production) and Magnesium Sulfate x 24 hours
  • Expectant management until 34 weeks if there is improvement
    -INPATIENT
53
Q

PRE-E management: Contraindications for expectant management (any gest.)

A
  • Eclampsia, HELLP, pulmonary edema, DIC, uncontrolled severe HTN, fetal demise, Abnormal fetal testing, abruption, non-viable fetus
  • Proceed to Delivery once pregnant person is stable
54
Q

Chronic HTN with Superimposed Pre-E

A
  1. Superimposed pre-E without SF
    - New onset of proteinuria with already diagnosed CHTN (non severe range BPs)
  2. Superimposed pre-E with SF
    -CHTN diagnosis and
    -Develops systemic changes
    -Develops severe range BP
    -Has abnormal labs
55
Q

Hypertensive Disorders of Pregnancy: Nursing Assessments in labor/during induction of labor: for pregnant person

A
  • HELLP labs on admission
  • Frequent BPs q 15min-1 hr
  • Lung sounds: pulmonary edema?
  • DTRs, Clonus
  • Monitor for symptoms: HA, RUQ/epigastric pain, visual changes
  • Safety checks – side rails up, prn
  • Decreased stimuli to prevent seizures – quiet, dim lighting, etc
56
Q

clonus

A
  • flex foot toward head when you relax it the foot should just drop (negative clonus)
  • if it doesnt smoothly drop then thats positive clonus
57
Q

Hypertensive Disorders of Pregnancy: Nursing Assessments in labor/during induction of labor: for fetus

A
  • continuous Fetal monitoring
58
Q

Hypertensive Disorders of Pregnancy: Nursing Assessments in labor/during induction of labor: for neonate

A

Monitor for issues associated with prematurity like resp distress, hypoglycemia, hypothermia

59
Q

Treatment for Prevention of Eclampsia in Patients with Pre-E with SF/HELLP/Acute Severe HTN

A
  • magnesium sulfate
  • CNS depressant used for seizure prophylaxis
    Secondary effect: relaxes smooth muscles- can be hard with labor when on this
60
Q

dosing of magnesium sulfate

A

-Loading: 4-6 grams loading dose IV over 20-30 min
-Maintenance: 1-2 grams/hr IV until 12-24 hours post-delivery
-NOTE: Magnesium sulfate can be given by IM injection (10 mg with 5 mg in each buttock) but issues with absorption, tissue necrosis, and it is extremely painful
- Patient who presents with an eclamptic seizure–treat with same Magnesium Sulfate dosing above

61
Q

side effects of magnesium sulfate

A

Flushing, HA, nystagmus ( eye moves rapidly up and down or side to side) , nausea, dry mouth, lethargy, dizziness
- monitor extra for hemorrhages since this is a smooth muscle relaxant

62
Q

toxcicity side effects of magnesium sulfate

A
  • Respiratory depression ( RR < 12) and arrest, pulmonary edema
  • decreased or absent DTR/ clonus, UOP < 30, EKG changes
    Treatment/Antidote:
  • 10% Calcium gluconate in 10 ml given over 10 minutes (always call for provider evaluation prior to giving)
  • Stop the Magnesium Sulfate
63
Q

Patients on Magnesium Sulfate: Nursing Assessments

A
  1. DTRs- should remain present (1+ or greater)
  2. Respirations- should remain > 12/minute
  3. Hourly Intake and Output-
    -Place indwelling foley catheter
    -Urine output should be > 30ml/hr output—because it is excreted from the body through the kidneys so want to make sure peeing and its not building up
  4. Serum magnesium levels- drawn PRN, should be in therapeutic range of 4-7mg/dl (range is lab specific)
    -Monitor for effects on contraction pattern, immediate postpartum period, and with epidural administration (likely to get hypotensive and cant fluid bolus them or give them ephedrine)
    -Monitor patient and newborn for effects of Magnesium sulfate
64
Q

Postpartum Care for pre e

A
  • There is usually rapid improvement after delivery for patients with pre-eclampsia, however, still at risk up to 6 weeks PP :
    1. Seizure precautions:
    Highest risk of seizures in first 48 hours after birth
  1. Magnesium Sulfate:
    Continued for 12-24 hours post delivery
  2. Postpartum hemorrhage meds
    NO METHERGINE since they have HTN
  3. Follow up:
    BP 7-10 days post delivery
    Increase in BP at 3-6 days pp
  • Risk factors:
    Future CVD disease
    Review preventive measures (diet, exercise, weight mgmt.)
65
Q

