Presentation is loading. Please wait.

Presentation is loading. Please wait.

Maternal Newborn Orientation Learning Module Reproductive Care Program of Nova Scotia September, 2013 Hypertensive Disorders of Pregnancy (HDP)

Similar presentations


Presentation on theme: "Maternal Newborn Orientation Learning Module Reproductive Care Program of Nova Scotia September, 2013 Hypertensive Disorders of Pregnancy (HDP)"— Presentation transcript:

1

2 Maternal Newborn Orientation Learning Module Reproductive Care Program of Nova Scotia September, 2013 Hypertensive Disorders of Pregnancy (HDP)

3 Objectives To review classifications of HDP To understand the maternal, fetal and neonatal implications To highlight skilled nursing care of women with HDP To review treatments and prevention of complications

4 Canadian Hypertension Education Program

5 Hypertension in Pregnancy Affects approximately 10% of all pregnancies Is a leading cause of maternal and fetal/neonatal mortality and severe morbidity in Canada and the world. responsible for approximately 13% of maternal deaths in Canada

6 Diagnosis of Hypertension* dBP 90 mmHg if dBP is < 90 mmHg but sBP is 140 mmHg, close monitoring is advised Severe hypertension sBP 160 mmHg and/or dBP 110 mmHg * Averaged over 2 measurements and (preferably) confirmed on 2 occasions; in 15 minutes if severe

7 Classification of HDP Pre-existing hypertension – pre-pregnancy, or prior to 20 weeks gestation Gestational hypertension – developing at or after 20 weeks gestation Two subgroups exist for both pre-existing and gestational hypertension: with co-morbid conditions (e.g. diabetes, cardiovascular disease) preeclampsia

8 Preeclampsia More wide-ranging maternal and fetal implications than hypertension alone Elevated BP (without preeclampsia) is of concern primarily as a potential cause of maternal morbidity Described as a potentially ominous disease peculiar to pregnancy; a pregnancy-specific syndrome of reduced organ perfusion (Gifford, et al, 2000)

9 Definition of Preeclampsia (SOGC) Hypertension (resistant, if pre-existing) Proteinuria – dipstick result of +2 or 24-hour collection of 0.3 to 0.5g/d Adverse conditions resulting from end-organ dysfunction including: complications such as oligohydramnios symptoms of headache, visual disturbances or RUQ pain abnormal lab tests - decreased platelet count or elevated liver enzymes (*results in pregnancy may differ from standard values)

10 Physiologic Changes During normal pregnancy: Blood volume increases by 30% to 50% Prostaglandin production is increased resulting in vasodilation and decreased vascular resistance BP normally falls during the second trimester Glomerular filtration rate increases by 50%; renal plasma flow increases by as much as 80% BUN and serum creatinine decrease

11 Placental Physiology In normal pregnancies: Placental implantation results in remodeling of the uterine spiral arteries. The result is large capacity vessels with low resistance, allowing increased placental blood flow and oxygenation Spiral artereries

12 Pathophysiology of Preeclampsia Placenta implantation is ineffective/incomplete Endothelial dysfunction associated with vascular reactivity and vasospasm Blood flow is decreased Placental perfusion may be significantly decreased Maternal arteries become damaged, potentially leading to activation of coagulation cascade

13 Progression of Preeclampsia The condition begins at conception; the only cure is delivery Symptoms and adverse effects worsen as pregnancy advances

14 Severe Preeclampsia Criteria for classification of severe preeclampsia: Onset <34 weeks gestation One or more adverse conditions, and/or Proteinuria 3 gm/d to 5 gm/d

15 Risk Factors for Preeclampsia Ethnicity: Nordic, African Canadian, South Asian Excessive weight gain Family history New partner 1 st pregnancy Previous history Age 40 Obesity (BMI 35) Pre-existing HTN Multiple pregnancy Inter-pregnancy interval < 2 years or 10 years

16 Maternal Complications Eclampsia Stroke Pulmonary edema Abruption End organ dysfunction

17 Signs/Symptoms of End-Organ Dysfunction: Headache Visual disturbances RUQ pain Nausea/vomiting Chest pain/dyspnea

18 Fetal Complications Oligohydramnios Intrauterine growth restriction (IUGR) Absent or reversed end-diastolic flow in umbilical artery (Doppler) Intrauterine fetal death (IUFD)

19 HELLP Syndrome Commonly considered a variant of preeclampsia Acronym for: Hemolysis – Hgb, LDH resulting from RBCs damaged by fibrin Elevated Liver enzymes – AST, ALT from liver edema and damage from fibrin Low Platelets – Thrombocytopenia < 150 x 10 9 /L from consumption of platelets due to damaged vascular endothelium

20 Caring for Women with HDP Antepartum fetal health surveillance Encourage FM counting Goal is 6 or more movements in 2 hours; at least daily and/or if movement is perceived If there are < 6 movements in 2 hours, further assessments are advised (SOGC) Ultrasound for fetal growth, AFV or BPP and/or umbilical artery Doppler

21 Caring for Women with HDP No evidence to support introduction of a low salt diet; strict bed rest is not advised Assess for signs and symptoms of complications or end-organ dysfunction associated with preeclampsia Follow an appropriate and consistent procedure for assessing BP

22 Guidelines for Assessment of BP Appropriate size cuff– 1 ½ times arm circumference Standard (26-33 cm) Large (33-41 cm) Extra large (> 41 cm) Woman should be sitting with the cuff positioned at the level of the heart Reprinted with permission of the Canadian Hypertension Education Program

23 Steps for Taking an Accurate BP A woman should rest comfortably for 5 minutes prior to taking BP; she should be seated with her feet resting on floor (or other), legs uncrossed with her arm well supported; she should not be talking during the assessment. No caffeine or nicotine within 30 minutes A regularly calibrated aneroid device should be used; if used, an automated BP device should be validated for use with women with preeclampsia.

