Terms in this set (77)
What is Preeclampsia
Preeclampsia is a pregnancy related disorder characterized by hypertension that presents after 20 weeks of pregnancy in the presence of other organ system involvement and or fetal growth restriction.
What is proteinuria
Glomerular damage allows protein to leak through glomerular membrane protein.
-excretion of ≥0.3 g protein in a 24-hour specimen.
correlates with ≥30 mg/dL (≥1+ reading on dipstick) in a random urine specimen with no evidence of UTI
What are the signs of kidney involvement
Significant proteinuria - a spot urine protein / creatinine ration > 0.3g protein in 24hr specimen.
Correlates with >30mg/dL or >1+ reading on dipstick in a random urine with no evidence of UTI
Oliguria < 80mL / 4 hours
What are the signs of liver involvement
Severe epigastric or right upper quadrant pain
Raised liver enzymes
What are the signs of haematological involvement
-Thrombocytopenia < 100,000 /μL-
-Haemolysis- rupturing of erythrocytes (red blood cells) and the release of their contents (cytoplasm) into surrounding fluid (e.g. blood plasma).
What is the diagnostic criteria for gestational hypertension
-New onset of hypertension arising after 20 weeks gestation-No additional maternal or fetal features of preeclampsia-Resolves within 3 months postpartum-The earlier the gestation at presentation and the more severe the hypertension, thehigher the likelihood of developing preeclampsia or an adverse pregnancy outcome
What is Chronic Hypertension
Pre-existing hypertension is a strong risk factor for the development of preeclampsia and requires close clinical surveillance.1 EssentialBP greater than 140/90 mmHg preconception or prior to 20 weeks without an underlying cause.orBP less than 140/90 entering pregnancy on antihypertensives
What is Secondary Hypertension
-hypertension as a result of another condition.
-chronic kidney disease (e.g. glomerulonephritis, reflux nephropathy and adultpolycystic kidney disease)-renal artery stenosis-systemic disease with renal involvement (e.g. diabetes mellitus, systemiclupus erythematosus) endocrine disorders (e.g. phaeochromocytoma, Cushing's syndrome andprimary hyperaldosteronism) coarctation of the aorta
What is Preeclampsia superimposed on chronic hypertension
Pre-existing hypertension develops systemic features of preeclampsia,
> 20 weeks gestation. Worsening or accelerated hypertension
increase surveillance for preeclampsia but is not diagnostic.
What are the moderate risk factors
-Age 40 years or more-First pregnancy-Multiple pregnancy-Interval since last pregnancy of more than 10 years-Body mass index of 35 or more at presentation-Family history of pre-eclampsia
What are the high risk factors
-Chronic hypertension-Chronic kidney disease-Hypertensive disease during a previous pregnancy-Diabetes-Autoimmune disease
Investigations on all woman that present with new onset hypertension should include
-Spot urine Protein Creatinine Ratio-FBP-Urea, creatinine, electrolytes-Liver function tests-Ultrasound assessment of fetal growth, amniotic fluid volume and umbilicalartery Doppler assessment
Further tests if features of preeclampsia are present are
-mid-stream urine sample for protein and microscopy. -If there is thrombocytopenia or a falling haemoglobin, investigations for disseminated intravascular coagulation and / or haemolysis are indicated
What is the pathological course of pre-eclampsia
The multiple organ involvement observed as preeclampsia progresses is caused by,
- plasma volume reduction due to capillary leakage and
- platelet aggregation caused by endothelial dysfunction
resulting in intravascular thrombosis
Hypo-perfusion of the kidney, liver, and brain.
What are the signs of neurological involvement
Persistent visual disturbances
Persistent new headache
HELLP stands for
Elevated Liver enzymes
Low Platelet count
The Symptoms of HELLP syndrome are
thrombocytopenia, elevated liver enzymes and haemolysis
What are the signs of severe pre-eclampsia
-Severe epigastric pain/ and or vomiting with abnormal -l
-altered mental state
What are the indications for delivery in woman with preeclampsia
-gestational age greater than 37 weeks
- hypertension becomes difficult to control
-deterioration in liver, kidney or neurological function
-neurological symptoms develop
-upper epigastric pain develops/vomiting and abnormal liver enzymes
-acute pulmonary edema develops
-HELLP syndrome develops
Management at less than 23 weeks
termination is recommended referral to tertiary hospital
Management at 23-31 weeks
transfer to tertiary hospital.
