Obstetric Complications
Hypertensive Disorders of Pregnancy
Gestational HTN (PIH)
Pre-clampsia
Eclampsia
Chronic HTN
Preeclampsia superimposed on chronic HTN
Risk Factors for Pregnancy Related HTN (PRH)
Fistr pregnancy
Age > 35
Family history
Pre-existing HTN or pre-existing vascular disease
Renal disease
Obesity
DM
Mutifetal pregnancy
Mother or sister with pre-eclampsia
Preclampsia
What is it?
When does it occur
Beside HTN, what else would be present?
Effect of fetus
What is the cure?
Preventive Measures
Measures work best with high risk reoccurrences
Prenatal monitoring
meds
Effects of Increased Vascular Resistance
Renal perfusion
Proteins
Vascular volume
Liver circulation
Cerebral vessels
Colloid oncotic pressure
Placental circulation
Manifestations
Classic signs
Additional signs
CV system
Increased
Reponses to angiotensin II
BP
SVR
Decreased
CO
Plasma volume
Hematologic
Increased
Hemoconcentration
Viscosity
Platelet clumping
Thrombocytopenia
Endothelium damage
Neurologic
Arterial vasospasm
Rupture of small capillaries
Small hemorrhages
Headache **
Hyperreflexia **
Convulsions (eclampsia)
Renal Decreased
GFR
Colloid osmotic pressure
Damage to glomeruli
Proteinuria
Fluid shift (edema)
Hypovolemia
Increase
HCT
Angiotensin II and aldosterone
BUN and Cr and uric acid
I
Hepatic
Impaired
Hepatic edema
Epigastric pain
Placenta
Decreased
Perfusion
Fetal hypoxemia
Acidosis
Perinatal death
Nutrients
IUGR
Mild Preclampsia
Activity restrictions
UA
Fetal assessment
Diet
Mild Severe
SBP 140 but < 160
DBP >90 but <110
Proteinuria > 0.3 g but < 2 g in 24 hr ( 1+ dipstick)
Cr (serum) normal
Platelets normal
Liver enzymes normal to slight
UO normal
Headache (severe)
Upper quad pain
visual disturbances ( absent or minimal
Pulm edema, Hrt failure
IUGR
BP > 160
DBP >110
>5 g in 24 hr urine and 3+ or higher dipstick)
>1.2
Decreased <100,000
Elevated
Oliguria
Present often
Often preceded seizures
Common
May be present
Present with reduced amniotic fluid
Goals for treatment
Maternal goals
Fetal goals
Inpatient Management Severe Preeclampsia
Bedrest
Antihypertensive
Anticonvulsants
Intrapartum management
Antihypertensives
Hydralazine
Calcium channel
Beta blocker
Anticonvulsants
Magnesium Sulfate (not really an anticonvulsants nor antihypertensive)
Relaxes smooth muscles
Reduces vasoconstriction
IV
Safe
Therapeutic levels 4-8 mg/dl
Nursing Process
Assessment
One-one nurse patient ratio
Head to toe
Weight
Vitals every 4 unless on magnesium
Breathe sounds for moistness
Check urine for protein
Fetal monitoring
Reflexes
Question about symptoms
Interventions
Monitor constantly for??
Lateral position (why??)
Control pain (why??)
Pitocin and MgSO4 (how to infuse??)
Epidural??
EFM
Prevent seizures
Magnesium Protocol
Need primary IV
MgSo4 is infused as a secondary infusion
4-6 gms loading does in 100 ml over 15-20 min
2gm/hr continuous infusion
Monitor for toxicity
BP every 2 hrs.
Reflexes every 2 hrs.
UO every 2 hrs.
Serum levels every 4-6 hrs
RR and O2 saturation every 2 hrs
sensorium
Treatment for MgSo4 Toxicity
Discontinue
Notify Health Care Provider
Have Calcium Gluconate available as antidote (1 gm) at 1 ml/min
Eclampsia
Generalized seizures
Breathing stops for a short time
Temporarily in coma
Doesn’t remember seizure when conscious
My have nonreassuring fetal patterns
Mau occur during pregnancy, or intrapartum or post partum
Complications of Seizure
Blood volume severely reduced during seizure
Fluid shifts
Oliguria
Cerebral hemorrhage
Ruptured placenta
Early labor
HE::P Syndrome
Management of Eclampsia
Monitor for impending seizure
Initiate preventive measures
Keep stimuli down
Padded siderails, bed low, wheels locked
O2 and suction
Intubation equipment
Meds
Actual Seizure
Remain in the room and activate emergency system
Attempt to place in lateral position
Note time and sequence of seizure
Insert airway after seizure and suction
Administer O2
Notify provider
Assess for complications
Admin MgSo4
General Care for Preeclampsia and Eclampsia
Weight
Activity restrictions
Reduce stimuli
Vital signs
Urinalysis for protein
Fetal assessment
Antihypertenives
Give O2 and monitor O2 sat
Monitor reflexes
IV sites checked
Monitor Pitocin and MgSo4
Monitor for S/S of pulm edema and CHF after seizure
Lasix
Digitalis
Monitor for visual disturbances
Monitor for headaches
Monitor for gastric pain (N&V)
Edema
Breathe sounds
Prevent seizure related injury
Prepare for delivery
Emotional support
Continue to monitor all of these post partum period
HELLP
H
Hemolysis of RBCs
EL
Elevated liver enzymes
LP
Low platelets
Incidence
Very serious and life-threatening
½ of women with preeclampsia develop HELLP
May occur post partum also
Manifestations
Hallmark symptom
Pain in upper R quadrant
Or lower R chest
Or midepigastric
Generalized malaise
Abd. tenderness
N/V
Severe edema
Headache
Diagnostics
Liver enzymes
Platelet count with CBC
Decreased haptoglobin
+ D-Dimer in woman with preelcampsia
Treatment
ICU
MgSO4
Hydralazine
Fluid replacement
Cervical ripening and induction if at least 34 weeks
If stable may wait for induction if < 34 weeks
Complications Bleeding
include:
Placental Abruption
Pulmonary Edema ( fluid buildup in the lungs)
Diseminated intravascular coagulation (DIC—blood clotting problems that result in hemorrhage)
Adult Respiratory distress syndrome (lung failure)
Ruptured liver hematoma
Acute renal failure
Intrauterine Growth restriction (IUGR)
Infant respiratory Distress syndrome (lung failure)
Blood transfusion
Chronic HTN
HTN preceded pregnancy or HTN before 20 weeks gestation
Prescribe antihypertensive if diastolic consistently > 90 mmHg
Tx
Diet
Prevent preeclampsia
Meds
Aldomet (Methydopa)
Calcium channel
Beta blockers
ACE not receommendedpregnancy
Diuretics are avoided