Hypertensive & Hemorrhagic Disorders PDF

Chapter 27: Hypertensive Disorders Chapter 28: Hemorrhagic Disorders CHRISTI CAMARENA, DNP, RNC-OB, C-EFM NURS 137 NURSING THE CHILDBEARING FAMILY  The following content is protected and may not be sh...

Chapter 27: Hypertensive Disorders Chapter 28: Hemorrhagic Disorders CHRISTI CAMARENA, DNP, RNC-OB, C-EFM NURS 137 NURSING THE CHILDBEARING FAMILY  The following content is protected and may not be shared, uploaded, or distributed. T H I S P O W E R P O I N T P R E S E N TAT I O N I S P R OT E C T E D BY U. S. C O P Y R I G H T L AW. I A M T H E E XC LU S I V E O W N E R O F T H E C O P Y R I G H T I N T H E C O U RS E M AT E R I A L S T H AT I C R E AT E. YO U M AY N OT R E P R O D U C E , D I S T R I B U T E , D I S P L AY, P O S T, O R U P LO A D M Y C O U R S E M AT E R I A L S O R R E C O R D I N G S O R C O U R S E M AT E R I A L S I N A N Y OT H E R WAY — W H E T H E R O R N OT A F E E I S C H A R G E D — W I T H O U T M Y E X P R E S S W R I T T E N C O N S E N T. T H E F O L LO W I N G T E X T B O O K I S U S E D T H R O U G H O U T T H I S P R E S E N TAT I O N : M AT E R N A L C H I L D N U R S I N G C A R E - 7 T H E D I T I O N , P E R R Y, C A S H I O N , A L D E N , O L S H A N S K Y, LO W D E R M I L K & H O C K E N B E R R Y, E L S E V I E R , 2 0 2 3. Objectives: 1. Differentiate among gestational hypertension, preeclampsia, and chronic hypertension. 2. Describe etiologic theories and pathophysiology of preeclampsia. 3. Compare care management of women with mild or severe gestational hypertension and preeclampsia with or without severe features. 4. Describe appropriate nursing actions during and after an eclamptic seizure. 5. Discuss the preconception, antepartum, intrapartum, and postpartum management of the woman with chronic hypertension. 6. Differentiate among causes of early pregnancy bleeding, including miscarriage, ectopic pregnancy, and cervical insufficiency. 7. Discuss signs and symptoms, possible complications, and management of miscarriage, ectopic pregnancy, and cervical insufficiency. 8. Compare and contrast placenta previa and placental abruption in relation to signs and symptoms. 9. Discuss the diagnosis and management of disseminated intravascular coagulation. Hypertensive Disorders: Significance and Incidence Hypertensive disorders are a major cause of perinatal morbidity and mortality worldwide, occurring in 5-10% of all pregnancies. Preeclampsia is also a leading cause of premature birth. Overall increasing risk in CA Postpartum Classification Above 140/90 → identify a head of time to get better management Gestational Gestational HTN After 20 Preeclampsia Multi disease system weeks of Eclampsia gestation HELLP Chronic Chronic HTN Before 20 Superimposed weeks of preeclampsia, eclampsia and HELLP gestation Gestational Hypertension §Onset of hypertension without proteinuria or other systemic findings diagnostic for preeclampsia after week 20 of the pregnancy. §Blood pressure normal adaptation to pregnancy: § SVR is lowest at 16 to 34 weeks and increases gradually to pre-pregnancy values by term. During the first trimester, SBP usually remains the same as the pre-pregnancy level but can decrease slightly as pregnancy advances. DBP begins to decrease in the first trimester, continues to drop until 24 to 32 weeks, and gradually returns to pre- pregnancy levels by term. §Hypertension defined as SBP≥140 mm HG or a DBP≥90 mm HG, recorded on two occasions at least 4 hours apart → if BP is high then recheck within 15 min then send to labor and delivery unit to get lab drowns to better see what going on §About 25-50% of cases go on to develop preeclampsia §Resolves after giving birth, may require 6 to 12 months → follow-up visit Preeclampsia Good summary so beneficial to know §Pregnancy-specific condition §Hypertension and proteinuria develop after 20 weeks gestation → other organ involve so always will see proteinuria and other symptoms §In the absence of proteinuria, preeclampsia is defined as hypertension ≥140 SBP or ≥90 DBP), along with either: § Thrombocytopenia § Impaired liver function § New-onset renal insufficiency → elevated creatinine § Pulmonary