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OB Chapter 27

Terms in this set (54)

OB Chapter 27
Exam 4
Gestational HTN
Onset of HTN without proteinuria after week 20 of pregnancy; may be transient or chronic in nature; most commonly occurs around 37wks; blood pressures return to normal within 6wks post delivery
HTN in pregnant moms
Above 140/90
Mild HTN
women with mild gestational hypertension usually have good pregnancy outcomes
Severe HTN
when proteinuria develops it moves them into preeclampsia. (this occurs in those women who are diagnosed with gestational hypertension prior to the 35 week of pregnancy
Preeclampsia
Pregnancy-specific syndrome in which HTN develops after 20wks in a previously normotensive woman and is characterized by presence of HTN & proteinuria
Eclampsia
Onset of seizure activity or coma in the woman diagnosed with preeclampsia, with no history of preexisting pathology that can result in seizure activities; initial presentation varies, 1/3 of women develop eclampsia during pregnancy, 1/3 during labor, 1/3 within 48h PP
What should you look for if your patient on PP had preeclampsia?
Seizure activity; many times these mothers will stay longer in L&D
Eclamptic seizures can occur before, during or after birth, 1/3 occur after birth, almost always within 48 hours PP
Chronic HTN
HTN that is present before pregnancy or develops before 20wks of gestation; most will have uncomplicated pregnancies but there's increased risk of poor fetal growth & fetal demise
Those with severe chronic HTN have an increased risk of perinatal mortality
Chronic HTN with superimposed preeclampsia
Women with chronic HTN may develop superimposed preeclampsia, which increases the mobidity for mother and fetus.
Approx. 25% of women with chronic HTN develop preeclampsia or eclampsia; this disorder is associated with severe maternal & fetal complications
Chronic HTN with superimposed preeclampsia
defined with the following findings:
1. Women with HTN before 20wks of gestations, with new onset proteinuria
2. Women with both HTN & proteinuria before 20wks of gestation
3. Sudden increase in proteinuria
4. Sudden increase in BP in woman whose HTN was previously well controlled
5. Thrombocytopenia
6. Elevated liver enzymes
Know Preeclampsia Etiology
S/S develop during pregnancy & disappear after birth; ultimate cause is unknown; seen more frequently in primigravidas younger than 20 & older than 40 having the highest rates of occurrence
Know Preeclampsia risk factors
Primigravidity, being over 40 or under 20; Multifetal pregnancy or hydatiform mole; Obesity
IUGR; placenta abruption; fetal death
Chronic renal disease and chronic HTN Collagen disease
Diabetes type 1
RH incompatibility
Periodontal disease
Increased in African Americans
S/S of Preeclampsia
1+ protein urea
Systolic BP increase 30 above baseline
Dystolic BP increase 15 above baseline
Gained 2lbs in 1 week
May have some edema
Preeclampsia pathophysiology
Main pathogenic factor: disruptions in placenta perfusion and endothelial cell dysfunction
Inadequate vascular remoeling=decreased placental perfusion and hypoxia=endothelial cell dysfunction=vasospasm, increased peripheral resistance and increased endothelial cell permeability=decreased tissue perfusion.
Preeclampsia vasospasm
Arteriolar vasospasm diminishes diameter of vessels which impedes circulation to all organs and increases BP
Reduced kidney perfusion
Leads to possible oliguria; serum uric acid levels increase; sodium & water are retained
Plasma colloid osmotic pressure r/t reduced kidney perfusion & vasospasm with preeclampsia
Decreases as serum albumin levels decrease; intravascular volume is reduced as fluid moves out of intravascular compartment resulting in hemoconcentration, increased blood viscosity and tissue edema, increasing risk for pulmonary edema
Decreased liver perfusion due to vasospasm
Impaired liver function & elevated liver enzymes; may complain of epigastric or right upper quadrant pain; hemorrhagic necrosis in the liver can cause a subcapsular hematoma and it is a life-threatening complications & surgical emergency
Decreased perfusion to retina
Leads to scotomata (blind spots: dim vision, double vision) and blurring; neuro complications associated with this include cerebral edema & hemorrhages, increased CNS irritability which manifests as headaches, hyperreflexia, positive ankle clonus, seizures
Other complications of preeclampsia
Restrictions of fetal growth; incidence of placental abruption, premature birth, and early degenerative aging of placenta; impaired placental perfusion leads to early degenerative aging of placenta & rate of fetal complications directly related to severity of disease
HELLP Syndrome
Laboratory diagnosis for a variant of severe preeclampsia that involves hepatic dysfunction characterized by;
Hemolysis (H)
Elevated liver enzymes (EL)
Low platelets (LP)-must be less than 100,000
Diagnosis associated with increased risk of adverse perinatal outcomes
HELLP Syndrome
