Lec. 5 complications in pregnancy - preexisting and gestational

Types of HTN

• gestational

• preclmpsia, eclampsia

• HELLP

• Chronic HTN

• preclampsia superimposed by chronic HTN

Gestational HTN - who is at risk

• <19 or >35

• 1st pregnancy

• morbidly obese

• multifetal gestation

• chronic renal dz

• chronic HTN

• Rh incompatibility

• molar pregnancy

• previous hx of this htn

Gestational HTN - Diagnostics

• Urinalysis - proteinureia present

• 24 hr urine - protein and creatanine present

• Uric acid - increased

• Liver enzymes - elevated or trending up

• CMP (serum creatanine, BUN, Uric acid, Mg, all inc as kidney fails)

• CBC - RBC and platelets trend down

• RST - looking for 2 HR excels from baby in 20 mins

• doppler study - placental BF

preclampsia - patho

multisys disorder that develops after 20 weeks gestation

• progresses from mild to severe

• cause: disruption in placental perfusion causing placental ischemia leading to maternal endothelial dysfxn

preclampsia - s/sx

cardiac - HTN, edema, blood clotting, DTR hyperactive

GU - oliguria, proteinureia

CNS - severe HA, visual dsiturbances, blurry spots

Resp - pulmonary edema

• weight gain

MIld Diagnostics -

HTN - >140/90 atleast 4 hours apart after 20 wks gestation

Proteinureia - >300m gin 24 hr specimen

thrombocytopenia - PLT count <100,000

impaired liver fxn - elevated blood lvls o fliver trasaminases to 2x normal concentration

renal insufficiency - sreum creatnin >1.1

s

Severe Diagnostics

HTN - >160/110 at least 4 hrs apart on bed rest

Preoteinuria - >5g in 24hr speciemen - no linger diagnostic

thrombocytpoenia - plt count > 100, 000

impaired liver fxn - inc. concentration o fliver enzymes 2x normal

renal insufficiency - >1.1

pulmonary edema - present

cerebral or visual disturbance - new onset

Eclampsia - what is it

onset of tonic, clonic seizures in client with preclampsia

occurs antepartum, intrapartem, postpartum

Eclampsia - warning signs

• sever HA

• Visual Disturbances

• Epigastric, RUQ pain

• NV
  hperreflexia with clonus - bend foot back, how many beats the foot gives back to reset = clonus, if rigid that is bad

• altered mental status

eclampsia - maternal risk

• cerebral hemorrhage

• Aspiraiton

• DIC

  • maternal death

eclampsia - fetal risk

• placental abruption

• fetal hypoxia

• fetal distress

• fetal death

eclampsia - management

• lie on left side

• maintain airway and O2

• seizure precautions

• Magnesium sulfate

• control severe HTN

• continuous maternal and fetal monitoring

• ABCs - O2 10L

• IV

eclampsia - nrusing management

• activity restriciton

• maternal and fetal assessment

• VS

• daily weight

• urianalysis

• emotional care

• low stimulation environment

eclampsia - med managment

• Mg Sulfate

• Antihypertensives - Labetolol, aldomet, Nifedipine

• Baby apsirin

Eclampsia - Magnesium SUlfate therapy

• VS Q 4hrs

• DTRs Q 1-4 hrs

• I and O restriciton

• Foley cath

• urine protein check

• Labs Q4

  • fetal surveillance

eclampsia - magnesium sulfate therapy - Magneisum toxicity

• signs - oliguria, loss of DTR, Respirations

• cure - calcium gluconate

HTN management - IV labetolol

first line

• inital dose 20mg, if BP sever up to 40mg in 10mins, then 80 every 10mins

• 220 mg max

  • avoid in - asthma, bradycardia, heart block

HTN management - IV hydralazine

first line also

• initial dose - 5-10mg IV, repeat every 20-40 min PRN

• monitor for: maternal hypotension, reflex tachycardia

HTN management - immediate release Nifdepine

IF IV Acces not available

• 10 mg PO

• repeat Q20min PRN

HELLP syndrome - what is it

labrpatory diagnostic variant of severe preclampsia

• Hemolysis

• Eleveated Liver enzymes

• Low platelets

HELLP syndrome - inc. risk for ___ with HELLP

• pulmonary edema

• renal failure

• liver hemorrhage failure

• DIC

• placental abruption

• Acute repiratory ditrss syndrome

• Sepsis

• Stroke

• fetal and maternal death

HELLP syndrome labs

PLT - <100,000

AST - >70

ALT - elevated

LDH - >600

Hgb/HCRT - dec. d/t hemolysis

Chronic HTN - accociated with inc incidence of

• placental abruption

• superimposed preclampsia

• inc. prenatal mortality

• fetal effects

• growth restriction

• preterm birth

Chronic HTN - treatment

maintain blood flow to vital organs and placenta

• prevent convulsions

• prevent preclampsia

  • identify dependent/pitting edema, deeps tendon reflex, clonus, lab tests, proetinueria

