Module 8 Unit A Flashcards
What is the proper technique to obtain a blood pressure reading?
Patient - rested (preferably for 10 min or more), seated w/legs uncrossed and back supported
No caffeine or tobacco should have been used for at least 30 minutes before measurement because these can temporarily elevate blood pressure.
An appropriate sized cuff (eg, one with a length 1.5 times the upper arm circumference or a cuff with a bladder that encircles at least 80% of the arm and a width of at least 40% of arm circumference) positioned at the level of the heart to ensure accurate readings should be used.
What is a normal range blood pressure in a pregnant person?
less than 120/80 mm Hg
Is an abnormal blood pressure reading in a pregnant person?
= or > 140/90
What is the definition of chronic hypertension?
Hypertension diagnosed or present before pregnancy or before 20 weeks gestation.
Hypertension that is diagnosed for the first time during pregnancy and that does not resolve in the typical postpartum period also is classified as chronic hypertension
What is the timing of onset of chronic hypertension?
hypertension diagnosed or present before pregnancy or before 20 weeks gestation. Hypertension that is diagnosed for the first time during pregnancy and that does not resolve in the typical postpartum period also is classified as chronic hypertension
What lab tests should the nurse midwife order in a pregnant person with chronic hypertension?
specific tests include serum creatinine, electrolytes, uric acid, liver enzymes, platelet count, and a quantitative measure of urine protein
Proteinuria is often present in women with renal complications of HTN, and it is particularly important to establish a baseline for this condition
Prenatal labs
Baseline labs after discovering issue: CBC, LFTs, CMP, 24 hr urine → eval for end organ damage that could have occurred prior to preg
EKG → screening purposes
Kidney function screening → creat, urine protein/creat ratio, 24hr urine = gold standards
Baseline labs to assess for superimposed pre E → CMP, LFTs, bili, creat, platelets
What are the maternal implications of chronic hypertension in pregnancy?
placental abruption, superimposed pre-e
What are the fetal implications of chronic hypertension in pregnancy?
PTB, FGR
How should the nurse midwife manage a pregnant person with chronic hypertension?
When first presents for prenatal care, an initial hx, physical examination, assessment of current medications, and baseline testing of renal function are performed
Often referred to a physician for management for prenatal care, collaborate at minimum
Antenatal management -
2.4g sodium intake/day = low sodium diet (no salt would not be helpful)
Wouldn’t want her to gain too much weight
Delivery -
IOL @ least @ 38 wks
May be monitored & followed until 40 wks if low-risk chronic HTN
What is the definition of chronic hypertension with super imposed preeclampsia?
Preeclampsia onset w/ hx of HTN before pregnancy or before 20 weeks of gestation
What is the timing of onset of chronic hypertension with superimposed preeclampsia?
prior to pregnancy or < 20 weeks, earlier in preg than pre-e alone
What lab tests should the nurse midwife order in a pregnant person with chronic hypertension with superimposed preeclampsia?
Lab tests - UA, Liver fxn test, CBC with diff, BUN, Creatinine
There are currently no useful tools for predicting superimposed preeclampsia
AST and ALT, creatinine, electrolytes (specifically potassium)
Blood urea nitrogen
CBC - platelet, and H&H
Spot urine protein/creatinine ratio or 24-hour urine for total protein and creatinine (to calculate creatinine clearance) as appropriate
What are the diagnostic criteria for chronic high pretension with superimposed preeclampsia?
worsening HTN w/new development of: proteinuria, elevated liver enzymes, thrombocytopenia, pulmonary edema, cerebral or visual disturbances, renal insufficiency
Not always easy to dx and is often a dx of exclusion
Sudden increase in baseline HTN or a sudden increase in proteinuria (above the threshold for normal or a clear change from baseline) should prompt assessment for a possible dx of superimposed pre-e and consideration for subspecialty (eg, MFM) referral.
What are the maternal implications of chronic hypertension with superimposed preeclampsia?
Maternal-Fetal Implications - cerebral hemorrhage, pulmonary edema, renal failure, hepatic rupture, and death, PTB, FGR
Maternal Fetal and Neonatal Death Stillbirth or perinatal death
Stroke, IUGR, pulmonary edema, PTB, renal insufficiency and failure, congenital anomalies (heart defects, hypospadias, esophageal atresia), MI, abruption, c/s, pp hemorrhage, GDM
What are the fetal implications of chronic hypertension with superimposed preeclampsia?
