hypertensive disorders in pregnancy lectures 4. 2 2 hypertension in pregnancy significance and...

Hypertensive Hypertensive disorders in disorders in pregnancypregnancy

Lectures 4Lectures 4

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Hypertension in PregnancyHypertension in PregnancySignificance and incidenceSignificance and incidence

Hypertensive disorders of pregnancy are Hypertensive disorders of pregnancy are the most common medical complication the most common medical complication reported during pregnancy reported during pregnancy

Preeclampsia complicates approximately Preeclampsia complicates approximately 5% to 10% of all pregnancies5% to 10% of all pregnancies

Significant contributor to maternal and Significant contributor to maternal and perinatal morbidity and mortalityperinatal morbidity and mortality In In woman with history of chronic woman with history of chronic hypertension or renal disease predating hypertension or renal disease predating pregnancy the occurrence of pregnancy the occurrence of preeclampsia is 25%preeclampsia is 25%

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Hypertension in PregnancyHypertension in Pregnancy Significance and incidenceSignificance and incidence

Preeclampsia predisposes the woman to Preeclampsia predisposes the woman to potentially lethal complications, including potentially lethal complications, including eclampsia, abruptio placentae, disseminal eclampsia, abruptio placentae, disseminal intravascular coagulation, acute renal intravascular coagulation, acute renal failure, adult respiratory distress failure, adult respiratory distress syndrome, cerebral hemorrhagesyndrome, cerebral hemorrhage

Causes of perinatal death related to Causes of perinatal death related to preeclampsia are uteroplacental preeclampsia are uteroplacental insufficiency and abruptio placentae, insufficiency and abruptio placentae, which lead to intrauterine fetal death, which lead to intrauterine fetal death, preterm birth, and low birth weightpreterm birth, and low birth weight

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Hypertension in PregnancyHypertension in PregnancySignificance and incidenceSignificance and incidence

Eclampsia (characterized by seizures) from Eclampsia (characterized by seizures) from profound cerebral effects of preeclampsia is profound cerebral effects of preeclampsia is the major maternal hazard.the major maternal hazard.

As a rule, maternal and perinatal morbidity As a rule, maternal and perinatal morbidity and mortality rates are highest among cases and mortality rates are highest among cases in which eclampsia is seen early in gestation in which eclampsia is seen early in gestation (before 28 weeks), maternal age is greater (before 28 weeks), maternal age is greater than 25 years, the woman is a multigravida, than 25 years, the woman is a multigravida, and chronic hyper tension or renal disease is and chronic hyper tension or renal disease is present present

The fetus of the eclamptic woman is at The fetus of the eclamptic woman is at increased risk from abruptio placentae, increased risk from abruptio placentae, preterm birth, intrauterine growth restriction preterm birth, intrauterine growth restriction (IUGR), and acute hypoxia(IUGR), and acute hypoxia

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Hypertension in Pregnancy Hypertension in Pregnancy ClassificationClassification

Chronic hypertensionChronic hypertension Pregnancy-induced hypertensionPregnancy-induced hypertension

Gestational hypertensionGestational hypertension PreeclampsiaPreeclampsia EclampsiaEclampsia

Preeclampsia superimposed on Preeclampsia superimposed on chronic hypertensionchronic hypertension

Standard definitions are not consistently Standard definitions are not consistently used by health care providersused by health care providers

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Chronic hypertensionChronic hypertension

Present before the pregnancy or Present before the pregnancy or diagnosed before week 20 of gestationdiagnosed before week 20 of gestation

or continuing beyond 42 days or continuing beyond 42 days postpartumpostpartum

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Gestational hypertensionGestational hypertension

Onset of hypertension without Onset of hypertension without proteinuria after the 20proteinuria after the 20thth week of week of pregnancypregnancy

Systolic BP > 140 mm HgSystolic BP > 140 mm Hg Diastolic BP >90 mm HgDiastolic BP >90 mm Hg

Diagnosis of onset during pregnancy Diagnosis of onset during pregnancy based on two measurements that meet based on two measurements that meet criteria for gestational BP elevation criteria for gestational BP elevation within a 1-week periodwithin a 1-week period

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PreeclampsiaPreeclampsia Pregnancy-specific syndromePregnancy-specific syndrome Hypertension develops after 20 weeks of Hypertension develops after 20 weeks of

gestation in previously normotensive womangestation in previously normotensive woman Proteinuria may be present Proteinuria may be present Multisystem, vasospastic disease process Multisystem, vasospastic disease process

characterized by hemoconcentration, characterized by hemoconcentration, hypertension, and proteinuriahypertension, and proteinuria

Disease of reduced organ perfusion with Disease of reduced organ perfusion with presence of hypertension and proteinuriapresence of hypertension and proteinuria

Complicates 3% to 7% of all pregnanciesComplicates 3% to 7% of all pregnancies

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ProteinuriaProteinuria

is a concentration of 0.1 g/L (1+ to is a concentration of 0.1 g/L (1+ to 2+ on dipstick measurement) or 2+ on dipstick measurement) or more in at least two random urinemore in at least two random urine specimens collected at least 6 hours specimens collected at least 6 hours apart.apart.

