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NUR 126 > Wk 14 cardiovascular OB: pregnancy > Flashcards

Wk 14 cardiovascular OB: pregnancy Flashcards

1
Q

Hypertension

Gestational hypertension

A 
Gestational hypertension: 
HTN: Systolic BP > 140    
         Diastolic BP > 90 
Develops after 20 weeks gestation
Returns to normal within 6 weeks postpartum
Proteinuria negative.
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2
Q

Chronic Hypertension

A

Chronic Hypertension
Present before the pregnancy or diagnosed before 20 weeks of gestation.
Risk of poor fetal growth and fetal demise.
Preconception counseling recommended with chronic hypertension.
6% to 8% of pregnancies have complications of hypertensive disorders.
Is the most common medical complication of pregnancy

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3
Q

HELLP Syndrome

A

HELLP: Risk with severe hypertension p. 544
H=Hemolysis:
EL=Elevated liver enzymes (AST and ALT)
LP=Low platelets (< 100,000/mm3)
C/section when platelets approach 100,000
General anesthesia vs epidural

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4
Q

HELLP Syndrome Symptoms

A

Symptoms:
Pain RUQ abdomen, lower chest or epigastric.
Caused by pressure on liver from fluid backup
Nausea/vomiting
Severe edema.
Manage in an ICU setting
Treatment includes appropriate for preeclampsia or eclampsia

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5
Q

Preeclampsia

A

Preeclampsia
Pregnancy specific syndrome.
Hypertension develops after 20 weeks gestation (no hx. of HTN).
Characterized by the presence of hypertension and proteinuria.
Poor perfusion and vasospasm are main pathogenic factors, not elevated BP.
Arteriolar vasospasm diminishes the diameter of the blood vessels, impedes blood flow to all organs and increases BP.

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6
Q

Mild Preeclampsia

A

Mild preeclampsia:
Systolic < 160mmHg
Diastolic < 110 mmHg
No evidence of organ dysfunction

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7
Q

Proteinuria (presence of greater than normal amounts of protein in the urine)

A

Proteinuria:
Concentration of > 0.3 mg/dl or more
24 hour urine: > 300 mg/dl protein in urine.
No organ dysfunction

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8
Q

Severe Preeclampsia

A

Severe Preeclampsia:
Systolic BP > 160 mmHg
Diastolic BP > 110 mmHg
Proteinuria of > 5 g per 24-hour specimen.
Oliguria (< 400 mL urine in 24 hrs.)
Cerebral disturbances (altered level of consciousness)
Headache
Drowsiness
Confusion
Visual disturbances such as scotomata, blurred vision, spots before eyes.
Scotomata: An area of diminished vision within the visual field
Hepatic: epigastric pain, right upper quadrant pain, impaired liver function or elevated liver enzymes
Thrombocytopenia: platelets < 100,000
Hemolytic anemia
Pulmonary edema
Fetal growth restriction.

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9
Q

Maternal complications of preeclampsia include

A 
Renal damage
Liver failure
Cerebral edema with seizures
Pulmonary edema
Decreased  placental circulation
Maternal deaths associated with preeclampsia
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10
Q

Maternal complications of preeclampsia

Renal damage

A

Renal damage
BUN, Creatinine, uric acid levels rise.
Glomerular damage causes reduced renal blood flow.
Protein allowed to leak across the glomerular membrane.
Rise in hematocrit from 3rd spacing.
Generalized edema

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11
Q

Maternal complications of preeclampsia

Liver failure

A

Liver failure
Elevated liver enzymes.
Epigastric pain from liver dysfunction

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12
Q

Maternal complications of preeclampsia

Cerebral edema with seizures

A 
Cerebral edema with seizures
Vasoconstriction of cerebral vessels
Small cerebral hemorrhages
Headache
Visual disturbances (blurred vision, spots before the eyes)
Hyperreflexia
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13
Q

Maternal complications of preeclampsia

Pulmonary edema

A

Pulmonary edema

Dyspnea is the primary symptom

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14
Q

Maternal complications of preeclampsia

Decreased placental circulation

A

Decreased placental circulation
Increased risk for abruptio placentae and HELLP.
Growth restriction
Persistent fetal hypoxemia

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15
Q

Maternal complications of preeclampsia

Maternal deaths associated with preeclampsia

A

Maternal deaths associated with preeclampsia

Due to complications of hepatic rupture, abruptio placentae, eclampsia and HELLP syndrome

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16
Q

Maternal complications of preeclampsia

Risk factors

A

Risk Factors:
More common in primigravida
First pregnancy for father/or fathered a previous preeclampsia pregnancy
Anemia
Family or personal history of preeclampsia
Chronic hypertension or preexisting vascular disease
Obesity
Diabetes mellitus
Antiphospholipid syndrome
Mayo Clinic - antiphospholipid-syndrome
Multifetal pregnancy
Pregnancy from assisted reproductive techniques.
Age: < 20 years and > 40 years
Race: African American and non-Hispanic Caucasian women highest rates
Morbidity and Mortality:
Preeclampsia is the second leading cause.

