preeclampsia (1).docx

8/12/2019 preeclampsia (1).docx

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PROCEDURAL REPORT

ON

PREGNANCY COMPLICATION:

PRE-ECLAMPSIA

Thina C. Torres

Sahara L. Ork

BSN II

Submitted to:

Mrs. Virgincita C. Barredo

Clinical Instructor


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Pre-eclampsia is part of a spectrum of conditions known as the hypertensive

disorders of pregnancy.A multisystem disorder usually associated with raised blood

pressure and proteinuria, pre-eclampsia is relatively common, affecting 2-8% of

pregnancies. Although outcome is often good, pre-eclampsia can be devastating and life

threatening for both mother and baby, particularly in developing countries.2 It may also

lead to an increased risk of cardiovascular disease in later life.

Although the cause is not fully understood, factors thought to have a role includegenes, the placenta, the immune response, and maternal vascular disease Inadequate blood

supply to the placenta leads to endothelial dysfunction, which accounts for the secondary

changes in maternal target systems (such as platelet aggregation and vasoconstriction)

responsible for the signs and symptoms of pre-eclampsia.

Factors associated with an increased risk of pre-eclampsia (adapted from Duckitt et

al6)

First pregnancy Pre-eclampsia in a previous pregnancy 10 years since previous pregnancy 40 years of age Body mass index 35 at booking in Family history of pre-eclampsia (especially mother or sister) Diastolic blood pressure 80 mm Hg at booking in Proteinuria at booking in Multiple pregnancy Underlying medical condition:

Chronic hypertension

Renal disease Diabetes Presence of antiphospholipid antibodies

Symptoms and signs associated with pre-eclampsia

Hypertension and proteinuria Persistent severe headache Persistent new epigastric pain Visual disturbances (such as blurred vision, diplopia, or floating spots) Vomiting Hyperreflexia, with brisk tendon reflexes Epigastric pain or tenderness Severe swelling of hands, face, or feet of sudden onset Serum creatinine concentration increased (> 110 mol/l) Platelet count reduced to < 100109/l Evidence of microangiopathic haemolytic anaemia Liver enzyme activity elevated (alanine aminotransferase, aspartate

aminotransferase, or both)


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MEDICINES FOR PRE-ECLAMPSIA

DRUG INDICATION DOSAGE COMMENT

Magnesium Sulfate

Hydralazine

(Apresoline)

Diazepam (Valium)

Calcium gluconate

Muscle relaxant;

prevents seizures

Antihypertensive

(peripheral

vasodilator);

used to

decrease

hypertension

Halt seizures

Antidote for

magnesium

intoxication

Loading dose

4-6 g

Maintaning

dose 1-2g/hrIV

510 mg/IV

510 mg/IV

1 g/IV (10

mL of a 10%

solution)

Infuse loading dose slowly over

1530 min. Always administer

as a piggyback infusion.

Assess respiratory rate, urineoutput, deep tendon

reflexes, and clonus every hour.

Urine output should be over 30

mL/hour and

respiratory rate over 12/min.

Serum magnesium

level should remain below 7.5

mEq/L.

Observe for CNS depression and

hypotonia in

infant at birth and calcium

deficit in the mother.

Administer slowly to avoid

sudden fall in blood pressure.

Maintain diastolic pressure over

90 mm Hg to ensure adequate

placental filling.

Administer slowly. Dose may be

repeated q 510 min (up to 30

mg/hour).

Observe for respiratory

depression or hypotension in

mother and respiratory

depression and hypotonia

in infant at birth.

Have prepared at bedside when

administering magnesium

sulfate Administer at 5 mL/min.


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DIAGNOSTIC TESTS

Clinical presentation and workup findings:

Clinical and laboratory tests are intended to define and determine the severity of

pre-eclampsia. Headaches, tinnitus, phosphene signals, visual disorders, brisk tendonreflexes, and vigilance disorders are related to cerebral edema; oliguria to acute renal

failure; uterine contraction, vaginal bleeding to placental abruption; vomiting to HELLP

syndrome; band-like epigastric pain to subcapsular hepatic hematoma; and dyspnea to

cardiac failure. Eclampsia, the major neurological complication of pre-eclampsia, is defined

as a convulsive episode or any other sign of altered consciousness arising in a setting of

pre-eclampsia, and which cannot be attributed to a pre-existing neurological condition.

