1. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 11: The Critically Ill Pregnant Woman

2. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Physiological Changes in Pregnancy See Table 11-1.

3. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Cardiac Output Changes in Pregnancy and Labor and Delivery

4. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Critical Periods of Development

5. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Teratogenic Medication Risk Categories

6. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Clinical Terminology: Hypertensive Disorders of Pregnancy See Box 11-2.

7. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Pathophysiology of Severe Preeclampsia Some unknown cause Arteriolar vasospasms and vasoconstriction Vascular endothelial damage Leakage of plasma in EVS + platelet aggregation Decreased colloidal osmotic pressure Potential for hypovolemia, pulmonary edema Alteration in tissue perfusion/ oxygenation to vital organs Liver- ischemia/necrosis/ edema Kidneys- decreased GFR/oliguria/ proteinuria Brain- cerebral edema/ hemorrhage/ seizures

8. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Hemodynamic Values in Nonpregnant and Pregnant Women

9. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Safe Administration of Magnesium Sulfate Use only premixed magnesium sulfate solutions. Two nurses must verify all changes made during the administration of the drug and mark all IV bags and tubings. Administer bolus in separate IVPB and stay with the patient the entire time. Assess vital signs, deep tendon reflexes, O2 sat, level of consciousness, fetal heart rate, magnesium level. Keep calcium gluconate and emergency equipment nearby for respiratory depression.

10. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Magnesium Sulfate Administration

11. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Interventions for Severe Preeclampsia

12. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Initial Trauma Management of the Pregnant Woman ABCs of resuscitation –Special considerations for CPR –Avoid vasopressors Labs and diagnostic tests Control bleeding and replace fluids at higher rate Once stabilized, perform neurological assessment Fetal assessment: determine life, including Kleihauer- Bertke test

13. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Special Considerations During CPR

14. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Arterial Blood Gas Values in Nonpregnant and Pregnant Women

15. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Strategies for Promoting Emotional Well- Being in High-Risk Pregnancies

16. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question A client with severe preeclampsia is receiving magnesium sulfate IV 2 g/hr maintenance dose. Which of the following should the nurse report to the obstetrician? A. Absent patellar reflex B. Serum magnesium level of 7 mg/dL C. Proteinuria D. Client is also receiving hydralazine

17. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer A. Absent patellar reflex Rationale: The nurse needs to report signs of magnesium sulfate toxicity, which would include a change in deep tendon reflexes - the absent patellar reflex. Although the magnesium level is therapeutic, the client can still be toxic. Proteinuria is a common finding in severe preeclampsia. Because of the decreased kidney perfusion, the patient is more prone to developing magnesium toxicity. Hydralazine is used to manage the blood pressure and would not lead to magnesium toxicity.

18. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question A client is admitted to the ICU with severe preeclampsia and the following hemodynamic values are obtained: PAWP 20 mm Hg, PAP 38/20. The nurse recognizes which of the following? A. These values represent hypovolemia. B. There should also be a low CVP reading. C. These values represent hypervolemia. D. The values are normal for a pregnant woman.

19. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C. These values represent hypervolemia. Rationale: The pulmonary artery wedge pressure (PAWP) and pulmonary artery pressure (PAP) are elevated and reflect hypervolemic changes. The client is in fluid overload. The PAWP and PAP would be decreased if the client was hypovolemic and needed more fluids. The CVP rises with fluid overload and decreases with fluid deficit. See Table 11-4 in the textbook for the normal hemodynamic values for a pregnant woman and a nonpregnant woman.

20. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following statements about HELLP syndrome is correct? A. Lab results reveal increased platelets. B. A possible complication of HELLP syndrome is acute respiratory distress syndrome. C. It usually occurs in young first-time mothers. D. HELLP syndrome is a form of mild preeclampsia.

21. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer B. A possible complication of HELLP syndrome is acute respiratory distress syndrome. Rationale: HELLP syndrome complications can include ARDS, DIC, renal failure, placental abruption, or liver hematoma or rupture. Labs reveal low platelets (<100,000/mm3) and elevated liver enzymes. White women, women over age 27, and women with multiple previous births are more likely to develop HELLP syndrome. HELLP syndrome is considered a form of severe preeclampsia.