Maternal-Fetal Implications - cerebral hemorrhage, pulmonary edema, renal failure, hepatic rupture, and death, PTB, FGR
Maternal Fetal and Neonatal Death Stillbirth or perinatal death
Stroke, IUGR, pulmonary edema, PTB, renal insufficiency and failure, congenital anomalies (heart defects, hypospadias, esophageal atresia), MI, abruption, c/s, pp hemorrhage, GDM
How should the nurse midwife manage a pregnant person with chronic hypertension with superimposed preeclampsia?
Initial management follows the same guidelines recommended for women with pre-e, including assessment of severity, baseline lab values, fetal well-being, and gestational age
Superimposed pre-e w/severe features- mag sulfate indicated during intra and postpartum
Increased monitoring for w/elevated BP especially in the second half of pregnancy
During pregnancy ~ baseline LFTs, serum creat, 24 hr urine, EKG, maintaining B/P within 120-160/80-105, taking low dose ASA, antiHTN meds → labetalol, nifedipine, methyldopa
What is the definition of gestational hypertension?
HTN w/o proteinuria nor severe features >/=140/90 for the first time after 20 wks in previously normotensive
What is the timing of onset of gestational hypertension?
HTN w/o proteinuria nor severe features >/=140/90 for the first time after 20 wks in previously normotensive
What lab tests should the nurse midwife order in a pregnant person with gestational hypertension?
urine dipstick, 24hr urine, TPCR, CBC, liver fxn, creatinine
What are the maternal implications of gestational hypertension?
.
Maternal-Fetal Implications -
Development of chronic HTN for mom
Up to 50% will eventually develop proteinuria or other end-organ dysfunction consistent w/dx of preeclampsia- progression more likely when the HTN dx before 32 weeks
What are the fetal implications of gestational hypertension?
None if controlled
How should the nurse midwife manage a pregnant person with gestational hypertension?
If pre-e is ruled out- encouraged to monitor BP at home and are seen once or twice weekly
Educate about danger signs and have a plan for who and when to call
Optimal gestational age for birth depends on the severity and fetal status
IOL usually after 37-38 wks
Fetal surveillance - start
Fundal height → increased risk for asymmetric FGR
NST or modified BPP 2 x/wk switching between full BPP
Growth US every 3-4 wks
Fetal kick counts daily @ home
Collaborate or consult depending on practice
Antenatal plan
Modified activity → decrease level of activity is beneficial → put on work release
Rest periods throughout the day –> lying in left lateral to improve maternal blood flow
Monitor B/P @ least 2 x/wk –> per ACOG 1 x at home & 1 x in office
Education on S/S of pre E, severe & when to call
What is the definition of preclampsia?
BP of > 140/90 after 20 weeks X 2 taken at least 4 hours apart
What is the timing of onset of preeclampsia?
After 20 weeks
What lab tests should the nurse midwife order in a pregnant patient with preeclampsia?
UA, liver fxn test, CBC with diff, urine dipstick
What is the difference between preeclampsia without severe features and preeclampsia with severe features?
Severe features
platelets <100,000
serum transaminase levels 2x normal
severe persistent RUQ pain
creatinine levels >1.1mg/dL or doubling of baseline
May not have proteinuria
cerebral sx (HA, visual disturbances, convulsions)
pulmonary edema
Although often accompanied by new-onset proteinuria, hypertension and other signs or symptoms of preeclampsia may present in some women in the absence of proteinuria.
What are the maternal implications of preeclampsia in pregnancy?
placental abruption, pregnancy loss, stroke, organ failure, and maternal death, preterm birth, FGR, stillbirth, and neonatal death
2x ↑ risk for cardiovascular disease and mortality from ischemic heart disease, HF or stroke
Likelihood of having HTN after perinatal period
What are the fetal implications of preeclampsia in pregnancy?
FGR, stillbirth, and neonatal death
How should the nurse midwife manage a pregnant person with preeclampsia?
