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80 Cards in this Set
- Front
- Back
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4 categories of hypertensive disorders
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Preeclampsia-Eclampsia (PIH- pregnancy induced hypertension)
Chronic hypertension Chronic hypertension with superimposed preeclampsia Transient (gestational) hypertension |
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Chronic Hypertension
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Develops before pregnancy or 20 wks gestation- not related to pregnancy
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Chronic hypertension with superimposed preeclampsia
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HTN in a pregnant woman who already has hypertension (may go even higher once preggo)
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Transient (gestational) hypertension
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HTN that comes and goes during labor and postpartum.
Get better with bedrest. Gone within 10 days of delivery. |
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Preeclampsia
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A progressive disease that requires intervention
10-14% of all primigravidas 5-7% in multigravidas Higher in African Americans/Africans 50,000 deaths/year |
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Ecclampsia
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means convulsion
Had a convulsion- she is eclamptic |
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PIH is more common in...
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primigravidas, women over 35 or teens younger than 18
It's a vasospastic disease |
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When do you see PIH?
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From 30 weeks gestation on
During labor Within the first 48 hours after birth Could even be a week after having the baby (nonsense!) -- very rare |
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PIH is characterized by these 3 things.
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What is....
Hypertension 140/90 or more Proteinurea (1+ or 300 mg/L) & Edema (not so much in diagnosis)? |
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Edema in PIH
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generalized accumulation of fluid in face, hands and abdomen. Not responsive to bedrest.
Really rapid weight gain Thought that the women retain sodium- drawing out fluid from intervascular |
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Proteinuria in PIH
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Serum albumin (protein) is lost into urine due to damaged glomeruli and damaged vascular endothelium
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Result of PIH (edema and proteinuria)
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Decreased intravascular volume
Increased viscosity of blood normal pregnancy: hematocrit- 32-42% hemoglobin- 10-14g/dl |
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Decreased in Renal Perfusion (in PIH)
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Increased serum Blood Urea Nitrogen (BUN), uric acid, and creatinine levels.
Decreased serum albumin (goes into urine) Increased protein in urine |
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Pathology in Preeclampsia is related to vascular endothelial damage
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Vasospasms occur without womans arterial systems (arteries and all major organs- including uterus and placenta)
This damages the vascular walls Platelets gather at the damaged spots These women are more sensitive to angiotensin II- making the intravascular endothelial cells contract which creates leaks in the vessels and platelets and fibrin pass and are deposited in the lining of the vessel. Platelets may go below 1000-4000 should be 150-400 (thousands) mg/dL (for preggo) non preggo 200-400 |
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HELLP Syndrome
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Associated with severe preeclampsia
Almost always occurs prior to 36 wks gestation H hemolysis EL elevated liver enzymes LP low platelet count |
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Hemolysis in PIH
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RBCs are damaged as they pass through the small damaged vessels. Causes platelets to accumulate at damaged site resulting in low platelet counts when below 100,000 it's thrombocytopenia
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Elevated Liver Enzymes in PIH
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decreased liver perfusion, causing impaired functioning which in turn causes liver enzymes to rise.
(AST & ALT) Will also see hepatic edema And subcapular hemorrhage Will see upper R quadrant or epigastric pain |
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Low Platelet in PIH
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If platelets go below 200,000 will get a platelet transfusion
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Most common cause of death in preggos
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intracerebral hemorrhage
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If the preeclampic mother needs to deliver they may give her...
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Give betamethazone or dethamexazone (corticosteroids) given to mother IM of 12 mgs (once a day for 2 day) to mature lungs by creating more surfactant, must be given 24-48 hours before birth. May be repeated every week.
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Non-pharmicological treatment of PIH
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BED REST
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Symptoms of PIH in Central Nervous System
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Has to do with cerebral edema
Headache (very common) Visual Disturbances (blurred and spots) Flashing Lights Hyper-reflexia (3+ is brisker than normal and 4+ is hyperactive) the more hyperactive the closer the woman is to having a seizure. If diminished reflexes 1+ or 0- none. Clonus- when the foot shakes after pulling back on foot when her knee is flexed. then let up on the pressure. Count the 'beats' of clonus. The more edema in brain the more she will have 'beats.' Do on both sides. |
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Symptoms of PIH is Respiratory System
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Assess for pulmonary edema due to increased capillary pulmonary permeability
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Characteristics in baby of PIH mother
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SGA or fetal hypoxia
RDS |
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Seizures in Ecclampsia
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Often Grand-mal can extend into coma
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Nursing Care during the seizure
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Make sure rails are padded
Lay woman on her side Administer O2 via mask Assess FHR |
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S & Sx of Worsening Preeclampsia
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Increasing edema, especially on hands and face.
