Class 3: Hypertensive Disorders of Pregnancy Flashcards
1
Q
what is the leading cause of maternal and perinatal morbidity and mortality worldwide?
A
- hypertension
2
Q
what is considered HTN in pregnancy (3)
A
- SBP >140
- and/or DBP >90
- requires at least 2 measurements, taken 15 min apart, and using same arm
3
Q
what is considered severe HTN in any setting?
A
- SBP > 160
- DBP >110
- based on average of at least 2 measurements, taken at least 15 min apart
4
Q
what is required to take accurate measurement of BP (4)
A
- person in sitting position w arm at level of heart
- an appropriately sized cuff
- arm w higher values
- manual BP should be used, or automated BP has been validated for use of pre-clampsia
5
Q
what are 3 categories of classification of HTN in pregnancy
A
- pre-existing HTN
- gestational HTN
- other hypertensive effects
6
Q
what are 3 types of other hypertensive effects
A
- transient HTN
- white coat HTN
- masked HTN
7
Q
what is considered pre-existing HTN
A
- HTN pre-pregnancy or diagnosis before 20 weeks gestation
8
Q
what impact does pre-existing HTN usually have on pregnancy (2)
A
- pregnancy usually uncomplicated
- ~25% develop pre-eclampsia or eclampsia
9
Q
pre-existing HTN causes an increased risk of: (2)
A
- poor fetal growth
- fetal stillbirth
10
Q
what are 2 subgroups of pre-existing HTN
A
- with super-imposed pre-eclampsia
- with comorbid conditions (Type l and ll diabetes or kidney disease)
11
Q
what is considered pre-existing HTN w superimposed pre-eclampsia (4)
A
one or more of the follow at >20 weeks gestation:
- resistant HTN
- new or worsening proteinuria
- one or more adverse conditions
- one or more severe complications
12
Q
what timing is considered gestational HTN
A
- detected at or after 20 weeks gestation
13
Q
describe symptoms of gestational HTN (2)
A
- no proteinuria
- no S&S of pre-eclampsia
14
Q
what are the subgroups of gestational HTN (2)
A
- with super-imposed pre-eclampsia
- with comorbid conditions (Type l or ll diabetes or kidney disease)
15
Q
gestational HTN w preeclampsia will include one or more of the following: (3)
A
- new proteinuria
- one or more adverse conditions
- one or more severe complications
16
Q
what are the 2 key components of pre-eclampia
A
- HTN
- new or worsening proteinuria
17
Q
what is pre-eclampsia? when does it occur?
A
- pregnancy-specific syndrome
- multisystem, vasospastic disease process (=decreased perfusion to all systems)
- occurs after 20 weeks gestation
18
Q
what does pre-eclampsia result in
A
- vasospastic –> reduced tissue perfusion to the major organs
19
Q
pre-eclampsia may or may not have evidence of….
A
- organ dysfunction
20
Q
what is severe preeclampsia defined as?
A
- preeclampsia with one or more severe complications –> both maternal and fetal complications exist
21
Q
what is considered proteinuria in a 24-hr urine specimen? random urine specimens?
A
- 24-hr urine specimen: conc of greater than 0.3g/L per 24 hrs
- a conc of 0.03g/L or more in at least two random urine specimens collected at least 6 hrs apart where there is no evidence of UTI
22
Q
when should significant proteinuria be suspected?
A
- when urinary dipstick proteinuria is >1+ (anything over trace protein)
23
Q
what systems are at risk w pre-eclampsia
A
all systems at risk for ischemic damage :
- hematologic
- CVS
- renal
- CNS
- pulmonary
- hepatic
- uteroplacental
24
Q
what is defined as an adverse condition
A
- those that we wait for and respond to (ex. low O2 sat) in order to avoid the severe complications (ex. pulmonary edema)
25
adverse conditions consist of... (3)
- maternal symptoms, signs, and abnormal lab results
- and abnormal fetal monitoring results that may herald...
