T4 - Hypertensive Disease (Josh) Flashcards
— disorders are the most common medical complication of pregnancy.
Hypertensive
***risen steadily since 1990 in all races and ethnic groups
What are some potentially lethal complications from Hypertensive Disorders?
Pre-eclampsia
Abruptio Placentae
DIC
Acute Renal Failure
Hepatic Failure
Adult Respiratory Distress Syndrome (ARDS)
Cerebral Hemorrhage
HELLP Syndrome
How HTN defined in pregnancy?
140/90 or more on at least 2 separate occasions 4-6 hrs apart within a maximum of 1 wk
***sitting, no tobacco/caffeine 30 mins prior
What is Gestational HTN?
onset of HTN without proteinurea after 20 wks gestation
— usually occurs 20 weeks after gestation in a previously normotensive patient AND has proteinurea.
Preeclampsia
What proteinurea is a sign of preeclampsia?
above 30 mg (1+ on dipstick) or more in 2 random specimens at least 6 hrs apart
or
300 mg in 24 hrs
What is difference b/t Preeclampsia and Eclampsia?
seizures
What is HTN that occurs before pregnancy or diagnosed before 20th week gestation?
Chronic HTN
***persists more than 6-12 wks PP
What is Preeclampsia superimposed on Chronic HTN?
Chronic HTN patient w/ new proteinurea or an exacerbation of HTN or Proteinurea, thrombocytopenia, or increase in hepatocellular enzymes
What BP is HTN?
What MAP is HTN?
140/90
MAP > 105
Are BP elevations over pre-pregnancy values diagnostic for preeclampsia?
No
but women with an increase of 30 (systolic) or 15 (diastolic) warrant further watching when they have proteinurea and hyperuricemia (uric acid of 6 or more)
What has to be elevated for it to meet the definition of Gestational HTN?
either systolic or diastolic
only one is needed to be elevated for it be diagnostic
What percentage of Primigravidas have Gestational HTN?
Multiparous?
Primigravidas = 6-17%
Multiparas = 2-4%
Gestational HTN is more frequent in — pregnancies.
multifetal
When does Gestational HTN normally develop?
at or after 37 weeks if they have no preexisting HTN
***BP returns to normal within 1-12 wks after delivery
What is Mild Preeclampsia?
140/90
MAP > 105
24 hr proteinurea > or = 0.3 g
What is Severe Preeclampsia?
160/110
Map > 105
24 hr proteinurea > 2 g
What is usually the first sign of preeclampsia?
elevated BP
— occurs in too many normal pregnancies to be used as a marker for preeclampsia.
Edema
What is the only cure for preeclampsia?
delivery
What weight gain is a sign of preeclampsia?
> 2 kg (4.4 lb) in one week
What is the etiology of preeclampsia?
disruption of placental perfusions and endothelial cell dysfunction
What is the cause of preeclampsia?
uknown
Preeclampsia:
What do disruption of placental perfusions and endothelial cell dysfunctions lead to?
Vasospasm
Increased Peripheral Resistence
Increased Endothelial Cell Permeability
***all leading to decreased tissue perfusion
T/F: The major pathological factor in preeclampsia is elevated BP.
False
it is poor perfusion as a result of vasospasm
Preeclampsia:
What drug do we give?
Mag Sulfate
4-6 g loading dose then a 2-3 g maintenance dose
***have a fan b/c they’ll be hot
What drug is needed in case of Mag toxicity?
Calcium Gluconate
A/E of Magnesium Sulfate
Works on big smooth muscles:
- affects heart
- LOC can drop b/c heart has slowed and O2 perfusion is low
What urine output is minimal?
30 mL /hr
Preeclampsia:
What are the affects on the Placenta?
impaired perfusion leads to early aging of placenta and IUGR of fetus
Preeclampsia:
What are the effects on Renal System?
decreased GFR results in oliguria, proteinurea, hyperuricemia, and sodium/water retention
Preeclampsia:
What are the effects on Hepatic System?
decreased perfusion can result in hepatic edema and subscapular hemorrhage a/e/b complaint of epigastric pain or RUQ pain
liver enzymes (AST, ALT, LDH) elevated
What are signs of impending preeclampsia?
epigastric pain
RUQ pain
Preeclampsia:
What are the Neurological effects?
vasospasms and decreased perfusion can result in:
- Cerebral Edema
- CNS irritability (headache, hyperreflexia, etc)
- Visual Disturbances (blurring)
Preeclampsia:
Lab Values
Decreased Serum Albumin which leads to decreased osmotic pressure –> edema
Increased HCT as a result of hemoconcentration
Increased BUN
Increased Serum Creatinine
Increased Serum Uric Acid
Parameters for Proteinurea
- Concentration at or above 30 mg/dL (> or = to 1+ on dipstick)
- At least 2 specimins
- At least 6 hrs apart
or. … - 24-hr specimne at or above 300mg/24 hrs
***both in absence of UTI
Nursing actions w/ Eclampsia
Keep patient safe
Turn on side
Suction
O2
IV Mag Sulfate
Monitor Fetus
Uterine and Cervical Assessment
Document
Eclampsia:
Following a seizure, why would we hold off delivery?
until antenatal glucocorticoids can be given
Why not use Lasix for preeclampsia?