In a 24-hour specimen, proteinuria is In a 24-hour specimen, proteinuria is a concentration of 0.3 g/L per 24 a concentration of 0.3 g/L per 24 hourshours

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EdemaEdema Pathologic edema is clinically Pathologic edema is clinically

evident, generalized accumulation of evident, generalized accumulation of fluid of the face, hands, or abdomen fluid of the face, hands, or abdomen that is not responsive to 12 hours of that is not responsive to 12 hours of bed rest. It may also be manifested bed rest. It may also be manifested as a rapid weight gain of more than 2 as a rapid weight gain of more than 2 kg in 1 week. The presence of edema kg in 1 week. The presence of edema is no longer considered necessary for is no longer considered necessary for the diagnosis of preeclampsiathe diagnosis of preeclampsia

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MILD PREECLAMPSIA SEVERE PREECLAMPSIA

MATERNAL EFFECTS

Blood pressure BP reading of 140/90 mm Hg x2, 4-6 hr apart Rise to >160/110 mm Hg on two separate occasions 4-6 hr apart with pregnant woman on bed rest

Mean arterial pressure (MAP)

>105 mm Hg >105 mm Hg

Weight gain Weight gain of more than 0.5 kg/wk during the second and third trimesters or sudden weight gain of 2 kg/wk at any time

Same as mild preeclampsia

Proteinuria— Qualitative dipstick— Ouantitative 24 hr analysis

Proteinuria of 0.3 g/L in a 24 hr specimen or >0.1 g/L in a random day-time specimen on two or more occasions 6 hr apart (because protein loss is variable); with dipstick, values varying from 1+ to 2 +

Proteinuria of >0.5 g/L in 24 hr or >4+ protein on dipstick

Edema Dependent edema, some puffiness of eyes, face, fingers; pulmonary edema absent

Generalized edema, noticeable puffiness; eyes, face, fingers; pulmonary edema possibly present

Reflexes May be normal Hyperreflexia ≥3+, possible ankle clonus

PreeclampsiaPreeclampsia

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MATERNAL EFFECTS

Reflexes May be normal Hyperreflexia ≥3+, possible ankle clonus

Urine output Output matching intake, ≥30 ml/hr or <650 ml/24 hr

<20 ml/hr or <400 ml to 500 ml/24 hr

Headache Absent/transient Severe

Visual problems Absent Blurred, photophobia, blind spots on funduscopy

Irritability/changes in affect

Transient Severe

Epigastric pain Absent Present

Serum creatinine Normal Elevated

Thrombocytopenia Absent Present

AST elevation Normal or minimal Marked


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FETAL EFFECTS

Placental perfusion Reduced Decreased perfusion expressing as IUGR in fetus; FHR: late decelerations

Premature placental aging

Not apparent At birth placenta appearing smaller than normal for duration of pregnancy, premature aging apparent with numerous areas of broken syncytia, ischemic necroses (white infarcts) numerous, intervillous fibrin deposition (red infarcts)


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HELLP syndromeHELLP syndrome

is a laboratory diagnosis for a variant is a laboratory diagnosis for a variant of severe preeclampsia characterized of severe preeclampsia characterized by hemolysis (H), elevated liver by hemolysis (H), elevated liver enzymes (EL), and low platelets (LP)enzymes (EL), and low platelets (LP)

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EclampsiaEclampsia

Seizure activity or coma in woman Seizure activity or coma in woman diagnosed with preeclampsia diagnosed with preeclampsia

No history of previous seizure No history of previous seizure disorderdisorder

Presentation variesPresentation varies One third in laborOne third in labor One third during deliveryOne third during delivery One third within 72 hours postpartumOne third within 72 hours postpartum

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Chronic hypertension with Chronic hypertension with superimposed preeclampsiasuperimposed preeclampsia

Women with chronic hypertension may Women with chronic hypertension may acquire preeclampsia or eclampsiaacquire preeclampsia or eclampsia