- severe maternal or fetal complications (that warrant delivery)
26
what adverse conditions might pre-eclampsia have on CNS (4)
- HA
- visual disturbance
- hyper-reflexic (deep tendon relfexes +3/+4 = abnormal)
- clonus --> assessed in ankles for number of beats
27
what severe complications might pre-eclampsia have on CNS (4)
- eclampsia
- cortical blindness or retinal detachment
- stroke or TIA
- GCS <13
28
what adverse conditions might pre-eclampsia have on cardiorespiratory system (2)
- chest pain/dyspnea
- O2 sats <97%
29
what severe complications might pre-eclampsia have on cardioresp system (4)
- uncontrolled severe HTN >12 hrs, despite use of 2 antihypertensive agents
- O2 sat <90%, need for 50% O2 for >1hr, intubation
- pulmonary edema
- myocardial ischemia or infarctation
30
what adverse conditions might pre-eclampsia have on hematological system (2)
- elevated INR or aPTT
- low plt count (<100 x 10^9/L)
31
what severe complications might pre-eclampsia have on hematological system (2)
- plt count <50 x 10^9/L
- transfusion of blood products
32
what adverse conditions might pre-eclampsia have on renal system (3)
- elevated serum creatinine
- elevated serum uric acid
- proteinuria
33
what severe complications might pre-eclampsia have on renal system (3)
- acute kidney injury
- kidney failure
- oliguria
34
what adverse conditions might pre-eclampsia cause in the hepatic system (3)
- NV
- RUQ or epigastric pain
- elevated serum AST/ALT
35
what severe complication might pre-eclampsia cause in the hepatic system (2)
- hepatic dysfunction
- hepatic hematoma or rupture
36
what adverse conditions might pre-eclampsia cause in the fetoplacental system (4)
- abnormal FHR
- absent or reversed end diastolic flow by Doppler --> umbilical artery
- placental insufficiency --> IUGR, oligohydramnios
37
what severe complications might pre-eclampsia cause in the fetoplacental system (2)
- abruption w evidence of maternal or fetal compromise
- stilbirth
38
what is included in mngmt of HTN disorders of pregnancy (4)
- monitoring for maternal complications
- monitoring for fetal complications
- delivery as needed
- balance of gains in fetal maturity vs risks of fetal & maternal compromise
39
what is included in monitoring for maternal complications in mngmt of HTN disorders of pregnancy (2)
- maintaining BP control
- adverse reactions/severe complications
40
what is included in monitoring for fetal complications in mngmt of HTN disorders of pregnancy
- adverse reactions/severe complications
41
describe what subjective data should be assessed when monitoring for maternal complications r/t HTN disorders (4)
- visual disturbances (blurred vision, spots, stars)
- headaches
- epigastric/RUQ pain
- NV
42
describe what physical data should be assessed when monitoring for maternal complications r/t HTN disorders (5)
- VS --> BP, O2 sat, RR
- deep tendon reflexes (+3/+4)
- clonus
- resp assess (O2 sat, auscultation)
- intake and output (urine output)
43
what lab tests are done for HTN disorders of pregnancy (4)
- CBC
- serum creatinine/uric acid (kidney fnxn)
- ASL or ALT (liver function)
- INR/aPTT
44
what is assessed r/t urine for HTN disorders of pregnancy
- proteinuria
45
what is included in fetal health surveilance for HTN disorders of pregnancy (4)
- daily fetal movement
- electronic fetal monitoring/NST
- US for assessment of fetal growth (IUGR) and deepest amniotic fluid pocket (oligohydramnios)
- umbilical artery doppler (to assess for increased resistance, absence, or reversed end-diastolic flow)
46
what is included in pharmacological control of HTN in pregnancy (4)
- labetolol
- hydralazine
- nifefipine
- methyldopa
47
what is the BP parameters for antihypertensive pharmacology for non-severe HTN without comorbid conditions
- maintain SBP at 130-155
- DBP at 80-105
48
what is the BP parameters for antihypertensive pharma therapy for severe HTN
- maintain SBP <160
- DBP <110
49
for mngmt of HTN disorders of pregnancy at home thru the antenatal home care program, education should be provided regarding: (6)
- ID of symptoms
- ID of clinical signs
- measurement of BP
- assess fetal activity daily
- regular prenatal appts, may have increased appts/specialized appts towards end of pregnancy or as needed
- when to come to hospital
50
what clinical signs should you provide education on for mngmt of HTN disorders at home (5)
- BP
- protein in urine
- decreased fetal movement
- parameters set by primary care providers
- report to clinical provider or present to triage
51
what education should be provided regarding measurement of BP in mngmt of HTN at home (3)
- taught to take BP on same arm
- sitting position
- well supported/position of the heart
52
what education should be provided regarding assessing daily fetal activity in mngmt of Htn at home
- decreased fetal activity can indicate fetal compromise --> report immediately
53
when is mngmt of HTN disorders done in hospital
- admitted for mngmt of severe pre-eclampsia or HELLP
54
what is included in mngmt of HTN disorders in hospital (12)
- frequent symptoms/physical assessment (usually hourly)
- IV access (2 18 G)
- antiHTN meds as ordered for BP control (assess effectiveness, oral or IV labetalol/hydralazine)
- frequent measurement of BPs, request parameters, observe trends
- assist w arterial line placement as needed
- lab work as ordered
- accurate I&O hourly --> foley w urometer
- confirm TFI with IV fluids
- prepare for birth/initiate induction as ordered
- electronic fetal monitoring
- provide calm, quiet enviro
- explain plans and interventions
55
what med might be used for mngmt of HTN disorders in the hospital if the gestational age is between 24 weeks and 34+6 weeks? why? when?
