OB EXAM 3 (Antepartum Complications: Hypertensive Disorders in Pregnancy)
pre E with severe features goals
*****keep BP between 140-155/90-105 -mom < 34 weeks we can try to keep her in a calm environ. (lower the lights, turn off TV, etc.) -if dx is made after 34 weeks, delivery is recommended
mag sulfate dosage
***THESE NEEEDDDD TO BE MEMORIZED*** -40 Gms in 1000 mL IVF (D51/2 NS) -4 to 6 gm load then 2 to 3 gms/hr -therapeutic blood level (4-7 meq/L)
nursing goals in HRP
-(#1) early identification! -appropriate interventions (what kind of monitoring and testing do they need?) -referrals -> basic care (low risk mamas, done in general Dr's office and health care dept.) -> speciality carer (more specific, looking at facility that can provide ICU care -> subspecialty care (very specific mom working with neonatologist)
chronic hypertension risk factors
-AMA -African American -Obese -considered low or high risk -most pt's have primary hypertension -patient's are managed in a pre-conception status -low risk: the mom's might be taken off their meds -high risk: continue on meds: labetalol
labs
-H&H (going to be increased because of hemoconcentration) -platelets (decreased) -liver enzymes (elevated because of damage to liver) -BUN, creatinine, uric acid (increased b/c slowed GFR) -urine protein (24 hour urine) *****gold standard for when you start assessing for Pre E
vasospasm: fetus
-IUGR -"old" placenta *vasospasm impacts the placenta!!, the increased pressure from the vasospasm will cause premature aging of the placenta* *old placenta = IUGR *increased calcification leads to decreased perfusion*
preeclampsia (Pre E)
-PREGNANCY ONLY CONDITION! (can't get it if you aren't pregnant) -"cure" is not to be pregnant anymore -most patients improve quickly after delivery, however some moms may only develop high BP after birth so carefully monitoring is crucial
risk factors for Pre E
-age (young and old) -first pregnancy/new partner -maternal medical conditions (renal disease, molar pregnancy, diabetes, chronic hypertension) -multiple gestations
maternal risk factors
-age extremes (very young or >35) -inadequate prenatal care -unmarried status -non-white race -low SES
peripheral and pulmonary edema
-as more fluid leaves the vasculature and moves into the tissues, we will see an increase in peripheral edema -it might be all the way up the legs, in the hands, most predictive is periorbital -if pt. is lying down we might see sacral edema
symptoms analysis
-ask about HA, dizziness spells which is R/T cerebral edema -HA are frontal HA usually -might feel dizzy sitting still
what is the CLONUS assessment?
-assessment of CNS irritability -positive clonus: foot will bounce back towards hand and pulse/vibrate -if you push foot forward and you feel it try to bounce back towards hand, that's positive clonus which indicates extreme CNS irritability -for most pt's this is pre seizure -as the nurse count how many times the foot bounces back
nursing care for eclampsia
-call for help -time seizure -suction, evaluate airway -lower HOB to decrease ROA -18 gauge IV -fetal assessment (likely to see bradycardia because mom stops breathing during seizure) -once mama has eclampsia that's a reason for delivery
newborn risk factors
-congenital abnormalities -preterm/LBW (these terms are not interchangeable) -SIDS -respiratory distress syndrome -maternal complications -racial/ethnicity
risk factor for Pre E (father)
-dad who fathered a pregnancy that turned out to be a pre-e pregnancy with one partner and then has a different partner now and that partner gets pregnancy, the father is at higher risk to father another pre-e pregnancy -lack of sperm exposure @ conception is a risk (some of the causes of pre-e may be related to sperm antibodies and if you have a new partner, your body is more likely to react to those sperm as being unfamiliar) -NEWER THE PARTNER = GREATER RISK FOR PRE-E
management for Pre E
-daily weight -BP -urine dip stick -kick counts (10 in an hr) -activity restriction*** -follow up visits 2 to 3 times per week -regular diet (don't do salt restriction) -meds *we don't want mama lying in bed, we don't want her going to work, cleaning the house etc., diversional activities are important such as light exercises and stress-free activities*
vasospasm: renal
-decreased GFR -retained BUN, creatinine, uric avid, Na, H2O, lost protein (albumin) -eventful oliguria -decreased colloid osmotic pressure leads to edema -intravascular shifts lead to hemoconcentration *as we lose intravascular fluids, our plasma levels decrease and become extravascular* *thicker blood is a result, WBC's will increase, so we need to be monitoring urine output!*
vasospasm: liver
-decreased liver function (because we are heaving this brutal pressure against the liver cells) -elevated enzymes (because these are indicators of liver damage and AST will be higher)
management for Pre E with severe features
-depends on severity and GA *mom's with severe pre E should be hospitalized in a hospital with ICU and NICU because we are looking at an increased risk for preterm birth*
reasons for delivery
-eclampsia (onset of seizures) -uncontrollable hypertension -pulmonary edema -placenta abruption -DIC -category 3 fetal strip -fetal gestation <24 weeks -fetal demise
hypertensive disorders in pregnancy
-effects 5-10% of pregnancies -rate consistently rising -racial considerations (more common in African Americans) -age extremes (mom's very young or >35)
gestational hypertension
-elevated BP dx after 20 WEEK GA -mama never had a problem with BP then she got pregnant and BAM she has high BP now -no other symptoms -140/90 at least on two separate occasions that are 4-6 hrs apart -resolves quickly after pregnancy usually within first week -usually weaned off meds within 1st 12 weeks
hepatic edema
-epigastric or RUQ pain (because the liver is surrounded by a capsule, the pressure on the capsule from the damaged and swollen liver cases pain) -some pt's may call this "heartburn" -capsular rupture (worst outcome!, if this happens pt. will have a gut full of blood and have surgical emergency)
HEELP syndrome cont.