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17
Q

Maternal complications of preeclampsia

prevention

A 
Prevention:
Early and regular prenatal care to prevent complications.
Weight gain, BP, protein in urine
Calcium, magnesium
Fish oil
Antihypertensive medications and diuretics
Antithrombotic agents
Aspirin-low-dose
Goals
Prevent seizures
Maintain pregnancy
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18
Q

Preeclampsia Tx.

Homecare: Preeclampsia mild

A

Homecare: Preeclampsia mild: Patient and Family education
Teach symptoms of worsening:
Headache or epigastric pain
Activity restrictions
Lying down for 1.5 hrs. on side ( increases placental blood flow)
Fetal activity
Record fetal movements (kick count). Report decrease or absence in 4 hr period.
BP
Family taught to use BP equipment. Check 2-4 times/day.
Weight.
Weight daily at same time with same clothing.
Urinalysis
Dipstick for protein (first voided midstream sample).
Diet
Regular without salt or a fluid restriction.
Calorie control if diabetic
Fetal assessment
Sonography for fetal growth and quantity of amniotic fluid

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19
Q

Severe Preeclampsia

Inpatient for severe preeclampsia

A

Goals of treatment:
Prevent seizures
Maintain the pregnancy until safe to deliver.
Collaborative Care
Bed rest (quiet with low stimuli)
Side lying position
Anticonvulsant medications
Magnesium sulfate
Antihypertensive medications:
Hydralazine (vasodilator) increases placental flow. (Preferred)
Nifedipine
Labetalol
Analgesics: Narcotics or epidural to reduce pain (lower seizure threshold and BP)
IV oxytocin for labor induction
Continuous electronic fetal monitoring
If delivery is the only option.
< 34 weeks gestation:
Steroids to accelerate fetal lung maturity and delay birth for 48 hrs.
If maternal or fetal condition deteriorates, immediate delivery.
Vaginal birth is preferred due to multisystem impairments.

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20
Q

Severe Preeclampsia

Magnesium Sulfate

A

Magnesium Sulfate
Nursing role
Monitor BP, pulse and respiratory status every 15-30 minutes.
respirations (at least 12/min)
Monitor lung sounds
Oxygen saturation of > 95%
Presence of deep tendon reflexes
LOC
Urine output > 30 mL/hr.
Resuscitation equipment (suction, oxygen) in room.
Calcium gluconate in room (antidote to magnesium)

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21
Q

Severe Preeclampsia

Magnesium Sulfate

A

Magnesium sulfate
Prevention or control of convulsions
Suction equipment ready to use.
Oxygen equipment ready to use

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22
Q

Severe Preeclampsia
Magnesium Sulfate
Precautionary measures

A 
Precautionary measures:
QUIET
Nonstimulating
Lights subdued
Call button within reach.
Emergency medications available:
Hydralazine or other antihypertensive
Magnesium sulfate: therapeutic serum magnesium level 4-8 mg/dl
Monitor BP, pulse and respiratory status every 15-30 minutes.
Calcium gluconate (antidote)
Emergency birth pack.
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23
Q

Magnesium Toxicity

A 
Magnesium is excreted in urine. Must monitor output.
Signs of magnesium toxicity:
Decreased deep tendon reflexes
Nausea
Flushing
Muscle weakness
Slurred speech.
Hyporeflexia  
Respiratory depression (< 12/min)
Decreased LOC
Nursing management:
Discontinue magnesium sulfate and call physician
Calcium gluconate (antidote)
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24
Q

Eclampsia

A

Eclampsia:
Onset of seizure activity or coma in the preeclampsia woman
Without history of existing pathology for seizures
May continue to have seizures, or may only have 1 seizure.
Hypotension and coma follow.
Nystagmus and muscular twitching persist for a period.
Disorientation and amnesia are present in the recovery period.
During the seizure, the pregnant woman and the fetus suffer hypoxia, and resulting metabolic acidosis.
Presentation of eclampsia:
During pregnancy
During labor
Within 72 hours after giving birth.