A unique form of coagulopathy (not DIC) occurs with HELLP syndrome. The platelet count is low, but coagulation factor assays, prothrombin time (PT), partial thromboplastin time (PTT), and bleeding time remain normal. In some instances hemolysis does not occur and the condition is called ELLP(not a separate illness)
HELLP appears in 5-20% with preeclampsia; common in Caucasian women
HELLP S/S
Malaise, flu-like symptoms, epigastric or right upper quadrant abdominal pain, nausea & vomiting, headache, Some develop thrombocytopenia;
Many do not have s/s of severe preeclampsia or may only have slight BP elevations-often misdiagnosed
Complications with HELLP
Renal failure, pulmonary edema, ruptured liver hematoma, DIC, ARSDS, variant of DIC, risk for placental abruption & pre-term birth; assess uterine tone & tenderness in the presence of vaginal bleeding; perform THOROUGH abdominal assessment-placental abruption presents with a very hard abdomen & requires emergency c-section
NURSE ALERT with placental abruption
Uterine tenderness in the presence of increasing tone may be the earliest finding of an abruption. Idiopathic preterm contractions also may be an early sign. Assess the abdomen. *Don't always wait on lab work they can die before you get the results! If this happens you need to be into the uterus within 7minutes for baby to survive
Lab tests for HELLP
CBC (including a platelet count), clotting studies, liver enzymes, chemistry panel (BUN, glucose), type & screen/cross match, LDH values
Cure for preeclampsia
Birth of the fetus
Care management for preeclampsia
Physical exam:
Accurate BP essential
Dependent Edema - assess edema for distribution, degree and pitting, seen most in feet and ankle
DTR reflexes - reflect the balance between cerebral cortex & spinal cord; they are evaluated as a baseline and to detect changes; hyperactive reflexes (clonus) best assessed at the ankel joint.
Care management for preeclampsia
Urinalysis for protein - check proteinuria by dipstick testing or 24h urine (results proteinuria is at least 30mg/dl or greater in at least 2 random urine specimens collected 6 hours apart. If 24 urine than results will be gerater than 300mg/24hrs.)
S/S of severe preeclampsia
Frontal headache; epigastric pain (heartburn); right upper quadrant abdominal pain (assess for placental abruption now!), visual disturbance such as scotoma, photophobia or double vision—if these signs are not associated with abruption a seizure will start—do not leave the room, calmly call for help & provide safety
Seizure interventions
Roll side to side, pad side rails, do not insert tongue blade; when seizure subsides check fetal heart rate
Mild preeclampsia & home care
Requires frequent maternal & fetal evaluation, BP less than 150/100, proteinuria less than 500mg/d; come in weekly for 24h urine, platelet count, hematocrit & liver function test; count fetal movement daily; Non stress test once or twice per week & biophysical profile as needed; activity restriction
Activity restriction for home care of mother with preeclampsia
Bed rest in lateral recumbent position is standard therapy & may improve uteroplacental blood flow, decreases BP and promotes diuresis; may give bathroom privileges may decrease negative effects such as boredom & depression; perform ROM & kegel exercise, relaxation techniques
Adverse physiological outcomes of bed rest
Cardiovascular deconditioning, diuresis with accompanying fluid and electrolyte and weight loss; muscle atrophy; thrombophlebitis; psychological stress
Diet for preeclampsic mother with home care
Pretty much the same as for the healthy pregnant women; adequate protein; 1200mg Ca; 400mcg folic acid; adequate zinc; 2-6g of sodium have been suggested to prevent preeclampsia but hasn't been proven; adequate fluid intake helps maintain fluid volume & aids in renal perfusion & bowel function; eat foods with roughage, 6-8 glasses of water per day & avoid ETOH/tobacco
Care management for severe preeclampsia
Nutrition, magnesium sulfate, control of BP; usually starts 34 wks or later & labor induction is performed; vaginal birth is considered safer & should be attempted; in pregnancies of less than 34wks the plan includes pharmacology to prevent seizures & control BP; continue fetal surveillance for indicators of worsening condition; corticosteroids may be given to promote lung maturation
Preeclampsia hospital care
Weekly non-stress test (NST) to monitor for decelerations; should have seizure precautions in place & limited visitors; weight measured on admission & daily after; breath sounds auscultated for crackles or diminished sounds indicating pulmonary edema; indwelling catheter may be inserted to measure output
Fetal assessment with severe preeclampsia
Ordered because of the potential for hypoxia r/t uteroplacental insufficiency; electronic fetal monitoring is done at least once/d; vaginal exam may be done to check cervical change; abdominal palpation establishes uterine tone & fetal size/activity/position; maintain bed rest with seizure precautions
Care Management
One of the most important goals of care for the woman with severe preeclampsia is prevention and control of convulsions.
