Hypertension and preeclampsia Flashcards by Callie Wanek

pregnancy specific condition in which hypertension and proteinuria develop after 20 weeks gestation in a previously normotensive woman

preeclampsia

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development of convulsions or coma in woman with S/S of pre-eclampsia

eclampsia

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hypertension present before the pregnancy or diagnosed before 20 weeks gestation, or that persists beyond 6 wks postpartum

chronic hypertension

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increase in
BP coinciding with proteinuria or
generalized edema.
- treat with antihypertensive

Chronic hypertension w/
superimposed preeclampsia/
eclampsia

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development
of hypertension during pregnancy or 1st
24 hours pp without other S/S of preeclampsia.

Transient hypertension

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current term for HTN

precipitated by pregnancy

pregnancy induced hypertension

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•5-7% of all pregnancies
•Among the 3 leading causes of
maternal death in U.S.
•85% seen during 1st pregnancy,
14-20% of multifetal pregnancies

preeclampsia incidence

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• Uterine ischemia/ under perfusion
• Prostacyclin/thromboxane imbalance (ASA) Disruption of the
balance of the hormones that maintain the diameter of the blood
vessels.
• Endothelial activation and dysfunction Damage to the lining of the
blood vessels that regulates the diameter of the blood vessels keeping
fluid and protein inside the blood vessels and keeps blood from
clotting.
• Hemodynamic vascular injury Injury to the blood vessels due to too
much blood flow,i.e. the garden hose hooked up to a fire hydrant
• Immunological Activation The immune system believes that damage
has occurred to the blood vessel and in trying to fix the “injury”
actually makes the problem worse (like scar tissue) and augments the
process.

preeclampsia - theories of causation

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• Decreased circulating blood volume
- hemoconcentration
- increased maternal hematocrit
• Increased Systemic Vascular Resistance (SVR)
• Resulting decreased organ perfusion including uterus and placenta

preeclampsia pathophysiology

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Increased blood volume
Vasodilation
Decreased systemic vascular resistance
Increased cardiac output
Decreased colloid osmotic pressure

normal pregnancy pathophysiology

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•Vasospasms destroy RBC and further
decrease perfusion
•Renal blood flow is lowered, glomerular
membranes damaged by vasospasms
and become more permeable to
protein= proteinuria*
•Overall increased systemic capillary
permeability = edema

preeclampsia patho 2

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•Primigravida
•<17 or >35
•Low socioeconomic status
•Underweight or overweight
•Diagnosis of PIH in previous pregnancy
•Multi-fetal pregnancy
•Diabetes mellitus – Gestational and Type
1
•Pre-existing or family history of HTN,
vascular, or renal disease
•Hydatiform mole
•Hydramnios

prenatal factor increasing risk for preeclampsia

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Abruptio placentae
Retinal detachment
Acute renal failure
Cardiac failure
Cerebral hemorrhage - leads to stroke
Maternal death
Fetal growth restriction, hypoxia, or death

complications resulting from preeclampsia

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Hypertension
•Systolic pressure rise of 30mmHg over
baseline
•Diastolic 15mmHg over baseline

characteristics of preeclampsia

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Proteinuria
•300 mg or more of protein in 24
hour UA
•1+ or 2+ on UA dipstick
Edema
•Greater that 1+ pitting edema after
8-12 hrs bedrest
•Weight gain of 2 pounds or more in
1 week

characteristics of preeclampsia 2

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Defined in the presence of one or more of the following
•BP systolic 160mmHg, diastolic
110mmHg. In left lateral position.
•Proteinuria= 5gm in 24 hours, or 3-4+
on dipstick.
•Oliguria <700-800ml in 24 hrs,
<30ml/hr.

