2155 Hypertensive Disorders in Pregnancy

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What are the 6 categories of hypertensive disorders?

1. Gestational hypertension "GH" (found >20 weeks)
2. Pre-eclampsia = GH + proteinuria +edema
3. Eclampsia = pre-eclampsia + seizures
4. Chronic hypertension = HTN prior to 20 weeks
5. Chronic hypertension w/pre-eclampsia
6. HELLP Syndrome = complication of pre-eclampsia, pt. very ill

What is the pathophysiology behind PIH (3) vs normal pregnancy (3)?

In a normal pregnancy:
-Vascular volume and CO increase
-Peripheral vascular resistance decreases
-BP does not increase b/c pregnancy women are resistent to angiotensin II (vascontrictor)
In PIH:
-Peripheral vascular resistance increases
-Women with PIH are NOT resistant to Angiotensin II
-Circulation to body organs and placenta are decreased

What are some pathologic changes R/T PIH (cardiac, hematologic, neurologic, renal, hepatic, placental) (6)?

1. Cardiac: increased BP and decreased CO
2. Hematologic: increased hemocenctration, platelet clumping, endothetlial damage (clots)
3. Neurologic: rupture of small capillaries in brain, sm. hemorrhage, HA, hyperreflecia, convulsions
4. Renal: decreased glomerular flow rate, damage to glomeruli (proteinuria), Increased BUN, creatinine, Uric acid
5. Hepatic: hepatic edema -> epigastric pain
6. Placental: Decreased perfusion-> decreased nutrients (IUGR), hypoxia, fetal death

Decreased colloid oncotic pressure can lead to pulmonary capillary leak -> pulmonary edema; dyspena

What is gestational hypertension (3)?

1. BP > 140/90
2. identified after 20 weeks
3. no proteinuria

What is Chronic HTN (4)?

1. HTN that precedes pregnancy or occurs <20 weeks gestation
2. pregnancy aggravates chronic HTN
3. 4-8X greater risk of placental abruption (pulses so much thru placenta it pulls it away.
4. antihypertensive meds may have teratogen affect on baby so try to get off if you can

What kind of HTN meds should you NOT give and why?

1. ACE inhibitors & angiotenesin II receptor antagonists b/c they decrease uterine blood flow → IUGR (intrauterine growth restriction) or fetal death

Aldomet (Methydopa) (2)

1. BP Med given if >160/100 (chronic HTN)
2. 750-2000mg/24 hours

If there was decreased blood flow to brain of mom & placenta what might you assess on the EFM (2)?

1. late decels
2. minimal variability

What are 10 risk factors of hypertensive disorders?

1. age extremes <19 or >40
2. History of PIH
3. 1st pregnancy w/father (genetic link?)
4. Parity - primipara or multipara >5
5. race ↑ in non-white, especially AA
6. low socioeconomic status
7. preexisting disease = DM, renal, vascular
8. family hx of HTN or gestational HTN
9. multiple gestation pregnancy
10. obesity

What 10 S/S of hypertensive disorders?

1. rise in BP over baseline 140/90
2. sudden wt. gain - due to ↑ in extracellular fluid, not explained by caloric intake. check for edema in fingers, face & feet
3. Proteinuria
4. decreased urine output
5. thirst
6. HA (brain not getting enough blood)
7. N/V
8. epigastric pain (RUQ=liver pain)
9. visual disturbances (blurred, flashes of light)
10. fatigue

What is preeclampsia & what is the cure (4)?

- Gestational hypertension (BP > 140/90 during 2nd half of pregnancy)+ proteinuria (renal involvement leads to proteinuria)+ often edema (wt. gain/since last seen)
- teach at 20 weeks
- patient can get critically ill very quickly
- cure is delivery of baby

What is Mild vs Severe Preeclampsia?

Mild = 140/90 + Proteinuria <500mg/24hours
Severe = >160/100 + proteinuria >500mg/24hours

What are the s/s of preeclampsia(3) ?

1. HTN BP > 140/90
-2 elevated values at least 6 hrs apart
-systolic increase of 30 mmHg over base
-diastolic increase of 15 mmHg over base
2. Proteinuria
-300-500 mg in urine
-100 mg (+1 dipstick)- must complete 2 random urine collections 6 or more hrs apart, single sample may not show, proteinuria may be late sign of preeclampsia
3. Edema
-Pathological edema, not dependent edema
-involves face, hands, as well as lower extremities
-weight gain 2.3 kg (5 lbs) or more in 1 week
-occur after 20th week of gestation

What are the treatments for mild preeclampsia (6)?

1. ↓ daily activities to force bed rest
2. high protein diet (must replace protein b/c peeing out due to glomerular damage)
3. hydration
4. office visits x2 weeks w/Labs
5. Weekly NST, BPP
6. CRITICAL pt & family education: teach S/S of worsening condition

What are the Severe Preeclampic symptoms (8)?