Magnesium Sulfate Administration
is administered as a secondary infusion (piggyback) to the main IV line by volumetric infusion pump.
Initial loading dose of 4 to 6 g(per protocol or physician's order) is infused over 15 to 20 minutes.
Followed by a maintenance dose that is diluted in an IV solution per physician's order (e.g., 40 g in 1000 ml of LR solution 1g= 25ml) and administered by infusion pump at 2 g/hour.
Magnesium Sulfate Administration
Should maintain a therapeutic serum magnesium level of 4 to 7 mEq/L.
Blood levels of magnesium sulfate are checked periodically. After the loading dose, there may be a transient lowering of the arterial blood pressure secon-dary to relaxation of smooth muscle by the magnesium sulfate
Decreases neuromuscular irritability, depressing cardiac conduction, and decreasing CNS irritability.
SE of loading dose of Magnesium Sulfate
Feeling of warmth, diaphoresis, burning at IV site
Symptoms of mild Magnesium Sulfate toxicity
Lethargy, muscle weakness, decreased or absent DTR, double vision, slurred speech; Increasing toxicity s/s include maternal hypotension, bradycardia, Bradypnea, cardiac arrest; serum magnesium levels obtained regularly per protocol & if any s/s of toxicity are present
Nursing Alert for Mg toxicity
IF Mg toxicity is suspected, prompt actions are needed to prevent respiratory or cardiac arrest. The magnesium infusion should be discontinued immediately. Calcium Gluconate or calcium chloride (antidotes for magnesium sulfate can be given IV also may be ordered (10 ml of a 10% solution, or 1 g) and given by slow IV push (usually by the physician) over at least a 3 minute period to avoid undesirable reactions such as arrhythmias, bradycardia, and ventricular fibrillation (Cunningham, 2010). After delivery the uterus may take longer to contract and the patient may need HEMABATE (not pitocin) to help stop bleeding. (some question about the use of methergine with these patients)
There will be Magnesium Sulfate drug calc on the test!!
Remember: 4-6g loading dose IVPB; maintenance typically 40g Mg in 1000mL LR-1g=25mL administered 2g/h
Control of BP in preeclampsia
Antihypertensive medications may be ordered to lower the diastolic blood pressure. Because a degree of maternal hypertension is necessary to maintain uteroplacental perfusion, antihypertensive therapy must not decrease the arterial pressure too much or too rapidly. The target range for the diastolic pressure is therefore less than 110 mm Hg and the systolic pressure less than 160 mm Hg ;Safe drugs to give include: hydralazine, labetalol (most common) and nifedipine
Eclampsia
Convulsions - usually preceded by various premonitory symptoms and signs, including persistent headache, blurred visions, severe epigastric pain, and altered mental status. However, convulsions can appear suddenly and without warning in a seemingly stable woman with only minimum blood pressure elevations; seizures may recur within moments of the first convulsion or the woman may never have another
S/S during seizure with eclampsia
Respirations which are halted & begin again with long, deep, stertorous inhalation; hypotension follows; muscular twitching; disorientation & amnesia persist for a while after convulsion
Immediate care during seizure
Goal is to ensure patent airway; turn woman on her side to prevent aspiration of vomitus & supine hypotension syndrome; note time & duration of seizure/convulsion; after convulsion ceases, suction food & fluid from glottis, admin 10L oxygen via face mask, insert 18 gauge if not in place & start magnesium; may give valium or other meds if convulsions continue; some continue magnesium for 12-24h after delivery for seizure prophylaxis
Nurse Alert for seizure
Immediately after a seizure, the woman may be very confused and can be combative. Pad the side rails to prevent injury, and maintain a quiet, darkened environment. It may take several hours for the woman to regain her usual level of mental functioning. The woman should not be left alone. Provide emotional support to the family and discuss with them the management and its rationale and the woman's progress; assess uterine activity, cervical change, & fetal status; membranes may rupture or fast dilation may have occurred—delivery may be immediate
Nurse Alert-Risks with Magnesium Sulfate
Risk for boggy uterus & a large lochia flow as a result of magnesium sulfate therapy; uterine tone & lochia should be assessed frequently
Preeclamptic woman & blood loss
Unable to tolerate excessive PP blood loss because of hemoconcentration; oxytocin or prostaglandin products are used to control bleeding; Ergo products (Ergotrate & Methergine) are contraindicated because they increase BP-give hemabate instead
Chronic HTN associated with
Increased incidence of placenta abruption, superimposed preeclampsia, increased perinatal mortality, fetal growth restriction
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