1. Hypertensive disorders in pregnancy Lectures 4

2. 2 2 Hypertension in Pregnancy Significance and incidence Hypertensive disorders of pregnancy are the most common medical complication reported during pregnancy Hypertensive disorders of pregnancy are the most common medical complication reported during pregnancy Preeclampsia complicates approximately 5% to 10% of all pregnancies Preeclampsia complicates approximately 5% to 10% of all pregnancies Significant contributor to maternal and perinatal morbidity and mortality In woman with history of chronic hypertension or renal disease predating pregnancy the occurrence of preeclampsia is 25% Significant contributor to maternal and perinatal morbidity and mortality In woman with history of chronic hypertension or renal disease predating pregnancy the occurrence of preeclampsia is 25%

3. 3 3 Hypertension in Pregnancy Significance and incidence Preeclampsia predisposes the woman to potentially lethal complications, including eclampsia, abruptio placentae, disseminal intravascular coagulation, acute renal failure, adult respiratory distress syndrome, cerebral hemorrhage Preeclampsia predisposes the woman to potentially lethal complications, including eclampsia, abruptio placentae, disseminal intravascular coagulation, acute renal failure, adult respiratory distress syndrome, cerebral hemorrhage Causes of perinatal death related to preeclampsia are uteroplacental insufficiency and abruptio placentae, which lead to intrauterine fetal death, preterm birth, and low birth weight Causes of perinatal death related to preeclampsia are uteroplacental insufficiency and abruptio placentae, which lead to intrauterine fetal death, preterm birth, and low birth weight

4. 4 4 Hypertension in Pregnancy Significance and incidence Eclampsia (characterized by seizures) from profound cerebral effects of preeclampsia is the major maternal hazard. Eclampsia (characterized by seizures) from profound cerebral effects of preeclampsia is the major maternal hazard. As a rule, maternal and perinatal morbidity and mortality rates are highest among cases in which eclampsia is seen early in gestation (before 28 weeks), maternal age is greater than 25 years, the woman is a multigravida, and chronic hyper­ tension or renal disease is present As a rule, maternal and perinatal morbidity and mortality rates are highest among cases in which eclampsia is seen early in gestation (before 28 weeks), maternal age is greater than 25 years, the woman is a multigravida, and chronic hyper­ tension or renal disease is present The fetus of the eclamptic woman is at increased risk from abruptio placentae, preterm birth, intrauterine growth restriction (IUGR), and acute hypoxia The fetus of the eclamptic woman is at increased risk from abruptio placentae, preterm birth, intrauterine growth restriction (IUGR), and acute hypoxia

5. 5 5 Hypertension in Pregnancy Classification Chronic hypertension Chronic hypertension Pregnancy-induced hypertension Pregnancy-induced hypertension Gestational hypertension Gestational hypertension Preeclampsia Preeclampsia Eclampsia Eclampsia Preeclampsia superimposed on chronic hypertension Preeclampsia superimposed on chronic hypertension Standard definitions are not consistently used by health care providers Standard definitions are not consistently used by health care providers

6. 6 6 Chronic hypertension Present before the pregnancy or diagnosed before week 20 of gestation Present before the pregnancy or diagnosed before week 20 of gestation or continuing beyond 42 days postpartum or continuing beyond 42 days postpartum

7. 7 7 Gestational hypertension Onset of hypertension without proteinuria after the 20 th week of pregnancy Onset of hypertension without proteinuria after the 20 th week of pregnancy Systolic BP > 140 mm Hg Systolic BP > 140 mm Hg Diastolic BP >90 mm Hg Diastolic BP >90 mm Hg Diagnosis of onset during pregnancy based on two measurements that meet criteria for gestational BP elevation within a 1-week period Diagnosis of onset during pregnancy based on two measurements that meet criteria for gestational BP elevation within a 1-week period

8. 8 8 Preeclampsia Pregnancy-specific syndrome Pregnancy-specific syndrome Hypertension develops after 20 weeks of gestation in previously normotensive woman Hypertension develops after 20 weeks of gestation in previously normotensive woman Proteinuria may be present Proteinuria may be present Multisystem, vasospastic disease process characterized by hemoconcentration, hypertension, and proteinuria Multisystem, vasospastic disease process characterized by hemoconcentration, hypertension, and proteinuria Disease of reduced organ perfusion with presence of hypertension and proteinuria Disease of reduced organ perfusion with presence of hypertension and proteinuria Complicates 3% to 7% of all pregnancies Complicates 3% to 7% of all pregnancies

