1. Complication during pregnancy and its nursing management: - Pregnancy induces hypertension. Clinical Aspect of Maternal and Child Nursing NUR 363 Lecture 2

2. OBJECTIVES List criteria for the diagnosis of preeclampsia List criteria for the diagnosis of severe preeclampsia/HELLP syndrome Discuss current management considerations

3. Hypertension Sustained BP elevation of 140/90 or greater Proper cuff size Measurement taken while seated

4. Forms of HTN in Pregnancy Gestational 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.

5. Forms of HTN in Pregnancy -Eclampsia is an extension of preeclampsia and is characterized by the client experiencing seizures.

6. Risk Factors Renal diseaseFamily history of PIH Age > 40Diabetes mellitus African AmericanTwin gestation Chronic hypertension

7. Cardiovascular Effects Increased cardiac output Increased systemic vascular resistance Hypovolemia

8. Neurologic Effects Headache Cerebral edema Hyper-reflexia

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

10. Renal Effects Decreased glomerular filtration rate Increased BUN/creatinine Proteinuria Oliguria Acute tubular necrosis

11. Fetal Effects Increased prenatal morbidity Placental abruption Fetal growth restriction Fetal distress

12. 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.

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

14. 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

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

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

17. 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

18. 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

19. Acute Medical Therapy Hydralazine Labetalol Nifedipine Nitroprusside Diazoxide Clonidine

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

21. Hydralazine Dose: 5-10 mg every 20 minutes Onset: 10-20 minutes Duration: 3-8 hours Side effects: headache, flushing, tachycardia. Mechanism: peripheral vasodilator

22. 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

23. 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

24. Clonidine Dose: 1 mg po Onset: 10-20 minutes Duration: 4-6 hours Side effects: unpredictable, avoid rapid withdrawal Mechanism: Alpha agonist, works centrally

25. 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

26. Seizure Prophylaxis Magnesium sulfate 4-6 g bolus 1-2 g/hour Monitor urine output With renal dysfunction, may require a lower dose

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

28. Toxicity (for Magnesium Sulfate) Respiratory rate < 12 Altered sensorium Urine output < 25-30 cc/hour