Lecture 1 - HTN

HTN disorders are one of the top causes of maternal morbidity and ___ in USA and canada.

HTN disorders can be classified into:

1. Gestational HTN disorders like Gestational HTN, ____, and eclampsia

2. Chronic HTN disorders like chronic HTN and ____ preeclampsia.

mortality; preeclampsia; superimposed

Gestational HTn is onset of HTN after ___ weeks of gestation. This is a BP of greating than _____/90. Only ____ of the pressures (systolic/diastolic) needs to be elevated.

To diagnose this you need at least 2 elevated measures at least ___ hours apart. The BP should return to normal within ____ weeks PP.

50% of pts diagnosed with this go on to develop ____.

20; 140; 1; 4; 12; preeclampsia

Preeclampsia is a pregnancy ____ condition. It develops after ___ weeks gestation and consists of _____ with at least one of the following:

1. ____ in which you can do a 24 hr urine collection to measure. A measurement of ___ mL or more.

2. Low platelet count called ____

3. Impaired ____ function

4. Persistent RUQ or ____ pain

5. Renal insufficiency

6. Pulmonary _____

7. New-onset cerebral or ___ disturbances

Risk factors include:

1. ____ or never having a fetus to viable age

2. ____ maternal age

3. Preeclampsia in a ____ pregnancy or family HX

4. A first pregnancy with a new ___

5. A partner who ___ a preeclamptic pregnancy in another woman

6. A ____ gestation or having more than 1 at once

7. Obesity

8. Pre-existing conditions

9. Assissted ____ tech

specific; 20; HTN; proteinuria; 300; thrombocytopenia; liver; epigastric; edema; vision; nulliparity; advance; previous; partner; fathered; multifetal; reproductvive

Eclampsia is when there is ___ activity or coma in a patient with preeclampsia with no ____ of a preexisting condition or seizure disorder. It occurs before, during, or ____ birth.

It may come suddently and is evident with ___ contraction of all body muscles precing the tonic-clonic convulsion.

During a seizure, ensure there is a patent ____ and client safety. Note the time of onset and ___ of seizure. Do not ___ the bedside but call for help. The side rails can be ___ w pillows/blackets.

After the seizure:

1. Place a ____ ox on and suction as needed.

2. VS

3. Admin ____ sulfate as needed

4. The ____ may have become hypertonic so she could be ready to deliver. Check the ___ status and fetal status using EFM

seizure; HX; after; tonic; airway; duration; leave; padded; pulse; magnesium; uterus; cervical

HTN that existed prior to pregnancy is called ___ HTN. Also it if it persists ____ weeks PP, it can also be called this.

If they already had HTN and are now having the signs of preeclampsia, this is called ____ preeclampsia. Diagnosis is based on:

1. A sudden inc in BP that was previously ____.

2. A new-onset of ____ or an inc in that amount in a patient who was known to have had it before.

This mostly affects non-hispanic ___ women and other RF include older age and obesity. Encourage ____ changes before conception.

For BP readings > 140/90 antiHTN therapy is recommended.

The patient may ____ if given methyldopa, labetalol, or nifedpine.

chronic; 12; superimposed; controlled; proteinuria; black; lifestyle; breastfed

The etiology of preeclampsia occurs as follows:

1. There is inadequate ____ of the blood vessels to the placenta. This causes the blood vessels to be ___ and have high resistance.

2. This decreases blood flow to the _____ leading to hypoxia.

3. The hypoxic placenta releases substances into maternal circulation leading to _____ cell dysfunction.

4. This leads to 3 things

   1. ____ which is when the blood vessels constrict. This leads to an inc in ____.

   2. Increased peripheral ____ which the heart has to overcome

   3. Increased endothelial cell ____ leading to edema and proteinuria.

5. These all leads to overall ___ perfusion.

Arteriolar vasospasms leads to dec perfusion to placenta, ____, liver, and brain. Dec perfusion to placenta leads to early degenerative ____ of the placenta and dec oxyggen/nutrients to fetus leading to _____.

remodeling; narrow; placenta; endothelial; vasospasm; BP; resistance; permeability; tissue; kidney; aging; IUGR

HELLP syndrom eis a severe pregnancy complication associated with _____. Symptoms are as follow:

1. H = ____ of RBCs

2. EL = elevated ____ enzymes like:

   1. An AST of greater than ___. The normal range is 4 to ___ units/L.

   2. A LDH > _____ which is normally 45 to _____ units/L

   3. A ALT > ____. Normal is 3 to ___ units/L

3. LP = low _____ of less than ____ x 10^9. This is a sign of _____.

Many report malaise, ____ like symptoms, epigastric or ___ pain. Symptoms tend to worsen at ___ and improve during daytime. This occurs more often in ____ women.

preeclampsia; hemolysis; liver; 70; 20; 600; 90; 50; 21; platelets; 100; bleeding; flu; RUQ; night; caucasian

Care management for HTN disorders includes:

1. Assessing BP and edema by classifying based on ___ of indentation

2. Assess deep tendon ___ which helps us to see the balance between cerebral cortex and spinal cord.

3. Do a 24 hr urine collection to look for ____. The level of ____ is an indicator of true renal status.

4. Test for ankle _____ which is hyperreflexia of the ankle. First you want to ____ the ankle and count any rhythmic muscle contractions.

depth; reflexes; proteinuria; creatinine; clonus; dorsiflex

The goals for therapy for gestational HTN and preeclampsia w/o severe features is to ensure maternal safety and deliver as close to ____ as possible.