- antepartum steroids to promote fetal lung maturity if between 24+0 and 34+6 weeks gestation when delivery is expected within 7 days
- ideally would wait 48 hours after admin for birth
56
what is eclampsia
- seizures in a woman diagnosed w preeclampsia, with no other history that would explain the seizures
57
how does pre-eclampsia lead to eclampsia (seizures)
- pre-eclampsia = vasospastic process = damage vessels = increased permeability = cerebral edema
58
describe the onset of eclampsia
- may be suddenly or can be preceded by specific signs and symptoms
59
what signs and symptoms may preced eclampsia (3)
- HA
- severe epigastric pain
- hyperreflexia
60
what is a concern w eclampsia
- during the convulsion, both the pregnant person and the fetus are not recieving O2
61
describe mngmt of eclampsia pre-convulsion or seizures (8)
- call bell easily accessible
- O2 working and mask available
- suction available and working
- side rails raised
- IV inserted
- room organized
- quiet/non-stimulating enviro
- emergency medical tray
62
describe mngmt of eclampsia during convulsion/seizure (4)
- maintain pt airway --> turn head to side, place pillow under shoulder or back
- call for help --> do not leave bedside
- protect from injury if possible (padded rails, etc.)
- observe and record activity/timing
63
describe mngmt of eclampsia post-convulsion/seizure (14)
- do not leave unattended until fully alert
- observe for coma
- suction as needed
- O2 by face mask at 10L/min
- IV inserted if not already
- catheter inserted if not already
- magnesium sulphate ordered
- monitor BP
- electronic fetal mvmt
- lab work as ordered
- hygeine for incontinence
- prepare for birth as needed
- risk for placental abruption --> monitor
- chest x-ray and ABG to rule out aspiration
64
describe preparation for birth in mngmt of eclampsia (4)
- assess uterine activity and cervical change
- ROM
- dilation
- delivery is most definitieve cure --> decisions concerning timing of delivery once stable
65
what med plays a role in eclampsia prevention and treatment
- magnesium sulfate IV
66
what is the usualy dose mg sulfate
- 4g IV loading dose --> piggy back infusion
- followed by 1-2g/hour IV
67
describe the monitoring of a pt of Mg sulfate
- requires close monitoring --> should not be left alone
68
describe what assessments should be done for a pt on Mg sulfate (6)
- assess resp hourly
- assess deep tendon reflex hourly (can decrease them)
- LOC hourly
- urine output hourly --> excreted in urine
- continuous electronic FHR
- uterine contraction monitoring
69
what is the antidote for Mg toxicity
- calcium gluconate
70
what are signs of magnesium toxicity (8)
- lethargy
- resp distress
- decreased reflexes/muscle weakness
- hypotension
- feeling warm/flushing
- headache
- NV
- slurred speech
71
what does HELLP syndrome stand for
Hemolysis
Elevated Liver enzymes
Low Platelets
72
when does HELLP syndrome occur
- can occur during later stages of pregnancy or after child birth
73
HELLP syndrome is considered a variant or complication of..
- pre-eclampsia
74
what is used to diagnose HELLP syndrome
- plt count less than 100 x 10^9/L with elevated liver enzymes (AST or ALT)
75
the pathophysiological changes of HELLP syndrome occur as a result of... (6)
- arteriolar vasospasms
- endothelial cell dysfunction with fibrin deposits
- adherence of plts in blood vessels
- red cells are damaged as they pass thru narrowed blood vessels = hemolyzed = decreased RBC and plt count and hyperbilirubinemia
- endothelial damage and fibrin deposits in the liver lead to impaired liver fnxn and can cause hemorrhagic necrosis
- liver enzymes elevated when hepatic tissue is damaged
76
what is the most definitive care for HELLP? what concerns are there w this?
- delivery
- decisions concerning timing of delivery once stable
77
what is there a risk of post-partum if mg sulfate was administered? what indication does this have?
- postpartum hemorrhage
- ongoing monitoring thru postpartum period, anti-htn med may continue
78
what is DIC
- disseminated intravascular coagulation
- disorder of clotting and bleeding
79
what pregnancy related conditions may trgger DIC (5)
- placental abruption
- postpartum hemorrhage
- preeclampsia/eclampsia/HELLP syndrome
- amniotic fluid embolism
- pregnancy related sepsis
80
what is included in mngmt of DIC (6)
- correct underlying cause
- volume expansion
- rapid replacement of blood products and clotting factors
- optimization of O2
- achievement of normal body temp
- continued reassessment of lab parameters
81
what does each grade of deep tendon reflexes mean? (0, +1, +2, +3, +4)
0: no response
1: sluggish or diminished
2: active or expected response
3: more brisk than expected, slightly hyperactive
4: brisk, hyperactive, intermittent or transient clonus
