Complication during pregnancy and its nursing management:

- Pregnancy induces hypertension.

Clinical Aspect of Maternal and Child NursingNUR 363Lecture 2

OBJECTIVES

List criteria for the diagnosis of preeclampsia

List criteria for the diagnosis of severe preeclampsia/HELLP syndrome

Discuss current management considerations

Hypertension

Sustained BP elevation of 140/90 or greater

Proper cuff size Measurement taken while seated

Forms of HTN in PregnancyGestational hypertension is also known as

pregnancy induced hypertension (PIH), or preeclampsia.

-Preeclampsia is a hypertensive disorder of pregnancy developing after 20 weeks gestation and characterized by edema, vasospasms of the arteries and proteinuria.

Forms of HTN in Pregnancy

-Eclampsia is an extension of preeclampsia and is characterized by the client experiencing seizures.

Risk Factors

Risk Factors

Renal disease Family history of PIH

Age > 40 Diabetes mellitus

African American Twin gestation

Chronic hypertension

Cardiovascular Effects Increased cardiac output Increased systemic vascular resistance Hypovolemia

Neurologic Effects

Headache Cerebral edema Hyper-reflexia

Hematologic Effects Volume contraction Elevated hematocrit Low platelets Anemia due to hemolysis

Renal Effects

Decreased glomerular filtration rate Increased BUN/creatinine Proteinuria Oliguria Acute tubular necrosis

Fetal Effects

Increased prenatal morbidity Placental abruption Fetal growth restriction Fetal distress

Severe Preeclampsia

BP > 180 systolic or 110 diastolic

Proteinuria > 5 g per day

Oliguria Elevated liver

enzymes

Low platelets Growth restriction Headache Epigastric pain Pitting edema.

Management

The ultimate cure is delivery Assess gestational age Assess cervix Fetal well-being Laboratory assessment Rule out severe disease!!

Gestational HTN at Term

Delivery is always a reasonable option if term

If cervix is unfavorable and maternal disease is mild, expectant management with close observation is possible

Indications for Delivery Worsening BP Nonreassuring fetal condition Fetal lung maturity Favorable cervix

Hypertensive Emergencies Fetal monitoring IV access IV hydration The reason to treat is maternal, not fetal May require ICU

Criteria for Treatment Diastolic BP > 105-110 Systolic BP > 200 Avoid rapid reduction in BP Do not attempt to normalize BP Goal is DBP < 105 not < 90

Nursing Care Focus

Assisting the woman in obtaining prenatal care Helping her cope with therapy Caring for acutely ill woman

Know what signs/symptoms to monitor for and when to intervene

Administering medications as prescribed

Acute Medical Therapy

Hydralazine Labetalol Nifedipine Nitroprusside Diazoxide Clonidine

Key Steps Using Vasodilators 250-500 cc of fluid, IV Allow time for drug to work Avoid over treatment

Hydralazine

Dose: 5-10 mg every 20 minutes Onset: 10-20 minutes Duration: 3-8 hours Side effects: headache, flushing,

tachycardia. Mechanism: peripheral vasodilator

Labetalol

Dose: 20mg, then 40, then 80 every 20 minutes, for a total of 220mg

Onset: 1-2 minutes Duration: 6-16 hours Side effects: hypotension Mechanism: Alpha and Beta block

Nifedipine

Dose: 10 mg po, not sublingual Onset: 5-10 minutes Duration: 4-8 hours Side effects: chest pain, headache,

tachycardia Mechanism: CA channel block

Clonidine

Dose: 1 mg po Onset: 10-20 minutes Duration: 4-6 hours Side effects: unpredictable, avoid rapid

withdrawal Mechanism: Alpha agonist, works centrally

Nitroprusside

Dose: 0.2 – 0.8 mg/min IV Onset: 1-2 minutes Duration: 3-5 minutes Side effects: cyanide accumulation,

hypotension Mechanism: direct vasodilator

Seizure Prophylaxis

Magnesium sulfate 4-6 g bolus 1-2 g/hour Monitor urine output With renal dysfunction, may require a

lower dose

Magnesium Sulfate

Is not a hypotensive agent Works as a centrally acting anticonvulsant Also blocks neuromuscular conduction Serum levels: 6-8 mg/dL

Toxicity (for Magnesium Sulfate)

Respiratory rate < 12 Altered sensorium Urine output < 25-30 cc/hour