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INTRODUCTION:
Preeclampsia is defined as a pregnancy-specific syndrome observed after the 20th week
of pregnancy with systolic blood pressure of >= 140 mm Hg or diastolic blood pressure of >= 90
mmHg, accompanied by significant proteinuria. Previous definitions included edema as part of
the diagnosis, but this has subsequently been dropped as being too non-specific. Likewise, the
criteria of a 30-point change in systolic blood pressure or a 15-point change in diastolic blood
pressure have been eliminated for the same reason in favor of an absolute blood pressure
threshold.
In the United States, hypertensive disorders of pregnancy account for nearly 15 percent of
maternal mortality; throughout the world these conditions are responsible for more than a third of
maternal deaths. The vast majority of these deaths and most infant deaths are due to
preeclampsia and eclampsia, arising either de novo or superimposed on chronic hypertension.
Long-term sequelae may also result. Women with chronic hypertension have an obvious long-
term risk from the persistent hypertension. However, women with preeclampsia, despite the
resolution of the disorder postpartum, are also at increased risk of cardiovascular disease in later
life compared to women with pregnancies without preeclampsia.
Two millennia ago, Celsus described puerperal seizures, termed eclampsia. In the late
19th century, it was recognized that increased blood pressure and proteinuria preceded the
seizures. Soon thereafter, physicians realized that these findings constituted the syndrome of
preeclampsia, which increased maternal and infant mortality and morbidity even if seizures did
not occur. Over the past decade, a great deal of attention has been focused on understanding the
pathophysiology of preeclampsia to assist in devising therapeutic interventions for subsequent
assessment. This has resulted in a better understanding of the pathophysiological mechanisms,
but many details remain unclear. In addition, clinical trials testing two promising therapies,
calcium supplementation and aspirin, to prevent preeclampsia or improve its outcome,
demonstrated at most minor benefits. Progress has been limited by the lack of animal models
with placental physiology comparable to humans. In contrast to preeclampsia, in chronic
hypertension where prior knowledge of pathophysiology of the disease in nonpregnant women
provides useful insight to treatment, little work has been done to apply these insights to therapy
for women with hypertension who become pregnant.
Infections of the urinary tract are the second most common type of infection in the body.
Urinary tract infections (UTIs) account for about 8.3 million doctor visits each year. Women and
pregnant mothers are especially prone to UTIs for reasons that are not yet well understood. One
woman in five develops a UTI during her lifetime. UTIs in men are not as common as in women
but can be very serious when they do occur.
This study wants to lessen the prevalence of this complication among pregnant woman in
order to decrease maternal and newborns mortality rate in our country. Nurses who play an
important role in the health care delivery system should expand and reach out people in the
community about the preeclampsia, HELLP Syndrome and their complications. By pursuing the
government’s project on Information, Education and Communication (IEC) about this disease,
surely will decrease the statistics of its incedence not only in our country but worldwide.
NAME: Liza
SEX: Female
NATIONALITY: Filipino
TIME: 11:00 pm
DATE DISCHARGED:?
TIME:?
DIAGNOSIS: Pregnancy Uterine 21 5/7 Weeks Age of Gestation Cephalic In PreTerm labor
Gravida 4 Para 3 (1201), Chronic Hypertension with Superimposed Preeclampsia Severe T/C
CVA Bleed, Poor OB History; HELLP Syndrome;UTI
OBJECTIVES OF THE STUDY
GENERAL OBJECTIVES
Client Centered
Nurse Centered
• To describe effects of illness on individuals and family members’ roles and functions
SPECIFIC OBJECTIVES
Client-Centered
• Use the nursing process to provide individualized care for clients who has experienced pre-
eclampsia, HELLPS Syndrome and UTI
• Support client and family, and encourage them to ask questions so that information could be
clarified and understood
Nurse-Centered
• Learn the pathophysiology and manifestations of pre-eclampsia, HELLPS Syndrome and UTI
• Identify common diagnostic tests used for the said condition and their nursing implications.
Liza experienced measles, mumps, and chickenpox as a child. She also experienced
diarrhea, fever, cough, colds and self-medicates with over the counter medications like
paracetamol and cough medications before she became pregnant. She has completed all her
immunizations and including three shots of tetanus toxoid during her prenatal visits. She has no
known allergies. She was never been hospitalized before. This was the first time patient she was
admitted in the hospital. She has taken prescribed ferrous sulfate regularly at home.
On June 1998, when she was 5 years old, patient had Dengue Hemorrhagic Fever and had
been hospitalized for 2 weeks at Montero Hospital in Malita.