9. 9 9 Proteinuria is a concentration of 0.1 g/L (1+ to 2+ on dipstick measurement) or more in at least two random urine specimens collected at least 6 hours apart. is a concentration of 0.1 g/L (1+ to 2+ on dipstick measurement) or more in at least two random urine specimens collected at least 6 hours apart. In a 24-hour specimen, proteinuria is a concentration of 0.3 g/L per 24 hours In a 24-hour specimen, proteinuria is a concentration of 0.3 g/L per 24 hours

10. 10 10 Edema Pathologic edema is clinically evident, generalized accumulation of fluid of the face, hands, or abdomen that is not responsive to 12 hours of bed rest. It may also be manifested as a rapid weight gain of more than 2 kg in 1 week. The presence of edema is no longer considered necessary for the diagnosis of preeclampsia Pathologic edema is clinically evident, generalized accumulation of fluid of the face, hands, or abdomen that is not responsive to 12 hours of bed rest. It may also be manifested as a rapid weight gain of more than 2 kg in 1 week. The presence of edema is no longer considered necessary for the diagnosis of preeclampsia

11. 11 11 MILD PREECLAMPSIASEVERE PREECLAMPSIA MATERNAL EFFECTS Blood pressureBP reading of 140/90 mm Hg x2, 4-6 hr apartRise to >160/110 mm Hg on two separate occasions 4-6 hr apart with pregnant woman on bed rest Mean arterial pressure (MAP) >105 mm Hg Weight gainWeight gain of more than 0.5 kg/wk during the second and third trimesters or sudden weight gain of 2 kg/wk at any time Same as mild preeclampsia Proteinuria — Qualitative dipstick — Ouantitative 24 hr analysis Proteinuria of 0.3 g/L in a 24 hr specimen or >0.1 g/L in a random day-time specimen on two or more occasions 6 hr apart (because protein loss is variable); with dipstick, values varying from 1+ to 2 + Proteinuria of >0.5 g/L in 24 hr or >4+ protein on dipstick EdemaDependent edema, some puffiness of eyes, face, fingers; pulmonary edema absent Generalized edema, noticeable puffiness; eyes, face, fingers; pulmonary edema possibly present ReflexesMay be normalHyperreflexia ≥3+, possible ankle clonus Preeclampsia

12. 12 12 MILD PREECLAMPSIASEVERE PREECLAMPSIA MATERNAL EFFECTS ReflexesMay be normalHyperreflexia ≥3+, possible ankle clonus Urine outputOutput matching intake, ≥30 ml/hr or <650 ml/24 hr <20 ml/hr or <400 ml to 500 ml/24 hr HeadacheAbsent/transientSevere Visual problemsAbsentBlurred, photophobia, blind spots on funduscopy Irritability/changes in affect TransientSevere Epigastric painAbsentPresent Serum creatinineNormalElevated ThrombocytopeniaAbsentPresent AST elevationNormal or minimalMarked Preeclampsia

13. 13 13 MILD PREECLAMPSIASEVERE PREECLAMPSIA FETAL EFFECTS Placental perfusionReducedDecreased perfusion expressing as IUGR in fetus; FHR: late decelerations Premature placental aging Not apparentAt birth placenta appearing smaller than normal for duration of pregnancy, premature aging apparent with numerous areas of broken syncytia, ischemic necroses (white infarcts) numerous, intervillous fibrin deposition (red infarcts) Preeclampsia

14. 14 14 HELLP syndrome is a laboratory diagnosis for a variant of severe preeclampsia characterized by hemolysis (H), elevated liver enzymes (EL), and low platelets (LP) is a laboratory diagnosis for a variant of severe preeclampsia characterized by hemolysis (H), elevated liver enzymes (EL), and low platelets (LP)

15. 15 15 Eclampsia Seizure activity or coma in woman diagnosed with preeclampsia Seizure activity or coma in woman diagnosed with preeclampsia No history of previous seizure disorder No history of previous seizure disorder Presentation varies Presentation varies One third in labor One third in labor One third during delivery One third during delivery One third within 72 hours postpartum One third within 72 hours postpartum

16. 16 16 Chronic hypertension with superimposed preeclampsia Women with chronic hypertension may acquire preeclampsia or eclampsia Women with chronic hypertension may acquire preeclampsia or eclampsia Increases morbidity for mother and fetus Increases morbidity for mother and fetus