Increases morbidity for mother and Increases morbidity for mother and fetusfetus

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EtiologyEtiology Unique to human pregnanciesUnique to human pregnancies Signs and symptoms develop only during Signs and symptoms develop only during

pregnancy and disappear after birth of the pregnancy and disappear after birth of the fetus and passage of placentafetus and passage of placenta

The cause is unknownThe cause is unknown Associated high risk factorsAssociated high risk factors

Primigravidity Primigravidity Multifetal pregnancyMultifetal pregnancy Preexisting medical condition (Preexisting medical condition (Obesity,Obesity, Chronic Chronic

renal disease, Chronic hypertension, Diabetes)renal disease, Chronic hypertension, Diabetes) Preeclampsia in a prior pregnancy or Preeclampsia in a prior pregnancy or Family Family

history of PIHhistory of PIH Maternal age <19 years; >40 yearsMaternal age <19 years; >40 years Rh incompatibilityRh incompatibility

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EtiologyEtiology

Current theoriesCurrent theories Increase vasoconstrictor toneIncrease vasoconstrictor tone Abnormal prostaglandin actionAbnormal prostaglandin action Endotelian cell activationEndotelian cell activation Immunologic factorImmunologic factor Genetic dispositionGenetic disposition dietdiet

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PathophysiologyPathophysiology

May be caused by disruptions in May be caused by disruptions in placental perfusion and placental perfusion and endothelial endothelial cell dysfunctioncell dysfunction

Main pathogenic factor is not an increase in Main pathogenic factor is not an increase in BP, but poor perfusion resulting from BP, but poor perfusion resulting from vasospasmvasospasm

Arteriolar vasospasm diminishes diameter of Arteriolar vasospasm diminishes diameter of blood vessels, which impedes blood flow to blood vessels, which impedes blood flow to all organs and increases BP all organs and increases BP

Significant decreases in placental, kidney, Significant decreases in placental, kidney, liver, and brain functionliver, and brain function

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PathophysiologyPathophysiology reflects alterations in the normal adaptations of reflects alterations in the normal adaptations of

pregnancy. pregnancy. Normal physiologic adaptations to pregnancy include Normal physiologic adaptations to pregnancy include

increased blood plasma volume, vasodilatation, increased blood plasma volume, vasodilatation, decreased systemic vascular resistance, elevated decreased systemic vascular resistance, elevated cardiac output, and decreased colloid osmotic pressurecardiac output, and decreased colloid osmotic pressure

Pathologic changes in the endothelial cells of the Pathologic changes in the endothelial cells of the glomeruli (glomeruloendotheliosis) are uniquely glomeruli (glomeruloendotheliosis) are uniquely characteristic of preeclampsia, particularly in characteristic of preeclampsia, particularly in nulliparous women (85%).nulliparous women (85%).

The main pathogenic factor is not an increase in blood The main pathogenic factor is not an increase in blood pressure but poor perfusion as a result of vasospasm. pressure but poor perfusion as a result of vasospasm. Arteriolar vasospasm diminishes the diameter of blood Arteriolar vasospasm diminishes the diameter of blood vessels, which impedes blood flow to all organs and vessels, which impedes blood flow to all organs and raises blood pressure raises blood pressure

Function in organs such as the placenta, kidneys, Function in organs such as the placenta, kidneys, liver, and brain is depressed by as much as 40% to liver, and brain is depressed by as much as 40% to 60%60%

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Laboratory diagnostic variant (not Laboratory diagnostic variant (not clinical) variant of severe preeclampsia clinical) variant of severe preeclampsia involves hepatic dysfunction, involves hepatic dysfunction, characterized by:characterized by:

Hemolysis (H)Hemolysis (H) Elevated liver enzymes (EL)Elevated liver enzymes (EL) Low platelets (LP)Low platelets (LP)

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The exact mechanism is unknownThe exact mechanism is unknown Arteriolar vasospasm, endothelial Arteriolar vasospasm, endothelial

damage, and platelet aggregation damage, and platelet aggregation with resultant tissue hypoxia are the with resultant tissue hypoxia are the underlying mechanisms for the underlying mechanisms for the pathophysiology of HELLP syndrome pathophysiology of HELLP syndrome

