Obstetric Complications

Hypertensive Disorders of Pregnancy❏ Chronic HTN

❏ before 20 weeks❏ Gestational HTN (PRH)

❏ after 20 weeks, without proteinuria❏ Preeclampsia

❏ more than or equal to 140/90 consistently❏ Preeclampsia superimposed on chronic HTN❏ Eclampsia

❏ onset of seizure activity or coma in a woman with preeclampsia❏ can occur before, during, or after birth

How to define hypertension:� BP: > 140/90, on 2 separate

occasions at least 4 - 6 hrs apart within a 1 week period

� occurs more frequently in multifetal pregnancies

Table 27-2

Risk Factors for Pregnancy Related HTN (PRH)❏ First pregnancy (primigravida)❏ Age > 35 (younger than 19 and over 40 in book)❏ Family history❏ Pre-existing HTN or pre-existing vascular disease❏ Renal disease❏ Obesity❏ DM❏ Multifetal pregnancy❏ Mother or sister with pre-eclampsia❏ multiparous with a new partner

Gestational Hypertension❏ onset of hypertension without proteinuria AFTER week 20 of pregnancy but

usually develops at or after 37 weeks of gestation❏ women usually have no evidence of preexisting hypertension and their BP

returns to normal within 6 weeks after giving birth❏ Can be classified as mild or severe❏ mild gestational hypertension: will usually have good pregnancy outcomes❏ If they develop proteinuria → it becomes preeclampsia❏ *** women who are diagnosed with gestational hypertension before 35 weeks

are more likely to have preeclampsia***

Preclampsia

❏ What is it?❏ HTN, proteinuria, generalized edema❏ generalized edema: loss of protein causes fluid to shift to interstitial space❏ epigastric (non the main one though)

❏ When does it occur?❏ last half of pregnancy

❏ Beside HTN, what else would be present? edema, proteinuria❏ Effect of fetus

❏ decrease perfusion ❏ IUGR (IntraUterine Growth Restriction), baby can be term but small

❏ What is the cure?❏ delivery

❏ hypertension and proteinuria develops after 20 weeks in a previously normotensive woman → develops during pregnancy and

❏ categorization (mild or severe) will determine management

Table 27-3 Common Laboratory Changes in Preeclampsia

Preventative Measures

❏ Measures work best with high risk reoccurrences❏ Prenatal monitoring❏ meds: applicable on high risk women but does not seem to work on low risk women

❏ Low dose aspirin❏ Ca, Mg, Fish oil Supplements

Effects of Increased Vascular Resistance

❏ Renal perfusion❏ Proteins❏ Vascular volume: edema❏ Liver circulation: epigastric pain, liver not being perfused well❏ Cerebral vessels: headache and visual disturbances❏ Colloid oncotic pressure❏ Placental circulation❏ Vasospasm and vasoconstriction

❏ decreases blood flow to major organs → damages glomerulus and leaks protein → protein decreases osmotic pressure → results in edema → Na and H2O retention to increase HR to increase BP → increases edema even more → decrease perfusion to liver → results in epigastric pain → decrease perfusion causes headache and visual disturbances

The main pathogenic factor is not an increase in BP but poor perfusion as a result of vasospasm and reduced plasma volume.

ManifestationsClassic signs❏ BP increases❏ test for protein (24 hour urine test), then dipstick

❏ proteinuria is defined as❏ 24 hr specimen: at or greater than 300mg/24 hr❏ Dipstick: at or greater than 30mg/dl (+1)

❏ Women with UTI watch for false positive❏ Deep tendon reflexes

❏ reflects the balance between cerebral cortex and spinal cord Additional signs❏ Liver enzymes may be up, creatinine and BUN may be up❏ Edema in the hands, face❏ headaches, epigastric pain, right upper quadrant pain, visual disturbances

CV system❏ Increased

❏ Response to angiotensin II❏ BP❏ SVR

❏ Decreased❏ CO❏ Plasma volume: protein loss due to the fluid shifting to the interstitial space

Hematologic❏ Increased

❏ Hemoconcentration❏ high H&H

❏ Viscosity❏ Platelet clumping

❏ Risk for strokes❏ Thrombocytopenia

❏ Risk for bleeding❏ Endothelium damage

Neurologic❏ Arterial vasospasm and decreased blood flow to the retina can lead to visual

disturbances such as scotoma (dim vision or blind or dark spots in the visual field), or blurred, double vision

❏ Rupture of small capillaries❏ Small hemorrhages❏ Cerebral edema❏ Increased CNS irritability:

❏ Headache **❏ Hyperreflexia ** → Deep tendon Reflexes❏ positive ankle clonus❏ Seizures : Convulsions (eclampsia)

Renal❏ Reduced renal perfusion

❏ Decreases GFR ❏ decreased GFR can lead to oliguria

❏ Decreases Colloid osmotic pressure as serum albumin levels decrease❏ Damage to glomeruli❏ Proteinuria❏ Fluid shift (edema)