17. 17 17 Etiology Unique to human pregnancies Unique to human pregnancies Signs and symptoms develop only during pregnancy and disappear after birth of the fetus and passage of placenta Signs and symptoms develop only during pregnancy and disappear after birth of the fetus and passage of placenta The cause is unknown The cause is unknown Associated high risk factors Associated high risk factors Primigravidity Primigravidity Multifetal pregnancy Multifetal pregnancy Preexisting medical condition (Obesity, Chronic renal disease, Chronic hypertension, Diabetes) Preexisting medical condition (Obesity, Chronic renal disease, Chronic hypertension, Diabetes) Preeclampsia in a prior pregnancy or Family history of PIH Preeclampsia in a prior pregnancy or Family history of PIH Maternal age 40 years Maternal age 40 years Rh incompatibility Rh incompatibility

18. 18 18

19. 19 19 Etiology Current theories Current theories Increase vasoconstrictor tone Increase vasoconstrictor tone Abnormal prostaglandin action Abnormal prostaglandin action Endotelian cell activation Endotelian cell activation Immunologic factor Immunologic factor Genetic disposition Genetic disposition diet diet

20. 20 20 Pathophysiology May be caused by disruptions in placental perfusion and endothelial cell dysfunction Main pathogenic factor is not an increase in BP, but poor perfusion resulting from vasospasm Main pathogenic factor is not an increase in BP, but poor perfusion resulting from vasospasm Arteriolar vasospasm diminishes diameter of blood vessels, which impedes blood flow to all organs and increases BP Arteriolar vasospasm diminishes diameter of blood vessels, which impedes blood flow to all organs and increases BP Significant decreases in placental, kidney, liver, and brain function Significant decreases in placental, kidney, liver, and brain function

21. 21 21 Pathophysiology reflects alterations in the normal adaptations of pregnancy. reflects alterations in the normal adaptations of pregnancy. Normal physiologic adaptations to pregnancy include increased blood plasma volume, vasodilatation, decreased systemic vascular resistance, elevated cardiac output, and decreased colloid osmotic pressure Normal physiologic adaptations to pregnancy include increased blood plasma volume, vasodilatation, decreased systemic vascular resistance, elevated cardiac output, and decreased colloid osmotic pressure Pathologic changes in the endothelial cells of the glomeruli (glomeruloendotheliosis) are uniquely characteristic of preeclampsia, particularly in nulliparous women (85%). Pathologic changes in the endothelial cells of the glomeruli (glomeruloendotheliosis) are uniquely characteristic of preeclampsia, particularly in nulliparous women (85%). The main pathogenic factor is not an increase in blood pressure but poor perfusion as a result of vasospasm. Arteriolar vasospasm diminishes the diameter of blood vessels, which impedes blood flow to all organs and raises blood pressure The main pathogenic factor is not an increase in blood pressure but poor perfusion as a result of vasospasm. Arteriolar vasospasm diminishes the diameter of blood vessels, which impedes blood flow to all organs and raises blood pressure Function in organs such as the placenta, kidneys, liver, and brain is depressed by as much as 40% to 60% Function in organs such as the placenta, kidneys, liver, and brain is depressed by as much as 40% to 60%

22. 22 22

23. 23 23 HELLP syndrome Laboratory diagnostic variant (not clinical) variant of severe preeclampsia involves hepatic dysfunction, characterized by: Laboratory diagnostic variant (not clinical) variant of severe preeclampsia involves hepatic dysfunction, characterized by: Hemolysis (H) Hemolysis (H) Elevated liver enzymes (EL) Elevated liver enzymes (EL) Low platelets (LP) Low platelets (LP)

24. 24 24 HELLP syndrome The exact mechanism is unknown The exact mechanism is unknown Arteriolar vasospasm, endothelial damage, and platelet aggregation with resultant tissue hypoxia are the underlying mechanisms for the pathophysiology of HELLP syndrome Arteriolar vasospasm, endothelial damage, and platelet aggregation with resultant tissue hypoxia are the underlying mechanisms for the pathophysiology of HELLP syndrome

25. 25 25 HELLP syndrome epigastric or right upper quadrant abdominal pain (possibly related to hepatic ischemia) 65% epigastric or right upper quadrant abdominal pain (possibly related to hepatic ischemia) 65% nausea and vomiting 50% nausea and vomiting 50%