1. HTN > 160/100
2. Proteinuria- 5 gm in 24 hr urine or 3+ on dipstick
3. Oliguria- 400-500ml/24 hr or persistent urine output < 30ml/hr
4. Hyperreflexia; 4+ w/ possible clonus
5. Cerebral and visual distrubances, HA, blurred vision, scotomata
6. Pulmonary edema or cyanosis (hear crackles)
7. Epigastric or RUQ pain
8. Thrombocytopenia

What are the S/S of severe preeclampsia (5)?

1. CNS = HA unrelieved by acetaminophen
2. CNS = "blind spots"
3. CNS = hyper-reflexia with clonus
4. Renal = ↓ GFR, urine output <30mL/hour, ↑ creatinine
5. Liver = epigastric pain, elevated liver enzymes

What are the treatments for severe preeclampsia (4)?

1. MgSO4 to prevent seizures
2. hospitalization for continual monitoring of Mom & baby
3. Monitor for development of HELLP
4. Delivery plan

What are the hourly assessments for severe preeclampsia (5)?

1. I&O, uriometer, all IVs and any fluid intake → make sure doesn't fall below 30mL/hr
2. VS q 1hr. listen to breath sounds b/c might be pulmonary edema. Temp q/4hr unless ROM
3. continuous EFM: sign of hypoxemia = late decal, loss of variability, bradycardia or tachycardia
4. LOC, reflexes (U & L , compare both sides), clonus, HA, epigastric pain & visual changes
5. May induce or C/S.

Additional nursing care for severe preeclampsia (7)

1. monitor labs (Mg levels)
2. CBC check for Hgb, platelets
3. Monitor MgSO4 levels within therapeutic range 4-8mg/dL
4. ALT
5. AST
6. BUN, creatinine, Uric acid. sign of improvement = diuresis 18-36 hours after treatment
7. monitor O2 saturation to watch for pulmonary edema, O2 may ↓ before you hear the edema

Magnesium Sulfate (for PIH) (8)

1. Anticonvulsant, NOT antihypertensive
2. Decreases the CNS to act as an anticonvulsant, also decreases frequency and strength of UC
3. ↑ seizure threshold blocking neuromuscular transmission so may ↓ BP
4. prevention/control of seizures of preeclampsia
5. prevention of preterm labor
6. Excreted by kidneys but in preeclampsia kidneys are damaged so may become toxic
7. Antidote is Calcium gluconate (Know where this is) & monitor EKG
8. Contraindications: myocardial damage, heart block, myasthenia gravis, impaired renal fx
Therapeutic level: 4-8 mg/dl (>8 may result in resp. depression and cardiac arrest)

MgSO4 how to administer, dosing, therapeutic level, absorption rate, loss of DTR level, & respiratory paralysis level (6)

1. ALWAYS give IVPB & IV pump system
2. Loading dose = 4-6g/20min, then 1-3g/hr
3. Therapeutic = 4-8mg/dL
4. Absorption rate = 3-4 hours
5. Loss of DTR 10mg/dL
6. Respiratory paralysis 15mg/dL

What are some nursing implications for Mag Sulfate (8)?

Monitor:
1. BP closely
2. RR, > 12
3. DTR
4. Urinary output, > 25-30 ml/hr
5. LOC
6. Have resuscitation equipment readily available
7. Calcium Gluconate present
8. assess every 6-8 hours)

What are the s/s of Mag toxicity (7)?

1. RR < 12
2. < 95% O2
3. NO DTRs
4. Sweating, flushing
5. Confused, lethargic, slurred speech, drowsy, disorientated
6. Decreased BP
7. >8 mg/dl level

What is eclampsia (3)?

1. Pre-eclampsia + seizures
2. Form of pregnancy induced HTN
3. CNS involvement leads to seizures

What are some eclampsia symptoms (4)?

1. Preeclampsia w/ seizures not attributed to other causes
2. Periods of hypoxia may occur in mother and fetus
3. Risk for aspiration due to relaxation of gastro esophageal sphincter during pregnancy
4.Should be preventable if preeclampsia is recognized in early stages

What are some signs of an impending seziure (5)?

1. Clonus last 3-60 seconds, may be stuperous for several minutes
2. hyperreflexia
3. HA
4. visual disturbances
5. epigastric or RUQ pain

Eclampsia "SEIZURE"

S = Safety, stay w/pt. protect, lateral position, turn to side
E = Establish airway, head side, 10L O2 mask, suction
I = IV MgSO4 2g over 3-5 min to stop, up to 6g. Valium 5-10mg IVP q10minutes - Max 30mg
Z = zealous observation, now long, activity, aura
U = uterine activity, contractions? abruption (abd will stay tense)?
R = Resuscitation - ventilation needed?
E = Evaluate fetus = EFM reassuring or not?

What are the interventions for eclampsia (7)?

1. Seizure precautions; pad side rails, bed in lowest position
2. Private room, quietest section of unit, keep door closed
3. O2 and suction equipment at bedside
4. Preeclampsia tray available; airway, hammer, ambu bag, magnesium sulfate, calcium gluconate
5. Dim lights, incoming phone calls
6. Group nursing interventions
7. Restrict visitors

What is the only cure of PIH?

Delivery of the baby

What are some preventative measures to take regarding PIH?