The definitive treatment of pre-e is delivery of the placenta
Expectant management requires consideration of the health of the woman and the fetus
If birth is not indicated for fetal well-being, then the goal of treatment is to treat the woman’s symptoms to allow the fetus to have more time in utero
Antihypertensive medication not recommended with pre-e unless severe features present
Increased surveillance includes weekly BP measurements, daily fetal movement counting, assessment of maternal symptoms, and monitoring platelet counts and liver enzyme levels
Collaboration, usually referral
Delivery 37 weeks IOL for mild
Intrapartum - keep total PO & IV fluid under 125 mL/hr
What is the definition of HELLP?
Continuum of severe preeclampsia. H = hemolysis, EL = elevated liver enzymes, LP= low platelet count, describe the laboratory presentation of this life-threatening disease.
No universally accepted strict definition
May not have HTN or proteinuria
Platelets <100,000
AST >/= 70 or 2x baseline level
Elevated LDH >600 & elevated bilirubin (these indicated hemolysis)
May have pulmonary edema and/or cerebral disturbances.
What is the timing of onset of HELLP?
Rapid progression to HELLP or eclampsia more likely to occur when onset of preeclampsia is prior to 34 weeks gestation
Timing of onset - commonly arises during the antepartum period, but may emerge PP
What lab tests should the nurse midwife order in a pregnant patient with HELLP?
Lab tests - CBC w/platelet estimate, UA, liver function, serum creatinine, LDH, AST, ALT, and testing for proteinuria should be obtained
What are the maternal implications of HELLP in pregnancy?
Maternal-Fetal Implications - increase risk for eclampsia, disseminated intravascular coagulation, acute renal failure, liver hematoma, placental abruption, FGR, PTB, neonatal respiratory distress syndrome, and perinatal death, oligohydramnios and nonreassuring fetal status demonstrated on antepartum surveillance.
Fetuses of those w/preeclampsia - increased risk of spontaneous or indicated preterm birth
Stroke, coagulopathy, ARDS, sepsis
Abruption, pulmonary edema, hepatic hematoma, coagulopathy
What are the fetal implications of HELLP in pregnancy?
FGR, PTB, neonatal respiratory distress syndrome, and perinatal death, oligohydramnios and nonreassuring fetal status demonstrated on antepartum surveillance.
Fetuses of those w/preeclampsia - increased risk of spontaneous or indicated preterm
How should the nurse midwife manage a pregnant patient with HELLP?
management focuses on stabilization of BP and assessment of fetal well-being to determine that optimal time for delivery
Immediate referral
In general, immediate birth for 34 weeks’ gestation or more is recommended
<34 weeks, a delay is recommended to allow for administration of corticosteroids to help fetal lung development as long as both the woman and the fetus are stable
Corticosteroids to tx thrombocytopenia in HELLP syndrome is not supported by evidence
What is the definition of eclampsia?
convulsive manifestation of the hypertensive disorders of pregnancy and is among the more severe manifestations of the disease. Defined by new-onset tonic-clonic, focal, or multifocal seizures in the absence of other causative conditions such as epilepsy, cerebral arterial ischemia, and infarction, intracranial hemorrhage, or drug use
What is the timing of onset of eclampsia ?
after or w/pre-e, most common 3rd trim, ↑in frequency as term approaches
What lab tests should the nurse midwife order in a pregnant patient with eclampsia?
liver fxn, CBC with diff, UA, Serial serum creatinine levels
Magnesium level for therapeutic level
What are the maternal implications of eclampsia in pregnancy?
Maternal-Fetal Implications - brain hemorrhage, permanent neurologic morbidities, and stroke, placental abruption may occur if the seizure prolonged
Abruption (10%), neuro deficits, aspiration pneumonia, pulmonary edema, cardiopulmonary arrest, acute renal failure, death (1%)
Coma in between seizures
What are the fetal implications of eclampsia in pregnancy?
Related to maternal neuro morbidities or mortality
How should the nurse midwife manage a person with eclampsia?