26. 26 26 HELLP syndrome Lab test Lab test platelet count less than 100,000/mm3 platelet count less than 100,000/mm3 Elevate liver enzymes levels Elevate liver enzymes levels  aspartate aminotransferase [AST]  alanine aminotransferase [ALT]) evidence of intravascular hemolysis (burr cells on peripheral smear or elevated bilirubin level) evidence of intravascular hemolysis (burr cells on peripheral smear or elevated bilirubin level) A unique form of coagulopathy (not DIC) occurs with HELLP syndrome. The platelet count is low, but coagulation factor assays, A unique form of coagulopathy (not DIC) occurs with HELLP syndrome. The platelet count is low, but coagulation factor assays, prothrombin time prothrombin time partial thromboplastin time partial thromboplastin time bleeding time remain normal bleeding time remain normal

27. 27 27 HELLP syndrome Associated with increased risk for: Associated with increased risk for: Pulmonary edema Pulmonary edema Acute renal failure Acute renal failure Disseminated intravascular coagulation (DIC) Disseminated intravascular coagulation (DIC) Placental abruption Placental abruption Liver hemorrhage or failure Liver hemorrhage or failure Adult respiratory distress syndrome Adult respiratory distress syndrome Sepsis Sepsis Stroke Stroke High risk for maternal death High risk for maternal death

28. Care management

29. 29 29 Chronic Hypertension Chronic hypertension associated with increased incidence of: Chronic hypertension associated with increased incidence of: Abruptio placentae Abruptio placentae Superimposed preeclampsia Superimposed preeclampsia Increased perinatal mortality Increased perinatal mortality Fetal effects Fetal effects Fetal growth restriction Fetal growth restriction Small for gestational age Small for gestational age

30. 30 30 Chronic Hypertension – cont’d Ideally management begins before conception Ideally management begins before conception Lifestyle changes may be necessary Lifestyle changes may be necessary In postpartum, high risk women monitored closely for complications In postpartum, high risk women monitored closely for complications May safely breastfeed even though low levels of antihypertensive medications will be in breast milk May safely breastfeed even though low levels of antihypertensive medications will be in breast milk

31. 31 31 Assessment and nursing diagnosis Interview Medical history Medical history DM, renal disease, chronic hypertension DM, renal disease, chronic hypertension Family history Family history Social history (marital, nutritional status, cultural beliefs, activity level, health habits) Social history (marital, nutritional status, cultural beliefs, activity level, health habits) BP BP Abnormal weight gain Abnormal weight gain Increase sign of edema Increase sign of edema Presents of proteinuria Presents of proteinuria Headache Headache Visual disturbance Visual disturbance Epigastric pain Epigastric pain

32. 32 32 Assessment and nursing diagnosis Physical examination BP BP Observation of edema (distribution, degree, pitting) Observation of edema (distribution, degree, pitting) Symptom reflecting central nervous system and visual system Symptom reflecting central nervous system and visual system Deep tendon reflexes Deep tendon reflexes Fetal status Fetal status Uterine tonicity Uterine tonicity Sign of progression of mild preeclampsia to severe preeclampsia or eclampsia Sign of progression of mild preeclampsia to severe preeclampsia or eclampsia Respiration (crackles, diminished breath sound) Respiration (crackles, diminished breath sound)

33. 33 33

34. 34 34

35. 35 35 Assessment and nursing diagnosis Lab tests Complete blood cell count (including a platelet count), hematocrit, hemoglobin Complete blood cell count (including a platelet count), hematocrit, hemoglobin Clotting studies (including bleeding time, PT (protrombine time), PTT (partial thromboplastin time), and fibrinogen) Clotting studies (including bleeding time, PT (protrombine time), PTT (partial thromboplastin time), and fibrinogen) Liver enzymes (lactate dehydrogenase [LDH], AST, ALT), glucose level Liver enzymes (lactate dehydrogenase [LDH], AST, ALT), glucose level Chemistry panel (blood urea nitrogen [BUN], creatinine, glucose, uric acid), Chemistry panel (blood urea nitrogen [BUN], creatinine, glucose, uric acid), Type and screen, possible crossmatch Type and screen, possible crossmatch Proteinuria Proteinuria