Likely to need preterm delivery
prolong delivery where possible
Management at 32-36 weeks
Aim to prolong pregnancy where possible
Delivery recommended at 37 weeks regardless of status
What is the dose of Magnesium Sulphate when treating preeclampsia/eclampsia
-loading dose of 4mg using an infusion pump over 20 mins
-Maintenance dose regime of 1g per hour thereafter. It is recommended that this is continued for 24 hours after the last seizure or till after birth. Loading dose initated again if seizure occurs
What is the mechanism of action of Magnesium
Cerebral vasodilator- reduces cerebral vasospasm and ischemia.
Superior to other anticonvulsants used to control and prevent fits.
What are the side effects of magnesium sulphate
-Causes loss of deep tendon reflexes, followed by
respiratory depression and ultimately respiratory
What is the antidote for magnesium sulfate
What drug can be used in the presence of seizures whilst preparing magnesium
Intravenous diazepam or clonazepam can be administered in the case of a prolonged seizure whilst preparing the magnesium sulphate solution
Treatment of hypertensive agents must be commenced when blood pressure is
170mmHg/ 110mmHg or higher
physicians choice below this
What is the recommended anthypertensive agent for acute severe hypertension
Nifedipine (Calcium channel antagonist)
Labetalol (Beta blocker)
What is the recommended dose of nifedipine for acute severe hypertension
10mg as a oral dose with a repeat dose of 10mg if an inadequate response after 30 mins
What is a common side effect of nifedipine
What is the anthypertensive agent of choice for intravenous administration for acute severe hypertension
Labetalol (Beta blocker)
What is the dose of Labetalol
20-80mg bolus over 2 minutes
repeat every 10 mins prn
What the side effects of labetalol
bradycardia, bronchospasm and headache
What level should BP be maintained above
BP should not fall below 140/80
What antihypertensive agents can be used in pregnancy
Management of Eclampsia
-oxygen by mask
-Magnesium Sulfate 4mg loading dose over 20mins
the 1mg and hour
-ECG, neuro obs
-vitals every 15mins
Before administering Magnesium Sulphate the midwife must check
Checked by 2 midwives
RR ≥ 12/min (Sadie-16)
Deep tendon reflexes are present
Urinary output is at least 100mls per hour over 4 hours (Sadie 30mls/hr for 4 hours).
Document baseline set of vital signs, deep tendon reflexes urinary output and conscious state.
Keep antidote ready
What types of seizures occur
Tonic and clonic
The body initially becomes rigid in a state of tonic muscular contractions that last 15-20 secs.
The facial muscles and then all body muscles alternatively contract and relax in rapid succession lasting about 1 min.
During the administration of magnesium sulphate what midwifery care is required
-Deep tendon reflexes recorded every 15 mins for 2hours then hourly
-Respiratory rate every 15 mins then hourly
continuous pulse oximetry
Fluid restrictions at 1ml/kg/hr (80mls on ave)
record fluid balance and urine output hrly
Signs of magnesium sulphate toxicity are
Loss of deep tendon reflexes/absent patella reflexes
SpO2 less than 95
Nausea, hot flushes, weakness
Management when absent of reduced patella reflexes
notify medical officer
collect blood serum levels
Calcium gluconate is administered with respiratory depression
stop infusion when respiration is less than 12 (16)
Systolic BP ≥ 140 or diastolic BP ≥ 90 occurring after 20 wks accompanied by significant proteinuria.
Progression of preeclampsia to generalized seizures that cannot be attributed to other causes. Seizures may occur postpartum.
Elevated blood pressure was known to exist before pregnancy.
Glomerular damage allows ___ to leak across the glomerular membrane.
