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Hypertensive disorders Flashcards

1
Q

What are the adverse risks for neonates r/t hypertension?

A

Fetal growth restriction
Preterm birth
Placental abruption
Death
Adverse effects of medications (Magnesium sulfate) – issues on fetus afterwards such as respiratory depression

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2
Q

Why does HTN cause fetal growth restriction?

A

babies don’t have as much perfusion b/c blood vessels constrict

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3
Q

Why does maternal HTN cause increase risk of preterm birth?

A

generally delivered early to prevent issues for baby and mom

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4
Q

Why does HTN cause placental abruption?

A

Vasoconstriction

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5
Q

What maternal consequences for pre-E or eclampsia cause?

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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6
Q

What are things that can change the accuracy of a BP?

A

Office visit generally are 5-10 mmhg higher than home monitoring d/t possible white coat syndrome

BP in a cold room while patient is talking can increase BP by 8-15 mmhg

Smoking, drinking caffeine, exercise for 30 minutes all increase BP

Medications

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7
Q

What should the cuff size for BP be? Too small? Too big?

A

Bladder width = 40% of circumference and encircle 80% of the upper arm

Too small raises rate as much as 10 to 20 mmHg

Too large will decrease the BP

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8
Q

What should the nurse make sure before taking a BP measurement? Why?

A

Seated with back supported
Legs uncrossed, feet on the ground
Arm supported at the level of the heart, supported
No talking
Rest for 5-10 minutes

Poor position can raise rate as much as 6-8 mmHg

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9
Q

What is normal BP for an adult?

A

Systolic <120 mmHg AND diastolic <80 mmHg

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10
Q

What is an elevated BP in a non-pregnant patient?

A

Systolic 120 to 129 mmHg AND diastolic <80 mmHg

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11
Q

In the non-pregnant adult population what is stage 1 for HTN? Stage 2?

A

Stage 1 – Systolic 130 to 139 mmHg OR diastolic 80 to 89 mmHg

Stage 2 – Systolic at least 140 mmHg OR diastolic at least 90 mmHg

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12
Q

What is a hypertensive crisis in an adult that is not pregnant?

A

Systolic >180 and/or diastolic >120

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13
Q

What are two different ways to have chronic HTN in pregnancy?

A

HTN prior to pregnancy (pre-existing) – using other guidelines

OR

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

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14
Q

What is the management on a patient with chronic HTN?

A

Baseline *HELLP labs at initial visit (NOB) or when diagnosed at less than 20 weeks
Home blood pressures–call with increasing BP or severe range
If uncontrolled, may need more frequent prenatal visits

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15
Q

When do you treat chronic HTN? What do you treat it with? What can it not be treated with?

A

Systolic BP > 140 OR diastolic > 90)

With continuous beta or calcium channel blockers
Labetalol, extended release Nifedipine, or Methyldopa

ACE inhibitors & angiotensin II receptor blockers are contraindicated in pregnancy so will need to be switched to above medication options

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16
Q

What are 2 reasons labetalol should be avoid for the treatment of chronic HTN?

A

Avoid labetalol in patients with asthma to avoid bronchospasm/vasoconstriction or patients with a HR < 60

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17
Q

What are the HELLP labs?

A

Platelets
Liver enzymes (AST, ALT)
Creatinine
Proteinuria

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18
Q

What is a normal platelet range? What is concerning?

A

150,000-400,000

<100,000

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19
Q

What is normal AST/ALT? What is concerning?

A

AST: 4-20 unit/L
ALT: 3-21 units/L

2 times the normal range

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20
Q

What is a normal creatinine? What is concerning?

A

0.4-0.8

> 1.1

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21
Q

What are 3 different ways to measure proteinuria? What is normal? Concerning?

A

24 hour urine:
Normal - <300mg/24 hours
Concern - >300mg/24 hours

P:C ratio:
Normal - <0.2
Concern - >/=0.3

Urine dip:
Normal - none to trace
Concern - >/= 2

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22
Q

Why is a urine dip not used as much?

A

Not as helpful because does quantify and pregnant women already have a sloppy GFR so a little protein in urine

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23
Q

How is well controlled chronic HTN without meds managed?