Worsening headache Epigastric or R upper quadrant pain Visual disturbances (flashing lights, spots, blurred) Decreased UO N/V Bleeding gums (low platelets) |
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Severe Preeclampsia
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BP hits 180/110 or higher at least 2 readings 6 hrs apart
Proteinuria is 3 + or greater Oliguria- equal to or less than 500 mL in 24 hours Cerebral disturbances Pulmonary edema or Cyanosis Epigastric or Upper quadrant pain Impaired liver function Thrombocytopenia SGA baby |
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Severe Preeclampsia Treatment
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Tx
Bedrest High protein moderate sodium diet Mag Sulfate (start with loading dose 4-6 gms over 20-30 mins) If has had too much, can see it by: increase in DTR, decrease in respiration, decrease UO and BP, decreased LOC Therapeutic Range of Mag Sulfate 4-8 mg/dL Calcium Gluconate is the drug to reverse effects. Will give corticosteroids and antihypertensives (aldomet, apresoline, normodyne) usually when diastolic gets to 110. (like between 90-100) usually given PO but can give IV |
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PEACE
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Promote bedrest, provide quiet environment
Ensure high protein intake (1g/kg/day) Antihypertensives Convulsants (mag sulfate) Evaluate physical parameters: BP, UO, Resp. Patella reflex |
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Mag Sulf Toxicity
BURP |
Blood Pressure Decreased
Urine Output Decreased Respirations less than 12 Patella Reflexes Absent |
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Gestational Diabetes
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Any degree of glucose intolerance with onset or first recognition during pregnancy.
(50% of those with GDM will become Type 2 in 10 years.) 70-110-120 is normal BG level Glucose levels in fetus directly proportional to maternal levels. So, increased fetal insulin secretion. |
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By what week will the fetus secret it's own insulin?
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By 10 wks gestation the fetus wil secret it’s own insulin at adequate levels for glucose coming across from mother
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Adjustments in the maternal metabolism during pregnancy
First Half of Pregnancy |
First half of pregnancy:
- CHO metabolism affected by rise in estrogen, progesterone, and other hormones. These hormones stimulate an increased production of insulin by the maternal pancreas. - They also increase maternal tissue response to insulin. Which then builds up glycogen stores in the liver and other tissues during the first half of pregnancy |
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Adjustments in the maternal metabolism during pregnancy
Second Half of Pregnancy |
Second half of pregnancy (beginning at 26-28 weeks):
There is an increased resistance to insulin. Cause- increasing levels of human placental lactogen HPL is an insulin antagonist. This means there is a decreased effectiveness of insulin. - This ensures an abundant supply of glucose for the fetus. Once placenta is delivered, there is an abrupt drop in HPL so the tissues go back to their pregnancy sensitivity to insulin |
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Signs and Symptoms of GDM
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Hunger and thirst
Frequent urination Blurred vision Excess weight gain during pregnancy |
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Nursing Assessments for GDM
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Monitor blood glucose
Monitor the fetus |
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Risk Factors for
Gestational Diabetes during Pregnancy |
-Prior gestastional diabetes
-Prior delivery of or current evidence of macrosomic baby (greater than 90% for weight) -Family history of diabetes -unexplained fetal death -prior delivery or current evidence of infant with congenital anomaly -maternal obesity -maternal age greater than 30 years ADA advocates universal screening. |
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American Diabetes Association advocates what for preggos?
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universal screening for pregnant women
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50 gram Oral Glucose Tolerance Test
What is it? When? |
Between 24-28 wks gestation
Plasma level is taken 1 hour after drinking glucola If level is above 135- she needs further testing. |
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3-Hour 100 gram Oral Glucose Tolerance Test
What is it? How is it administered? What do results mean? |
Fasting level in AM less than 95
1-hour less than 180 2-hours less than 155 3-hours less than 140 Two of these must be abnormal Fasts over night for at least 8 hours but less than 14. Take fasting level Then drink 100 gm oral glucose solution Plasma glucose is measure at 1 hour, 2 hours and 3 hours later. |
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How many extra calories does a pregnant women need?