This can be managed at home if:

1. BP is less than 155 over ____

2. There is no inc in proteinuria

3. Norma _____ count and liver enzymes

Interventions can include:

1. Inital maternal labs including serum ____, platelets, liver enzymes, and 24-hour urine

2. Weekly labs include all the above but also ____ and maternal weight. Evaluated weekly includes s/s of ____ features

3. BP should be monitored ____ per week and protienuria should be assessed weekly via a ____ stick with an abnomral of 2+

4. Daily fetal ____ counts

5. NST or ____ once/twice a wekk until birth

6. An ultrasound eval of the _____ fluid index and estimated fetal ____ every 3 weeks.

7. Activity should be ______ and only use gentle exercise

8. Relaxation techniques

9. A regular diet with fluid intake of about 6 to ___ 8ox cups

10. Limit caffeine and avoid alc/tobacco

term; 105; platelet; creatinine; hematocrit; severe; twice; dip; movement; BPP; amniotic; weight; restricted; 8

Patients with severe gestational HTN and preeclampsia with severe features sohould be ____ immediately for evaluation.

______ sulfate should be given to prevent eclampsia or more specifically seizures.

____ meds may need to be given to control BP.

Maternal assessment should include BP, urine output, _____ status, epigastric pain, labor, and vaginal _____.

Maternal labs should include platelet count, ____ enzymes, and creatinine. They need to be on continuous ____(monitoring) and BPP. An ____ should be performed to look at fetal growth and amnionitc fluid.

If the patient is 34 wks or greater, we need to ____ birth after stabilization as the risks of continuing of pregnancy is greater than that of preterm birth.

If < 34 weeks and are not indicated for giving birth immediately are candidates for expectant management which includes:

1. Hospitalization and consult with ______

2. Oral ____ meds and ongoing assessments

3. Give ______ for lung maturity

4. BP should be measured every ____ min

hospitalized; magnesium; antihypertensive; cerebral; vaginal; liver; EFM; ultrasound; expedite; perinatologist; antihypertensive; betamethasone; 15

For severe gestational HTN and preeclampsia w severe features, intrapartum care iincludes:

1. Continuous ____

2. Assess CNS, CV, Pulm, hepatic, and ____ systems

3. Have patient on bedrest with a ___ and darkened environment. You should limit the amount of ____ at one time.

4. Have oxygen and ___ equipment readily available

5. Emergency drugs that should be avilable include labetalol, hydralazine, ____, mag sulfate, and ____ gluconate.

6. To reduce the risk of pulmonary edema IV and oral fluids should be limited to ____ ml/hr

EFM; renal; quiet; visitors; suction; nifedipine; calcium; 125

Magnesium sulfate is given to prevent/treat ____ or eclampsia. The initial loading dose is 4-6g in 100mL IV fluid over 15 to ___ minutes. A maintenance dose is 1 to ___ g/hr or 40g in 1000mL LR.

You should adminster as ___ using infusion pump. THe therapeutic level of serum magnesium is 4 to ___ mEq/L.

When giving this medication, you want to check VS, level of ____, reflexes, headache, _____ disturbances and see if they’re lethargic.

It also causes sytemic vasodilation which may cause the patient to feel ____ and hot. It causes the extremeties to feel ___ making it diffcult to move them.

To avoid complications, do the following checks _____:

1. Assess BP and if it is over 180 over ___ notify provider. If RR is below ____ notify provider

2. Assess DTR and clonus

3. Assess urine output if it is less than ___ mL/hr call provider.

4. FHR and activity

Mild signs of toxicity includes lethargy, muscle _____, dec DTRs, ___ vision, and slurred speech. Inc toxicity includes hypotension, ____ (Hr), bradypnea, and cardiac arrest. If toxicity occurs, stop influsion, and give ____ ____ slowly. This can spread to the infant which can cause them to be born with ____ (DTR), bradypnea, etc in which you want them on calcium trandusion and ___ ventilation

This is contrainidcated for patients with myasthenia ___, heart block, renal disease, and ___ insuffieicney. It is escreted via ____ so dec UO can lead to toxicity.

seizures; 30; 2; IVPB; 7; conciousness; visual; flushed; heavy; 110; 12; 25; weakness; double; bradycardia; calcium gluconate; hyporeflexia; mechanical; gravis; myocardial; kidneys

BP can be controlled using hte folllowing meds:

1. ____ which is an arteroolera vasodilator.

2. ____ which is a alpha/beta blocker

3. ____ which is a calcium channel blocker.

hydralazine; labetalol; nifedipine

PP care for HTN disorders include:

1. VS, I&Os, DTRs, LOC, visual disturbances, and ____ pain

2. Mag sulfate should be continued for 12 to ___ hours.

3. S/S of preeclampsia should resolve within ___ hrs after birth.

4. May need to adminster ___ meds

5. Evaluate blood loss carefully and methergine is ____ if they have a hemorrhage.

6. Mag sulfate potentiates actions of narcotics, CNS ____ and CC-blockers lile nifedipine

epigastric; 24; 48; antihypertensive; contraindicated; depressants

Complications of HTN disorders in pregnancy include:

1. Placenta ___ due to bleeding between placenta and uteirne wall

2. Stroke, cerebral hemorrhage, and ____

3. Hepatic/renal failure, _____ and DIC

4. Pulmonary ___

5. Specific to the fetus: placentral insufficinecy, ____, prematurity, hypoxia/acidosis.

abruption; seizures; coagulopathies; edema; IUGR