Complcations of Pregnancy Part 2 Hypertensive Disorders of Pregnancy

10% of pregnancies are complicated by hypertensive disorders, 76,000 deaths per year worldwide are preeclampsia and related hypertensive disorders, Highes rates in Native American and African American women

Evaluate BP readings in a seated position with feet on the floor for improved accuracy (when possible)

Hypertension: Systolic blood pressure:≥ 140 mm Hg or Diastolic blood pressure:≥ 90 mm HG (These numbers are specific to OB), Severe Hypertension: Systolic blood pressure: ≥160 mm Hg or Diastolic blood pressure: ≥110 mm Hg, Hypertensive Emergnecy: Persistant severe HTN 2 severe BP values (≥160/110) taken 15-60min apart Severe values do not need to be consecutive

If sever BP elevations persist for 15 min o more begin tx STAT, Severe HTN first line Meds: IV lebetalol (Normodyne, Trandate) (most common) IV Hydralazine (Apresoline) P.O. nifedipine (Procardia) (Just as effective as above IV meds), Prevention of Seizure in PreE: Magnesium Sulffate Must have an order to give any meds!

Trigger: If severe elevations (SBP≥160 or DBP≥110) Persist* for 15 mins or more OR if two severe elevations are obtained with 15 min. Treatment is clinically indicated., I don’t think we need to know the whole algorithm it’s there if you wan to look at it. At least know trigger for use of algorithm.

Class: Antihypertensive, beta blocker, Action: Produces drop in BP without decreasing maternal HR or cardiac output? (not sure how that’s true as beta blockers lower HR I thought but ok lol), Dosage: IVP: Initial dose 20mg over 2 mins may increase IVP dosage to 80mg 200mg P.O. labetalol staring dose, SE: Hypotension, dizziness, N/V, dysrythmias, Nursing Interventions: After IVP bolus, assess BP q5mins for 30 mins then q30mins for 2 hours, then hourly for 6 hours

Classifcation: Antihypertensive, Vasodilator, Action: Relaxes arterial smooth muscle, Indications: Severe hypertension, Preeclampsia, Dosage/Route: IVP: 5-10mg over 2 minutes every 20 min PRN, Max dose should not exceed 25mg/24hours, Excretion: Liver, Contraindications/Precautions: Coronary heart disease, maternal pulse under 60. Avoid use with active asthma, heart disease or congestive heart failure. May cause neonatal bradycardia ., Adverse Reaction: Headache, dizziness, drowsiness, hypotension (placental impact), pigastric pain (confused with worsening preeclampsia

Classification: Calcium channel blocker, Antihypertensive, Action: Relaxes muscles of the heart and blood vessels, Indications: Hypertension & Preterm labor, Dosage/Route: 10-20mg P.O. for severe hypertension, SE: Increase maternal HR, overshoot hypotension and fetal bradycardia, dizziness, peripheral edema, lower extremity edema, flushing, and flushing sensation., Avoid used with: Asthma, heart disease, CHF

Classification: Anticonvulsant, Action: Decreases the CNS to acts as an anticonvulsant also decreases frequency and strength of UC, Indicaitons: Prevention/ control of seizures of preeclampsia. Neuro protection for preterm labor for baby., Dosage/Route: IV loading dose: 4-6g over 20-30 mins (with 6g over 30 min being most common) IVPB continuous infusing 2g/hour via pump, Therapeutic level: 4-8mg/dl (>8 may result in respiratory depression and cardiac arrest), Contraindication: Myocardial damage, heart block, myasthenia gravis, impaired renal function., Antidote: Calcium gluconate

1. Chronic hypertension (CHTN), 2. Chronic hypertension + superimposed preeclampsia, 3. Gestational hypertension (GHTN), 4. Preeclampsia (PreE) & Eclampsia

Ok thanks

HTN precedes pregnancy (or occurs <20wks GA) Preganancy aggravates CHTN, Treatment:, Control BP with Antihypertensive, Ensure baby is getting adequate perfusion, Monitor for new onset symptoms of preeclampsia, Consider IOL @ 37 wks, IF S&S of PreE develop: CHTN with superimpose preeclampsia will be diagnosed

⬆️Peripheral vascular resistance= circulation to body organs is decreased, HTN BP>140/90 x2 reading 6 hours apart More accurate Dx: S⬆️30 mmHg or D⬆️ 15mmHg, NO severe features of preeclampsia or proteinuria, Tx: Increased surveillance, Antihypertensives, low dose aspirin. Monitor for S&S of PreE development “Cure”: delivery of baby! Consider IOL 37wks (remember can still have preeclampsia for 6wks postpartum)

Ok Thanks!