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epigastric or right upper quadrant epigastric or right upper quadrant abdominal pain (possibly related to abdominal pain (possibly related to hepatic ischemia) 65% hepatic ischemia) 65%

nausea and vomitingnausea and vomiting 50%50%

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HELLP syndromeHELLP syndrome Lab testLab test

platelet count less than 100,000/mmplatelet count less than 100,000/mm33 Elevate liver enzymes Elevate liver enzymes levels levels aspartate aminotransferase [AST] aspartate aminotransferase [AST] alanine aminotransferase [ALT])alanine aminotransferase [ALT]) evidence of intravascular hemolysis (burr cells on evidence of intravascular hemolysis (burr cells on

peripheral smear or elevated bilirubin level)peripheral smear or elevated bilirubin level)

A unique form of coagulopathy (not DIC) A unique form of coagulopathy (not DIC) occurs with HELLP syndrome. The platelet occurs with HELLP syndrome. The platelet count is low, but coagulation factor assays, count is low, but coagulation factor assays,

prothrombin time prothrombin time partial thromboplastin timepartial thromboplastin time bleeding time remain normalbleeding time remain normal

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HELLP syndromeHELLP syndrome Associated with increased risk for:Associated with increased risk for:

Pulmonary edemaPulmonary edema Acute renal failureAcute renal failure Disseminated intravascular coagulation (DIC)Disseminated intravascular coagulation (DIC) Placental abruptionPlacental abruption Liver hemorrhage or failureLiver hemorrhage or failure Adult respiratory distress syndromeAdult respiratory distress syndrome Sepsis Sepsis Stroke Stroke

High risk for maternal deathHigh risk for maternal death

Care managementCare management

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Chronic Hypertension Chronic Hypertension

Chronic hypertension associated Chronic hypertension associated with increased incidence of:with increased incidence of: Abruptio placentaeAbruptio placentae Superimposed preeclampsiaSuperimposed preeclampsia Increased perinatal mortality Increased perinatal mortality Fetal effects Fetal effects

Fetal growth restriction Fetal growth restriction Small for gestational ageSmall for gestational age

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Chronic Hypertension – cont’d Chronic Hypertension – cont’d

Ideally management begins before Ideally management begins before conceptionconception

Lifestyle changes may be necessaryLifestyle changes may be necessary In postpartum, high risk women In postpartum, high risk women

monitored closely for complicationsmonitored closely for complications May safely breastfeed even though May safely breastfeed even though

low levels of antihypertensive low levels of antihypertensive medications will be in breast milkmedications will be in breast milk

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Assessment and nursing diagnosisAssessment and nursing diagnosisInterviewInterview Medical historyMedical history DM, renal disease, chronic hypertensionDM, renal disease, chronic hypertension Family historyFamily history Social history (marital, nutritional status, cultural Social history (marital, nutritional status, cultural

beliefs, activity level, health habits)beliefs, activity level, health habits) BPBP Abnormal weight gainAbnormal weight gain Increase sign of edemaIncrease sign of edema Presents of proteinuriaPresents of proteinuria HeadacheHeadache Visual disturbanceVisual disturbance Epigastric painEpigastric pain

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Assessment and nursing diagnosisAssessment and nursing diagnosis

Physical examinationPhysical examination BPBP Observation of edema (distribution, degree, Observation of edema (distribution, degree,

pitting)pitting) Symptom reflecting central nervous system and Symptom reflecting central nervous system and

visual systemvisual system Deep tendon reflexesDeep tendon reflexes Fetal statusFetal status Uterine tonicityUterine tonicity Sign of progression of mild preeclampsia to Sign of progression of mild preeclampsia to

severe preeclampsia or eclampsia severe preeclampsia or eclampsia Respiration (crackles, diminished breath sound)Respiration (crackles, diminished breath sound)

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Assessment and nursing diagnosisAssessment and nursing diagnosis

Lab testsLab tests Complete blood cell count (including a platelet Complete blood cell count (including a platelet

count), hematocrit, hemoglobincount), hematocrit, hemoglobin Clotting studies (including bleeding time, PT Clotting studies (including bleeding time, PT

(protrombine time), PTT (partial thromboplastin (protrombine time), PTT (partial thromboplastin time), and fibrinogen)time), and fibrinogen)

Liver enzymes (lactate dehydrogenase [LDH], Liver enzymes (lactate dehydrogenase [LDH], AST, ALT), glucose level AST, ALT), glucose level

Chemistry panel (blood urea nitrogen [BUN], Chemistry panel (blood urea nitrogen [BUN], creatinine, glucose, uric acid), creatinine, glucose, uric acid),

Type and screen, possible crossmatchType and screen, possible crossmatch ProteinuriaProteinuria

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Lab testsLab testsNORMAL PIH HELLP

