Hehi Test 2 - Pregnancy Complications

Front 1

Chronic Hypertension

Back 1

before pregnancy or prior to 20 weeks gestation; does not resolve postpartum

Front 2

Gestational Hypertension

Back 2

onset of hypertension w/o proteinuria after 20 weeks of pregnancy. Diagnosis of is made in the postpartum period if the women has developed preeclampsia and BP returns to normal values.

(replaces the term PIH)

Front 3

Pre-eclampsia

Back 3

after 20 weeks gestation
• Hypertension
- BP > 140/90
- 30/15 increase
• Proteinuria
- 0.3 g in 24 hour urine
- 1 + dipstick
• Edema
- generalized
- weight gain of 2 kg (4.5 lbs) or more/week

Front 4

Eclampsia

Back 4

pre-eclampsia + onset of seizure activity or coma in a patient with preeclampsia w/ no history of preexisting pathology that can result in seizure activity.

presentation varies: 1/3 during pregnancy, 1/3 during labor, 1/3 w/in 72hrs PP.

Front 5

4 things present in Chronic Hypertension w/superimposed pre-eclampsia

Back 5

- new onset of proteinuria and/or increase
- sudden increase in BP
- thrombocytopenia (deficiency of platelets in the blood)
- increased liver enzymes

Front 6

Etiology of hypertension

Risk factors for developing

(pg. 719)

Back 6

the cause is unknown

risk factors: Primigravidity, multifetal presentation, preexisting DM, Af. Amer.

Front 7

Pathophysiology of hypertension
characterized by 3 things

(pg. 719)

Back 7

1) vasospasms - sudden constriction of a blood vessel reducing its diameter and flow rate
2) changes in coagulation system
3) disturbances in systems r/t volume and BP control

*Main pathogenic factor is NOT inc. in BP, but rather poor perfusion as a result of vasospasm.

Front 8

Etiology of hypertension - what is known:
- With an increased maternal blood pressure fluid moves from ____ to ____. -Blood becomes hemoconcentrated with a decreased _____ and ______.
-An elevated BP in pregnancy and subsequent vasoconstriction will result in ______ with alterations in ____.
(p. 719)

Back 8

- Vascular system to extravascular spaces.
- renal plasma flow and GFR (glomerular filtration rate)
-uteroplacental perfusion, fetal growth.

Front 9

Maternal Complications of Hypertension (p. 722)
-Cardiac
-Cerebral
-Hemtologic
-Hepatic
-Pulmonary
-Renal
-Retinal
-Trauma
-Other organs

Back 9

-Cardiac – dysrhythmias, congestive heart failure
-Cerebral – hemorrhage, thrombosis, cerebral hypoxia, edema, coma, HA unrelieved w/ tylenol
-Hematologic – disseminated intravascular coagulation (DIC) – loss of platelets and clotting factors, unable to form additional clots.
-Hepatic – necrosis, liver rupture
-Pulmonary – acute airway obstruction - eclampsia, pulmonary edema – non-cardiogenic, cardiogenic (hypervolemic)
-Renal – acute tubular necrosis, cortical necrosis, oliguria
-Retinal – detachment, hemorrhage
-Trauma – related to eclamptic seizure
-Other organs – hemorrhage into adrenal gland, intestine, pancreas, and spleen

Front 10

Fetal Complication of Hypertension

Back 10

Abruption placenta, placental infarction, IUGR, acute hypoxia, prematurity, death

Front 11

HELLP syndrome
H =
EL =
LP =

Back 11

• H = hemolysis – vasospasms, RBCs lysed – makes them dysfunctional for carrying O2
• EL = elevated liver enzymes – vasoconstriction occurs in hepatic vasculature builds up fibrin clots to repair damaged endothelial lining – microemboli thoroughout vasculature – in the liver causes a rise in liver enzymes b/c of hypoxia in hepatic tissue.
1. Vasospasms
2. Intra-arterial lesions
3. Platelet aggregation
4. Fibrin accumulation
5. Microemboli in hepatic vasculature
•LP = low platelets (< 150,000)
1. Vasospasms
2. Platelet consumption

Front 12

HELLP can identified by LABS and what symptoms?

Back 12

Pre-elclampsia
HA
blurred vision
RUQ pain
N/V

Front 13

Etiology of hypertension - what is known:
- With an increased maternal blood pressure fluid moves from ____ to ____. -Blood becomes hemoconcentrated with a decreased _____ and ______.
-An elevated BP in pregnancy and subsequent vasoconstriction will result in ______ with alterations in ____.
(p. 719)

Back 13

- Vascular system to extravascular spaces.
- renal plasma flow and GFR (glomerular filtration rate)
-uteroplacental perfusion, fetal growth.