Etiology unclear, Pregnancy-specific hypertensive disease with multisystem involvements Nervouse system, Cardiovascular system, Respiratory systems, Kidneys, Liver, Eyes Placenta: ⬇️Perfusion, ⬇️nutrients/oxygen, IUGR, hypoxia, fetal death, Usually after 20 wks GA (most near term or postpartum), Eclampsia=Preeclampsia + presence of seizure!

Primiparity, Previous preeclampsia pregnancy, Chronic hypertension or chronic renal disease or both, History of thrombophili, Multifetal pregnancy, In vitro fertilization, Family history of preeclampsia, Type 1 diabetes, Obesity, Systemic lupus erythematosus, Advanced maternal age (older than 40 (35 years)

Look at the chart!

Any of the following findings:, Severe HTN on two occasion while on bedrest, Thrombocytopenia (⬇️platelets), Impaired liver function ⬆️AST/ALT RUQ pain with no other cause, Progressive renal insufficiency (⬆️serum creatinine), Pulmonary Edema (Causes difficulty breathing), New onset cerebral or visual disturbance Perisistent HA unrelieved by Tylenol Seeing spots/sparkles/floaters or other vision changes

Proteinuria ≥ 0.3g in a 24 hour urine Caused by damage to glomeruli, ⬇️Urine output, ⬆️Uric acid, Swelling of face or hands, N&V (in the 2nd half of pregnancy), Sudden weight gain, Irritable Nervous system: (+) Clonus Hyperactive reflexes

Private room, quiet section of unit, keep door closed, Pad side rails, keep bed in lowest position, O2 and suction equipment readily available, Preeclampsia supplie available: Airway, reflex hammer, ambu bag, magnesium sulfate, calcium gluconate, Dim lights, block incoming phone calls, Group nursing interventions, Restrict visitors

Vital signs, Neuro Assessment: reflexes (brachial & patellar), HA, visual disturbances, Clonus, Respiratory Assessment: Clear lungs? Pulmonary edema? Breath sound assessment q4hrs, Fetal surveillance: EFM,US,BPP, growth US, Edema, weight gain, I&O, RUQ pain (may radiate), Safety: Check your room!

Support woman’s arm, instruct her to let it go totally limp while being held, Place thumb over woman’s tendon and strike the thumb with the small end of the hammer, Normal: Slight flexion of the forearm, DTR rating scale: 0 absent +1 present hypoactive +2 normal reflex +3 brisker than average +4 hyperactive reflex

Sitting: Allow leg to dangle freely Strike the tendon with hammer just below patella, Suppine: Support weight of leg and stretch the tendons. Strike the partially stretched tendon just below patella, leg should be relaxed

Place pt supine, support their leg then dorsiflex the foot sharply and hold the stretch, Normal: No movement will be felt, Clonus Present: Rapid rhythmic contractions indicate hyperreflexia Mild= 2 movements Mod=3-5 Severe=>6

Ok thanks!

Pathological edema vs. dependent edema, Usually involves face, hands, as well as lower extremeties, Weight gains 2.3kg (5lb) or more in 1 week, Occurs after 20th week gestation

Hourly assessments of VS, respiratory system, neurological system and I&O, Monitor BP closely (high and low), Respiratory rate Less than 12 minutes= magnesium sulfate is too high!, DTR, Urinary output Less than 30 ml/hour=kidney complications r/t PreE, Level of consciousness, Have resuscitation equipment readily available, Have antidote available: Calcium Gluconate

RR ⬇️12, SpO2 ⬇️95%, BP ⬇️100/60, Serium magnesium level ⬆️8mg/dl, Absence of DTRs, Sweating flushing, Confused, lethargic, slurred speech, drowsy, or disoriented, Antidote: Calcium gluconate 1g IVP over 3min Airway & Ventilator support PRN

Look at chart!

PreE with: Seisures not attributed to other causes, Hypoxia may occur in mother and fetus, Risk for aspiration, Other risk factors: CVA, cerebral edema, anoxia, coma, maternal death (0.4-14%0, Eclampsia should be preventable!

S: Safety-stay with pt, protect, lateral position, E: Establish airway, suction, O2 mask, I: IV medication Immediatley give 2gs Mag sulfate over 5 minutes (up to a total of 6gs) For recurrent seizure or when mag is contraindicated: Lorazepam, Diazepam, Phenytoin or Keppra, Z: Zealous observation: How long, activity, aura?, U: Uterine activity, contractions, abruption*, R: Resuscitation, ventilation if necessary, E: Evaluate fetus: EFM, reassuring?

H: Hemolysis, EL: Elevated liver Enzymes, LP: Low platelets Syndrome

Look at picture I’m sorry I had zero idea how to make that a question

Avoid liver palpating, mat cause trauma, Transport carefully to avoid sudden increase in intra-abdominal pressure, Have ICU available, Medications: Magnesium Sulfate & Antihypertensives, Fluid replacement to increase reduced intrvascular volume, Consider delivery if possible, Fetus: Steroids, biophysical profile