Diuretic therapy further reduces placental perfusion
***only used if evidence of CHF or PE
— is a sign of impending eclampsia.
Hyperreflexia
Absence of — in a patient on Mag is a sign of toxicity.
reflexes
***mag level > 9 mg/dL
Management of Mild Preeclampsia
Bedrest
Daily BP and Weights
Fetal Surveillance
Monitor Proteinurea
What S/S of preeclampsia should we tell client to report?
BP 140/90
Decreased Fetal Mvmt
Headache
Visual Disturbances
Epigastric or RUQ pain
Proteinurea
Decreased Urine Output
N/V
Malaise
Vag Bleeding or Abd. Tenderness
What type of diet does a preeclapsia client needs?
same as normal healthy pregnant woman
**do not limit salt (except w/ chronic htn) b/c they need it to maintain blood volume
Management of Severe Preeclampsia
Hospital Bed Rest
Maternal and Fetal Surveilance (possibly in ICU)
Quiet, nonstimulating environment (prevent seizures)
Meds
Delivery
Meds for Preeclampsia:
Why give Magnesium Sulfate?
calm the CNS to prevent seizures
What meds for Preeclampsia?
Mag Sulfate
Oral Antihypertensives
When would we give an oral antihypertensive med for preeclampsia?
> 160/100
***hold if diastolic below 90 b/c it could reduce uteroplacental perfusion
Preeclampsia during Postpartum.
1/3 of all cases occurred after delivery and the risk remained for up to 28 days PP
After delivery, how do we prevent preeclampsia from progressing to eclampsia?
Mag Sulfate is given 12-24 hrs post-delivery
A/E of Magnesium Sulfate during PP period.
Interferes w/ uterus clamping down –> BOGGY UTERUS and heavy lochia (increased risk for PP hemorrhage)
Mag Sulfate can cause a Boggy Uterus PP. What meds do we give to counteract?
Oxytocin
***Methergine and Ergotrate are contraindicated b/c they can increase BP
PP Preeclampsia:
How often should BP be measured?
q 4 hrs for 48 hrs
PP Preeclampsia:
Why would we be cautious in giving analgesics to help with pains?
Mag Sulfate potentiates the effects of analgesics
Can mom breastfeed when on Mag Sulfate?
Yes
HELLP is a — diagnosis, not a — diagnosis.
laboratory
clinical
HELLP stands for…
Hemolysis
Elevated Liver enzymes
Low Platelets
**HELLP Syndrome is a variant of severe preeclampsia that affects 1 in 1000 pregnancies
— is a varient of severe preeclampsia where arteriole vasospasm, endotheliel cell damage, and platelet aggregation result in tissue hypoxia.
HELLP Syndrome
S/S of HELLP Syndrome
Can have None
Can look like preeclampsia
N/V
Epigastric Pain or RUQ pain
General Malaise
Complications from HELLP Syndrome
Renal failure
PE
Ruptured Liver Hematoma
DIC
Placental Abruption
Nursing Responsibilities for HELLP
Assess for signs of bleeding (petechie, bruising, etc)
Assess for Epigastric or RUQ pain
Assess of Jaundice
Assess Fetal Status (risk for abruption)
What is a Burr Cell?
triangular helmet shaped cells found in blood
usually indicative of disorders of small blood vessels
Management of HELLP Syndrome:
What if client is less than 34 weeks pregnant?
Greater than 34 weeks?
Less = administer corticosteroid
Greater = deliver
With —, there is always a secondary diagnosis.
DIC
***treat the underlying problem to fix it
DIC:
What labs are reduced?
Platelets
Fibrinogen
DIC:
What labs are elevated?
Fibrin Degradation Products
Prothrombine Time (PT) = increased
PTT (increased)
D-Dimer Test
Protamine (positive)
Nursing responsibilities for DIC
Monitor for bleeding
Monitor urinary output w/ Foley
Side-lying position of pregnant
O2 at 10-12 L (as ordered)
Blood products (as ordered)