Front 14

Maternal Complications of Hypertension (p. 722)
-Cardiac
-Cerebral
-Hemtologic
-Hepatic
-Pulmonary
-Renal
-Retinal
-Trauma
-Other organs

Back 14

-Cardiac – dysrhythmias, congestive heart failure
-Cerebral – hemorrhage, thrombosis, cerebral hypoxia, edema, coma, HA unrelieved w/ tylenol
-Hematologic – disseminated intravascular coagulation (DIC) – loss of platelets and clotting factors, unable to form additional clots.
-Hepatic – necrosis, liver rupture
-Pulmonary – acute airway obstruction - eclampsia, pulmonary edema – non-cardiogenic, cardiogenic (hypervolemic)
-Renal – acute tubular necrosis, cortical necrosis, oliguria
-Retinal – detachment, hemorrhage
-Trauma – related to eclamptic seizure
-Other organs – hemorrhage into adrenal gland, intestine, pancreas, and spleen

Front 15

Fetal Complication of Hypertension

Back 15

Abruption placenta, placental infarction, IUGR, acute hypoxia, prematurity, death

Front 16

HELLP syndrome
H =
EL =
LP =

Back 16

• H = hemolysis – vasospasms, RBCs lysed – makes them dysfunctional for carrying O2
• EL = elevated liver enzymes – vasoconstriction occurs in hepatic vasculature builds up fibrin clots to repair damaged endothelial lining – microemboli thoroughout vasculature – in the liver causes a rise in liver enzymes b/c of hypoxia in hepatic tissue.
1. Vasospasms
2. Intra-arterial lesions
3. Platelet aggregation
4. Fibrin accumulation
5. Microemboli in hepatic vasculature
•LP = low platelets (< 150,000)
1. Vasospasms
2. Platelet consumption

Front 17

HELLP can identified by LABS and what symptoms?

Back 17

Pre-elclampsia
HA
blurred vision
RUQ pain
N/V

Front 18

MgSO4 used to:
most common admin. is IV loading dose:
can be give up to __ to __ hrs PP
Excreted by ____
Desired levels:

Back 18

prevent or control seizures
IV: 4-6g, 1-2 IV/hr basal rate
12-24hrs
Kidneys - if impaired dosing is different
4-8mg/ dl

Front 19

Nursing care of patient on MgSO4

Back 19

*think neuromuscular blockade
- VS watch RR - watch trends
- Check DTR q 12hr
- Auscultate breath sounds q 2hr – looking for S&S pulmonary edema
- Foley catheter – excreted in urine
- I&O q 1 hr – MgSO4 excretions
- Fluids on pump
- bedrest

Front 20

Hypertensive crisis is indicated by DBP > __
Pharm. control of HT in pregnancy

Back 20

100mm Hg

Hydralazine – arteriolar vasodialator - afterload reducer, whimpy dose works well in OB patients- normally a healthy population so easy response to meds.
- Labetalol- beta-blocking, causes vasodilation
- Nitropresside – only used to stabilize before going to OR
- Nifedipine

Front 21

Eclampsia protocol

Back 21

MgSO4 Initial dose 4-6g IV over 5-10min
Continuous IV 2-3g IV/ hour
Recurrent seizure 2-4g IV over 3-5min
Recurrent seizure - paralyze + intubate (SEDATE)

Front 22

Invasive Hemodynamic Monitoring

Back 22

-Refractory oliguria
-Pulmonary edema – uncertain etiology
-Hypertension refractory to traditional management

Front 23

Nursing management for pre-elampsia

Back 23

- Nurse to patient ratio based upon patient needs
- MgSO4
DTR’s q 1hr
- Frequent VS – if stable q 1h, but may need q 5min if not
- Frequent BP assessment -
- Medications for BP control
- I & O q 1hr
- Fetal monitoring
- Labs – mag levels, SaO2
- Auscultate lungs

Front 24

Nursing management for Eclampsia

Back 24

-Protect patient
-Turn to side
-Administer MgSO4
-Assess type of seizure, duration, physical activity, fetal response
-Suction and oxygenate after seizure
-Documentation

Front 25

Preterm Labor:

occurs in ____ of all births
Preterm labor is the #1 cause of ____
makes up ____% of neonatal mortality

Back 25

Onset of labor > 20 and < 37 completed week
5-15%
cerebral palsy
75-80%

most cases of preterm labor the cause is unknown.

Front 26

Low birth weight <_____ grams

Back 26

2500

Front 27

Predisposing factors of preterm birth

Back 27

low socioeconomic status
nonwhite race
maternal age of 18 years or less or of 40 years or more
low pregnancy weight
multiple gestations- account for 10% of all preterm births
**previous preterm birth- recurrence risk of 17-37%
one or more spontaneous second-trimester Abs
maternal behaviors
smoking
cocaine
no prenatal care

Front 28

Uterine Causes of preterm labor

Back 28

Uterine malformations
unicornuate (uterus that forms w/ the cervix and is usually connected to the vagina) or bicornuate (heart shaped) uterus
Cervical incompetence (0.1-2% of all pregnancies)
secondary to trauma from prior OB or GYN procedure

Front 29

Infectious causes of preterm labor

Back 29

- STDs
Neisseria gonorrhoeae
Chlamydia trachomatis
Trichomonas vaginalis
Gardnerella vaginalis
- Chorioamnionitis (bacterial infection of chorion, amnion, and amniotic fluid)
- Group B streptococci- culture or treatment has NOT been established as beneficial for the prevention of preterm birth

Front 30

Tocolytic agents for preterm labor Medication and action

(p. 778)

Back 30

- Beta agonists: relaxes smooth muscle, bronchodilation
1) Ritodrine (only FDA approved, expensive)
2) Terbutaline (cost less)
- MgS04: CNS depressent, relaxes smooth muscle
- Indomethacin: prostaglandin inhibitor; relaxes uterine muscle
- Nifedipine: Ca channel blocker relaxes smooth muscle by blocking Ca entry

Front 31

Beta Agonists
Ritodrine
Terbutaline
MOA: promotes binding of intracellular calcium; inhibits actin and myocin chain

What are the maternal and fetal SE?
What nursing care should be administered?