Characteristics of Severe preeclampsia KNOW

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Hyperreflexia of 4+, possibly clonus
Cerebral and visual disturbances–HA, altered LOC, blurred vision
Pulmonary edema
Epigastric pain(RUQ)
Thrombocytopenia–platelets adhere to injured vascular epithelium

Characteristics of Severe preeclampsia 2

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•Thorough history of pregnancy, family
history, risk factors, diet
•Physical findings
-EDC established/confirmed
-Fetal assessment: FHR, biophysical
profile, check for IUGR

PIH/Preeclampsia assessment

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Maternal reports of:
•decreased fetal movement
•heartburn
•gastric upset
•headache
•visual disturbances - cerebral edema
•numbness of hands and feet - cerebral edema

preeclampsia assessment: physical findings

BP
•Obtain in left lateral position
•Take BP in same position on
same arm each time
•Take BP at least twice 6 or
more hours apart
Urine
•Clean catch specimen--assess with
dipstick
•24 hour collection more accurate
•Reduced output

preeclampsia assessment: physical findings 2

Deep tendon reflexes (DTR)
•Graded from 0-4+
•0--no response
•1+--low normal
•2+--average, normal
•3+--brisker than average
•4+--hyperactive
Clonus
•Briskly dorsiflex the foot while slightly
flexing the knee
•Foot will have jerky “beats” before
returning to normal position
•Sign of extreme hyperreflexia

preeclampsia assessment: physical findings 3

Weight gain--monitor if more than 2
pounds per week
•5 pound weight gain severe
•Indicator of edema
•Nonpitting edema may be seen
Pitting edema
•1+: edema minimal at pedal sites,
2mm indentation
•2+: marked edema of lower ext.,
4mm
•3+: edema evident in face, hands,
abdomen, sacrum, 6mm
•4+: generalized edema, 8mm

preeclampsia assessment: physical findings 4

Respiratory
•Arteriolar vasospasm produces reduced
O2 use by organs
•Crackles and wheezing
•Pulmonary edema–percuss dull
•Dyspnea occurs
Cardiovascular
• Increased total peripheral vascular resistance due to vasospasm
• Coagulation factors altered
• Severe pre-eclampsia causes hypovolemia and hemoconcentration
resulting in increased fluid movement from vessels into tissues

preeclampsia and body system changes

Cerebral
•Abnormally high cerebral perfusion
due to loss of autoregulation
•Cerebral edema--drowsiness,
dizziness, visual disturbances
•Hyperreflexia
•Severe continuous headaches
•Vomiting

preeclampsia and body system changes 2

``` Renal • Glomerular function altered • Protein leakage into urine • Uric acid clearance abnormal • Urine concentrating ability decreased • Altered renin-angiotensin-aldosterone system--BP regulation ```

preeclampsia and body system changes 3

``` Hepatic • 10% have hepatic involvement • HELLP syndrome • Thrombosis of hepatic vessels, DIC • Stretching of liver capsule r/t edema • Hepatic hematomas • Hepatic rupture--fatal in 70% of cases ```

preeclampsia and body system changes 4

* Severe condition due to preeclampsia * 2-12% of Pre-eclampsia/PIH cases * Most frequent in older Caucasian women

HELLP syndrome

``` H: hemolysis of RBC due to vasospasm •EL: elevated liver enzymes •LP: low platelets due to clumping on lining of vessels ```

HELLP syndrome

Arteriolar vasospasms damage the endothelial layer • allow formation of platelets and then fibrin network • As RBCs are forced through this network at high pressure they are destroyed • Cells are changed into less effective O2 carrying shapes=hemolysis • As more RBCs are destroyed, maternal jaundice occurs

HELLP pathophysiology

``` • Maternal hepatic failure due to microemboli on liver -results in ischemia and tissue damage -obstruction to blood flow and fibrin causes hepatic distention=epigastric pain and elevated liver enzymes •Increasing pressure can rupture liver •Circulating volume of platelets decreases as they are consumed by damaged vessels and fibrin formations=thrombocytopenia ```

HELLP pathophysiology 2

``` • Perceived as crisis situation • Concerns - need for long-term bedrest/hospitalization - separation from family, children - financial • Expresses feelings of ambivalence • Crying, withdrawal, grief for loss of “perfect” pregnancy ```

preeclampsia - psychosocial responses