DM in pregnancy

most common endocrine disorder affecting pregnancy - turns pregnancy high risk

3 types:

• pregestational type 1 - autoimmune destruciton of pancreatic B cells, requires insulin

• Pregestational type 2 - insulin resistance with relative insulin deficiency

• Gestational - glucose intolerance first recognized during pregnancy, sccreened for @ 24-28 wks, A1GDM and A2GDM

Pregestational DM

• can be Type 1 or 2

• maternal risk - Hypo/hyperglycemia, DKA, preclampsia, polyhydramios, shoulder dystocia, C section

• Fetal Risk - miscarriage, stillbirth, macrosmia, neonate hypoglycemia, resp. distress, NICU admission

• requires close monitoring

Gestational DM

• can be A1GDM or A2GDM

• maternal risk - similar to other, reccurence in future pregnancy, predisopsition for future type 2

• fetal risk - macrosomia, shoulder dystonia, birht injury, noenatal hypoglycemia, RDS, NICU admit

• resolves postpartum

Gestational DM - diagnostics

who needs to be screened

• Obesity, Previous GDM, previous macrosomic infant, strong family history

• screen at 24 -28 wks

• blood glucose goal - in 1hr <140mg/dl

diabetes management - Gestational

A1GDM - diet and exercise

A2GDM - Medication and insulin

• inc. fetal surveillance

• postpartum DM screeing at 4-12 wks

• edu. on future type 2 risk

Diabetes management - Pregestational

• more intense monitoring

• baseline renal and opthomalgic eval.

• early anatomy scan, fetal echo

• frequent insulin adjustments

  • monitor for progression of diabetic complications

Thyroid disorders - Hyperthyroidism

Graves dz - 90-95% of cases

• rare in pregnancy

• watch for: weight loss, HR over 100, goiter

• inc. risk of pregnancy complications

thyroid disorders - Hypothyroidism

if untreated risk for infertility/miscarriage

watch for: weight gain, lethargy, dec. in exercise capacity, cold intolerance

thyroid hormone supplements, monitor thyroid studies

Hyperemesis gravidium

excessive vomitting w/ dehydration, electrolyte imbalances, ketosis, acetonuria

• restricts fetal growth

hyperemesis gravidium - S/sx

• persistent N/V

• inability to retain fluid/food

• dehydration

• dry tongue/mucous membranes

• dec. tugor

• scant/inc. concentraion of urine

• inc. hematocrit, dec. K, Dec. Na

• Inc. BUN, creatanine

• Urine Ketones

• Inc. AST/ALT (liver enzymes)

hyperemesis gravidium - Tx

• PO/IV fluids

• antiemetics

• TPN

Nuring interventions

• I and O

• small frequent amounts of food or liquid

• stress management

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hyperemesis gravidium - Education

• sit upright after meals

• easily digested carbs: crackers, potatos,

• avoid odors

• emotional support

Substance abuse during preganncy - nursing priorities

• screen early/regularly

• additional assessment for women with substanc abuse issues

• nonjudgmental therapeutic ommunication

• edu. about risk

• refer for treatment/support

• monitor maternal/fetal well being

• follow up care

othe rpregnancy complications - Iron deficiency anemia

most common s/s - fatigue, pallor, weakness, Iron + vitamin C inc. absorption,

• avoid taking wit calcium

other pregnancy complications - asthma

meternal oxygenation = fetal oxygenation, continue perscribed meds

other pregnancy complication - intrahepatic cholestasis

s/s intense itching, reports severe pruritis to provider

other pregnancy comlpications - cardiac dz

pregnancy inc cardiac work load

• watch for decompensation: inc. HR, low BP, edema, lung crackles, SOB, Inc RR, cyanosis