On September 2007, she gave birth to her first baby through Normal Spontaneous
delivery at Malita Provincial Hospital. She was diagnosed to have Pregnancy Induced
Hypertension with a blood pressure of 160/ 120 mmHg and confined at the said hospital for
about 2 weeks.
On July 2009, she gave birth to her second baby at Davao Regional Hospital; the baby
was delivered preterm by 28 weeks AOG. She was diagnosed again to have Pregnancy Induced
hypertension with a blood pressure of 260/ 120 mmHg and confined at the said hospital for 2
weeks. Other than this she has no known chronic illnesses and endures only an occasional cough
and cold.
2 months prior to admission, patient visited their health center for her prenatal check up
and found out her Blood pressure of 180/110 mmHg. The Physician referred her to SPMC for
further evaluation but the patient refused due to fear of hospitalization.
1 month prior to admission, patient visited their health center for her 2nd prenatal check
up, her BP shoot up to 190/130 mmHg, Physician prescribed Nifedipine and Captopril and
patient complied with those medications but no BP monitoring done after the prenatal check up.
1 week prior to admission, patient fell down from the table due to an accident. Her head
hit the floor and caused severe headache and experienced tinnitus. No medications taken and
patient continued to do her activities of daily living such as managing her own “sari-sari” store.
1 day prior to admission, patient experienced facial asymmetry, sudden paralysis of the
left side of the body, sudden troubled speaking, numbness, dizziness, orbital edema and loss of
blinking reflex. No consultation done due to fear of hospitalization.
1 hour prior to admission, the patient’s neighbor took the patient’s BP and the result was
260/150. Then the family rushed the patient to SPMC OB-ER.
Family History and Socio-cultural Background
Patient X is the eldest among seven siblings. Her mother passed away due to
cerebrovascular accident. Her father was known hypertensive and died also due to cerebral
vascular accident. The eldest, 4th, 5th and her youngest siblings are currently in good condition
while the 2nd and her 3rd siblings are known hypertensive. Based on the genogram, the patient has
higher risk to acquire hypertensive disorder.
The patient is High School graduate and she is self employed. She has her own small
sari-sari store that supports their daily needs. She got married at the age of 24 years old and have
____ children. Her husband is a tricycle driver who earns 200-300 pesos per day.
Patient X was raised as Roman Catholic, were she learned about religious values but she
still believes in super natural forces and superstitious beliefs. When it comes to health matters,
she seeks the help of an albularyo and uses herbal medicines to treat their illnesses. But when
serious matters arise they still refer to medical professionals for help.
Lifestyle
The patient does not smoke. Her husband and relatives that share the same residence as
her are heavy smokers, consuming approximately 1-2 packs per day. She has sedentary lifestyle.
Her hobbies are watching t.v, taking charge with her small sari-sari store and playing mahjong
with her friends. Her diet consists frequently of her favorite dish “bulad” and “ginamus” with
tomatoes. She catches sleep at 8 in the evening and usually wakes at 6 in the morning.
Community Resources
Patient X resides in an urban type of community. Her home is located near the Matina
Health Center, where she usually goes for pre-natal check up. The modes of transportation in
their community are jeepneys and tricycles.
IV. ANATOMY AND PHYSIOLOGY
Central Nervous System
Cerebrum; is the largest and most developmentally advanced part of the human brain. It is
responsible for several higher functions, including higher intellectual function, speech, emotion,
integration of sensory stimuli of all types, initiation of the final common pathways for
movement, and fine control of movement.
The cerebrum is divided into a right and a left hemisphere and is composed of pairs of frontal,
parietal, temporal, and occipital lobes.
The left hemisphere controls the majority of functions on the right side of the body, while the
right hemisphere controls most of functions on the left side of the body The crossing of nerve
fibers takes place in the brain stem. Thus, injury to the left cerebral hemisphere produces sensory
and motor deficits on the right side, and vice versa.
Cerebellum; the second largest area, is responsible for maintaining balance and further control
of movement and coordination.
Brain stem; is the final pathway between cerebral structures and the spinal cord. It is responsible
for a variety of automatic functions, such as control of respiration, heart rate, and blood pressure,
wake-fullness, arousal and attention.
Medulla Oblongata; relays motor and sensory impulses between other parts of the brain and the
spinal cord. Reticular formation (also in pons, midbrain, and diencephalon) functions in
consciousness and arousal. Vital centers regulate heartbeat, breathing (together with pons) and
blood vessel diameter.
Hypothalamus; controls and intergrates activities of the autonomic nervous system and pituitary
gland. Regulates emotional and behavioral patterns and circadian rhythms. Controls body
temperature and regulates eating and drinking behavior. Helps maintain the waking state and
establishes patterns of sleep. Produces the hormones oxytocin and antidiuretic hormone.
