Lecture 14 Hypertensive disorders of pregnancy

Question 1

Complications of pregnancy-associated hypertensive disorders

Answer 1

1. Uteroplacental insufficiency.
2. Premature birth.
3. IUGR, oligohydramnios, and fetal demise.

Question 2

Diagnosis of hypertension

Answer 2

1. Requires 2 blood pressure readings, taken at least 4 hours apart. (Obstetric client: BP should be taken after 20 weeks of gestation.)
2. A systolic blood pressure greater than 140 mm Hg OR a diastolic blood pressure greater than 90 mm Hg.

Question 3

Lactate dehydrogenase (LDH)

Answer 3

An enzyme released as a result of hemolysis; elevated in preeclampsia.

Question 4

HELLP syndrome

Answer 4

H - Hemolysis (AEB decreased RBCs and platelets, hyperbilirubinemia, and elevated lactate dehydrogenase)
EL - Elevated Liver enzymes (AST and ALT)
LP - Low Platelets (less than 100,000)
A laboratory diagnosis (not a separate illness) for a variant of severe preeclampsia that involves hepatic dysfunction.

Question 5

Gestational hypertension

Answer 5

The onset of hypertension without proteinuria or other systemic findings diagnostic of preeclampsia after week 20 of pregnancy.

Question 6

Preeclampsia

Answer 6

A pregnancy-specific condition in which hypertension and proteinuria develop after 20 weeks of gestation in a woman who previously had neither condition. Can also develop in the early postpartum period.

Question 7

Eclampsia

Answer 7

The onset of seizure activity or coma in a woman with preeclampsia who has no history of preexisting pathology that can result in seizure activity.

Question 8

Superimposed preeclampsia

Answer 8

Preeclampsia with preexisting chronic hypertension (difficult to diagnose).

Question 9

Cause and resolution of preeclampsia

Answer 9

1. Believed to be the result of disruptions in placental perfusion (placental ischemia) and endothelial cell dysfunction.
2. Disease is linked to the placenta; therefore it begins to resolve after the placenta has been expelled.

Question 10

Renal changes in preeclampsia

Answer 10

1. Proteinuria - primarily albumin.
2. Decreased GFR, oliguria, and elevated serum creatinine - due to decreased renal perfusion.
3. Uric acid clearance is decreased; serum uric acid levels increase.
4. Sodium and water are retained.

Question 11

Neurologic changes in preeclampsia

Answer 11

1. Cerebral edema causes increased irritability of the CNS - hyperreflexia, positive ankle clonus, headaches, seizures.
2. Visual disturbances (e.g., scotoma - dim vision or blind or dark spots in the visual field) occur due to retinal arteriolar spasm.

Question 12

Medications used to treat preeclampsia

Answer 12

1. Daily low-dose aspirin (60 to 80 mg) beginning late in the 1st trimester can help high risk women.
2. Antihypertensives (labetalol, hydralazine, methyldopa, nifedipine) are useful for severe hypertension.
3. Magnesium sulfate is used for seizure prevention but not as an antihypertensive agent.

Question 13

Deep tendon reflexes (DTRs)

Answer 13

1. Reflect the balance between the cerebral cortex and the spinal cord.
2. Normal finding = 2+ response.
3. Clonus = hyperactive reflexes; observed in the ankle by sharply dorsiflexing the patient’s foot and watching for oscillations as the foot drops to the plantar-flexed position.

Question 14

Magnesium sulfate (seizure prevention)

Answer 14

1. Drug of choice for the prevention/treatment of eclampsia - decreases hyperreflexia and minimizes the risk of seizure activity.
2. A therapeutic serum magnesium level of 4 to 7 mEq/L is maintained.
3. Antitode for magnesium sulfate toxicity: Calcium gluconate.
4. Nursing considerations: Maintain a quiet, darkened environment to reduce stimuli; assess DTRs hourly; regularly assess urine output and FHR tracing. Notify provider of respiratory less than 12/min.
5. Side effects: A feeling of warmth, flushing, diaphoresis, burning at the IV site, sedation, nausea.

Question 15

Clinical signs that demonstrate resolution of preeclampsia include _

Answer 15

Diuresis and decreased edema.

Question 16

The client has been on magnesium sulfate for 20 hours for the treatment of preeclampsia. She just delivered a viable infant girl 30 minutes ago. What uterine findings does the nurse expect to observe or assess in this client?

Answer 16

Boggy uterus with heavy lochia flow. [High serum levels of magnesium can cause a relaxation of smooth muscle such as the uterus. Because of this tocolytic effect, the client will most likely have a boggy uterus with increased amounts of bleeding. All women experience uterine bleeding in the postpartum period, especially those who have received magnesium therapy. Rather than scant lochial flow, however, this client will most likely have a heavy flow attributable to the relaxation of the uterine wall caused by magnesium administration.]

Question 17

The client is being induced in response to worsening preeclampsia. She is also receiving magnesium sulfate. It appears that her labor has not become active, despite several hours of oxytocin administration. She asks the nurse, “Why is this taking so long?” What is the nurse’s most appropriate response?

Answer 17

“The magnesium is relaxing your uterus and competing with the oxytocin. It may increase the duration of your labor.” [Because magnesium sulfate is a tocolytic agent, its use may increase the duration of labor. The amount of oxytocin needed to stimulate labor may be more than that needed for the woman who is not receiving magnesium sulfate.]

Question 18

Which intervention is most important when planning care for a client with severe gestational hypertension?

Answer 18

Induction of labor is likely, as near term as possible. [By 34 weeks of gestation, the risk of continuing the pregnancy may be considered greater than the risks of a preterm birth.]

Question 19

A woman with severe preeclampsia has been receiving magnesium sulfate by intravenous infusion for 8 hours. The nurse assesses the client and documents the following findings: temperature of 37.1° C, pulse rate of 96 beats per minute, respiratory rate of 24 breaths per minute, BP of 155/112 mm Hg, 3+ DTRs, and no ankle clonus. The nurse calls the provider with an update. The nurse should anticipate an order for which medication?

Answer 19

Hydralazine. [Hydralazine is an antihypertensive medication commonly used to treat hypertension in severe preeclampsia. Typically, it is administered for a systolic BP higher than 160 mm Hg or a diastolic BP higher than 110 mm Hg.]