Module 8 Unit A

Question 1

What is the proper technique to obtain a blood pressure reading?

Answer 1

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.

Question 2

What is a normal range blood pressure in a pregnant person?

Answer 2

less than 120/80 mm Hg

Question 3

Is an abnormal blood pressure reading in a pregnant person?

Answer 3

= or > 140/90

Question 4

What is the definition of chronic hypertension?

Answer 4

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

Question 5

What is the timing of onset of chronic hypertension?

Answer 5

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

Question 6

What lab tests should the nurse midwife order in a pregnant person with chronic hypertension?

Answer 6

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

Question 7

What are the maternal implications of chronic hypertension in pregnancy?

Answer 7

placental abruption, superimposed pre-e

Question 8

What are the fetal implications of chronic hypertension in pregnancy?

Answer 8

PTB, FGR

Question 9

How should the nurse midwife manage a pregnant person with chronic hypertension?

Answer 9

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

Question 10

What is the definition of chronic hypertension with super imposed preeclampsia?

Answer 10

Preeclampsia onset w/ hx of HTN before pregnancy or before 20 weeks of gestation

Question 11

What is the timing of onset of chronic hypertension with superimposed preeclampsia?

Answer 11

prior to pregnancy or < 20 weeks, earlier in preg than pre-e alone

Question 12

What lab tests should the nurse midwife order in a pregnant person with chronic hypertension with superimposed preeclampsia?

Answer 12

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

Question 13

What are the diagnostic criteria for chronic high pretension with superimposed preeclampsia?

Answer 13

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.

Question 14

What are the maternal implications of chronic hypertension with superimposed preeclampsia?

Answer 14

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

Question 15

What are the fetal implications of chronic hypertension with superimposed preeclampsia?

Answer 15

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

Question 16

How should the nurse midwife manage a pregnant person with chronic hypertension with superimposed preeclampsia?

Answer 16

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

Question 17

What is the definition of gestational hypertension?

Answer 17

HTN w/o proteinuria nor severe features >/=140/90 for the first time after 20 wks in previously normotensive

Question 18

What is the timing of onset of gestational hypertension?

Answer 18

HTN w/o proteinuria nor severe features >/=140/90 for the first time after 20 wks in previously normotensive

Question 19

What lab tests should the nurse midwife order in a pregnant person with gestational hypertension?

Answer 19

urine dipstick, 24hr urine, TPCR, CBC, liver fxn, creatinine

Question 20

What are the maternal implications of gestational hypertension?

Answer 20

.

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

Question 21

What are the fetal implications of gestational hypertension?

Answer 21

None if controlled

Question 22

How should the nurse midwife manage a pregnant person with gestational hypertension?

Answer 22

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

Question 23

What is the definition of preclampsia?

Answer 23

BP of > 140/90 after 20 weeks X 2 taken at least 4 hours apart

Question 24

What is the timing of onset of preeclampsia?

Answer 24

After 20 weeks

Question 25

What lab tests should the nurse midwife order in a pregnant patient with preeclampsia?

Answer 25

UA, liver fxn test, CBC with diff, urine dipstick

Question 26

What is the difference between preeclampsia without severe features and preeclampsia with severe features?

Answer 26

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.

Question 27

What are the maternal implications of preeclampsia in pregnancy?

Answer 27

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

Question 28

What are the fetal implications of preeclampsia in pregnancy?

Answer 28

FGR, stillbirth, and neonatal death

Question 29

How should the nurse midwife manage a pregnant person with preeclampsia?

Answer 29

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

Question 30

What is the definition of HELLP?

Answer 30

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.

Question 31

What is the timing of onset of HELLP?

Answer 31

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

Question 32

What lab tests should the nurse midwife order in a pregnant patient with HELLP?

Answer 32

Lab tests - CBC w/platelet estimate, UA, liver function, serum creatinine, LDH, AST, ALT, and testing for proteinuria should be obtained

Question 33

What are the maternal implications of HELLP in pregnancy?

Answer 33

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

Question 34

What are the fetal implications of HELLP in pregnancy?

Answer 34

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

Question 35

How should the nurse midwife manage a pregnant patient with HELLP?

Answer 35

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

Question 36

What is the definition of eclampsia?

Answer 36

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

Question 37

What is the timing of onset of eclampsia ?

Answer 37

after or w/pre-e, most common 3rd trim, ↑in frequency as term approaches

Question 38

What lab tests should the nurse midwife order in a pregnant patient with eclampsia?

Answer 38

liver fxn, CBC with diff, UA, Serial serum creatinine levels

Magnesium level for therapeutic level

Question 39

What are the maternal implications of eclampsia in pregnancy?

Answer 39

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

Question 40

What are the fetal implications of eclampsia in pregnancy?

Answer 40

Related to maternal neuro morbidities or mortality

Question 41

How should the nurse midwife manage a person with eclampsia?

Answer 41

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

Question 42

What is the definition of postpartum preeclampsia?

Answer 42

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

Question 43

What is the timing of onset of postpartum preeclampsia?

Answer 43

after 48 hours to 3-10 days postpartum most common; up to 4-6 weeks

Question 44

What lab and tests should the nurse midwife order in a person with postpartum preeclampsia?

Answer 44

serial BP’s, UA or 24hr urine for proteinuria, uric acid, weight

Question 45

How should the nurse midwife manage a postpartum person with preeclampsia?

Answer 45

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

Question 46

What evidence based strategy can be used to prevent preeclampsia?

Answer 46

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

Question 47

Why is magnesium sulfate used as part of the management of preeclampsia?

Answer 47

Decreases CNS irritability, vasodilation cerebrally, anticonvulsant and tocolytic.

Question 48

When should magnesium sulfate be used as part of the management of preeclampsia?

Answer 48

As seizure prophylaxis in preeclampsia with severe features.

In reducing eclampsia and prevention of eclampsia in intrapartum and postpartum periods

Question 49

What are the signs of magnesium sulfate toxicity?

Answer 49

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

Question 50

What 1st line anti hypertensives should be used in the management of preeclampsia?

Answer 50

labetalol, hydralazine IV, but Nifedipine PO can also be used

Question 51

How should the nurse midwife manage an eclamptic seizure?

Answer 51

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

Question 52

What is mitral valve prolapse?

Answer 52

a condition in which the two valve flaps of the mitral valve don’t close smoothly or evenly

Question 53

Does mitral valve prolapse require antibiotic treatment during the intrapartum period?

Answer 53

No