hypertensive disorders of pregnancy Flashcards
4 HTN disorders of pregnancy
-chronic HTN
-gestational HTN
-chronic HTN w superimposed preeclampsia
-preeclampsia/eclampsia
elevated BP that predates pregnancy
chronic HTN
what normal Tx for chronic HTN are not recommended in pregnancy (2)
-weight loss
-extremely low sodium diets
who is at risk for chronic HTN
-advanced maternal age
-obesity
-lack of exercise
-comorbidities
-diabetes
-smoking
meds you can’t use to treat HTN during pregnancy
ACE inhibitors
med to treat HTN during pregnancy (3)
-b blocker (labetalol)
contraindicated in pts with HF or asthma
-CCB (nifedipine)
-methyldopa
blood pressure elevation after 20 weeks of gestation (in absence of proteinuria and other features preeclampsia)
gestational HTN
what is considered proteinuria
-protein/creatinine ratio 0.3mg/dL (more than +1)
-300 mg or more of protein in 24 hr urine
what bp is treated during pregnancy
160/110
(or Sbp +30/Dbp +15 over baseline)
what happens with preeclampsia (patho)
-constricted spiral arteries to placenta
-vasospasms (endothelial damage)
-decreased maternal CO (impaired blood flow to organs)
-hypovolemia
-platelet aggregation that further constrict spiral arteries
-decreased tissue perfusion, increased cellular hypoxia
preeclampsia diagnostic criteria (2)
-bp 140/90
-protein/Cr ration >0.3 or >300 mg in 24 hr urine
(+edema, thrombocytopenia)
risk factors preeclampsia
-genetic
-multiples
->35 yo or teenagers
-diabetes
-obesity
-preexisting HTN/renal disease
-Hx of thrombophilia
-IVF
-SLE (autoimmune disorders)
severe features of preeclampsia (7)
elevated BP + atleast one feature = severe
-Sbp >160
-Dbp >110
-thrombocytopenia (plt <100)
-impaired liver function (severe RUQ pain, unresponse to meds)
-progressive renal insufficiency (Cr>1.1)
-pulmonary edema
-new onset cerebral/visual disturbances (headache, blurred vision)
complications severe preeclampsia
-pulmonary edema
-MI
-stroke
-acute resp distress
-coagulopathy (DIC)
-severe renal failure
-retinal injury
-abruption
diagnosis of superimposed preeclampsia (with women who had chronic HTN)
-sudden exacerbation HTN (previously well controlled)
-sudden onset S+S (headache, blurred vision)
-Plt >100
-development pulmonary congestion/edema
-development renal insufficiency
-sudden/sustained protein increase (proteinuria)
what value is considered thrombocytopenia
plt >100,000
prenatal pt care for HTN disorders
-daily assessment of symptoms
-daily fetal kick counts
-serial assessments bp (atleast 2x weekly)
-labs weekly (platelets, liver enzymes)
-ultrasound to assess fetal growth
-antenatal steroids (accelerates fetal lung maturity)
PRES
what does it stand for and what is it
posterior reversible encephalopathy syndrome
= swelling of brain caused by HTN crisis, leads to seizures
how to elicit clonus
sharp dorsiflexion of foot
clonus = shaking of foot
med to protect from seizures with preeclampsia
magnesium sulfate
smooth muscle relaxer
when do you worry about creatinine in pregnancy
> 1.1
UPCR
urine protein creatinine ratio
(should be 0.3 or less)
eclampsia interventions
-airway
-call for help
-lateral recumbent position
-oxygen
-suction
-VS monitoring
-protect pt
-reorient pt
-magnesium sulfate
(mag not effective: versed, ativan, valium, dilantin)
meds you can give if magnesium isn’t working to stop eclampsia
versed
ativan
valium
dilantin
therapeutic mag levels
5-8
S+S PRES
-quick onset
-seizures are late symptoms
-headache
-blurry vision
-cortical blindness
-N/V
-impaired LOC
nursing assessments for pregnant pts
-VS
-DTRs
-I&O
-S/S of severe preeclampsia (RUQ pain, headache, blurred vision, edema)
-CTX
-ROM
-abdominal pain
-bleeding
-lab tests
-RR
classifications edema
+1 = 2 mm
+2 = 4 mm
+3 = 6 mm
+4 = 8 mm
*lab values??