❏ Hypovolemia❏ Increase

❏ HCT (fluid leaves the intravascular space)❏ Angiotensin II and aldosterone❏ BUN and Cr and serum uric acid

Hepatic

❏ Impaired❏ decreased liver perfusion can lead to impaired liver function and elevated

liver enzymes

❏ Hepatic edema

❏ Epigastric pain or right upper quadrant pain

❏ can occur is hepatic edema and subcapsular hemorrhage develop

PlacentaDecreased placental Perfusion� restriction of fetal growth� increased incidence of placental abruption, premature birth❏ Fetal hypoxemia

❏ Acidosis: not enough O2❏ Perinatal death

❏ Nutrients❏ IUGR

Mild Preclampsia❏ Activity restrictions

❏ might be able to stay at home as long as patient adheres with plan❏ Rest few times a day to decrease pressure on v. cava❏ BP same position and same arm ❏ kick counts (daily fetal movement counts)

❏ UA❏ Fetal assessment❏ Diet:

❏ Lots of proteins and calories in diet❏ Na restriction

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 treatmentMaternal goals

❏ Avoid Seizures❏ Increase CO❏ Prevent complications such as stroke

Fetal goals❏ Improve placental blood flow❏ Fetal Oxygenation

Inpatient Management Severe PreeclampsiaMost are hospitalized and put in private room

❏ Bedrest: cannot get up to use bathroom, bathe in bed, side rails up❏ Antihypertensive❏ Anticonvulsants❏ Intrapartum management❏ Low stimulus environment: low lighting, no noise, soft relaxing music

Antihypertensives❏ Hydralazine: used often due to its history of safety, increases CO and improves

perfusion❏ Calcium channel (Nifedipine)❏ Beta blocker (Labetalol): decreases BP and HR

Anticonvulsants❏ Magnesium Sulfate (not really an anticonvulsants nor antihypertensive)

❏ Preeclampsia seizures❏ Prevents seizures❏ Given even after birth :continued usually for 12-24 hrs after birth

❏ CNS depressant: Relaxes smooth muscles and uterus❏ Reduces vasoconstriction❏ Relaxes brain activity to prevent seizures

❏ seizures occurs 24 - 48 hrs after birth → watch mother carefully❏ may be on pitocin❏ Epidural is not given if pt has coagulation problems❏ IV❏ Safe❏ Therapeutic levels 4-8 mg/dl for MgSO4 for patients with preeclampsia

❏ IV, secondary infusion (for MgSO4 and Pitocin)❏ must have a primary bag of fluid hanging

❏ Recovery: UOP decrease, BP goes back to normal

Nursing ProcessAssessment❏ One-one nurse patient ratio: (like a little ICU: continuous monitoring when patient is

on MgSO4 and Pitocin)❏ Head to toe❏ Weight❏ Vitals every 4 unless on magnesium (According to the unit, ex. Q2H)❏ Breathe sounds for moistness❏ Check urine for protein❏ Fetal monitoring❏ Reflexes: Arm reflex(need baseline) Q2H, Absent , 1+, 2+, 3+, 4+ hyperreflexia❏ Question about symptoms

❏ headache, visual disturbances, edema (swelling around ring finger)

Interventions❏ Monitor constantly for??

❏ S&S seizures: hyperreflexia, twitching, epigastric pain - these s/s may happen right before seizure

❏ Lateral position (why??):❏ venous return, increase blood flow❏ maximize uteroplacental blood flow, reduce BP, promote diuresis

❏ Control pain (why??)❏

❏ Pitocin and MgSO4 (how to infuse??)❏ IV MgSO4, per physician order to decrease hyperreflexia and minimize risk of

seizure❏ Epidural: only if there is no coagulation problem❏ EFM (Electronic Fetal Monitoring)❏ Prevent seizures

❏ reduce stimuli in the room❏ keep beeping in the room to a minimum, turn volume lower, not off

Magnesium Protocol❏ Need primary IV❏ MgSo4 is infused as a secondary infusion

❏ 4-6 gms loading dose in 100 ml over 15-20 min❏ 2 gm/hr continuous infusion❏ Book says loading dose is 4-6g infused over 15-30min, followed by maintenance

dose diluted and administered at 2g/hr❏ Monitor for toxicity

❏ BP every 2 hrs.❏ Reflexes every 2 hrs. → need at least 2+❏ S&S of Toxicity: drowsiness, lethargy, slurred speech, depressed RR, oliguria,

sudden drop in BP, hyporeflexia, fetal distress❏ UO every 2 hrs. → MgSO4 is excreted by kidneys❏ Serum levels every 4-6 hrs should be between 4-6 (book says therapeutic serum

