T4 - Hypertensive Disease (Josh) Flashcards by Josh Miller

— disorders are the most common medical complication of pregnancy.

Hypertensive

***risen steadily since 1990 in all races and ethnic groups

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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

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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

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What is Gestational HTN?

onset of HTN without proteinurea after 20 wks gestation

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— usually occurs 20 weeks after gestation in a previously normotensive patient AND has proteinurea.

Preeclampsia

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What proteinurea is a sign of preeclampsia?

above 30 mg (1+ on dipstick) or more in 2 random specimens at least 6 hrs apart

300 mg in 24 hrs

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What is difference b/t Preeclampsia and Eclampsia?

seizures

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What is HTN that occurs before pregnancy or diagnosed before 20th week gestation?

Chronic HTN

***persists more than 6-12 wks PP

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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

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What BP is HTN?

What MAP is HTN?

140/90

MAP > 105

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Are BP elevations over pre-pregnancy values diagnostic for preeclampsia?

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)

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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

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What percentage of Primigravidas have Gestational HTN?

Multiparous?

Primigravidas = 6-17%

Multiparas = 2-4%

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Gestational HTN is more frequent in — pregnancies.

multifetal

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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

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What is Mild Preeclampsia?

140/90

MAP > 105

24 hr proteinurea > or = 0.3 g

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What is Severe Preeclampsia?

160/110

Map > 105

24 hr proteinurea > 2 g

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What is usually the first sign of preeclampsia?

elevated BP

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— occurs in too many normal pregnancies to be used as a marker for preeclampsia.

Edema

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What is the only cure for preeclampsia?

delivery

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What weight gain is a sign of preeclampsia?

> 2 kg (4.4 lb) in one week

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What is the etiology of preeclampsia?

disruption of placental perfusions and endothelial cell dysfunction

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What is the cause of preeclampsia?

uknown

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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

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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)