``` • Vigilant BP monitoring LABS • CBC with platelets • Type, screen, crossmatch for 2U packed RBCs • UA for protein • Electrolytes, fibrinogen, clotting, liver function tests •Fetal Assessment -NST -US for growth, maturity -Amniocentesis -Biophysical profile -Doppler flow studies ```

Preeclampsia - diagnostic procedures

• High risk for CNS injury r/t HTN and excessive fluid volume •Monitor BP q 15min or more •Maintain fluid balance and document - may restrict fluids to 125 ml/hr(PO&IV) - monitor urinary output - measure and document every emesis

preeclampsia interventions

``` •Assess DTR and clonus •Assess for subjective S/S: HA, visual disturbances, LOC •Bedrest in left lateral position •Administer medications -MgSo4: prevent seizures -Labetolol: antihypertensive -Betamethasone: babies surfactant •Altered tissue perfusion r/t renal disturbances •Assess for edema •Document strict I & O •Daily weight ```

preeclampsia interventions 2

``` •Altered tissue perfusion r/t cardiovascular disturbances •Take VS q 15-30 minutes •Observe for cardiac irregularities, tachycardia, chest pain •Observe for neck vein distention •Assess for generalized edema ```

preeclampsia interventions 3

``` •Assess capillary refill time •Assess temperature of extremities • High risk for altered respiratory function: decreased r/t excessive fluid • VS-Respiratory rate q 15-30 minutes •Assess breath sounds •Observe for dyspnea, SOB, tachypnea ```

preeclampsia interventions 4

``` •Listen for dry hacking cough •Administer O2 at 10-12L/min •High risk for hepatic injury r/t HTN •Assess epigastric pain •Observe for jaundice •Observe for signs of shock • High risk for impaired fetal well being r/t altered uretoplacental perfusion • Maintain bedrest • Treat for altered tissue perfusion • NST, US, biophysical profile, kick counts • Continuous EFM: rate, variability, decelerations ```

preeclampsia interventions 5

``` •Anxiety and fear r/t risk of harm to mother or fetus •Explain disease process, explain rationale •Clarify and interpret MD orders, procedures, and tests •Provide support ```

preeclampsia interventions 6

• Purpose is not to lower blood pressure! • Prevent seizures • Increases uterine blood flow • Increases prostacyclin to prevent uterine vasoconstriction • Always administered as secondary infusion via infusion pump

magnesium sulfate

``` •Loading dose of 4-6 g bolus given over 15-30 minutes •Maintenance dose 2-4 g q hour •Therapeutic level 4-8 mEq •Antidote at bedside--calcium gluconate ```

magnesium sulfate 2

``` Signs of Discomfort • Sweating & Flushing Signs of Toxicity • N/V • Depressed deep tendon reflexes • Flaccid paralysis • Hypocalcemia • Depressed cardiac function • Respiratory depression ```

side effects of magnesium sulfate

``` Monitor VS closely Monitor DTR--patellar and biceps • 4+: very brisk • 3+: brisker than average • 2+: average, normal response • 1+: diminished Monitor serum magnesium levels • loss of DTRs: 10 mEq/L • respiratory depression: 15 mEq/L • cardiac arrest: 25 mEq/L MgSO4 discontinued if levels too high or s/s of toxicity--Shut it off!! • ALWAYS have calcium gluconate at bedside ```

Preeclampsia : Magnesium Sulfate Nursing | Care

* Presence of seizures: clonic/tonic * Seizure not due to other causes * Risk peaks at 24 hours post delivery * Periods of hypoxia occur in mother and fetus * High risk for aspiration * Hypertension and impaired perfusion damage organs

Characteristics of eclampsia

• The principles of seizure management should follow the basic principles of airway, breathing and circulation. • Magnesium sulfate is the therapy of choice to control seizures.

eclampsia

• Stay with her and call for help • Maintain a safe environment • Place the woman in the left lateral position and administer oxygen. • Assess the airway and breathing and check pulse and blood pressure. Pulse oximetry is helpful.

management of eclampsia

• Once stabilized, plans should be made to deliver the woman but there is no particular hurry… assuming there is no acute fetal concern such as a fetal bradycardia. • The woman's condition will always take priority over the fetal condition

eclampsia 2