-incidence -risk factors (severe symptoms) -symptoms (changes in liver enzymes, severe epigastric RUQ pain, changes in lab work) -management
nursing assessment
-interview (have you been pregnant before?, new partner?, does the new partner have any children?) -physical exam (weight, BP, edema, fundoscopy, DTR's/clonus) -symptom analysis -labs -fetus -> FHT -> BPP (to get general idea of baby's overall well being) -> US (to look at fetal movement and positioning, amount of amniotic fluids because in severe Pre E moms the amniotic fluid may be diminished) -> doppler flow (looking @ cord to see what ischemic changes are happening)
most common antihypertensives in conjunction with mag are?
-labetalol (trandate) -nifedipine (procardia) -aldomet (methyldopa)
reducing the risk of Pre E
-low dose ASA for high risk mothers (12 and 28 weeks) *give during 2nd tri.* -give to mothers with (previous Pre E, multifetal gestation, chronic hypertension, preexisting diabetes, renal disease, autoimmune disease)
Pre-eclampsia (Pre E)
-pregnancy disorder that occurs after 20 weeks gestational age -Sx include (for dx) elevated BP and PROTEINURIA -commonly also see edema (but edema is not necessary for the dx) -increase >30/15 in BP -classified as Pre E or with severe features -no cost-effective screening tool -symptom related -pre-e is occasionally diagnosed in PP period
HEELP syndrome
-primarily a lab dx -these pt's appear with more vague and flu-like symptoms
nursing care for a pt. with Pre E and severe features
-pt's on mag will most likely have a foley -ensure adequate fluid intake -take BP every 30 min-1 hr -assess edema -check DTR, the more brisk the reflexes are this an indicator of CNS irritability -have O2 and suction -total fluid intake limited to 125/hr -I&O's -in emergent situations, mag can be given IM in the ventrogluteal site, dose will be split into 2 injections *it burns and hurts*, if giving this make sure to mix lidocaine with it in the syringe
cerebral edema
-pt's will present with HA, blurred vision, dizziness -can lead to seizures -in a normal brain the fissures of the brain should be more closer together and the brain should look more wrinkled instead of folded
post delivery treatment: nursing care
-pt. on mag -I&O -therapeutic levels -listen to heart and lungs -assess IV -DTR -mom who's on mag will stage on mag 24-48 hrs or til we are sure we can keep her BP normal; -a patient with chronic hypertension can have super imposed Pre E, so their BP will get worse, BP will probs get back to pre pregnant levels but it doesn't mean it's gonna get completely back to normal
vasospasm: eyes
-scotomata (a partial loss of vision or blind spot in an otherwise normal visual field) -pt. will need fundoscopy exam!
mag sulfate
-smooth muscle relaxant -interferes with the release of acetocholine to decrease CNS irritability -nursing care -pt. teaching
Pre E can do one of three things, what are they all?
-stay the same -progress to eclampsia -progress to HEELP syndrome
conservative management for Pre E with severe features
-steroids (betamethasone, celestone, these will improve surfactant production in newborn) -start on mag sulfate and oral hypertensive -careful nursing assessments (30 min, and 1 hr assess.) -EFM continuous -pt. teaching -seizure precautions (side rails up, suction and O2 set up in room) -meds -induction
eclampsia
-the onset of seizure activity or coma in a patient with no previous history -1/3 of seizures occur in pregnancy -1/3 occur in labor -1/3 occur within 72 hours of delivery -if patient is already on mag but still has seizures, we will give Lorazepam 2 mg over 5 min period, can be given in place of mag
causes of Pre E
-unknown -some ideas (ASA studies, diet changes-> high protein diet) -placenta related (because the only time you have a placenta is when you're pregnant)
Pre E post delivery treatment
-usually resolves within 48 hrs -vascular changes -> diuresis -the problem with diuretics: it pulls fluid from the vascular system, but the vascular system is already so dry so we're gonna make things worse, question the order if you see a diuretic!!