Hemoglobin/hematocrit 12 to 16 gm/dl/37% to 47%

May ↑ ↓

Platelets 150,000 to 400,000/mm3 Unchanged <100,000/mm3

PT/PTT 12 to 14 sec/60 to 70 sec Unchanged Unchanged

Fibrinogen 150 to 400 mg/dl 300 to 600 mg/dl Present

Fibrin split products (FSP) Absent Absent ↓

Blood urea nitrogen (BUN) 10 to 20 mg/dl <10 mg/dl ↑

Creatinine 0.5 to 1.1 mg/dl <1 mg/dl ↑

Lactate dehydrogenase (LDH) 45 to 90 U/L Unchanged ↑

Aspartate aminotransferase (AST) 4 to 20 U/L Unchanged ↑

Alanine aminotransferase (ALT) 3 to 21 U/L Unchanged ↑

Creatinine clearance 80 to 125 ml/min 130 to 180 ml/min ↓

Burr cells/schistocytes Absent Absent Present

Uric acid 2 to 6.6 mg/dl 4.5 to 6 mg/dl >10 mg/dl

Bilirubin (total) 0.1 to 1 mg/dl Unchanged or ↑ ↑

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Nursing actions are derived from medical Nursing actions are derived from medical management, health care provider management, health care provider directives, and nursing diagnoses. directives, and nursing diagnoses.

Early prenatal care, identification of Early prenatal care, identification of pregnant women at risk for preeclampsia, pregnant women at risk for preeclampsia, and recognition and reporting of physical and recognition and reporting of physical warning signs are essential components warning signs are essential components in the optimization of maternal and in the optimization of maternal and perinatal outcomes. perinatal outcomes.

The role of the nurse's skills in assessing The role of the nurse's skills in assessing the woman for factors and symptoms of the woman for factors and symptoms of preeclampsia cannot be overestimatedpreeclampsia cannot be overestimated

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Mild preeclampsiaMild preeclampsia

Goal is to ensure maternal safety and Goal is to ensure maternal safety and deliver a healthy newborndeliver a healthy newborn May be safely managed at home by nurse May be safely managed at home by nurse

(2-3 times per week) or by themself(2-3 times per week) or by themself Maternal assessment (weight, urine dipstick Maternal assessment (weight, urine dipstick

protein determination, BP, DFMC)protein determination, BP, DFMC) Fetal assessment (ultrasound every 3 weeks, Fetal assessment (ultrasound every 3 weeks,

DFMC, NST or BPP 1-2 times per weekDFMC, NST or BPP 1-2 times per week Activity restrictionActivity restriction DietDiet

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Severe preeclampsia and HELLP-Severe preeclampsia and HELLP-syndromesyndrome

At greater risk for pregnancy At greater risk for pregnancy complicationscomplications

Should be hospitalized for at least 24 Should be hospitalized for at least 24 hours for observation and treatment if hours for observation and treatment if necessarynecessary

Intrapartum careIntrapartum care Magnesium sulfateMagnesium sulfate Control of blood pressureControl of blood pressure Postpartum carePostpartum care

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Severe preeclampsia and Severe preeclampsia and HELLP-syndromeHELLP-syndrome

Antepartum careAntepartum care focuses on stabilization and preparation for birth. focuses on stabilization and preparation for birth. Assessments include review of the cardiovascular Assessments include review of the cardiovascular

system, pulmonary system, renal system, hematologic system, pulmonary system, renal system, hematologic system, and CNS. system, and CNS.

Fetal assessments for well-being (e.g., NST, BPP, Doppler Fetal assessments for well-being (e.g., NST, BPP, Doppler velocimetry) are important because of the potential for velocimetry) are important because of the potential for hypoxia related to uteroplacental insufficiency. hypoxia related to uteroplacental insufficiency.

Baseline laboratory assessments include metabolic Baseline laboratory assessments include metabolic studies for liver enzyme (AST, ALT, LDH) determination, studies for liver enzyme (AST, ALT, LDH) determination, complete blood count with platelets, coagulation profile complete blood count with platelets, coagulation profile to assess for DIC, and electrolyte studies to establish to assess for DIC, and electrolyte studies to establish renal functioning.renal functioning.

Weight is measured on admission and every day Weight is measured on admission and every day thereafter. thereafter.

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An indwelling urinary catheter facilitates monitoring of An indwelling urinary catheter facilitates monitoring of renal function and effectiveness of therapy. renal function and effectiveness of therapy.

If appropriate, vaginal examination may be done to If appropriate, vaginal examination may be done to check for cervical changes. check for cervical changes.