What percentage need to come from CHO? Protein? Fat? How do you divide them? |
Pregnant woman needs 300 extra calories
GD will need 40-50% of calories need to come from complex CHO 15-20% from protein and 20-30% of fat No concentrated sweet. Should be divided in to 3 meals and 3 snacks. Bedtime snack must consist of protein and complex carb |
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Maternal Complications for
Women with Diabetes |
HYDRAMNIOS- large amount of amniotic fluid due to increased fetal urination from fetal hyperglycemia
PREGNANCY INDUCED HTN (PIH)- especially if diabetes has already damaged vessels KETOACIDOSIS- adipose tissue is broken down resulting in increased ketone bodies in the blood, which are acidic. HPL (Human Placental Lactogen) causes insulin to be ineffective, so fats are broken down in an attempted to get energy. May lead to coma or death for mom and baby UTIs & PYELONEPHRITIS- SPONTANEOUS ABORTION from poor glycemic control HYPOGLYCEMIA from OD of insulin or skipped meals HYPERGLYCEMIA that causes macrosomia of baby |
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Fetal/Newborn Risks for Gestational Diabetes
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Come from high maternal plasma glucose levels
Major cause of death for newborn of Gestational Diabetes is congenital defects (of heart CNS and skeletal system) |
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Congenital defects from gestational diabetes mainly occur it what systems?
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Heart
CNS Skeletal system |
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Large for Gestational Age risks
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Increased risk for birth trauma from macrosomia- weight greater than 4000-4500 g (8-13 to 9-4)
Shoulder dystocia- head is delivered but shoulders are wedged behind the mother’s pubic bone CPD- Cephalopelvic disproportion Most notable characteristic of sugar babies Macrosomia Leads to excessive growth and fat deposits |
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IUGR with Type 1 DM
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Hypoglycemia and hospital policy
Respiratory distress syndrome- RDS Polycythemia Vascular damage and blood flow to placenta is not as efficient End up with uteroplacental insufficiency Should check blood sugar every 1 hour for 4 hours Then every 2 hours x 2 Then every 4 hours x 2 High levels of fetal insulin interrupt production of surfactant Polycythemia- mothers blood has so much glucose that it causes trouble with o2 in blood getting to the fetus so it builds more RBCs |
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Women with gestational diabetes are at a higher risk for urinary tract infections because they
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Spill more glucose into the urine
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Methergine
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Causes the smooth muscle of the uterus to contract.
Also causes large arteries to contract which can lead to hypertension (especially in women whose BP is already elevated). Often used when Pitocin is ineffective. Given IM or orally. |
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Hemabate
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Reduces blood loss secondary to uterine atony.
Stimulates myometrial contractions to control post-partum hemorrhage. Often used when Pitocin is ineffective. Used to induce labor when fetal death. Given IM in a large muscle. May cause nausea, diarrhea, and fever. Delay breast feeding 24 hours after admin. |
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Ibuprofen (Advil, Motrin)
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Nonopioid analgesic; nonsteroidal anti-inflammatory drug.
Given for mild to moderate pain, such as post-partum cramping. Given orally with a full glass of water. Remain upright for 15-30 minutes and don’t take on an empty stomach. |
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Total Placenta Previa
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the placenta is totally covering the cervical os. Will see bleeding earlier and more severely because of the general movement of the cervix
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Partial Placenta Previa
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the placenta partially covers the os. Will see bleeding later when the cervix softens and begins to pull away
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Marginal Placenta Previa
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when the edge of the placenta is at the margin of the os
Will see bleeding later when the cervix softens and begins to pull away |
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Low-Lying Placenta
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when placenta is implanted in the lower uterine segment, close to the cervical os
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Normally the placenta implants where?
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In the upper third of the uterus.
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Factors Associated with Placenta Previa
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-Multiparity
-Advanced Marternal Age -Uterine Anomalies -History of Placenta Previa -History of C-Section or Other Abdominal Surgery -Multiple Gestation -Smoking |
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Clinical Manifestations of Placenta Previa
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70% of Women for Placenta Previa has PAINLESS VAGINAL BLEEDING
Previa should be suspected when there's bleeding occuring after 24 wks. Bleeding is associated with stretching and thinning of lower uterine segment during third trimester. The placental attachment is gradually disrupted because the uterus can't contract to stop the bleeding by stopping the flow from the vessels. Initial bleeding is usually a small amount and may stop because clots form. However, it may reoccur at any time Bleeding is bright red in color. Vitals may remain normal even when relatively significant blood loss. Fetal heart rate may be reassuring unless there is a major detachment. Upon palpation- soft, relaxed, non-tender uterus with normal tone You never to a vaginal exam when the woman is bleeding from the vagina! Because it can cause further separation and bleeding |
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Diagnosis of Placenta Previa
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Standard of Diagnosis is Transabdominal Ultrasound. If location of placenta is questionable then do transvaginal ultrasound
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Medical Management of Placenta Previa
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Expectant Management: Implemented with fetus is immature.