Back 31

Maternal: **tachycardia, hyperglycemia,
hypotension, hypokalemia, pulmonary edema

Newborn: hypoglycemia, lactic acidosis, ileus (painful obstruction of intestine), death

Nsg Care:
Check VS
Hold if HR > 120 bpm or hypotensive
Auscultate breath sounds
I & O- Watch for oliguria
IDDM – contraindicated
Fetal response

Front 32

In what instances would administration of Terbutaline or Ritodrine (beta agonists) be contraindicated?

Back 32

- If HR is > 120bpm
- Hypotensive
- IDDM (insulin dependent diabetes mellitus)

Front 33

MgS04
Inhibits the reuptake of _____ at ____
Maternal SE?
Neonatla SE?

Back 33

-acetylcholine at nerve synapses
Maternal:
- pulmonary edema, neuromuscular,
- respiratory, or myocardial depression

Neonatal: hypermagnesemia, hypocalcemia

Front 34

Effect on fetal surveillance
• Biophysical profile (BPP) (Am J Obstet Gynecol, April 1994) • Previous studies indicated ↓ fetal breathing and FHR activity

• Most have studied term fetuses who may respond differently than preterm fetuses
- 31 fetuses of 25 patients between 24-35 weeks gestation
- BPP performed before IV MgSO4, at 2 hrs. and 12 hrs. after loading dose

RESULTS OF STUDY?

Back 34

- Results showed no significant difference in fetal breathing movements

Front 35

Nursing care for patients receiving MgSO4?

3 Potential complications?

Back 35

Frequent VS
Auscultate breath sounds
SaO2 monitor
DTR’s q 1-2 hours (watch trending down)
Fetal surveillance
Labs
Bedrest
I & O

Potential for decreased RR, atelectisis, pulmonary edema

Front 36

Indomethacin

MOA:
Maternal SE:
Neonatal SE:
Nursing care:

Back 36

Prostaglandin synthesis inhibitor, relaxes smooth muscle

Maternal: N/V, dizziness, skin rash, dec. renal blood flow, PP hemorrhage

Neonatal: ventricular hypertrophy,
**oligohydramnios

Nsg. care: Give large dose per rectum
Give PO dose with food, I & O - Potential for oliguria,

Postpartum
Be prepared for hemorrhage
IV
Medications
Fundal massage

Front 37

Nifedipine
MOA:
Maternal SE:
Neonatal SE:

Back 37

-Ca channel blockade

- Maternal SE: hypotension, tachycardia, facial flushing, palpitations, HA, peripheral edema, nausea

Neonatal SE: questionable teratogen (malformation), questionable acidosis

Front 38

Hemorrhagic complications
Blood loss and S&S
-Class I:
-Class II:
-Class III:
-Class IV:

Back 38

-Class I:
Bl. loss: < 900cc
S&S: No s/s of volume deficit
-Class II:
Bl. loss: 1200 - 1500 cc
S&S: Early signs of volume deficit: ↑ HR and /or ↑ RR; may have ↓ perfusion to extremities
-Class III
Bl. loss: 1800-2100cc
S&S: Blood loss sufficient to cause overt hypotension; marked tachycardia
(> 120 bpm); tachypnea (30-50/min); cold ,clammy skin
-Class IV:
Bl. loss: 2400cc (volume deficit exceeds 40%)
S&S: Absent pulse in extremities; oliguria /anuria

Front 39

Perterm labor - adjunctive therapy

What can decrease
-the incidence of RDS in infants born at 29-34 wks
-reduce severity of RDS in infants born 24-28wks
-reduce mortality and incidence of IVH (intraventricular hemorrage) in infants born 24-28wks

Back 39

corticosteroids

IM injection that accelerates fetal lung maturity when preterm birth is threatened.

Front 40

Gestational Age and survival %
23wks
24wks
25wks
26-28wks
29wks

Back 40

Gestational Age Survival %
23 weeks 0-8 %
24 weeks 15-20 %
25 weeks 50-60 %
26-28 weeks 80 %
29 weeks 90 %

Front 41

Preterm PROM nursing care

Back 41

-Limit cervical exams
-Assess for S&S of infection
foul smelling Af, maternal fever, fetal tachycardia, BPP decreased scores, tender uterus
-Bedrest - inpatient
-Prepare patient for preterm birth
-Prophylactic antibiotics to improve perinatal outcome by preventing infection and prolong gestation.
PCN, EES, Ampicillian, Clindamycin