Clinical examination should include resting blood pressure measurement using an

appropriate cuff, and screening for weight gain, edema (including signs of acute pulmonary

edema and cerebral edema), cardiomyopathy, and acute renal failure. The fetus should be

assessed by electrocardiotocography. Laboratory tests include: a complete blood count

with platelets, haptoglobin, and lactate dehydrogenase; a blood smear to test for

schistocytes; bilirubin, aspartate transaminase, and alanine transaminase in order to

identify potential HELPP syndrome; electrolyte, urea, and creatinine assessment to check

for acute renal failure or uremia; 24-hour proteinuria; prothrombin, activated thrombin

time, and fibrinogen (microangiopathic hemolytic anemia); blood group; and irregular

antibody screening. Other examinations include fetal ultrasound with Doppler velocimetry

of the umbilical, cerebral, and uterine arteries, estimation of fetal weight, assessment of

fetal well-being by Manning score, and examination of the placenta.

Although the definition of severe pre-eclampsia varies,1,21,22 several components

of this definition are usually accepted: maternal systolic blood pressure 160 mmHg or

diastolic blood pressure 110 mmHg; maternal neurological disorders such as persistent

headaches, phosphene signals, tinnitus, and brisk, diffuse, polykinetic tendon reflexes,

eclampsia, acute pulmonary edema, proteinuria 5 g/day, oliguria 120 mol/L, HELLP syndrome, thrombocytopenia 300 mg total protein in a 24-hour urine collection, or a protein creatinine ratio

>30 mg/mmol).


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NURSING INTERVENTIONS

Monitor Antiplatelet Therapy. Because of the increased tendency for platelets to cluster

along arterial walls, a mild antiplatelet agent, such as low-dose aspirin, may prevent or

delay development of pre-eclampsia (Duley et al., 2009). Because aspirin is such a common,

over-the-counter drug, women may not appreciate that this is a serious drug prescriptionfor them. Be certain they are taking low-dose aspirin (50150 mg) as excessive salicylic

levels can cause maternal bleeding at the time of birth.

Promote Bed Rest. When the body is in a recumbent position, sodium tends to be excreted

at a faster rate than during activity. Bed rest, therefore, is the best method of aiding

increased evacuation of sodium and encouraging diuresis. Rest should always be in a

lateral recumbent position to avoid uterine pressure on the vena cava and prevent supine

hypotension syndrome.

Promote Good Nutrition. A woman needs to continue her usual pregnancy nutrition. At

one time, stringent restriction of salt was advised to reduce edema. This is no longer true

because stringent sodium restriction may activate the reninangiotensin-aldosterone

system and result in increased blood pressure, compounding the problem.

Provide Emotional Support. It is difficult for a woman with pre-eclampsia to appreciate

the potential seriousness of symptoms because they are so vague. Neither high blood

pressure nor protein in urine is something she can see or feel. She may be aware that

edema is present, but it seems unrelated to the pregnancy: it is her hands that are swollen,

not a body area near her growing child. Women are also used to having severe disorders

treated with some form of medication. With mild pre-eclampsia, no medication other than

low-dose aspirin is prescribed. This can make a woman underestimate the severity of her

situation. She may take instructions such as getting rest lightly. In addition, it is not always

easy to comply with an instruction such as to get additional rest during the day. Ninety

percent of women of childbearing age work outside their home at least part time. Most

women with PIH, therefore, are being asked to take a leave of absence from work. Most

working women contribute financially to the running of their household, such as providing

a part or all of the mortgage or rent or car payments. If a woman is unmarried, her income

is probably her sole support, so it seems difficult to leave work on the basis of a few vague

symptomsa little swelling or a little headache. Health care providers cannot solve

financial problems, but be certain to ask enough questions at health care visits so that

financial need, if present, can be determined. Questions such as, What will it mean to your

family if you have to be on bed rest? and How long a maternity leave does your workallow? bring concerns out into the open.A woman with small children must usually make

child care arrangements so she can get sufficient rest. The woman who spends

considerable time chauffeuring school-age children to activities may need to investigate car

pooling as an alternative. Another may need to discontinue being a volunteer leader or ask

her family for more help around the house, such as cleaning or cooking. Ask, What will it

mean to your other children or your husband if you have to rest? to allow her to begin to

face these problems. Remember that having a wife or mother on bed rest is a stress on the

total family, so other family members may need support as well. Women with beginning

signs of hypertension will be seen approximately weekly or more frequently for the


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remainder of pregnancy. Be certain a woman understands that if symptoms worsen before

her next health care visit, she should call and report them immediately. Because there is no

cure for pre-eclampsia, adherence to bed rest and attempts to reduce symptoms early are

crucial.