36. 36 36 Lab tests NORMALPIHHELLP Hemoglobin/hematocrit12 to 16 gm/dl/37% to 47% May ↑↓ Platelets150,000 to 400,000/mm 3 Unchanged<100,000/mm 3 PT/PTT12 to 14 sec/60 to 70 secUnchanged Fibrinogen150 to 400 mg/dl300 to 600 mg/dlPresent Fibrin split products (FSP)Absent ↓ Blood urea nitrogen (BUN)10 to 20 mg/dl<10 mg/dl↑ Creatinine0.5 to 1.1 mg/dl<1 mg/dl↑ Lactate dehydrogenase (LDH)45 to 90 U/LUnchanged↑ Aspartate aminotransferase (AST)4 to 20 U/LUnchanged↑ Alanine aminotransferase (ALT)3 to 21 U/LUnchanged↑ Creatinine clearance80 to 125 ml/min130 to 180 ml/min↓ Burr cells/schistocytesAbsent Present Uric acid2 to 6.6 mg/dl4.5 to 6 mg/dl>10 mg/dl Bilirubin (total)0.1 to 1 mg/dlUnchanged or ↑↑

37. 37 37 Preeclampsia Nursing actions are derived from medical management, health care provider directives, and nursing diagnoses. Nursing actions are derived from medical management, health care provider directives, and nursing diagnoses. Early prenatal care, identification of pregnant women at risk for preeclampsia, and recognition and reporting of physical warning signs are essential components in the optimization of maternal and perinatal outcomes. Early prenatal care, identification of pregnant women at risk for preeclampsia, and recognition and reporting of physical warning signs are essential components in the optimization of maternal and perinatal outcomes. The role of the nurse's skills in assessing the woman for factors and symptoms of preeclampsia cannot be overestimated The role of the nurse's skills in assessing the woman for factors and symptoms of preeclampsia cannot be overestimated

38. 38 38 Mild preeclampsia Goal is to ensure maternal safety and deliver a healthy newborn Goal is to ensure maternal safety and deliver a healthy newborn May be safely managed at home by nurse (2-3 times per week) or by themself May be safely managed at home by nurse (2-3 times per week) or by themself Maternal assessment (weight, urine dipstick protein determination, BP, DFMC) Maternal assessment (weight, urine dipstick protein determination, BP, DFMC) Fetal assessment (ultrasound every 3 weeks, DFMC, NST or BPP 1-2 times per week Fetal assessment (ultrasound every 3 weeks, DFMC, NST or BPP 1-2 times per week Activity restriction Activity restriction Diet Diet

39. 39 39 Severe preeclampsia and HELLP- syndrome At greater risk for pregnancy complications At greater risk for pregnancy complications Should be hospitalized for at least 24 hours for observation and treatment if necessary Should be hospitalized for at least 24 hours for observation and treatment if necessary Intrapartum care Intrapartum care Magnesium sulfate Magnesium sulfate Control of blood pressure Control of blood pressure Postpartum care Postpartum care

40. 40 40 Severe preeclampsia and HELLP-syndrome Antepartum care focuses on stabilization and preparation for birth. focuses on stabilization and preparation for birth. Assessments include review of the cardiovascular system, pulmonary system, renal system, hematologic system, and CNS. Assessments include review of the cardiovascular system, pulmonary system, renal system, hematologic system, and CNS. Fetal assessments for well-being (e.g., NST, BPP, Doppler velocimetry) are important because of the potential for hypoxia related to uteroplacental insufficiency. Fetal assessments for well-being (e.g., NST, BPP, Doppler velocimetry) are important because of the potential for hypoxia related to uteroplacental insufficiency. Baseline laboratory assessments include metabolic studies for liver enzyme (AST, ALT, LDH) determination, complete blood count with platelets, coagulation profile to assess for DIC, and electrolyte studies to establish renal functioning. Baseline laboratory assessments include metabolic studies for liver enzyme (AST, ALT, LDH) determination, complete blood count with platelets, coagulation profile to assess for DIC, and electrolyte studies to establish renal functioning. Weight is measured on admission and every day thereafter. Weight is measured on admission and every day thereafter.