what scan if fetal growth restriction is suspected
doppler velocimetry (umbilical artery doppler blood flow)
*deliver if reversed end diastolic velocity
Tx/plan of care for preeclampsia/women at risk for preeclampsia
-low dose aspirin (after 1st tri)
-antiHTN meds (for >160/110)
-mag (for severe preeclampsia)
-corticosteroids (betamethasone and dexamethasone for fetal lung maturity)
-epidural (vasodilates, as long as plt above 80)
corticosteroids to accelerate fetal lung maturity (2)
betamethasone
dexamethasone
(usually before 34 weeks, atleast 24 hrs before delivery)
delivery indications (maternal)
-recurrent severe HTN
-recurrent S+S severe preeclampsia
-progressive renal insufficiency
-persistent thrombocytopenia or HELLP syndrome
-pulmonary edema
-eclampsia
-suspected abruption (depends on amount of abruption)
-progressive labor or ROM
when to deliver for preeclampsia w/o severe features?
w/ severe features?
37 weeks w/o severe features
34 weeks or sooner if severe features
delivery indications (Fetal)
-34 wks gestation
-severe fetal growth restriction
-persistent oligohydramnios (<5 cm)
-BPP 4/10 or less on atleast 2 tests
-reversed end-diastolic flow on umbilical artery doppler
-recurrent variable/late decels on NST
-fetal death
normal amniotic fluid volume (cm)
what is considered oligo
6-25 cm
oligo: <5 cm
how can NSAIDs affect bp
increases bp
what postpartum pts should receive antiHTN therapy
persistent BP 150/100 atleast 2 occasions 4-6 hrs apart
what postpartum pts should receive mag
new onset HTN or visual disturbances
what is chronic HTN postpartum
elevated bp after 12 weeks PP
signs of abruption on TOCO
low amplitude, high frequency contractions
oxygen deprivation process in fetus
-hypoxemia
-hypoxia
-metabolic acidosis
-metabolic acidemia
what on TOCO tells us there is an interruption in oxygenation to fetus
variable, late or prolonged ecels
what on TOCO tells us there will not be metabolic acidemia
moderate variability or accelerations
what is HELLP syndrome (acronym)
hemolysis (RBC)
elevated
liver enzymes
low
platelets
S+S HELLP syndrome
-malaise
-headache
-N/V, indigestion w pain after eating
-RUQ pain
-shoulder pain/pain with deep breathing
-bleeding
-changes in vision
-swelling
Tx HELLP
-corticosteroids
-supportive care w blood products
subtype of preeclampsia characterized by sudden or progressive deterioration in maternal and/or fetal condition (may or may not have elevated bp; most common in white women)
HELLP syndrome
med options for severe HTN (>160/110) (3)
IV access:
-hydralazine
-labetalol
no IV access:
-nifedipine
risk factors for stroke
-HTN
-diabetes
-heart disease
-sickle cell anemia
-thrombocytopenia
-smoking
-lupus
-complications of labor
types stroke
ischemic (infarction)
hemorrhagic:
-intracerebral
-subarachnoid
BEFAST acronym for stroke
Balance (loss balance, dizziness, headache)
Eyes (sudden loss vision)
Face (uneven)
Arm (weakness)
Speech (difficulty)
Time (call 911)
S+S stroke
-headache
-visual changes
-epigastric pain
-seizures
-N/V
-focal/global neurologic deficits
-severe HTN
-facial/arm muscle weakness
-facial deficit
-convulsions
imaging for stroke
CT (can’t see full extent)
MRI (can see ischemic changes)