edema § New-onset cerebral or visual disturbances § Most commonly a severe, persistent headache Preeclampsia §Risk factors: Nulliparity, obesity, multifetal gestation, hx of preeclampsia, chronic HTN, preexisting DM or GDM, renal disease, autoimmune disease, chronic HTN, age≥35, assisted reproduction, limited sperm exposure* → if not exposed to foreign DNA from different type of sperms → failed to enlarge or expand and handle increase blood volume §Pathophysiology § Progressive disorder, placenta is the root cause. § Spiral arteries in the uterus fail to thin and develop saclike vessels with large diameters, therefore; they are unable to handle the increased blood volume of pregnancy. § Disruptions in placental perfusion result in ischemia and endothelial cell injury and dysfunction & stimulate release of toxins that damage endothelial cells=vasospasm → see lots of edema § Main pathogenic factor=POOR PERFUSION Preeclampsia First one to see §Reduced kidney perfusion=decreased glomerular filtration rate, protein and albumin is lost in the urine, uric acid clearance is decreased, serum uric acid levels increase, sodium and water are retained, decreased serum albumin results in fluid Elevate shift out of the hgb/hct intravascular space >>>hemoconcentration, increased blood viscosity, tissue edema, and pulmonary edema → swollen every where → blood getting thicker §Reduced liver perfusion=impaired liver function and AST/ALT → will put really high number on exam elevated liver enzymes, hepatic edema and subcapsular hemorrhage can occur>>>epigastric or Rupture RUQ pain → pt can lose their liver and required transplant with preeclampsia with HELLP → liver cause more severe conditions §Cerebral edema and retinal arteriolar vasopasm =increased CNS irritability >>>headaches, hyperreflexia, clonus, seizures, visual disturbances (scotoma and blurred or double vision) → once have seizures = ecclampsia Care Management Goal: Maternal Safety & Healthy (close to term) Newborn → won't get better until the placenta is out §Identifying and Preventing Preeclampsia § Early risk identification, low-dose aspirin & disease detection → 81 mg /day for women > 35 yo or hx of preeclampsia §Assessment § BP ≥140/90, severe range ≥160/110 Cut off for HTN → 2 different tx for regular vs severe § Many factors influence BP measurement, including the accuracy of the equipment used, the duration of the rest period before recording the BP, and the client’s posture. Deed tendon refluxes → put the pt on their side to get an accurate BP reading § Edema, DTRs, clonus, proteinuria ? protein dip is not very accurate § 24-hr urine collection ≥300mg or PCR≥0.3 → always draw 24hr urine lab but recently ppl use PCR = proteinuria over creatinine ratio § Severe features: New-onset headache not relieved by medication, visual disturbances & epigastric/RUQ pain → can weight themself to see if any changes or unable to put on socks  Care Management: Interventions Gestational Hypertension Severe Gestational Hypertension → with other symptoms so required to be in hospital since progressive quickly Preeclampsia without Severe Features Preeclampsia with Severe Features §Managed at home with frequent maternal/fetal §Hospitalized immediately and placed on magnesium assessment if reliable patient with BP≤155/105, no sulfate to prevent eclamptic seizures other symptoms → will be magnesium sulfate to decrease the CNS irritability and getting seizures §Antihypertensive medication as needed (≥160/110) might have reaction with magnesium sulfate §Twice weekly: BP monitoring, non-stress testing or. biophysical profile, amniotic fluid index, doppler studies How well the baby being perfuse §Symptom assessment: BP, urine output, CNS status, prn IUGR, symptom assessment, and weekly labs & § Labetalol, hydralazine, nifedipine (BP goal 140-150/90-100) → very specific order to get in the goal range A If BP 90/60 = insufficient fetal perfusion → distress urine studies epigastric/abdominal pain, UCs, vaginal bleeding (r/t placental abruption) §Activity restriction instead of complete bedrest §Labs: CBC (platelets), liver enzymes, serum creatinine §Patient education: abdominal pain, severe HA, UC’s, → low