41. 41 41 Severe preeclampsia and HELLP-syndrome An indwelling urinary catheter facilitates monitoring of renal function and effectiveness of therapy. An indwelling urinary catheter facilitates monitoring of renal function and effectiveness of therapy. If appropriate, vaginal examination may be done to check for cervical changes. If appropriate, vaginal examination may be done to check for cervical changes. Abdominal palpation establishes uterine tonicity and fetal size, activity, and position. Abdominal palpation establishes uterine tonicity and fetal size, activity, and position. Electronic monitoring to determine fetal status is initiated at least once a day. Electronic monitoring to determine fetal status is initiated at least once a day. The woman's room must be close to staff and emergency drugs, supplies, and equipment. Noise and external stimuli must be minimized. Seizure precautions are taken The woman's room must be close to staff and emergency drugs, supplies, and equipment. Noise and external stimuli must be minimized. Seizure precautions are taken Bed rest is commonly ordered. Bed rest is commonly ordered.

42. 42 42 Severe preeclampsia and HELLP-syndrome Intrapartum nursing care involves continuous monitoring of maternal and fetal status as labor progresses. The assessment and prevention of tissue hypoxia and hemorrhage, both of which can lead to permanent compromise of vital organs, continue throughout the intrapartum and postpartum periods (Leicht & Harvey, 1999). involves continuous monitoring of maternal and fetal status as labor progresses. The assessment and prevention of tissue hypoxia and hemorrhage, both of which can lead to permanent compromise of vital organs, continue throughout the intrapartum and postpartum periods (Leicht & Harvey, 1999).

43. 43 43 Severe preeclampsia and HELLP-syndrome Magnesium sulfate As prophylaxis against convulsion As prophylaxis against convulsion I/V as a secondary infusion to the main intravenous (IV) line by volumetric infusion pump I/V as a secondary infusion to the main intravenous (IV) line by volumetric infusion pump An initial loading dose of 4 to 6 g of MgSO4 per protocol or physician's order is infused over 20 to 30 minutes. This dose is followed by a maintenance dose of magnesium sulfate that is diluted in an IV solution per physician's order (e.g., 40 g of magnesium sulfate in 1000 ml of lactated Ringer's solution) and administered by infusion pump at 1 to 3 g/hr. An initial loading dose of 4 to 6 g of MgSO4 per protocol or physician's order is infused over 20 to 30 minutes. This dose is followed by a maintenance dose of magnesium sulfate that is diluted in an IV solution per physician's order (e.g., 40 g of magnesium sulfate in 1000 ml of lactated Ringer's solution) and administered by infusion pump at 1 to 3 g/hr. This dose should maintain a therapeutic serum Mg level of 4 to 8 g/dl. This dose should maintain a therapeutic serum Mg level of 4 to 8 g/dl. Serum magnesium levels are obtained after the patient has received magnesium sulfate for 4 to 6 hours. Serum magnesium levels are obtained after the patient has received magnesium sulfate for 4 to 6 hours.

44. 44 44 Severe preeclampsia and HELLP- syndrome Magnesium sulfate Intramuscular (IM) MgSO4 is seldom used because absorption rate cannot be controlled, injections are painful, and tissue necrosis may occur. Intramuscular (IM) MgSO4 is seldom used because absorption rate cannot be controlled, injections are painful, and tissue necrosis may occur. However, the IM route may be used with some women who are being transported to a tertiary care center. However, the IM route may be used with some women who are being transported to a tertiary care center. The IM dose is 4 to 5 g given in each buttock, a total of 10 g (with 1% procaine possibly being added to the solution to reduce injection pain), and can be repeated at 4-hour intervals. The IM dose is 4 to 5 g given in each buttock, a total of 10 g (with 1% procaine possibly being added to the solution to reduce injection pain), and can be repeated at 4-hour intervals. Z-track technique should be used for the deep IM injection, followed by gentle massage at the site. Z-track technique should be used for the deep IM injection, followed by gentle massage at the site.

45. 45 45 Severe preeclampsia and HELLP- syndrome Magnesium sulfate Magnesium sulfate interferes with the release of acetylcholine at the synapses, Magnesium sulfate interferes with the release of acetylcholine at the synapses, decreasing neuromuscular irritability, decreasing neuromuscular irritability, depressing cardiac conduction, depressing cardiac conduction, and decreasing CNS (central nervous system) irritability. and decreasing CNS (central nervous system) irritability. Because magnesium circulates free and unbound to protein and is excreted in the urine, accurate recordings of maternal urine output must be obtained. Because magnesium circulates free and unbound to protein and is excreted in the urine, accurate recordings of maternal urine output must be obtained. Diuresis is an excellent prognostic sign; however, if renal function declines, all of the magnesium sulfate will not be excreted and can cause magnesium toxicity. Diuresis is an excellent prognostic sign; however, if renal function declines, all of the magnesium sulfate will not be excreted and can cause magnesium toxicity. Serum magnesium levels are obtained on the basis of the woman's response and if any signs of toxicity are present. Serum magnesium levels are obtained on the basis of the woman's response and if any signs of toxicity are present. Early symptoms of toxicity include nausea, a feeling of warmth, flushing, muscle weakness, decreased reflexes, and slurred speech. Early symptoms of toxicity include nausea, a feeling of warmth, flushing, muscle weakness, decreased reflexes, and slurred speech.

