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Chapter 11:
The Critically Ill Pregnant
Woman
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Physiological Changes in Pregnancy
See Table 11-1.
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Cardiac Output Changes in Pregnancy and
Labor and Delivery
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Critical Periods of Development
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Teratogenic Medication Risk Categories
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Clinical Terminology: Hypertensive
Disorders of Pregnancy
See Box 11-2.
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Pathophysiology of Severe Preeclampsia
Some unknown
cause
Arteriolar
vasospasms and
vasoconstriction
Vascular
endothelial
damage
Alteration in tissue
perfusion/
Leakage of plasma
in EVS + platelet
aggregation
Decreased
colloidal osmotic
pressure
Potential for
hypovolemia,
pulmonary edema
oxygenation to
vital organs
Liverischemia/necrosis/
edema
Kidneysdecreased
GFR/oliguria/
Brain- cerebral
edema/
proteinuria
seizures
hemorrhage/
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Hemodynamic Values in Nonpregnant and
Pregnant Women
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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.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Magnesium Sulfate Administration
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Nursing Interventions for Severe
Preeclampsia
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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 KleihauerBertke test
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Special Considerations During CPR
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Arterial Blood Gas Values in Nonpregnant
and Pregnant Women
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Strategies for Promoting Emotional WellBeing in High-Risk Pregnancies
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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
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.
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.
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.
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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.
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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.
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