HEELP syndrome post delivery treatment
-usually resolves within 72-96 hrs -gets worse then gets better (keep an eye out for bleeding @ IV site and when they brush their teeth, petechiae may be present)
about ____% of mamas diagnosed with gestational hypertension will continue on to develop preeclampsia
25
A nurse in the prenatal clinic is assessing a woman at 34 weeks' gestation. The client's blood pressure is 166/100 mm Hg and her urine is +3 for protein. She states that she has a severe headache and occasional blurred vision. Her baseline blood pressure was 100/62 mm Hg. What is the priority nursing action? A. Arranging transportation to the hospital B. Obtaining a prescription for an antihypertensive C. Rechecking the blood pressure within 30 minutes D. Obtaining a prescription for acetaminophen to relieve the headache
A. Arranging transportation to the hospital
Which interventions are included in the nursing care for a client receiving magnesium sulfate for severe preeclampsia? Select all that apply. A. Monitoring deep tendon reflexes B. Assessing urine output every 8 hours C. Maintaining a dark, quiet environment D. Using a pump to regulate the medication E. Having calcium gluconate available at the bedside F. Notifying the care provider if the respiratory rate is slower than 20 breaths/min
A. Monitoring deep tendon reflexes C. Maintaining a dark, quiet environment D. Using a pump to regulate the medication E. Having calcium gluconate available at the bedside
With regard to preeclampsia and eclampsia, nurses should be aware that: A. Preeclampsia is a condition of the first trimester; eclampsia is a condition of the second and third trimesters B. Preeclampsia results in decreased function in such organs as the placenta, kidneys, liver, and brain C. The causes of preeclampsia and eclampsia are well documented D. Severe preeclampsia is defined as preeclampsia plus proteinuria
B. Preeclampsia results in decreased function in such organs as the placenta, kidneys, liver, and brain
BP, MAP, protein values for Pre E
BP > 140/90 MAP > 105 Protein > 1+ (30 mg/dl, 300 mg in 24 hour urine)
Pre E with severe features
BP >160/90 MAP >105 Protein >2+ on dipstick (2 grams in 24 hr urine) -worsening maternal symptoms -worsening fetal symptoms (lower BPP, more perfusion issues)
nursing role
Remember that hypertensive disorders in pregnancy are very complicated and can be dangerous. Nurses are often on the front line to identify patients, complete assessments and teach patients what they need to know to care for themselves
high risk pregnancy
any pregnancy in which the life or health of the mother or baby is endangered by a disorder either coincidental with the pregnancy or unique to the pregnancy. this includes biophysical, psychosocial, sociodemographic and environmental factors
chronic and gestational hypertension
both conditions usually manageable resulting in good maternal and fetal outcomes
what is the antidote for mag toxicity?
calcium gluconate
what does the EL mean in HEELP syndrome?
elevated liver enzymes
betamethosone
give 2 injections, 24 hrs apart, 12 mg IM in ventrogluteal ideally will happen 48 hrs before delivery
what does the H mean in HEELP syndrome?
hemolysis
hypertensive crisis medication
if BP is consistently > 160/110 give -Hydralazine (Apressoline) *given in 5 mg doses, IV PUSH SLOWLY over 3-5 min -maternal assessment (take BP every 3-5 min for 15-20 min 3x) -fetal assessment
How can you also diagnose pre e if the patient doesn't have proteinuria but has high BP?
if the pt. has thrombocytopenia, impaired liver fx, renal insufficiency, pulmonary edema, or new onset cerebral edema or vision changes
Pre E and why you will have problem with the vascular system
in pre-e the spiral arteries don't remodel which will cause placenta ischemia and this along with increased pressure in vessels will release a toxin that damages endothelial cells in vessels
what does IUGR stand for?
intrauterine growth restriction
mag toxicity
level of about 10 is mag toxicity, patient will have decreased DTR, slurred speech, trouble swallowing, a 14 or higher level can put the pt. into respiratory distress
what does the LP mean in HEELP syndrome?
low platelets
what is the drug of choice if patient has Pre E severe features?
magnesium sulfate (MgSO4)
eclampsia post delivery treatment
may still have seizures
interview
medical, family, social history
chronic hypertension
pt already had dx with HTN who just happens to get pregnant
mag is excreted in
urine
underlying etiology of pre-e
vasospam -> decreased vessel size -> elevated BP -> decreased perfusion
patho outline
vasospasm -> endothelial damage (leaky vessels) -> platelet plugs (use faster than you can make them) -> platelet clumps -> irregular vessel lining -> tear and break RBC as they try to pass through -> hemolysis -> burr cells
statistics maternal death causes
worldwide: hypertensive disorders, infection, hemorrhage united states: hypertensive disorders, pulmonary embolus, hemorrhage