Prenatal careL early dx, determine baseline BP
Low-dose aspirin- 60-90 mg
Calcium supplement

What are some interventions to do at home regarding PIH?

BP should be in sitting position, same arm, do not lay supine
Daily weight
Activity restrictions; expectant mother shoudl rest in lateral positions as much as possible
Fetal surveillance; 1-2 weekly NST, us, daily kick counts, biophysical profile
Increase in frequency of office visits, 2x week
Antihypertensive meds

What is the assessment scale of edema?

+1; minimal edema of lower extremities
+2; marked edema of lower extremities
+3; edema of lower extremities, face, hands, sacral area
+4; generalized massive edema that inclues ascities

What is the deep tendon rating scale?

0; reflex absent
1; reflex present, hypoactive
2; normal
3; brisker then average
4; hyperactive reflex, clonus

How do you assess for clonus (9)?

1. Supine
2. Support leg
3. Dorsiflex foot sharply!
4. Hold the stretch
5. Normal- no movement
6. Clonus present when there is rapid rhythmic contractions that indicate hyperreflexia
7. Mild- 2 movements
8. Moderate- 3-5
9. Severe- >6

What are the interventions in the hospital regarding eclampsia?

Activity restriction, quiet enviornment
BP monitoring
Fetal surveillance
Daily weight
I&O, may require foley
Breath sound assessment q4
Edema assessment
Check urine for protein
Check reflexes-> clonus
Assess subjective symptoms; HA, visual disturbances, epigastric pain
Antihypertensive medication, goal to keep diastolic pressure , 100 mgHg to decrease risk of intracranial bleed (Hydralazine, Procardia, Normodyne)
Anticonvulsant medication
Evaluate lab data

Calcium Gluconate (3)

1. 1 gm of Calcium gluconate IV over 3 minutes
2. Repeat q hr prn
3. Provide airway & ventilator support prn

Hydralazine (Apresoline) (5)

1. Antihypertensive
2. Relaxes arterial smooth muscle
3. Excreted by liver
4. Contrainidicated in CAD
5. Adverse Rxn: HA, dizziness, drowsiness, hypotension, epigastric pain

Labatalol (Normodyne, Trandate) (9)

1. Antihypertensive. Txt of severe HTN.
2. Beta Blocker
3. Produces drop in BP w/o decreasing maternal HR or CO
4. 20-40mg q 10-15/min, MAX 220mg
5. LT txt = 100mg BID, MAX 2400mg/24 hr
6. Category C = adverse in animal fetus, no info on human
7. Blocks alpha-1 & beta adrenergic receptors → vasodilation & ↓ BP
8. S/E- hypotension, dizziness, N/V, dysrrhymias
9. Nursing interventions; After IV bolus, assess BP q5 min for 30 min, then q 30 for 2 hrs, then hourly for 6 hrs

What is HELLP syndrome (acronym + 5)?

H- hemolysis (↓ Hgb & RBCs); occurs as RBCs travel through constricted vessels, causing anemia & changes in RBC morphology
E L- elevated liver enzymes; occurs when hepatic blood flow is obstructed by fibrin deposits. Hyperbilirubinemia & jaundice can occur.
L P- low platelets syndrome; due to vascular damage resulting from vasospams, platelets aggregate at site of damage, resulting in thrombocytopenia elsewhere

1. It is a complication os preeclampsia
2. (version of pre-eclampsia but liver involved)
3. Life threatening variation of preeclampsia
4.Occurrence more frequent in older, white multiparas women
5. Occurs at pre-term gestation

What are some S/S of HELLP (6)?

1. Often most prominent symptom is pain in RUQ, lower chest, or epigastric area
2. Lab changes:
3. Low hematocrit
4. Liver impairment, following are elevated: LDH, AST, ALT, bilirubin
5. Renal Impairment; elevated uric acid and creatinin
6. Coagulation abnormalities: < 100,000 platelets, everything else normal

What are the nursing interventions for HELLP (7)?

1. Avoid palpating liver, may cause trauma
2. Transport carefully to avoid sudden increase in intra-abdominal pressure
3. ICU bed
4. Meds: Mag sulfate (seizures), hydralazine (BP)
5. Fluid replacement to increase reduced vascular volume
6. Consider delivery if possible
7. Fetus: steroids, biophysical profile

How does MgSO4 affect Pitocin

Pitocin helps with contractions & MgSO4 relaxes smooth muscles so they can counteract each other.

Mg level

1.8-2.6

ALT (Alanine Amiontransferase) level

7-35 u/l

Does obesity cause an increase or decrease in ALT?

Increase

AST (Aspartate Transaminase) level

10-36 u/l

Resolution of Gestation hypertensive disorders

1. after birth, resolution is rapid 1st 24 hours
2. If seized continue MgSO4 1st 24 hours w/continued assessments
3. watch in early PP, still at risk for seizures, pulmonary edema related to fluid shifts
4. preeclampsia may initially reappear 1st 72hrs-1 week
5. support bonding, MgSO4 is not contraindicated w/BF. baby may be limp

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