Abdominal palpation establishes uterine tonicity and Abdominal palpation establishes uterine tonicity and fetal size, activity, and position. fetal size, activity, and position.

Electronic monitoring to determine fetal status is Electronic monitoring to determine fetal status is initiated at least once a day. initiated at least once a day.

The woman's room must be close to staff and The woman's room must be close to staff and emergency drugs, supplies, and equipment. Noise and emergency drugs, supplies, and equipment. Noise and external stimuli must be minimized. Seizure external stimuli must be minimized. Seizure precautions are taken precautions are taken

Bed rest is commonly ordered. Bed rest is commonly ordered.

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Intrapartum nursing care Intrapartum nursing care involves continuous monitoring of maternal involves continuous monitoring of maternal

and fetal status as labor progresses. The and fetal status as labor progresses. The assessment and prevention of tissue assessment and prevention of tissue hypoxia and hemorrhage, both of which can hypoxia and hemorrhage, both of which can lead to permanent compromise of vital lead to permanent compromise of vital organs, continue throughout the organs, continue throughout the intrapartum and postpartum periods (Leicht intrapartum and postpartum periods (Leicht & Harvey, 1999).& Harvey, 1999).

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Magnesium sulfateMagnesium sulfate As prophylaxis against convulsionAs prophylaxis against convulsion I/V as a secondary infusion to the main intravenous (IV) I/V as a secondary infusion to the main intravenous (IV)

line by volumetric infusion pumpline by volumetric infusion pump An initial loading dose of 4 to 6 g of MgSO4 per protocol An initial loading dose of 4 to 6 g of MgSO4 per protocol

or physician's order is infused over 20 to 30 minutes. or physician's order is infused over 20 to 30 minutes. This dose is followed by a maintenance dose of This dose is followed by a maintenance dose of magnesium sulfate that is diluted in an IV solution per magnesium sulfate that is diluted in an IV solution per physician's order (e.g., 40 g of magnesium sulfate in physician's order (e.g., 40 g of magnesium sulfate in 1000 ml of lactated Ringer's solution) and administered 1000 ml of lactated Ringer's solution) and administered by infusion pump at 1 to 3 g/hr. by infusion pump at 1 to 3 g/hr.

This dose should maintain a therapeutic serum Mg level This dose should maintain a therapeutic serum Mg level of 4 to 8 g/dl. of 4 to 8 g/dl.

Serum magnesium levels are obtained after the patient Serum magnesium levels are obtained after the patient has received magnesium sulfate for 4 to 6 hours.has received magnesium sulfate for 4 to 6 hours.

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Severe preeclampsia and HELLP-Severe preeclampsia and HELLP-syndrome Magnesium sulfatesyndrome Magnesium sulfate

Intramuscular (IM) MgSO4 is seldom used Intramuscular (IM) MgSO4 is seldom used because absorption rate cannot be controlled, because absorption rate cannot be controlled, injections are painful, and tissue necrosis may injections are painful, and tissue necrosis may occur. occur.

However, the IM route may be used with some However, the IM route may be used with some women who are being transported to a tertiary women who are being transported to a tertiary care center. care center.

The IM dose is 4 to 5 g given in each buttock, a The IM dose is 4 to 5 g given in each buttock, a total of 10 g (with 1% procaine possibly being total of 10 g (with 1% procaine possibly being added to the solution to reduce injection pain), added to the solution to reduce injection pain), and can be repeated at 4-hour intervals. and can be repeated at 4-hour intervals.

Z-track technique should be used for the deep IM Z-track technique should be used for the deep IM injection, followed by gentle massage at the site.injection, followed by gentle massage at the site.

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Severe preeclampsia and HELLP-Severe preeclampsia and HELLP-syndrome Magnesium sulfatesyndrome Magnesium sulfate

Magnesium sulfate interferes with the release of acetylcholine at Magnesium sulfate interferes with the release of acetylcholine at the synapses, the synapses,

decreasing neuromuscular irritability, decreasing neuromuscular irritability, depressing cardiac conduction, depressing cardiac conduction, and decreasing CNS (central nervous system) irritability. and decreasing CNS (central nervous system) irritability. Because magnesium circulates free and unbound to protein and Because magnesium circulates free and unbound to protein and

is excreted in the urine, accurate recordings of maternal urine is excreted in the urine, accurate recordings of maternal urine output must be obtained. output must be obtained.

Diuresis is an excellent prognostic sign; however, if renal Diuresis is an excellent prognostic sign; however, if renal function declines, all of the magnesium sulfate will not be function declines, all of the magnesium sulfate will not be excreted and can cause magnesium toxicity.excreted and can cause magnesium toxicity.