A

Expectant Management until IOL* between 38-39 weeks
Baseline HELLP labs at NOB
No antenatal screening/growth US

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24
Q

How is well controlled chronic HTN with meds managed?

A

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 – done every couple of weeks

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25
Q

How is CHTN with superimposed pre-E w/ or w/o severe symptoms managed?

A

Follow management guidelines for pre-E with or without severe features

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26
Q

Why do you induce a patient with CHTN?

A

prevent seizure, stroke, hematologic complications, renal or hepatic disease

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27
Q

What is gestational HTN?

A

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

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28
Q

How do you manage gestational HTN?

A

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

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29
Q

What is the cause of pre-ecamlpsia?

A

Caused by placental and maternal vascular dysfunction and resolves after delivery

Failure of uterine spiral arteries to expand

Exaggerated inflammatory response

Inappropriate endothelial-cell activation/endothelial damage

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30
Q

What are the risk factors for pre-ecampsia?

A

Pre-eclampsia in a previous pregnancy
Maternal medical history: DM, HTN, renal disease, SLE (lupus), hypercoagulability (clotting disorders), autoimmune disorders
First pregnancy
< 18 and > 35 y.o.
Obesity
Multiple gestation
Pre-E in 1st degree relative
IVF/infertility
Race – African Americans
New paternity
First pregnancy by new partner

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31
Q

What in maternal medical history places her at increase risk for pre-eclampsia?

A

DM
HTN
Renal disease
SLE (lupus)
Hypercoagulability (clotting disorders)
Autoimmune disorders

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32
Q

What puts a patient in high risk for pre-e? Prevention?

A

History of pre-E
Multifetal gestation
Chronic HTN
Diabetes
Renal disease
Autoimmune

Low dose ASA

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33
Q

What puts a patient at moderate risk of Pre-E? Prevention?

A

TWO OR MORE:
Nulliparity
BMI>30
Fam. Hx of Pre-e
Sociodemographic (AA, low socioeconomic)
AMA > 35

Low dose ASA

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34
Q

When giving aspirin for pre-E prevnetion how much is given? When does it start? Who is it given to?

A

81 mg aspirin daily

Initiated between 12 and 28 weeks, preferably before 16 weeks continue until delivery

High and moderate risk

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35
Q

What is the fluid off balance in pre-E?

A

Persons with preeclampsia are in a state of total volume overload AND have depleted intravascular volume.

Fluid leaks out of intravascular space and collects in the intervillous space/tissues (edema).

Vasospasm and limited intravascular volume causes diminished flow to organs (IUGR, Oliguria).

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36
Q

What are patients with pre-E at high risk for d/t their fluid imbalance?

A

The patient is at higher risk for hypotension and inadequate perfusion with an epidural.

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37
Q

D/t the fluid imbalance with pre-E what should be limited? Why?

A

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
Avoiding these will decrease the risk for pulmonary edema and overload

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38
Q

What is pre-E without severe symptoms?

A

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

New onset proteinuria

39
Q

What is proteinuria defined by?

A

≥ 300mg/dL on a 24-hour urine

Urine Protein/Creatinine (P:C ratio) of ≥ 0.3

Urine dipstick of ≥ 2+ (use only if quantitative measurement is not available)

40
Q

When is proteinuria required for a diagnosis? When is it not required?

A

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

41
Q

What are s/s that pre-e without severe symptoms is transitioning to with severe symptoms?

A

RUQ or epigastric abdominal pain (liver located there)
Severe headache not relieved by Tylenol, rest
Visual changes (persistent scotomata- flassy sparkley lights or blurry vision)

42
Q

What is pre-E with severe symptoms?

A

HTN after 20 weeks AND one or more of the following:
Severe range HTN: Systolic BP > 160 or diastolic BP > 110 on at least two BPs repeated within 15 minutes
Symptoms of central nervous system dysfunction:
New onset severe HA/visual disturbances
Hepatic abnormality:
Impaired liver function (LFTs 2 x normal)
Severe persistent RUQ/epigastric pain
Thrombocytopenia: platelets < 100,000 microliter
Renal insufficiency
Serum creatinine > 1.1 mg/dl or doubling
Pulmonary edema

43
Q

What the the severe symptoms of Pre-E indicate?

