obstetric complications

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Obstetric Complications

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Page 1: Obstetric Complications

Obstetric Complications

Page 2: Obstetric Complications

Hypertensive Disorders of Pregnancy

Gestational HTN (PIH)

Pre-clampsia

Eclampsia

Chronic HTN

Preeclampsia superimposed on chronic HTN

Page 3: Obstetric Complications

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

Page 4: Obstetric Complications

Preclampsia

What is it?

When does it occur

Beside HTN, what else would be present?

Effect of fetus

What is the cure?

Page 5: Obstetric Complications

Preventive Measures

Measures work best with high risk reoccurrences

Prenatal monitoring

meds

Page 6: Obstetric Complications

Effects of Increased Vascular Resistance

Renal perfusion

Proteins

Vascular volume

Liver circulation

Cerebral vessels

Colloid oncotic pressure

Placental circulation

Page 7: Obstetric Complications

Manifestations

Classic signs

Additional signs

Page 8: Obstetric Complications

CV system

Increased

Reponses to angiotensin II

BP

SVR

Decreased

CO

Plasma volume

Page 9: Obstetric Complications

Hematologic

Increased

Hemoconcentration

Viscosity

Platelet clumping

Thrombocytopenia

Endothelium damage

Page 10: Obstetric Complications

Neurologic

Arterial vasospasm

Rupture of small capillaries

Small hemorrhages

Headache **

Hyperreflexia **

Convulsions (eclampsia)

Page 11: Obstetric Complications

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

Page 12: Obstetric Complications

Hepatic

Impaired

Hepatic edema

Epigastric pain

Page 13: Obstetric Complications

Placenta

Decreased

Perfusion

Fetal hypoxemia

Acidosis

Perinatal death

Nutrients

IUGR

Page 14: Obstetric Complications

Mild Preclampsia

Activity restrictions

UA

Fetal assessment

Diet

Page 15: Obstetric Complications

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

Page 16: Obstetric Complications

Goals for treatment

Maternal goals

Fetal goals

Page 17: Obstetric Complications

Inpatient Management Severe Preeclampsia

Bedrest

Antihypertensive

Anticonvulsants

Intrapartum management

Page 18: Obstetric Complications

Antihypertensives

Hydralazine

Calcium channel

Beta blocker

Page 19: Obstetric Complications

Anticonvulsants

Magnesium Sulfate (not really an anticonvulsants nor antihypertensive)

Relaxes smooth muscles

Reduces vasoconstriction

IV

Safe

Therapeutic levels 4-8 mg/dl

Page 20: Obstetric Complications

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

Page 21: Obstetric Complications

Interventions

Monitor constantly for??

Lateral position (why??)

Control pain (why??)

Pitocin and MgSO4 (how to infuse??)

Epidural??

EFM

Prevent seizures

Page 22: Obstetric Complications

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

Page 23: Obstetric Complications

Treatment for MgSo4 Toxicity

Discontinue

Notify Health Care Provider

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

Page 24: Obstetric Complications

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

Page 25: Obstetric Complications

Complications of Seizure

Blood volume severely reduced during seizure

Fluid shifts

Oliguria

Cerebral hemorrhage

Ruptured placenta

Early labor

HE::P Syndrome

Page 26: Obstetric Complications

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

Page 27: Obstetric Complications

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

Page 28: Obstetric Complications

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

Page 29: Obstetric Complications

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

Page 30: Obstetric Complications

HELLP

H

Hemolysis of RBCs

EL

Elevated liver enzymes

LP

Low platelets

Page 31: Obstetric Complications

Incidence

Very serious and life-threatening

½ of women with preeclampsia develop HELLP

May occur post partum also

Page 32: Obstetric Complications

Manifestations

Hallmark symptom

Pain in upper R quadrant

Or lower R chest

Or midepigastric

Generalized malaise

Abd. tenderness

N/V

Severe edema

Headache

Page 33: Obstetric Complications

Diagnostics

Liver enzymes

Platelet count with CBC

Decreased haptoglobin

+ D-Dimer in woman with preelcampsia

Page 34: Obstetric Complications

Treatment

ICU

MgSO4

Hydralazine

Fluid replacement

Cervical ripening and induction if at least 34 weeks

If stable may wait for induction if < 34 weeks

Page 35: Obstetric Complications

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

Page 36: Obstetric Complications

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