Recognize early warning signs (triggers) of these conditions and treating severe HTN
Mag sulfate remains the standard of care for the prevention and treatment of eclampsia for women who have pre-e with severe features
What is the definition of postpartum preeclampsia?
preeclampsia in the postpartum period, most between day 3-10 pp and majority were not diagnosed with preE or HTN in pregnancy
Begins 48 hrs- 4 weeks PP
What is the timing of onset of postpartum preeclampsia?
after 48 hours to 3-10 days postpartum most common; up to 4-6 weeks
What lab and tests should the nurse midwife order in a person with postpartum preeclampsia?
serial BP’s, UA or 24hr urine for proteinuria, uric acid, weight
How should the nurse midwife manage a postpartum person with preeclampsia?
ER initiate mag infusion, and hypertensive control with labetalol, hydralazine, and nifedipine which will transition to PO and go home with one or more of these (labetalol, hydralazine, nifedipine) and continue until at least 6 weeks postpartum.
See 3d-1w later in office for BP and lab check, continue close monitoring until 6 weeks PP and give PIH warning signs.
Referral - hospitalization &physician care, 24 hrs of mag, additional antihtn meds if needed
If eclamptic, mag given for 24 hours after last seizure
What evidence based strategy can be used to prevent preeclampsia?
Low dose (81mg/d, 60-80mg) aspirin b/w 12-28 wks (best before 16 wks), continue until delivery
No intervention has proved unequivocally effective at eliminating risk of pre-e (ACOG).
However, using aspirin, routine BP monitoring and education about warning signs of when to call office or go to the hospital are all recommended. Encouraging healthy lifestyles, reducing risks of DM, cardiac disease all will help as well
Why is magnesium sulfate used as part of the management of preeclampsia?
Decreases CNS irritability, vasodilation cerebrally, anticonvulsant and tocolytic.
When should magnesium sulfate be used as part of the management of preeclampsia?
As seizure prophylaxis in preeclampsia with severe features.
In reducing eclampsia and prevention of eclampsia in intrapartum and postpartum periods
What are the signs of magnesium sulfate toxicity?
hypotension, resp depression, decreased DTRs, EKG changes, oliguria, SOB/chest pain-
Antidote for toxicity is Ca Gluconate or Ca Chloride IV
Reverses mild-mod respiratory dysfunction
If severe - ventilate
What 1st line anti hypertensives should be used in the management of preeclampsia?
labetalol, hydralazine IV, but Nifedipine PO can also be used
How should the nurse midwife manage an eclamptic seizure?
Mag is more effective than phenytoin, diazepam, or nimodipine;
Benzodiazepines and phenytoin are justified only in the context of antiepileptic treatment or when mag is contraindicated or unavailable.
Mag administered IM or IV- superior to phenytoin, diazepam, or lytic cocktail (usually chlorpromazine, promethazine, and pethidine) and also is associated with less maternal and neonatal morbidity
Immediate mgmt of eclamptic seizure- Mag effective in controlling eclamptic seizures -
4-6 grams over 15-20 minutes
Seize despite mag - - 1st recommended therapy is additional loading dose of mag sulfate 2 g IV over 5 minutes
If continues w/seizures despite repeat loading dose → alternative anticonvulsants considered → lorazepam (Ativan), diazepam (valium), midazolam (Versed), or phenytoin ( )
Anesthesia should be called immediately when a patient suffers a seizure
Turn to lateral ‘recumbent’ position. The side-lying position prevents aortocaval compression, helps the tongue fall to the side of the mouth and lessens the risk of aspiration. If possible, cushion the head from injury by placing a soft object under the head.
Open airway with a jaw thrust and/or oral airway, if needed. Do not insert any object other than the oral airway, if needed, into the mouth. Nasal airways will often cause nosebleeds
Check for air movement and reposition if there is no air movement. Be aware that an oral airway can make the patient vomit and may not be necessary.
Resuscitation of the mother is the key to protecting the fetus. This point is counterintuitive for many Labor and Delivery personnel, who may incorrectly focus on the baby is key
Following a maternal seizure, fetal bradycardia is commonly seen due to maternal hypoxia. Stabilization of the mother is the first priority followed by resuscitation of the fetus
What is mitral valve prolapse?
a condition in which the two valve flaps of the mitral valve don’t close smoothly or evenly
Does mitral valve prolapse require antibiotic treatment during the intrapartum period?
No
