Obstetric Complications

Hypertensive Disorders of Pregnancy

Chronic HTN
before 20 weeks
Gestational HTN (PRH)
after 20 weeks
Preeclampsia
more than or equal to 140/90 consistently
Preeclampsia superimposed on chronic HTN
Eclampsia

Risk Factors for Pregnancy Related HTN

(PRH)

First pregnancy
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

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?
Effect of fetus
decrease perfusion
IUGR (IntraUterine Growth Restriction), baby can be term but small
What is the cure?
delivery

Preventive 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

Manifestations
Classic signs
BP increases
test for protein (24 hour urine test), then dipstick
Women with UTI watch for false positive
Deep tendon reflexes
Additional signs
Liver enzymes may be up, creatinine and BUN may be up
Edema in the hands, face

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
Rupture of small capillaries
Small hemorrhages
Headache **
Hyperreflexia ** Deep tendon Reflexes
Convulsions (eclampsia)

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

Hepatic

Impaired

Hepatic edema

Epigastric pain

Placenta
Decreased
Perfusion
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
UA
Fetal assessment
Diet:
Lots of proteins and calories in diet
Na restriction

Mild

Severe

SBP 140 but < 160

BP > 160

DBP >90 but <110

DBP >110

Proteinuria > 0.3 g but < 2 g in 24 hr ( 1+

dipstick)

>5 g in 24 hr urine and 3+ or higher

dipstick)

Cr (serum) normal

>1.2

Platelets normal

Decreased <100,000

Liver enzymes normal to slight

Elevated

UO normal

Oliguria

Headache (severe)

Present often

Upper quad pain

Often preceded seizures

visual disturbances ( absent or minimal

Common

Pulm edema, Hrt failure

May be present

IUGR

Present with reduced amniotic fluid

Goals for treatment

Maternal goals
Avoid Seizures
Increase CO
Prevent complications such as stroke
Fetal goals
Improve placental blood flow
Fetal Oxygenation

Inpatient Management Severe

Preeclampsia
Most are hospitalized and put in private room
Bedrest: cannot get up to use bathroom, bathe in bed
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
Beta blocker: decreases BP and HR

Anticonvulsants

Magnesium Sulfate (not really an anticonvulsants nor antihypertensive)

Preeclampsia seizures
Prevents seizures
Given even 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 Process
Assessment
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
Control pain (why??)

Pitocin and MgSO4 (how to infuse??)

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
Monitor for toxicity
BP every 2 hrs.
Reflexes every 2 hrs. need at least 2+
UO every 2 hrs. MgSO4 is excreted by kidneys
Serum levels every 4-6 hrs should be between 4-6
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 will feel a warm flush 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

Eclampsia

Generalized seizures
Breathing stops for a short time results in fetal hypoxia
Temporarily in coma
Doesnt 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

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

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, Dont open pts mouth if its closed you can
insert airways after seizure will end
Administer O2
Notify provider
Assess for complications
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

HELLP

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

of women with preeclampsia develop HELLP

May occur post partum also

Manifestations
Hallmark symptom
Pain in upper R quadrant
Or lower R chest
Or midepigastric

Generalized malaise
Abd. tenderness
N/V
Severe edema
Headache
Skin may look jaundice

Diagnostics
Liver enzymes
Platelet count with CBC
Decreased haptoglobin
+ D-Dimer in women with preeclampsia

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 (DICblood 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
Prevent preeclampsia
Meds
Aldomet (Methydopa)
Calcium channel
Beta blockers
ACE not receommendedpregnancy
Diuretics are avoided