Serum magnesium levels are obtained on the basis of the Serum magnesium levels are obtained on the basis of the woman's response and if any signs of toxicity are present. woman's response and if any signs of toxicity are present.

Early symptoms of toxicity include nausea, a feeling of warmth, Early symptoms of toxicity include nausea, a feeling of warmth, flushing, muscle weakness, decreased reflexes, and slurred flushing, muscle weakness, decreased reflexes, and slurred speech.speech.

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Severe preeclampsia and Severe preeclampsia and HELLP-syndrome HELLP-syndrome Magnesium sulfateMagnesium sulfate

Deep tendon reflexesDeep tendon reflexes Urine outputUrine output Respiration rateRespiration rate Consciousness Consciousness

If magnesium toxicity is suspected, the infusion should be If magnesium toxicity is suspected, the infusion should be discontinued immediately. discontinued immediately.

Calcium gluconate, the antidote for magnesium sulfate, may Calcium gluconate, the antidote for magnesium sulfate, may also be ordered (10 ml of a 10% solution, or 1 g) and given also be ordered (10 ml of a 10% solution, or 1 g) and given by slow IV push (usually by the physician) over at least 3 by slow IV push (usually by the physician) over at least 3 minutes to avoid undesirable reactions such as arrhythmias, minutes to avoid undesirable reactions such as arrhythmias, bradycardia, and ventricular fibrillation.bradycardia, and ventricular fibrillation.

Because magnesium sulfate is also a tocolytic agent, its use Because magnesium sulfate is also a tocolytic agent, its use may increase the duration of labor. A preeclamptic woman may increase the duration of labor. A preeclamptic woman receiving magnesium sulfate may need augmentation with receiving magnesium sulfate may need augmentation with oxytocin during labor. The amount of oxytocin needed to oxytocin during labor. The amount of oxytocin needed to stimulate labor may be more than that needed for a woman stimulate labor may be more than that needed for a woman who is not on magnesium sulfate.who is not on magnesium sulfate.

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Severe preeclampsia and Severe preeclampsia and HELLP-syndrome HELLP-syndrome

antihypertensive agentantihypertensive agent Starts if diastolic pressure is higher than 100 to 110 Starts if diastolic pressure is higher than 100 to 110

mm Hgmm Hg Order to decrease the diastolic blood pressure to 90 to Order to decrease the diastolic blood pressure to 90 to

100 mm Hg 100 mm Hg Prevent left ventricular failure and cerebral Prevent left ventricular failure and cerebral

hemorrhage. hemorrhage. decrease the arterial pressure too much or too rapidlydecrease the arterial pressure too much or too rapidly agent of choice is agent of choice is hydralazine IV hydralazine IV labetalol hydrochloride IV labetalol hydrochloride IV methyldopa orally methyldopa orally Nifedipine orallyNifedipine orally

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EclampsiaEclampsia

Premonitory signs and symptomsPremonitory signs and symptoms HeadacheHeadache Blurred visionBlurred vision Severe epigastric painSevere epigastric pain Altered mental statusAltered mental status

Tonic- clonic convulsionsTonic- clonic convulsions HypotensionHypotension ComaComa

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EclampsiaEclampsia

Immediate careImmediate care Ensure a patent airwayEnsure a patent airway Patient safety a major concernPatient safety a major concern Post-seizure decision regarding timing Post-seizure decision regarding timing

and method of birthand method of birth

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EclampsiaEclampsiaTONIC-CLONIC CONVULSION SIGNSTONIC-CLONIC CONVULSION SIGNS Stage of invasion: 2 to 3 sec, eyes are Stage of invasion: 2 to 3 sec, eyes are

fixed, twitching of facial muscles occursfixed, twitching of facial muscles occurs Stage of contraction: 15 to 20 sec, eyes Stage of contraction: 15 to 20 sec, eyes

protrude and are bloodshot, all body protrude and are bloodshot, all body muscles are in tonic contractionmuscles are in tonic contraction

Stage of convulsion: muscles relax and Stage of convulsion: muscles relax and contract alternately (clonic), contract alternately (clonic), respirations are halted and then begin respirations are halted and then begin again with long, deep, stertorous again with long, deep, stertorous inhalation, coma ensuesinhalation, coma ensues

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EclampsiaEclampsiaINTERVENTIONINTERVENTION

Keep airway patent: turn head to one Keep airway patent: turn head to one side, place pillow under one shoulder side, place pillow under one shoulder or back if possible Call for assistance or back if possible Call for assistance Protect with side rails up Observe Protect with side rails up Observe and record convulsion activityand record convulsion activity