threshold = 1.1 is high for pregnancy vaginal bleeding, decreased fetal movement (daily fetal §Fetal assessment: continuous EFM, ultrasound, doppler movement count) studies as needed §Induction of labor at or near term. §Timing of birth (expectant management if150/100 (on 2 occasions 4 hours apart) should take an antihypertensive postpartum § Typically prescribed labetalol (low levels in breastmilk, no impact on supply) §Long-term follow-up https://www.cmqcc.org/resource/cvd-risks-infographic-english-pdf  Chapter 28: Hemorrhagic Disorders Second recording Early Pregnancy Bleeding Late Pregnancy Bleeding ◦ Miscarriage (SAB) ◦ Placenta Previa ◦ Cervical Insufficiency ◦ Placental Abruption ◦ Ectopic Pregnancy ◦ Cord Insertion and Placental Variations ◦ Clotting Disorders in Pregnancy  Early Pregnancy Bleeding: Miscarriage (Spontaneous Abortion, SAB) → some State consider abortion even there is no fetal heart beat before term and it is not legal so often many women die d/t complication §“A pregnancy that ends as a result of natural Whether cramping or not? → question ask to determine what type n what will be the tx causes before 20 weeks gestation.” §10-25% of pregnancies end in miscarriage with 80% of them before 12 weeks §Risk factors: chromosomal abnormalities (50%), extremes in maternal age, dietary deficiencies morbid obesity, heavy alcohol use, high blood glucose levels, excessive caffeine intake (>500mg daily) Ketoacidosic→ compromise Oz §Care Management: § Anxiety § Deficient Fluid Volume § Acute Pain § Situational Low Self-Esteem § Risk for Infection § Expectant management vs. medical management (Prostaglandin) § Surgical Management (D&C) Dilation and evacuation  "Incompetent cervix" Cervical Insufficiency → the cervix don't want to close and keep wanting to dilate §Acquired (previous cervical trauma from childbirth or mechanical dilation of cervix) §Congenital (collagen disorders, uterine anomalies, hx of DES use by patient’s mother) §Diagnosed by pelvic exam or ultrasound (60 ml=50% mortality) Cord Insertion and Placental Variations → might have 1 question but dont spend too much time on this slide §Vasa Previa: Fetal vessels lie over cervical os and are implanted into fetal membranes instead of the placenta. § Velamentous Insertion of the Cord: Cord vessels branch at the membranes then insert into placenta. § Succenturiate Placenta: Placenta is divided in 2 or more lobes and fetal vessels run between the lobes. → suspect twin but one die off §Battledore (marginal) Insertion of the Cord Risk for IUGR but baby could be normal § Vasa previa is often diagnosed during pregnancy by ultrasound using color and pulsed Doppler imaging §Potential Outcomes: Fetal hemorrhage, PPH Clotting Disorders in Pregnancy → often resolve after delivery but could not n happen pretty commonly 1 question §Disseminated Intravascular Coagulation (DIC): In the OB population, DIC is often triggered by the release of large amounts of tissue thromboplastin due to: Should be in the ICU § Placental Abruption § Preeclampsia and/or HELLP § Amniotic Fluid Embolus § Postpartum Hemorrhage § Severe Sepsis § Acute fatty liver of pregnancy § Retained IUFD Intrauterine fetal death §Management is correction of the underlying cause §Nursing Interventions: Assessment of bleeding, fluid/blood/clotting factor replacement, optimization of oxygenation, normal body temperature, hemodynamic monitoring, monitoring urine output, continuous EFM-deliver if pregnant → even with severly preterm baby since mom will be better w/out  Summary…What should you focus on? §Know the diagnostic criteria for gestational hypertension, preeclampsia (with and without severe features), eclampsia, HELLP syndrome and chronic hypertension §Differentiate between the care management for each hypertensive disorder of pregnancy §Understand the interventions for a client experiencing an eclamptic seizure, including magnesium sulfate §Understand the differences between types of miscarriages, signs and symptoms, and care management. §Differentiate between placenta previa and placental abruption, including care management differences. §Identify common causes of DIC in pregnancy and care management.