Eclampsia

A
  1. New-onset seizure in a hypertensive obstetrical patient with preeclampsia in the absence of other neurologic conditions, that would explain the seizure
    - May have impending seizure “aura”or headache
  2. Can occur with or without severe features of preeclampsia
  3. Seizure distribution:
    -Most eclampsia occurs antepartum
    -13 to 36% occurs intrapartum
    -Can occur in postpartum women, usually in first 48 hours
66
Q

Nursing Care: DURING Eclamptic Seizure

A
  1. OBSTETRIC EMERGENCY!
    -CALL FOR HELP
  2. Document:
    -Time of seizure, length, involvement of which body part
    -Seizures are usually self limiting (<4 min)
  3. Protect airway:
    -O2, suction PRN, turn to LLP (on side), tilt head down to the side, no tongue blade or restraints
  4. Safety:
    -Side rails up with pillows/padding
  5. Magnesium sulfate:
    -Give bolus/loading dose (4-6 grams over 20-30 min via IV piggyback)
  6. Other Meds: Diazepam or Ativan only if sustained seizure (uncommon)
67
Q

Nursing Care: FOLLOWING Eclamptic Seizure

A
  1. Check maternal/fetal status
    -Maternal BP- is it still elevated?
    -Check for signs of abruption: bleeding, uterine tenderness, firm, boardlike, frequent contractions
    -Has baby delivered?
  2. Fetal heart rate:
    -Prolonged deceleration of FHR, late decelerations, decreased variability, rebound tachycardia all possible during or after seizure
    -Usually, will self correct once patient is stabilized, allowing for successful vaginal birth
    -If not recovered after 10-15 min, despite intrauterine resuscitation, emergency C/S may be warranted
68
Q

Acute Onset of Severe HTN

A
  1. Sudden onset of systolic BP > 160 or diastolic BP >110 or both
    -Repeat within 15 minutes to confirm
  2. Rapid notification of provider
  3. Treat with first line antihypertensives (within 30-60 mins)
    -IV Hydralazine or Labetalol or oral Immediate-release Nifedipine if no IV
69
Q

HELLP syndrome

A
  • Hemolysis of Red Blood Cells
  • Elevated Liver enzymes
    1. AST/ALT > 2 times normal
    2. LDH >600 unit/L (not always used)
    -Low Platelet count (<100,000)
70
Q

HELLP Syndrome risk factors

A

A history of preeclampsia or HELLP

71
Q

HELLP syndrome patho

A
  • RBCs - Distorted from passing through the small, damaged blood vessels causing micro-angiopathic hemolytic anemia
  • Vascular damage - associated with vasospasm and platelet aggregation
  • Obstruction - Fibrin-like deposits cause obstruction and hepatocellular injury and swelling of the liver
  • This may lead to epigastric pain, liver capsule rupture, hyperbilirubinemia, DIC, kidney failure, and death
72
Q

HELLP Patient Presentation:

A
  1. Variable presentation, but most common symptoms include:
    -Abdominal pain and tenderness in the mid-epigastrium
    -Nausea, vomiting, and generalized malaise
    -Less common signs and symptoms include headache, visual changes, jaundice, and ascites.
  2. 15 to 20% of patients with HELLP syndrome did not have HTN or proteinuria
    -But…preeclampsia with SF and HELLP syndrome are both associated with serious hepatic presentations, including infarction, hemorrhage, and rupture
  3. About 30% of cases present in postpartum period, most in first 48 hrs.
73
Q

Know Your Medications

A
  1. Magnesium Sulfate is used for prevention of maternal seizure- crosses the placenta
    -Loading (bolus) dose – 4-6 gms IV over 20-30 min
    -Maintenance dose – 2 gms/hr
    -Common side effects: flushing, nausea, burning at IV site
    -Therapeutic Magnesium level/range – 4-7mg/dl
  2. Antihypertensives are used to prevent maternal stroke – all cross the placenta
  3. First line medications for acute-onset severe hypertension; give ASAP:
    -Hydralazine 5-10 mg IV
    -Labetalol 20-40 mg IV (avoid in Asthma or with pulse < 60)
    -Immediate-release Nifedipine 10-20 mg PO if no IV
74
Q

What is chronic HTN with superimposed pre eclampsia or eclampsia

A

Yeah preeclampsia either with or without severe features but with a previous chronic hypertension diagnosis (either pre-existing hypertension or hypertension that occurred before 20 weeks gestation) 

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