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Eclampsia Eclampsia AFTER CONVULSION AFTER CONVULSION OR SEIZUREOR SEIZURE

Do not leave unattended until fully alertDo not leave unattended until fully alert Observe for postconvulsion coma, incontinenceObserve for postconvulsion coma, incontinence Use suction as neededUse suction as needed Administer oxygen via face mask at 10 L/minAdminister oxygen via face mask at 10 L/min Start IV fluids and monitor for potential fluid overloadStart IV fluids and monitor for potential fluid overload Give magnesium sulfate or other anticonvulsant drug as orderedGive magnesium sulfate or other anticonvulsant drug as ordered Insert indwelling urinary catheter Insert indwelling urinary catheter Monitor blood pressure Monitor blood pressure Monitor fetal and uterine status Monitor fetal and uterine status Expedite laboratory work as ordered to monitor kidney function, Expedite laboratory work as ordered to monitor kidney function,

liver function, coagulation system, and drug levelsliver function, coagulation system, and drug levels Provide hygiene and a quiet environment Provide hygiene and a quiet environment Support and keep woman and family informed Support and keep woman and family informed Be prepared for delivery when woman is in stable conditionBe prepared for delivery when woman is in stable condition

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Postpartum nursing carePostpartum nursing care After birth the symptoms of preeclampsia or eclampsia After birth the symptoms of preeclampsia or eclampsia

resolve quickly, usually within 48 hours. resolve quickly, usually within 48 hours. The hematopoietic and hepatic complications of HELLP The hematopoietic and hepatic complications of HELLP

syndrome may persist longer. syndrome may persist longer. These patients often show an abrupt decrease in platelet These patients often show an abrupt decrease in platelet

count, with a concomitant increase in LDH and AST levels, count, with a concomitant increase in LDH and AST levels, after a trend toward normalization of values has begun. after a trend toward normalization of values has begun. Generally the laboratory abnormalities seen with HELLP Generally the laboratory abnormalities seen with HELLP syndrome resolve in 72 to 96 hours.syndrome resolve in 72 to 96 hours.

Blood pressure is measured at least every 4 hours for 48 Blood pressure is measured at least every 4 hours for 48 hours or more frequently as the woman's condition warrants. hours or more frequently as the woman's condition warrants.

Even if no convulsions occurred before the birth, they may Even if no convulsions occurred before the birth, they may occur within this period. occur within this period.

MgSO4 infusion may be continued 12 to 24 hours after the MgSO4 infusion may be continued 12 to 24 hours after the birth. birth.

Assessments for effects and side effects continue until the Assessments for effects and side effects continue until the medication is discontinued.medication is discontinued.

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Postpartum nursing carePostpartum nursing care The woman is at risk for a boggy uterus and a large lochial flow as a The woman is at risk for a boggy uterus and a large lochial flow as a

result of the magnesium sulfate therapy. Uterine tone and lochial result of the magnesium sulfate therapy. Uterine tone and lochial flow must be monitored closely.flow must be monitored closely.

The preeclamptic woman is unable to tolerate excessive postpartum The preeclamptic woman is unable to tolerate excessive postpartum blood loss because of hemoconcentration. Oxytocin or prostaglandin blood loss because of hemoconcentration. Oxytocin or prostaglandin products are used to control bleeding. products are used to control bleeding.

Ergot products (e.g., Ergotrate, Methergine) are contraindicated Ergot products (e.g., Ergotrate, Methergine) are contraindicated because they can increase blood pressure.because they can increase blood pressure.

The woman is asked to report symptoms such as headaches and The woman is asked to report symptoms such as headaches and blurred vision. blurred vision.

The nurse assesses affect, level of consciousness, blood pressure, The nurse assesses affect, level of consciousness, blood pressure, pulse, and respiratory status before an analgesic is given for pulse, and respiratory status before an analgesic is given for headache. headache.

Magnesium sulfate potentiates the action of narcotics, CNS Magnesium sulfate potentiates the action of narcotics, CNS depressants, and calcium-channel blockers; these drugs must be depressants, and calcium-channel blockers; these drugs must be administered with caution. administered with caution.

The woman may need to continue an antihypertensive medication The woman may need to continue an antihypertensive medication regimen if her diastolic blood pressure exceeds 100 mm Hg at regimen if her diastolic blood pressure exceeds 100 mm Hg at discharge.discharge.

hypertensive disorders in pregnancy lectures 4. 2 2 hypertension in pregnancy significance and...

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