A

There tell us that there is end organ damage going on which is why they have any of there symptoms

44
Q

When do you only want to wait 15 minutes before rechecking if patient is in the severe rage HTN?

A

You will need to start implementing interventions before then

45
Q

What are patients with pre-E with severe features at high risk for?

A

Stroke

46
Q

What is the management for pre-e without severe features before 37 weeks?

A

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

47
Q

What is the management for pre-e without severe features after 37 weeks?

A

Admit and Deliver/Induction

48
Q

What is the management of pre-E with severe symptoms before 34 weeks?

A

Give corticosteroids (lung maturity) and Magnesium Sulfate x 24 hours
Expectant management until 34 weeks unless

49
Q

What are the contraindications for expectant management? What do you do?

A

Eclampsia, HELLP, pulmonary edema, DIC, uncontrolled severe HTN, fetal demise, Abnormal fetal testing, abruption, non-viable fetus

Proceed –> Delivery once pregnant person is stable

50
Q

What is the management of pre-E with severe symptoms after 34 weeks?

A

Initiate Magnesium Sulfate
Deliver/Induction

51
Q

When a patient is on expectant management with severe features will they leave the hospital?

A

Patients with severe features will not leave the hospital even with management. Management will be inpatient

52
Q

What is superimposed pre-E without SF?

A

New onset of proteinuria with already diagnosed CHTN (non severe range BPs)

53
Q

What is superimposed pre-E with SF?

A

CHTN diagnosis
Develops systemic changes
Develops severe range BP
Has abnormal labs

54
Q

When a pregnant patient with HTN is in labor/induced what is the care?

A

HELLP labs on admission
Frequent BPs q 15min-1 hr
Lung sounds
DTRs, Clonus
Monitor for symptoms - HA, RUQ/epigastric pain, visual changes
Safety checks – side rails up, prn
Decreased stimuli– quiet, dim lighting, etc.

55
Q

What is the care for a neonate when there is a maternal hypertensive disorder? For the fetus?

A

Fetus: Continuous fetal monitoring – looking for late decelerations r/t poor placental perfusion

Neonate: Monitor for issues associated with prematurity

56
Q

What is clonus?

A

flex foot briskly towards head and drop the foot. Should just drop but if it taps then there is irritability of the CNS

57
Q

Why are safety checks and decrease stimuli so important in a patient with HTN in pregnancy?

A

d/t risk of seizure

58
Q

Why is magnesium sulfate given in all pregnant patients with HTN? Secondary effects?

A

NS depressant used for seizure prophylaxis

Secondary effect: relaxes smooth muscles therefore it can be hard to stimulate labor and contractions because of the smooth muscle relaxation. Can also lead to PPH because uterus doesn’t want to contract

59
Q

What is the loading dose of magnesium sulfate? Maintenance?

A

Loading: 4-6 grams loading dose IV over 20-30 min

Maintenance: 1-2 grams/hr IV until 12-24 hours post-delivery

60
Q

Does magnesium sulfate have to be given IV?

A

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

61
Q

What are the side effects of magnesium sulfate?

A

Flushing, HA, nystagmus, nausea, dry mouth, lethargy, dizziness, burning at IV site

62
Q

What are toxicity side effects of magnesium sulfate? What is the treatment?

A

Respiratory depression and arrest, pulmonary edema

10% Calcium gluconate in 10 ml given over 10 minutes (always call for provider evaluation prior to giving)
Stop the Magnesium Sulfate

63
Q

If a patient is having a eclamptic seizure what is the treatment?

A

gnesium Sulfate dosing as prevention

Loading: 4-6 grams loading dose IV over 20-30 min

Maintenance: 1-2 grams/hr IV until 12-24 hours post-delivery

64
Q

What monitoring should be done with magnesium sulfate?

A

DTRs- should remain present (1+ or greater)
Respirations- should remain > 12/minute
Hourly Intake and Output
Serum magnesium levels- drawn PRN

65
Q

Why is it so important to watch I&O for magnesium sulfate? How will they be voiding?

A

Place indwelling foley catheter

Urine output should be > 30ml/hr output—because mg sulfate is excreted through the kidneys so if not urinating building up in body and can lead to toxicity

66
Q

What is the therapeutic range for magnesium sulfate?