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25
Q

Eclampsia GOAL

A

GOAL: Maintain a patent airway.
Aspiration leading cause of maternal morbidity and mortality with a seizure. (Chest x-ray and ABGs may be ordered)
Turn head to the side
Call for assistance
Suction secretions
Observe and document:
Time, duration, and description of seizure.
Time refers to how long the seizure lasted.
Urinary or fecal incontinence during seizure (record this)
Monitor fetus, if possible. (Mom is priority)
Fetal bradycardia and decreased FHR variability are common.

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26
Q

Eclampsia Postpartum Care

A

After birth:
Symptoms of preeclampsia or eclampsia resolve, within 48 hours.
Resolution:
Diuresis within 24 hours of birth
Labs with HELLP syndrome resolve in 72 to 96 hours.
Monitor vitals, I&O, deep tendon reflexes, LOC, uterine tone, and lochia flow.
Magnesium sulfate infusion is continued 12-24 hours for seizure prophylaxis.

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27
Q

Eclampsia Postpartum Care

At Risk

A

At Risk:
Boggy uterus and large lochia flow
Result of tocolytic (anti-contraction) effects of magnesium.
Oxytocin or prostaglandin products used to control bleeding.
Methergine contraindicated due to hypertensive effects.
Prolonged recovery due to prolonged bedrest.
Nurse with patient when ambulating: Assess weakness, dizziness, SOB, and muscle soreness.
If severe preeclampsia, premature infant in specialty nursery.

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28
Q

The patient has eclampsia and is ordered the following medication why?
magnesium sulfate IVPB?

A

magnesium sulfate IVPB

Control seizure activity

29
Q

The patient has eclampsia and is ordered the following medication why?
calcium gluconate IV?

A

calcium gluconate IV

Patient respirations < 12/min. and decreased LOC

30
Q

The patient has eclampsia and is ordered the following medication why?
Hydralazine IV

A

Hydralazine IV

Control hypertension

31
Q

Chronic hypertension

A

BP > 140/90 prior to pregnancy or prior to 20 weeks pregnancy

32
Q

Gestational hypertension

A

BP > 140/90 after 20 weeks of pregnancy

33
Q

Preeclampsia

A

BP > 140/90 after 20 weeks gestation and protein in urine

34
Q

Severe preeclampsia

A

BP >160/110 and signs of organ dysfunction

35
Q

Eclampsia

A

Onset of seizure activity in the preeclampsia woman

36
Q

HELPP Syndrome

A

Red blood cell destruction, elevated AST and ALT, and platelets < 100,000

37
Q

Hemorrhagic disorders

Early pregnancy bleeding

A

Early pregnancy bleeding – occurs in the 1st half of the pregnancy
Abortion (various types)
Ectopic pregnancy
Hydatiform Mole

38
Q

Hemorrhagic disorders

Late pregnancy bleeding

A

Late pregnancy bleeding – 2nd half of pregnancy
Placenta previa
Abruptio placentae

39
Q

Hemorrhagic Disorders

Maternal Risks

A 
Maternal Risks:
Hypovolemia
Anemia
Infection
Preterm labor
Preterm birth
Decreased oxygen to fetus
40
Q

Hemorrhagic Disorders

Fetal Risks

A 
Fetal Risks:
Blood loss or anemia
Hypoxemia
Hypoxia
Anoxia
Preterm birth
41
Q

Early Pregnancy Bleeding

Miscarriage

A

Early pregnancy bleeding disorders: (Occurs during 1st half of pregnancy)
Miscarriage (Spontaneous abortion)
Pregnancy ends before 20 weeks gestation or 500 gram birth weight without medical or surgical method.

42
Q

Early Pregnancy Bleeding
Miscarriage
types

A

Types:
-Threatened (Goal to save pregnancy)
Bleeding first sign. Closed cervical os. Uterine cramping, back ache, pressure follows.
-Inevitable
Cannot stop!! Moderate to heavy amount of bleeding with an open cervical os. Mild to severe uterine cramping. Rupture of membranes and passage of products of conception.
-Incomplete
Moderate to heavy amount of bleeding with an open cervical os. Expulsion of the products of conception, but retention of the placenta. D & C performed.
-Complete
All fetal tissue is passed, the cervix is closed, and slight bleeding. Mild uterine cramping.
-Missed
Fetus has died but the products of conception are retained in utero for up to several weeks.
Diagnosed by ultrasound when fetal growth stops or decreased in size.

43
Q

Early Pregnancy Bleeding

Premature dilation of the cervix

A

Premature dilation of the cervix
Passive and painless dilation of the cervical os without labor or contractions of the uterus. (incompetent cervix).
Occurs in the 2nd or early 3rd trimester with miscarriage or preterm birth.