46. 46 46 Severe preeclampsia and HELLP-syndrome Magnesium sulfate Deep tendon reflexes Deep tendon reflexes Urine output Urine output Respiration rate Respiration rate Consciousness Consciousness If magnesium toxicity is suspected, the infusion should be discontinued immediately. If magnesium toxicity is suspected, the infusion should be discontinued immediately. Calcium gluconate, the antidote for magnesium sulfate, may also be ordered (10 ml of a 10% solution, or 1 g) and given by slow IV push (usually by the physician) over at least 3 minutes to avoid undesirable reactions such as arrhythmias, bradycardia, and ventricular fibrillation. Calcium gluconate, the antidote for magnesium sulfate, may also be ordered (10 ml of a 10% solution, or 1 g) and given by slow IV push (usually by the physician) over at least 3 minutes to avoid undesirable reactions such as arrhythmias, bradycardia, and ventricular fibrillation. Because magnesium sulfate is also a tocolytic agent, its use may increase the duration of labor. A preeclamptic woman receiving magnesium sulfate may need augmentation with oxytocin during labor. The amount of oxytocin needed to stimulate labor may be more than that needed for a woman who is not on magnesium sulfate. Because magnesium sulfate is also a tocolytic agent, its use may increase the duration of labor. A preeclamptic woman receiving magnesium sulfate may need augmentation with oxytocin during labor. The amount of oxytocin needed to stimulate labor may be more than that needed for a woman who is not on magnesium sulfate.

47. 47 47 Severe preeclampsia and HELLP-syndrome antihypertensive agent Starts if diastolic pressure is higher than 100 to 110 mm Hg Starts if diastolic pressure is higher than 100 to 110 mm Hg Order to decrease the diastolic blood pressure to 90 to 100 mm Hg Order to decrease the diastolic blood pressure to 90 to 100 mm Hg Prevent left ventricular failure and cerebral hemorrhage. Prevent left ventricular failure and cerebral hemorrhage. decrease the arterial pressure too much or too rapidly decrease the arterial pressure too much or too rapidly agent of choice is agent of choice is hydralazine IV hydralazine IV labetalol hydrochloride IV labetalol hydrochloride IV methyldopa orally methyldopa orally Nifedipine orally Nifedipine orally

48. 48 48 Eclampsia Premonitory signs and symptoms Premonitory signs and symptoms Headache Headache Blurred vision Blurred vision Severe epigastric pain Severe epigastric pain Altered mental status Altered mental status Tonic- clonic convulsions Tonic- clonic convulsions Hypotension Hypotension Coma Coma

49. 49 49 Eclampsia Immediate care Immediate care Ensure a patent airway Ensure a patent airway Patient safety a major concern Patient safety a major concern Post-seizure decision regarding timing and method of birth Post-seizure decision regarding timing and method of birth

50. 50 50 Eclampsia TONIC-CLONIC CONVULSION SIGNS Stage of invasion: 2 to 3 sec, eyes are fixed, twitching of facial muscles occurs Stage of invasion: 2 to 3 sec, eyes are fixed, twitching of facial muscles occurs Stage of contraction: 15 to 20 sec, eyes protrude and are bloodshot, all body muscles are in tonic contraction Stage of contraction: 15 to 20 sec, eyes protrude and are bloodshot, all body muscles are in tonic contraction Stage of convulsion: muscles relax and contract alternately (clonic), respirations are halted and then begin again with long, deep, stertorous inhalation, coma ensues Stage of convulsion: muscles relax and contract alternately (clonic), respirations are halted and then begin again with long, deep, stertorous inhalation, coma ensues

51. 51 51 EclampsiaINTERVENTION Keep airway patent: turn head to one side, place pillow under one shoulder or back if possible Call for assistance Protect with side rails up Observe and record convulsion activity Keep airway patent: turn head to one side, place pillow under one shoulder or back if possible Call for assistance Protect with side rails up Observe and record convulsion activity