Monitor Maternal Well-being. Take blood pressure frequently (at least every 4 hours) or

with a continuous monitoring device to detect any increase, which is a warning that a

womans condition is worsening. Obtain blood studies such as a complete blood count,platelet count, liver function, blood urea nitrogen, and creatine and fibrin degradation

products as ordered to assess renal and liver function and the development of DIC, which

often accompanies severe vasospasm. Because a woman is at high risk for premature

separation of the placenta and resulting hemorrhage, a blood sample for type and cross-

match is usually also obtained. Daily hematocrit levels are used to monitor blood

concentration. This level will rise if increased fluid is leaving the bloodstream for

interstitial tissue (edema). Also, anticipate the need for frequent plasma estriol levels (a

test of placenta function) and electrolyte levels. A womans optic fundus is assessed daily

for signs of arterial spasm, edema, or hemorrhage. Obtain daily weights at the same time

each day as another evaluation of fluid retention. Ensure that a woman is wearing the same

amount of clothing at each weighing so any change in weight is not influenced by a change

in the weight of her clothing. An indwelling urinary catheter may be inserted to allow

accurate recording of output and comparison with intake. Urinary output should be more

than 600 mL per 24 hours (more than 30 mL/hr); an output lower than this suggests

oliguria. Urinary proteins and specific gravity are measured and recorded with voiding or

hourly if an indwelling catheter is present. A 24-hour urine sample may be collected for

protein and creatinine clearance determinations to evaluate kidney function. A woman

with mild pre-eclampsia spills between 0.5 g and 1 g of protein every 24 hours (1_ on a

random sample); a woman with severe pre-eclampsia spills approximately 5 g per 24 hours

(3_ to 4_ on an individual specimen).

Monitor Fetal Well-being. Generally, single Doppler auscultation at approximately 4-hour

intervals is sufficient at this stage of management. However, the fetal heart rate may be

assessed continuously with an external fetal monitor. A woman may have a nonstress test

or biophysical profile done daily to assess uteroplacental sufficiency. Oxygen

administration to the mother may be necessary to maintain adequate fetal oxygenation and

prevent fetal bradycardia.


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Prenatal Care

On the planned day of birth, a pediatrician should be alerted that the woman has

been receiving magnesium sulfate. This is because if magnesium sulfate is given

intravenously

within 2 hours of a babys birth, the baby may beborn with respiratory depression because

the drug crosses the placenta. A fetal heart rate monitor may show loss of variability ofheartbeat immediately after magnesium therapy; an ultrasound may reveal reduced fetal

breathing movements. Observe carefully for other signs of fetal effects, such as late

deceleration with labor contractions. Magnesium sulfate is continued for 12 to 24 hours

after birth in the woman to prevent eclampsia during this period. The dose is then tapered

and discontinued. Breastfeeding usually is delayed until the medication is discontinued. A

long-term effect of magnesium sulfate therapy is osteoporosis. A woman may be started on

a course of calcium postpartally to decrease this problem.

Intraprenatal Care

If the pregnancy is more than 24 weeks along, a decision about birth will be made as

soon as a womans conditionstabilizes, usually 12 to 24 hours after the seizure. There is

some evidence that a fetus does not continue to grow after pre-eclampsia/eclampsia

occurs, so terminating the pregnancy at this point is appropriate for both mother and child.

For an unexplained reason, fetal lung maturity appears to advance rapidly with PIH

(possibly from the intrauterine stress), so even though the fetus is younger than 36 weeks,

the lecithinsphingomyelin ratio may indicate fetal lung maturity.

Cesarean birth is always more hazardous for the fetus because of the association of

retained lung fluid. Further, a woman with eclampsia is not a good candidate for surgery.

Because her vascular system is low in volume, she may become hypotensive with regional

anesthesia, such as an epidural block. The preferred method for birth, therefore, is vaginal.

If labor does not begin spontaneously, rupture of the membranes or induction of labor with

intravenous oxytocin may be instituted. If this is ineffective and the fetus appears to be in

imminent danger, cesarean birth is indicated.

Post Delivery Care

Postpartum hypertension may occur up to 10 to 14 days after birth, although it

usually occurs no more than 48 hours after birth. Monitoring blood pressure in the

postpartumperiod and being alert that pre-eclampsia can occur as late as 2 to 3 weeks post

birth is essential to detect residual hypertensive or renal disease (Cantey, Tecklenburg, &Titus, 2007). Urge women who had an elevation of blood pressure during pregnancy to

return for a postpartum checkup to have their blood pressure evaluated to be certain it has

returned to normal.

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