Obstetric Complications

Hypertensive Disorders of Pregnancy

Chronic HTN
before 20 weeks
Gestational HTN (PRH)
after 20 weeks, without proteinuria
Preeclampsia
more than or equal to 140/90 consistently
Preeclampsia superimposed on chronic HTN
Eclampsia
onset of seizure activity or coma in a woman with preeclampsia
can occur before, during, or after birth

Table 27-2
How to define hypertension:
BP: > 140/90, on 2 separate
occasions at least 4 - 6 hrs apart
within a 1 week period
occurs more frequently in multifetal
pregnancies

Risk Factors for Pregnancy Related HTN

(PRH)

First pregnancy (primigravida)

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
multiparous with a new partner

Gestational Hypertension

onset of hypertension without proteinuria AFTER week 20 of pregnancy but

usually develops at or after 37 weeks of gestation
women usually have no evidence of preexisting hypertension and their BP
returns to normal within 6 weeks after giving birth
Can be classified as mild or severe
mild gestational hypertension: will usually have good pregnancy outcomes
If they develop proteinuria it becomes preeclampsia
*** women who are diagnosed with gestational hypertension before 35 weeks
are more likely to have preeclampsia***

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? edema, proteinuria
Effect of fetus
decrease perfusion
IUGR (IntraUterine Growth Restriction), baby can be term but small
What is the cure?
delivery
hypertension and proteinuria develops after 20 weeks in a previously normotensive
woman develops during pregnancy and
categorization (mild or severe) will determine management

Table 27-3 Common Laboratory Changes in Preeclampsia

Preventative 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

The main pathogenic factor is not an increase in BP but poor perfusion as a result of vasospasm and reduced plasma
volume.

Manifestations
Classic signs
BP increases
test for protein (24 hour urine test), then dipstick
proteinuria is defined as
24 hr specimen: at or greater than 300mg/24 hr
Dipstick: at or greater than 30mg/dl (+1)
Women with UTI watch for false positive
Deep tendon reflexes
reflects the balance between cerebral cortex and spinal cord
Additional signs
Liver enzymes may be up, creatinine and BUN may be up
Edema in the hands, face
headaches, epigastric pain, right upper quadrant pain, visual disturbances

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 and decreased blood flow to the retina can lead to visual
disturbances such as scotoma (dim vision or blind or dark spots in the visual field), or
blurred, double vision
Rupture of small capillaries
Small hemorrhages
Cerebral edema
Increased CNS irritability:
Headache **
Hyperreflexia ** Deep tendon Reflexes
positive ankle clonus
Seizures : Convulsions (eclampsia)

Renal

Reduced renal perfusion

Decreases GFR
decreased GFR can lead to oliguria
Decreases Colloid osmotic pressure as serum albumin levels decrease
Damage to glomeruli
Proteinuria
Fluid shift (edema)
Hypovolemia
Increase
HCT (fluid leaves the intravascular space)
Angiotensin II and aldosterone
BUN and Cr and serum uric acid

Hepatic

Impaired
decreased liver perfusion can lead to impaired liver function and elevated
liver enzymes

Hepatic edema

Epigastric pain or right upper quadrant pain

can occur is hepatic edema and subcapsular hemorrhage develop

Placenta
Decreased placental Perfusion
restriction of fetal growth
increased incidence of placental abruption, premature birth
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 (daily fetal movement 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, side rails up
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 (Nifedipine)
Beta blocker (Labetalol): decreases BP and HR

Anticonvulsants

Magnesium Sulfate (not really an anticonvulsants nor antihypertensive)

Preeclampsia seizures
Prevents seizures
Given even after birth :continued usually for 12-24 hrs 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
maximize uteroplacental blood flow, reduce BP, promote diuresis
Control pain (why??)

Pitocin and MgSO4 (how to infuse??)

IV MgSO4, per physician order to decrease hyperreflexia and minimize risk of
seizure
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
Book says loading dose is 4-6g infused over 15-30min, followed by maintenance
dose diluted and administered at 2g/hr
Monitor for toxicity
BP every 2 hrs.
Reflexes every 2 hrs. need at least 2+
S&S of Toxicity: drowsiness, lethargy, slurred speech, depressed RR, oliguria,
sudden drop in BP, hyporeflexia, fetal distress
UO every 2 hrs. MgSO4 is excreted by kidneys
Serum levels every 4-6 hrs should be between 4-6 (book says therapeutic serum
MgSO4 is 4-7)
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 may feel expected side effects (a warm flush, diaphoresis,
burning at IV site ) 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
Maintain a quiet, darkened environment to avoid stimuli that may precipitate
seizure activity

Eclampsia

Generalized seizures
Usually preceded by premonitory signs and symptoms
persistent headache, blurred vision, severe epigastric or right upper quad
pain, altered mental status
Can occur suddenly without warning
Breathing stops for a short time results in fetal hypoxia
hypotension, muscular twitching, disorientation, amnesia persist for a while after
seizure
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

persistent headache, blurred vision, severe epigastric or right upper quad pain,
altered mental status
Initiate preventive measures
Keep stimuli down
Padded side rails, bed low, wheels locked
O2 and suction
Intubation equipment
Meds

Actual Seizure

Keep airway patent: turn head to one side, place pillow under one shoulder/back if
possible
Do not leave unattended: Remain in the room and activate emergency system
Attempt to place in lateral position: prevent aspiration of vomitus
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
If not in place start IV
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

Clinical signs that demonstrate resolution of preeclampsia include: diuresis

and decreased edema

HELLP

It is a laboratory diagnosis for a variant of severe preeclampsia that involves hepatic dysfunction.

RBCs are damaged as they pass through narrowed blood vessels and become hemolyzed, resulting in
Decreased RBC, platelet count, hyperbilirubinemia

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 (book says 5-20% of women

with preeclampsia)

May occur post partum also

Usually develop in third trimester of pregnancy of within 48 hours after birth

Caucasion women

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

Generalized malaise, influenza like symptoms

Abd. tenderness
N/V
Severe edema
Headache
Skin may look jaundice
A small percentage of women will have symptoms of thrombocytopenia:
bruising or hematuria
** Many women with HELLP may not have signs or symptoms of severe
preeclampsia. BP may only be mildly elevated, proteinuria may be absent

Diagnostics
Liver enzymes ALT, AST elevated
Platelet count with CBC : Platelets < 100,000
Decreased haptoglobin
+ D-Dimer in women with preeclampsia, elevated
Bilirubin increased
Burr cells present
BUN and creatinine increased
Normal Lab Values
ALT: 4-36
AST: 0-35
Platelets: 150,000-400,000
D-Dimer: <0.5mg/L
BUN: 10-20
Creatinine: 0.5-1.2
Bilirubin: 0.3-1

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 : Recommeded 2.4g sodium/day
Prevent preeclampsia
Meds
Aldomet (Methydopa)
Calcium channel (Nifedipine)
Beta blockers (Labetolol)
ACE not receommended pregnancy
Diuretics are avoided
Patient with chronic htn can develop superimposed preeclampsia
Significant increase in htn plus one of the following
New onset of symptoms
Thrombocytopenia
Elevated liver enzymes