Consists of observation and bed rest (home or in the hospital) Usually if the women is on bed rest in the hospital she probably had more bleeding. Fetal Surveillance: Non-stress test. Biophysical profile (BPP) 1-2x a week. Women will be on pelvic rest (nothing in the vagina) C-Section: Depends on gestation age of fetus and amount of bleeding present. In post partum- when contracting after c-section the lower third does not contract as well, so there’s a higher chance of post-partum hemorrhage |
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Abruptio Placenta
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Premature Separation of normally implanted placenta from the uterine wall prior to delivery.
Usually occurs after 20 wks gestation. Occurs 1 in 120 pregnancies. More common in Caucasians and African-Americans Cause is unknown |
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Risk Factors for Abruptio Placenta
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Hypertension is #1 (40-50% of cases)
Excessive Intrauterine Pressure Caused by Multiple Pregnancy Increased Maternal Age Smoking and Drinking During Pregnancy Sudden Changes in intrauterine pressure (like an amniotomy or blunt trauma) |
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Abruptio Placenta affects on infant
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Fetal Death is common in extensive abruptions.
If the infant does survive there’s an increased risk of neurological damage because of fetal anoxia |
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Marginal Abruptio Placenta
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When the edge of the placenta separates from uterine wall.
Bleeding escapes into the vagina. It may become more severe or bleeding may stay the same Involves the veins at the edge of the placenta. |
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Central Abruptio Placenta
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Placenta separates in the center and blood becomes trapped between uterus and placenta
Bleeding is concealed. Arteries are disrupted. A high pressure arterial bleed occurs so placental function is compromised. With a severe central bleed, a large blood clot forms behind the placenta. Since the blood as nowhere to go it begins to invade the myometrial tissues (muscle of uterus) between muscle fibers When palpate the uterus it will feel board-like or rigid and the abdomen is extremely tender |
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The inability of the uterus to contract after central abruptio placenta results in
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couvelaire uterus
--Usually necessitates a hysterectomy. Uterus usually turns blue |
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What happens with the large clot formation in central abruptio placenta?
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With the large clot formation you get all the bleeding and the damage occuring to wall tissue so the body releases large amounts of thromboplastin (or factor III)
This then triggers the development of DIC (disseminated intravascular coagulation) So then platelets and fibrin are all used up from continuous clotting that is taking place Excessive clotting activated production of with fibrin split (degredation) products that act to stop clotting function. This in turn will cause more bleeding. So the increase in fibrin split products, decrease in platelets and reduction of fibrinogen combine to result in generalized hemorrhage. May see oozing/bleeding at IV, around gums, nose. Petechiae. |
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Treatment of Central Abruptio Placenta
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IV blood work for coagulation, cross match for transfusions more than 3 units
May give fresh frozen plasma (has clotting factors) or cryoprecipitate (given IV highly concentrated with clotting factors and fibrinogen) |
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Platelets
Normal pregnancy and DIC |
Normal >100,000
DIC Reduced |
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Bleeding time
Normal pregnancy and DIC |
Normal 7-8 min
DIC Prolonged |
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Fibrinogen
Normal pregnancy and DIC |
Normal 300-600mg/dl
DIC Decreased |
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Complete Abruptio Placenta
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Almost total or total separation of placenta from wall of uterus.
Would see severe vaginal bleeding C-section is done as soon as possible Ideally you’d get cryoprecipitate before surgery Generally you’d administer whole blood Usually a hysterectomy is needed. |
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Uterine Rupture
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Uncommon emergency
Maternal Deaths from Hemorrhage Rarely happens at any other time than labor. |
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Uterine Rupture
causes |
Giving too much pitocin
Previous C-sections Prior Uterine Surgery |
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Uterine Rupture
S/Sx |
S/Sx
Acute Severe Abdominal Pain Woman will say things like “I feel like I’m dying” Rapid onset of symptoms of shock (tachycardia, weak pulse, low BP, pallor, moist cool clamy skin, rapid shallow respirations, decreased UO) Fetal Distress Bleeding may be concealed Upon palpation you can feel baby parts |
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Uterine Rupture
Tx |
Blood and Fluid replacement
C-Section Hysterectomy |
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Vaginal Hematoma
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Occurs from injury to blood vessel during birth process
Because soft tissue offers very little resistance Can be 250-500mL Large if considered 5 cm or larger or if they are expanding |
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Vaginal Hematoma Risk Factors
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If has PIH there is damage to vessel
Precipitous Birth Prolonged Section Stage of Labor Macrosomia- big ass kid |
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Vaginal Hematoma Tx
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if they are expanding- will need surgical management and bleeding vessel is ligated and wound is closed
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Vaginal Hematoma S/Sx
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perineal pain and tenderness out of proportion
Will start looking ecchymotic May see a bulging blue mass |