44
Q

Early Pregnancy Bleeding
Premature dilation of the cervix
Collaborative care

A

Collaborative care:
Bed rest, hydration, tocolysis (inhibit contractions).
Prophylactic cervical cerclage (previous miscarriage)
11-15 weeks gestation.
No intercourse, prolonged standing, or heavy lifting.
Cerclage removed at 37 weeks, or left in place for C-section birth.

45
Q

Early Pregnancy Bleeding

Ectopic pregnancy

A

Ectopic pregnancy
Fertilized ovum is implanted outside the uterine cavity.
95% are in the fallopian tube.
Is the leading cause of 1st trimester maternal death in US.
Leading cause of infertility.

46
Q

Early Pregnancy Bleeding
Ectopic pregnancy
risk factors

A 
Risk Factors:
Pelvic infection
Pelvic inflammatory disease (PID)
Sexually transmitted diseases
History of ectopic pregnancies
Surgical procedures of the uterus/tubes
Failed tubal ligation
Assisted reproductive procedures
Gamete intrafallopian transfer (GIFT)
Intrauterine device (IUD)
Defects in fallopian tubes
Cigarette smoking
Vaginal douching
47
Q

Early Pregnancy Bleeding
Ectopic pregnancy
Clinical presentation

A

Clinical presentation:
A missed menstrual period
Adnexal fullness and tenderness
Suggests an unruptured tubal pregnancy
Tenderness can progress from a dull to a colicky pain when the tube is stretched.
Pain may be unilateral, bilateral, or diffuse over abdomen.
Dark red or brown abnormal vaginal bleeding in 50-80%

48
Q

Early Pregnancy Bleeding
Ectopic pregnancy
pain

A

Pain increases with tube rupture.
Blood irritates the peritoneum
Referred shoulder pain from diaphragmatic irritation with blood in the peritoneal cavity.
Exhibit signs of shock r/t amount of blood loss in the abdominal cavity and not obvious vaginal bleeding.
Cullen sign: ecchymotic blueness around the umbilicus.

49
Q

Early Pregnancy Bleeding
Ectopic pregnancy
Collaborative care

A

Collaborative care:
Present to ED with first-trimester bleeding or pain.
All women with c/o abdominal pain, vaginal spotting or bleeding, and a positive pregnancy test should be screened for ectopic pregnancy.
Lab: serum progesterone, B-hCG.
Transvaginal ultrasound to confirm uterine or tubal pregnancy.

50
Q

Early Pregnancy Bleeding
Ectopic pregnancy
Collaborative care
Symptoms of ruptured tube

A 
Symptoms of ruptured tube:
Vertigo
Shoulder pain
Hypotension
Tachycardia
51
Q

Early Pregnancy Bleeding
Ectopic pregnancy
Therapeutic management

A

Therapeutic management
Intact fallopian tube, early pregnancy, size < 3.5 cm, fetus not living.
Methotrexate inhibits cell division.
Repeat beta-hCG levels
Surgical treatment if medication fails or tube ruptures
Ruptured fallopian tube- HEMORRHAGE
Control the bleeding and prevent hypovolemic shock.
Salpingectomy to remove ectopic pregnancy
Decreased fertility and remaining tube may also carry risk of ectopic pregnancy

52
Q 
Hydatidiform Mole (molar pregnancy)
2 types:
A

Complete or classic mole

Partial mole

53
Q 
Hydatidiform Mole (molar pregnancy)
Complete or classic mole
A

Complete or classic mole
Resembles a bunch of white grapes. No fetus, no placenta.
Trophoblasts develop abnormally and the placenta develops, but not the embryo.
Chorionic villi – grapelike structures
Uterus is larger than expected for the duration of the pregnancy.
Maternal blood has no placenta to receive it, leading to hemorrhage into the uterine cavity and vaginal bleeding

54
Q 
Hydatidiform Mole (molar pregnancy)
Partial mole
A

Partial mole
2 sperm fertilize an ovum. Have embryonic or fetal parts and amniotic sac.
Congenital anomalies are usually present.