Loss of protein from the kidneys reduces coloid osmotic pressure and allows fluid to shift to the interstitial spaces leading to:
Vasoconstriciton of cerbral vessels leads to cerebral hemorrhages. Signs and symptoms that accompany this are:
headache, visual disturbances, blurred vision, "spots" before the eyes, hyperreflexia
Decreased placental circulation results in what for the fetus?
abruption placentae, DIC, FGR
Lab values indicating preeclampsia or HELLP, platelet/coagulopathy results: Platelet count <___; ___ PT or PTT; ___ fibrinogen; ___ D-dimer
100,000; elevated; decreased; increased
With severe preeclampsia the Pt is kept on bedrest in the lateral position and her environment is kept quiet. External stimuli (___, ___) that might precipitate a ___ should be reduced.
lights; noise; seizure
When antihypertensive drugs are administered the ___ ___ ___ must be monitored closely because a sudden fall in maternal BP may precipitate fetal distress.
fetal heart rate
Diuretics are administered only in the presence of ___ ___.
Corticosteroids can also help your baby's ___ become more mature in as little as 48 hours — an important step in helping a premature baby prepare for life outside the womb. Typical drug:
Patients with severe preeclampsia may have ___ abnormalities (thrombocytopenia) that contraindicate use of epidural analgesia.
Following delivery, careful assessment of the pt ___ loss and signs of ___ are essential because the hypovolemia caused preeclampsia may be aggravated by loss during the delivery.
Assessment for s/s of preeclampsia must be continued for at least __ hours, and mag sulfate is continued (usually for 24 hours PP) to prevent ___.
___ is marked by generalized, or grand mal, seizures that typically begin with twitching about the ___.
___ are absent during the seizure because the diaphragm tends to remain fixed. Breathing usually resumes shortly after the seizure and is often ___ and ___.
respirations; rapid; deep
___ may be given IV to control the seizures.
Pulmonary ___, circulatory or ___ failure, and intracranial ___ are additional complications that may occur with eclampsia.
edema; renal; hemorrhage
With eclampsia, the patient's ___ should be auscultated frequently.
Eclampsia: urine output should be assessed ___. Below __ ml/hour indicated renal failure.
____ is an added complication that may occur with severe preeclampsia or eclampsia, and the nurse should observe for unexpected bleeding.
Disseminated Intravascular Coagulation
With eclampsia, the pt should be assessed for ruptured ___, signs of ___, or ___ ___ because eclampsia stimulates uterine irritability.
membranes; labor; placenta abruption
After maternal and fetal conditions are stabilized, the fetus is usually delivered, either by ___ if the pt cervix is favorable or by ___ if cervix unfavorable or if fetus is extremely preterm or IUGR noted.
induction of labor; c-section
What does HELLP stand for?
Hemolysis, Elevated Liver enzymes, Low Platelets
HELLP is a life-threatening variation of ___.
The prominent symptom of HELLP syndrome is pain in the ___, the lower chest, or ___ area (caused by ___ distention).
RUQ; epigastric; liver
Management of pt with HELLP should be in a setting where there is full ___ facilities.
Most HELLP pts improve within __ to __ hours post partum. Liver studies begin to normalize and urine output improves.
Signs of impending seizure include the following:
hyperreflexia or presence of clonus (or both), increasing signs of cerebral irritability (headache, visual disturbance), & epigastric pain.
Physical examination, measurement of BP and assessment for the presence of proteinuria are the cornerstones of screening in antenatal care.
Eclampsia can be defined as
Occurrence of one or more seizures superimposed on pre-eclampsia
Seizures may occur in pregnancy, intrapartum and in the puerperium
Seizures may even occur in a woman who appears to have mild pre-eclampsia
The seizure is usually self-limiting and lasts for one to two minutes.
Maternal organ systems that are susceptible to excessive inflammation and endothelial damage are
Kidney, liver, CNS, lungs, systemic vasculature, coagulation and the heart.
Placenta and fetus are also at risk
The more organ systems that are affected, the more maternal and perinatal complications arise
What ethnicities are at greater risk of hypertension in pregnancy and why?
Latin Americans, African, Filipino and those of low SES due to health inequalities,
lifestyle factors -
What are the dramatic warning signs of impending eclampsia
Pain in the upper abdomen caused by congested liver and severe persistent headache.
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