MgSO4 is 4-7)❏ RR and O2 saturation every 2 hrs → CNS is depressed, turn MgSO4 or decrease

if RR is 12, if lower, turn it off❏ sensorium❏ Inform mother that she may feel expected side effects (a warm flush, diaphoresis,

burning at IV site ) when medication is first administered

Treatment for MgSo4 Toxicity

� Discontinue

� Notify Health Care Provider

� *Have Calcium Gluconate available as antidote (1 gm) at 1 ml/min

� Maintain a quiet, darkened environment to avoid stimuli that may precipitate seizure activity

Eclampsia❏ Generalized seizures

❏ Usually preceded by premonitory signs and symptoms❏ persistent headache, blurred vision, severe epigastric or right upper quad

pain, altered mental status❏ Can occur suddenly without warning

❏ Breathing stops for a short time → results in fetal hypoxia❏ hypotension, muscular twitching, disorientation, amnesia persist for a while after

seizure❏ Temporarily in coma❏ Doesn’t remember seizure when conscious❏ May have nonreassuring fetal patterns❏ May occur during pregnancy, intrapartum or postpartum

Complications of Seizure❏ Blood volume severely reduced during seizure❏ Fluid shifts❏ Oliguria❏ Cerebral hemorrhage❏ Ruptured placenta❏ Early labor❏ HELLP Syndrome

Management of Eclampsia❏ Monitor for impending seizure: know S&S

❏ persistent headache, blurred vision, severe epigastric or right upper quad pain, altered mental status

❏ Initiate preventive measures❏ Keep stimuli down❏ Padded side rails, bed low, wheels locked❏ O2 and suction❏ Intubation equipment❏ Meds

Actual Seizure

❏ Keep airway patent: turn head to one side, place pillow under one shoulder/back if possible

❏ Do not leave unattended: Remain in the room and activate emergency system❏ Attempt to place in lateral position: prevent aspiration of vomitus❏ Note time and sequence of seizure❏ Insert airway after seizure and suction, Don’t open pts mouth if it’s closed you can

insert airways after seizure will end❏ Administer O2❏ Notify provider❏ Assess for complications❏ If not in place start IV❏ Admin MgSo4 - drug of choice

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

� Breath sounds

� Prevent seizure related injury

� Prepare for delivery

� Emotional support

� Continue to monitor all of these postpartum period

Clinical signs that demonstrate resolution of preeclampsia include: diuresis and decreased edema

HELLP

It is a laboratory diagnosis for a variant of severe preeclampsia that involves hepatic dysfunction.

● RBCs are damaged as they pass through narrowed blood vessels and become hemolyzed, resulting in Decreased RBC, platelet count, hyperbilirubinemia

HELLP The pathogenesis of HELLP syndrome is not well understood. The findings of this multisystem disease are attributed to abnormal vascular tone, vasospasm and coagulation defects.To date, no common precipitating factor has been found. The syndrome seems to be the final manifestation of some insult that leads to microvascular endothelial damage and intravascular platelet activation. With platelet activation, thromboxane A and serotonin are released, causing vasospasm, platelet agglutination and aggregation, and further endothelial damage. Thus begins a cascade that is only terminated with delivery.

Incidence

❏ Very serious and life-threatening

❏ ½ of women with preeclampsia develop HELLP (book says 5-20% of women with preeclampsia)

❏ May occur post partum also

❏ Usually develop in third trimester of pregnancy of within 48 hours after birth

❏ Caucasion women

Manifestations� Hallmark symptom

� Pain in upper R quadrant

� Or lower R chest

� Or midepigastric

� Generalized malaise, influenza like symptoms

� Abd. tenderness

� N/V

� Severe edema

� Headache

� Skin may look jaundice

� A small percentage of women will have symptoms of thrombocytopenia: bruising or hematuria

** Many women with HELLP may not have signs or symptoms of severe preeclampsia. BP may only be mildly elevated, proteinuria may be absent

Diagnostics� Liver enzymes ALT, AST elevated

� Platelet count with CBC : Platelets < 100,000

� Decreased haptoglobin

� + D-Dimer in women with preeclampsia, elevated

� Bilirubin increased

� Burr cells present

� BUN and creatinine increased

Normal Lab Values

ALT: 4-36

AST: 0-35

Platelets: 150,000-400,000

D-Dimer: <0.5mg/L

BUN: 10-20

Creatinine: 0.5-1.2

Bilirubin: 0.3-1

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)

� Disseminated 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 : Recommeded 2.4g sodium/day

� Prevent preeclampsia

� Meds

� Aldomet (Methydopa)

� Calcium channel (Nifedipine)

� Beta blockers (Labetolol)

� ACE not receommended pregnancy

� Diuretics are avoided

� Patient with chronic htn can develop superimposed preeclampsia

� Significant increase in htn plus one of the following

� New onset of symptoms

� Thrombocytopenia

� Elevated liver enzymes