52. 52 52 Eclampsia AFTER CONVULSION OR SEIZURE Do not leave unattended until fully alert Do not leave unattended until fully alert Observe for postconvulsion coma, incontinence Observe for postconvulsion coma, incontinence Use suction as needed Use suction as needed Administer oxygen via face mask at 10 L/min Administer oxygen via face mask at 10 L/min Start IV fluids and monitor for potential fluid overload Start IV fluids and monitor for potential fluid overload Give magnesium sulfate or other anticonvulsant drug as ordered Give magnesium sulfate or other anticonvulsant drug as ordered Insert indwelling urinary catheter Insert indwelling urinary catheter Monitor blood pressure Monitor blood pressure Monitor fetal and uterine status Monitor fetal and uterine status Expedite laboratory work as ordered to monitor kidney function, liver function, coagulation system, and drug levels Expedite laboratory work as ordered to monitor kidney function, liver function, coagulation system, and drug levels Provide hygiene and a quiet environment Provide hygiene and a quiet environment Support and keep woman and family informed Support and keep woman and family informed Be prepared for delivery when woman is in stable condition Be prepared for delivery when woman is in stable condition

53. 53 53 Postpartum nursing care After birth the symptoms of preeclampsia or eclampsia resolve quickly, usually within 48 hours. After birth the symptoms of preeclampsia or eclampsia resolve quickly, usually within 48 hours. The hematopoietic and hepatic complications of HELLP syndrome may persist longer. The hematopoietic and hepatic complications of HELLP syndrome may persist longer. These patients often show an abrupt decrease in platelet count, with a concomitant increase in LDH and AST levels, after a trend toward normalization of values has begun. Generally the laboratory abnormalities seen with HELLP syndrome resolve in 72 to 96 hours. These patients often show an abrupt decrease in platelet count, with a concomitant increase in LDH and AST levels, after a trend toward normalization of values has begun. Generally the laboratory abnormalities seen with HELLP syndrome resolve in 72 to 96 hours. Blood pressure is measured at least every 4 hours for 48 hours or more frequently as the woman's condition warrants. Blood pressure is measured at least every 4 hours for 48 hours or more frequently as the woman's condition warrants. Even if no convulsions occurred before the birth, they may occur within this period. Even if no convulsions occurred before the birth, they may occur within this period. MgSO4 infusion may be continued 12 to 24 hours after the birth. MgSO4 infusion may be continued 12 to 24 hours after the birth. Assessments for effects and side effects continue until the medication is discontinued. Assessments for effects and side effects continue until the medication is discontinued.

54. 54 54 Postpartum nursing care The woman is at risk for a boggy uterus and a large lochial flow as a result of the magnesium sulfate therapy. Uterine tone and lochial flow must be monitored closely. The woman is at risk for a boggy uterus and a large lochial flow as a result of the magnesium sulfate therapy. Uterine tone and lochial flow must be monitored closely. The preeclamptic woman is unable to tolerate excessive postpartum blood loss because of hemoconcentration. Oxytocin or prostaglandin products are used to control bleeding. The preeclamptic woman is unable to tolerate excessive postpartum blood loss because of hemoconcentration. Oxytocin or prostaglandin products are used to control bleeding. Ergot products (e.g., Ergotrate, Methergine) are contraindicated because they can increase blood pressure. Ergot products (e.g., Ergotrate, Methergine) are contraindicated because they can increase blood pressure. The woman is asked to report symptoms such as headaches and blurred vision. The woman is asked to report symptoms such as headaches and blurred vision. The nurse assesses affect, level of consciousness, blood pressure, pulse, and respiratory status before an analgesic is given for headache. The nurse assesses affect, level of consciousness, blood pressure, pulse, and respiratory status before an analgesic is given for headache. Magnesium sulfate potentiates the action of narcotics, CNS depressants, and calcium-channel blockers; these drugs must be administered with caution. Magnesium sulfate potentiates the action of narcotics, CNS depressants, and calcium-channel blockers; these drugs must be administered with caution. The woman may need to continue an antihypertensive medication regimen if her diastolic blood pressure exceeds 100 mm Hg at discharge. The woman may need to continue an antihypertensive medication regimen if her diastolic blood pressure exceeds 100 mm Hg at discharge.