Wk 14 cardiovascular OB: pregnancy

Question 1

Hypertension

Gestational hypertension

Answer 1

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

Question 2

Chronic Hypertension

Answer 2

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

Question 3

HELLP Syndrome

Answer 3

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

Question 4

HELLP Syndrome Symptoms

Answer 4

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

Question 5

Preeclampsia

Answer 5

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.

Question 6

Mild Preeclampsia

Answer 6

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

Question 7

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

Answer 7

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

Question 8

Severe Preeclampsia

Answer 8

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.

Question 9

Maternal complications of preeclampsia include

Answer 9

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

Question 10

Maternal complications of preeclampsia

Renal damage

Answer 10

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

Question 11

Maternal complications of preeclampsia

Liver failure

Answer 11

Liver failure
Elevated liver enzymes.
Epigastric pain from liver dysfunction

Question 12

Maternal complications of preeclampsia

Cerebral edema with seizures

Answer 12

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

Question 13

Maternal complications of preeclampsia

Pulmonary edema

Answer 13

Pulmonary edema

Dyspnea is the primary symptom

Question 14

Maternal complications of preeclampsia

Decreased placental circulation

Answer 14

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

Question 15

Maternal complications of preeclampsia

Maternal deaths associated with preeclampsia

Answer 15

Maternal deaths associated with preeclampsia

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

Question 16

Maternal complications of preeclampsia

Risk factors

Answer 16

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.

Question 17

Maternal complications of preeclampsia

prevention

Answer 17

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

Question 18

Preeclampsia Tx.

Homecare: Preeclampsia mild

Answer 18

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

Question 19

Severe Preeclampsia

Inpatient for severe preeclampsia

Answer 19

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.

Question 20

Severe Preeclampsia

Magnesium Sulfate

Answer 20

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)

Question 21

Severe Preeclampsia

Magnesium Sulfate

Answer 21

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

Question 22

Severe Preeclampsia
Magnesium Sulfate
Precautionary measures

Answer 22

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.

Question 23

Magnesium Toxicity

Answer 23

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)

Question 24

Eclampsia

Answer 24

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.

Question 25

Eclampsia GOAL

Answer 25

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.

Question 26

Eclampsia Postpartum Care

Answer 26

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.

Question 27

Eclampsia Postpartum Care | At Risk

Answer 27

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.

Question 28

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

Answer 28

magnesium sulfate IVPB | Control seizure activity

Question 29

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

Answer 29

calcium gluconate IV | Patient respirations < 12/min. and decreased LOC

Question 30

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

Answer 30

Hydralazine IV | Control hypertension

Question 31

Chronic hypertension

Answer 31

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

Question 32

Gestational hypertension

Answer 32

BP > 140/90 after 20 weeks of pregnancy

Question 33

Preeclampsia

Answer 33

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

Question 34

Severe preeclampsia

Answer 34

BP >160/110 and signs of organ dysfunction

Question 35

Eclampsia

Answer 35

Onset of seizure activity in the preeclampsia woman

Question 36

HELPP Syndrome

Answer 36

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

Question 37

Hemorrhagic disorders | Early pregnancy bleeding

Answer 37

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

Question 38

Hemorrhagic disorders | Late pregnancy bleeding

Answer 38

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

Question 39

Hemorrhagic Disorders | Maternal Risks

Answer 39

``` Maternal Risks: Hypovolemia Anemia Infection Preterm labor Preterm birth Decreased oxygen to fetus ```

Question 40

Hemorrhagic Disorders | Fetal Risks

Answer 40

``` Fetal Risks: Blood loss or anemia Hypoxemia Hypoxia Anoxia Preterm birth ```

Question 41

Early Pregnancy Bleeding | Miscarriage

Answer 41

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.

Question 42

Early Pregnancy Bleeding Miscarriage types

Answer 42

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.

Question 43

Early Pregnancy Bleeding | Premature dilation of the cervix

Answer 43

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.

Question 44

Early Pregnancy Bleeding Premature dilation of the cervix Collaborative care

Answer 44

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.

Question 45

Early Pregnancy Bleeding | Ectopic pregnancy

Answer 45

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.

Question 46

Early Pregnancy Bleeding Ectopic pregnancy risk factors

Answer 46

``` 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 ```

Question 47

Early Pregnancy Bleeding Ectopic pregnancy Clinical presentation

Answer 47

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%

Question 48

Early Pregnancy Bleeding Ectopic pregnancy pain

Answer 48

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.

Question 49

Early Pregnancy Bleeding Ectopic pregnancy Collaborative care

Answer 49

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.

Question 50

Early Pregnancy Bleeding Ectopic pregnancy Collaborative care Symptoms of ruptured tube

Answer 50

``` Symptoms of ruptured tube: Vertigo Shoulder pain Hypotension Tachycardia ```

Question 51

Early Pregnancy Bleeding Ectopic pregnancy Therapeutic management

Answer 51

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

Question 52

``` Hydatidiform Mole (molar pregnancy) 2 types: ```

Answer 52

Complete or classic mole | Partial mole

Question 53

``` Hydatidiform Mole (molar pregnancy) Complete or classic mole ```

Answer 53

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

Question 54

``` Hydatidiform Mole (molar pregnancy) Partial mole ```

Answer 54

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

Question 55

``` Hydatidiform Mole (molar pregnancy) Increased risks ```

Answer 55

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

Question 56

Hydatidiform Mole | Clinically

Answer 56

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

Question 57

Hydatidiform Mole | Therapeutic management

Answer 57

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

Question 58

Late Pregnancy Bleeding

Answer 58

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

Question 59

Late Pregnancy Bleeding | 3 types

Answer 59

- 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

Question 60

Late Pregnancy Bleeding Placenta previa Risks

Answer 60

``` 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 ```

Question 61

Late Pregnancy Bleeding Placenta previa Clinical findings

Answer 61

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.

Question 62

Late Pregnancy Bleeding Placenta previa Complications

Answer 62

``` 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 ```

Question 63

Late Pregnancy Bleeding Placenta previa Nursing care

Answer 63

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)

Question 64

Abruptio placentae

Answer 64

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

Question 65

Abruptio placentae | risks

Answer 65

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

Question 66

Abruptio placentae | Clinical manifestations

Answer 66

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)

Question 67

Abruptio placentae | Mild abruption and < 36 weeks without distress

Answer 67

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.

Question 68

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

Answer 68

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.

Question 69

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

Answer 69

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