24 Taking an Accurate BP Increase cuff pressure rapidly to approximately 30 mmHg above the disappearance of the radial pulse. Open the control valve so that the rate of deflation of the cuff is approximately 2 mmHg per heart beat Note the first appearance of sound (phase I Korotkoff) – sBP and absence of sound (Phase V Korotkoff) – dBP

25 Taking an Accurate BP Record the BP to the closest 2 mmHg on the manometer; record the womans pulse. For the initial assessment, BP should be taken on both arms; the arm with the higher BP should be then used consistently.

26 Antihypertensive Therapy Decisions about antihypertensive therapy are influenced by the presence of co-morbid conditions Women without co-morbid conditions should have therapy to lower dBP to 80 to 105 mmHg For women with co-morbid conditions, the goal is for sBP to be 130 to 139 mmHg, and the dBP to be 80 to 90 mmHg

27 Non-Severe Hypertension Labetolol 100 to 400 mg bid to tid (maximum 2g/day) Nifedipine PA tablets (intermediate release) – 10 to 20 mg po bid to tid (maximum 1200 mg/day) XL tablets (slow-release) – 20 to 60 mg po od (maximum 120 mg/d) Methyldopa 250 to 500 mg po bid to qid (maximum 2 g/day)

28 Therapy for Severe Hypertension Labetolol 20 mg IV; repeat 20 to 80 mg q 30 minutes, or 1 to 2 mg/min, to a maximum of 300 mg Hydralazine 5 mg IV; repeat 5 to 10 mg q 30 minutes, or 0.5 to 10 mg/hr, to a maximum of 20 mg Nifedipine (oral) 5 to 10 mg capsule (either bitten and swallowed or just swallowed), q 30 minutes, or 10 mg PA tablet q 45 minutes, to a maximum of 80 mg/d

29 Points re Antihypertensives Note that there are 3 preparations of Nifedipine - capsules, intermediate-release tablets (PA), and slow- release tablets (SL) Care must be taken to avoid a drop in dBP to < 80 mmHg as uteroplacental perfusion may be adversely affected. Women with preeclampsia are more likely to experience hypotension with antihypertensive treatment. Atenolol is not advised because of negative effects on fetal growth; ACE inhibitors and ARBs are fetotoxic, especially to the fetal kidneys

30 Labour and Birth Timing of birth depends on gestation, the presence and severity of complications and/or signs and symptoms of end-organ dysfunction If gestation is < 34 weeks, administration of steroids will be considered Induction (with cervical ripening, if necessary) is preferred unless there are other obstetrics indications for cesarean section

31 Other Considerations for Labour and Birth Early anesthesia consultation is advised Epidural/spinal anesthesia/analgesia is preferred, if indicated, provided platelets are >75 x 10 9 /L Platelets may be administered prior to vaginal or cesarean birth if < 20 to 50 x 10 9 /L Routine IV bolus prior to administration of epidural medication or to improve abnormal EFM tracing is avoided Antihypertensives are continued during labour

32 Magnesium Sulphate (MgSO 4 ) Given to prevent or treat eclampsia IV loading dose (usually 4 gm), followed by 1 to 2 gm/hr If a seizure occurs, another bolus will be given

33 Care of Women Receiving MgSO 4 Close assessment is indicated, including FHR Avoid fluid overload; administer MgSO 4 bolus in 100 ml of IV fluid Calculate intake and output hourly; caution if urine output is low because the risk of magnesium toxicity increases Assess for signs of magnesium toxicity: weakness hyporeflexia respiratory rate

34 Antidote 10 ml of 10% solution of calcium gluconate given IV over 3 minutes Stop MgSO 4 infusion Provide respiratory support

35 If a Seizure Occurs… Call for help Promote lateral position Prepare MgSO 4 bolus (and infusion if not already started) Post seizure: ensure adequacy of airway check vital signs, O 2 saturation, and FHR assess for signs of abruption

36 Postpartum Care Hypertension may worsen (or symptoms may first appear) following birth BP peaks at day 3 to 6 MgSO 4 will be continued – usually 24 hours (duration varies) NSAIDs should not be used if BP is difficult to control, platelets are < 50 x 10 9 /L, there is oliguria, or elevated creatinine

37 True/False Quiz 1.Stroke in pregnancy is unlikely unless sBP is >180 to 200 mmHg. TF 2.The BP goal for pregnant women with co- morbid conditions is 130 to 139/80 to 90 mmHg.TF 3.Pulmonary edema from fluid administration is a leading cause of death in women with preeclampsia. TF 4.MgSo 4 is given to lower BP.TF

38 True/False Answers 1.Stroke in pregnancy is unlikely unless sBP is >180 to 200 mmHg. TF 2.The BP goal for pregnant women with co- morbid conditions is 130 to 139/80 to 90 mmHg.TF 3.Pulmonary edema from fluid administration is a leading cause of death in women with preeclampsia. TF 4.MgSo 4 is given to lower BP.TF

39 Summary Hypertensive Disorders of Pregnancy are associated with a number of potentially serious maternal, fetal and pregnancy complications. Careful assessment for development of a HDP is essential throughout pregnancy, during labour and in the postpartum period.

40 Thank you! We welcome your feedback. Please take a few moments to complete a short evaluation: If you have any questions, please contact the RCP office at or


Download ppt "Maternal Newborn Orientation Learning Module Reproductive Care Program of Nova Scotia September, 2013 Hypertensive Disorders of Pregnancy (HDP)"

Similar presentations


Ads by Google