A

4-7mg/dl

67
Q

What maternal effects should be monitored for when giving magnesium sulfate?

A

effects on contraction pattern, immediate postpartum period, and with epidural administration (d/t decrease BP)
hypotonia, lethargic, resp depression

68
Q

When mom is receiving magnesium sulfate what should the newborn be monitored for?

A

hypotonia, lethargic, resp depression

69
Q

What is postpartum care for a patient with HTN disorders?

A

Seizure precautions:
Highest risk of seizures in first 48 hours after birth

Magnesium Sulfate:
Continued for 12-24 hours post delivery

Postpartum hemorrhage meds
NO METHERGINE! Will make BP increase

Follow up:
BP 7-10 days post delivery
Increase in BP at 3-6 days pp

70
Q

What does HTN disorders in pregnancy put the patient at risk for PP?

A

Future CVD disease

71
Q

What is eclmapsia? Who can this occur in? What could occur before?

A

New-onset seizure in a hypertensive obstetrical patient with preeclampsia in the absence of other neurologic conditions, that would explain the seizure

Can occur with or without severe features of preeclampsia

May have impending seizure “aura”or headache (visual, smell)

72
Q

When does more eclampsia occur?

A

Most eclampsia occurs antepartum (in pregnancy)
but can occur in postpartum women, usually in first 48 hours

73
Q

What is should be documented during an eclamptic seizure?

A

Time of seizure, length, involvement
Seizures are usually self limiting (<4 min)

74
Q

What interventions should be done for the patent during a eclamptic seizure?

A

O2
Suction PRN
Turn to LLP and tilt head down to the side
No tongue blade or restraints
Side rails up with pillows/padding

75
Q

What medications should be given to a patent during a eclamptic seizure?

A

Give bolus/loading dose (4-6 grams over 20-30 min via IV piggyback) – even if already had Mg

Other Meds: Diazepam or Ativan only if sustained seizure (uncommon)

76
Q

When caring for mom after a eclamptic seizure what should be monitored?

A

Maternal BP
Check for signs of abruption – vaginal bleeding, board like uterus, very tender uterus, tachysystole
Has baby delivered b/c can cause baby to deliver

77
Q

What are possible FHR changes after a eclamptic seizure? Will they self-correct? If not, then what?

A

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

78
Q

What is acute onset of severe HTN?

A

Sudden onset of systolic BP > 160 or diastolic BP >110 or both

Repeat within 15 minutes to confirm

79
Q

What is the treatment of acute onset of severe HTN?

A

Rapid notification of provider
Treat with first line antihypertensives (within 30-60 mins of diagnosis because high risk for stroke)
IV Hydralazine or Labetalol or oral Immediate-release Nifedipine if no IV

80
Q

What is HELLP?

A

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

81
Q

What increases a patient’s risk for HELLP?

A

history of preeclampsia or HELLP

82
Q

What is the patho of HELLP?

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

83
Q

What can HELLP lead to?

A

This may lead to epigastric pain, liver capsule rupture, hyperbilirubinemia, DIC, kidney failure, and death

84
Q

What are the most common s/s of HELLP? Less common?

A

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.

85
Q

Does magnesium sulfate cross that placenta?

A

Yes

86
Q

Does antihypertensive to prevent maternal stroke cross the placenta?

A

Yes but they are safe

87
Q

What are first line medications for acute-onset severe HTN?

A

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

88
Q

What is the dose for hydrazine? Route?

A

Hydralazine 5-10 mg IV

89
Q

What is the dose for labetalol? Route? When should it be avoided?

A

Labetalol 20-40 mg IV

Avoid in Asthma or with pulse < 60

90
Q

What is the dose for nifedipine? Route?

A

Immediate-release Nifedipine 10-20 mg PO if no IV

91
Q

What is pre-E with SF and HELLP syndrome both associated with?

A

serious hepatic presentations, including infarction, hemorrhage, and rupture

92
Q

If patient with HTN disorder experiences hypotension what should you not do?

A

don’t want to give them fluid bolus or ephedrine or phenylephrine

93
Q

If a patient with a RR <12 and is on Mg sulfate what do you think could be occurring?

A

Magnesium toxicity

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