55
Q 
Hydatidiform Mole (molar pregnancy)
Increased risks
A

Increased risks:
Early teens
> 40 years who have take Clomid for ovulation stimulation

56
Q

Hydatidiform Mole

Clinically

A

Hydatidiform Mole
Clinically
Mole development cannot be distinguished from a normal pregnancy.
Diagnosed by ultrasound; no fetal gestational sac or cardiac action.
Uterus larger than expected for weeks pregnant.
Vaginal bleeding occurs in 95% of patients.
Anemia, excessive N/V and abdominal cramps are common findings

57
Q

Hydatidiform Mole

Therapeutic management

A

Therapeutic management
Evacuation of the mole
Type and cross for possible blood transfusion.
Avoid pregnancy for 1 year. (No IUD method of birth control)
A rise in HCG levels may indicate a normal pregnancy when the patient is trying to get pregnant, or a recurrent molar pregnancy, which requires chemotherapy.
Follow-up for malignant changes in trophoblastic tissue.
Malignant changes - choriocarcinoma

58
Q

Late Pregnancy Bleeding

A

Occurs during 2nd half of pregnancy
Placenta previa
Placenta is implanted in the lower uterine segment near or over the internal cervical os

59
Q

Late Pregnancy Bleeding

3 types

A
  • Marginal (low-lying) Placenta is implanted in lower uterus, border is > 3 cm from the internal os.
  • Partial: Lower border of the placenta is within 3 cm of the internal os.
  • Total internal os is entirely covered by the placenta
60
Q

Late Pregnancy Bleeding
Placenta previa
Risks

A 
Placenta previa
Risks:
Previous placenta previa
Previous cesarean birth
Suction curettage for miscarriage. (scarring)
Multiple gestation
Multiparity
> 35 years old
African or Asian ethnicity
Smoking
61
Q

Late Pregnancy Bleeding
Placenta previa
Clinical findings

A

Clinical findings:
Suspect placenta previa with uterine bleeding after 20 weeks gestation
Painless uterine bleeding-70% (Bright red)
Vaginal bleeding with uterine contractions-20%
Vital signs may be normal, even with heavy flow
40% of blood volume can be lost before signs of shock.
Clinical presentation and decreased urine output are better indicators than vitals
Fetal HR changes do not occur until a major detachment of placenta occurs.
Abdomen is soft, relaxed, and nontender uterus with normal tone.

62
Q

Late Pregnancy Bleeding
Placenta previa
Complications

A 
Placenta previa
Complications:
Premature rupture of membranes
Preterm labor and birth
Greatest risk of fetal death is caused by preterm birth.
Surgery-related trauma
Anesthesia complications
Postpartum hemorrhage, anemia
Surgical complications
63
Q

Late Pregnancy Bleeding
Placenta previa
Nursing care

A

Nursing care:
< 36 weeks, not in labor, bleeding mild or stopped, rest and observation.
Bleeding assessment: weigh pads- 1 g = 1 ml of blood.
H & H and coagulation studies.
IV
Antepartum steroids (betamethasone) if fetus < 34 weeks.
No vaginal or rectal exams
At 37 weeks, fetal lung maturity tests
Schedule cesarean delivery-may be emergent. (Plan for hemorrhage)

64
Q

Abruptio placentae

A

Abruptio placentae
Premature separation of the placenta.
Detachment of part or all of the placenta from implantation site.
Significant maternal and fetal morbidity and mortality

65
Q

Abruptio placentae

risks

A 
Risk factors:
 Maternal hypertension
Cocaine (vasospasms)
Smoking 
Multiple gestation
Polyhydramnios
Blunt abdominal trauma (car crash/domestic violence)
66
Q

Abruptio placentae

Clinical manifestations

A

Clinical manifestations:
Vaginal bleeding (may not reflect true blood loss)
Abdominal and low back pain
Uterine irritability with frequent low intensity contractions
High uterine resting tone (intrauterine pressure catheter)
Uterine tenderness at site of abruption.
Additional signs: back pain, nonreasurring fetal heart rate, shock, and fetal death.
Board-like abdomen and tender. (Concealed hemorrhage)

67
Q

Abruptio placentae

Mild abruption and < 36 weeks without distress

A

Abruptio placentae
Mild abruption and < 36 weeks without distress:
Hospitalized and closely observed for bleeding and labor.
Danger for mom: hemorrhage, hypovolemic shock, clotting abnormal.(DIC)
Fetal monitoring.
Danger for fetus: Anoxia, blood loss, preterm birth.

68
Q

Abruptio placentae
Mild abruption and < 36 weeks without distress
Condition deteriorates

A

Condition deteriorates:
Immediate birth.
Corticosteroids to accelerate fetal lung maturity.
Rh negative mom receives immune globulin.
Vaginal birth if mom and baby stable or fetus is dead.

69
Q

Abruptio placentae
Mild abruption and < 36 weeks without distress
Nursing care

A

Nursing care:
IV, vitals, serial labs assessed, Foley with strict I & O, (urine > 30 ml/hr)
Emotional support.

NUR 126 (23 decks)

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