Cardiovascular System
Heart; lies in the mediastinum, behind the body of the sternum. The shape of the heart tends to
resemble the chest. The heart has chambers divided into four cavities with the right and left
chambers (atria and the ventricles) separated by the septum. It pumps the blood to circulate
properly.
Baroreceptor, pressure-sensitive sensory receptors, are located in the aorta, internal carotid
arteries, and other large arteries in the neck and chest. They send impulses to the cardiovascular
center in the medulla oblongata to help regulate blood pressure. The two most important
baroreceptor reflexes are the carotid sinus reflex and the aortic reflex.
Chemoreceptors, sensory receptors that monitor the xhemical composition of blood, are located
close to the baroreceptors of the carotid sinus and the arch of the aorta in small structures called
carotid bodies and aortic bodies, respectively. These chemoreceptors detect changes in blood
level of O2, CO2, and H+.
Endocrine System
Renin-Angiotensin-Aldosterone system. When blood volume falls or blood flow to the kidneys
decreases, juxtaglomerular cells in the kidneys secrete renin into the bloodstream. In sequence,
renin and angiotensin converting enzyme (ACE) act on their substrates to produce the active
hormone angiotensin II, which raises blood pressure in two ways. First, angiotensin II is a potent
vasoconstrictor; it raises blood pressure by increasing systemic vascular resistance. Second, it
stimulates secretion of aldosterone, which increases reabsorption of sodium ions and water by
the kidneys. The water reabsorption increases total blood volume, which increases blood
pressure.
Antidiuretic hormone. ADH is produced by the hypothalamus and released from the posterior
pituitary in response to dehydration or decreased blood volume. Among other actions, ADH
causes vasoconstriction, which increases blood pressure.
Atrial Natriuretic Peptide. Released by cells in the atria of the heart, ANP lowers blood
pressure by causing vasodilation and by promoting the loss of salt and water in the urine, which
reduces blood volume.
Liver; is a reddish brown organ with four lobes of unequal size and shape. A human liver
normally weighs 1.4–1.6 kg (3.1–3.5 lb), and is a soft, pinkish-brown, triangular organ. It is both
the largest internal organ (the skin being the largest organ overall) and the largest gland in the
human body.
This organ plays a major role in metabolism and has a number of functions in the body,
including glycogen storage, decomposition of red blood cells, plasma protein synthesis, hormone
production, and detoxification. It lies below the diaphragm in the abdominal-pelvic region of the
abdomen. It produces bile, an alkaline compound which aids in digestion via the emulsification
of lipids. The liver's highly specialized tissues regulate a wide variety of high-volume
biochemical reactions, including the synthesis and breakdown of small and complex molecules,
many of which are necessary for normal vital functions. The various functions of the liver are
carried out by the liver cells or hepatocytes.
Reproductive System
Ovaries; it is an almond-shape organ. It contains the ova and is responsible in expelling the
ova. It also produces estrogen and progesterone.
Fallopian Tubes; is approximately 10-12 cm. It has three parts the isthmus, ampulla, and the
indifublum. Fertilization happen in the ampulla.
Uterus; is the organ for implantation and pregnancy. it is a pear shaped organ which has 3 parts;
fundus, corpus, and the isthmus. It gives nourishment to a growing fetus
Sensitivity to AngiotensinII
O2 supply- Hypertension
Extracellular Anasarca
Platelet consumed
DIC
Paradoxical Bleeding
CVA (Possible)
UTI
Change in Urine Color Immune response by the body (defense Inc. WBC subsequent
mechanism of the body to foreign bodies) to pus formation
Interruption in the normal homeostatic
environment of the urinary tract
Cytokine and
prostaglandin release
Multiparity(G4P3)
O2 supply- Hypertension
Extracellular Anasarca
Platelet consumed
DIC
Paradoxical Bleeding
CVA (Possible)
UTI
Change in Urine Color Immune response by the body (defense Inc. WBC subsequent
mechanism of the body to foreign bodies) to pus formation
Cytokine and
prostaglandin release
Narrative Pathophysiology
The general consensus is that preeclampsia is an endothelial cell disorder resulting in
mild-to-severe microangiopathy of target organs such as brain, liver, kidney, and placenta.While
hypertension may be the most common presenting symptom, it should not be viewed as the
initial pathogenetic process. Evidence of other organ involvement before hypertension becomes
fulminant is not uncommon. Several circulating markers of endothelial cell injury have been
shown to be elevated in women who develop preeclampsia before they became symptomatic.
These include endothelin, cellular fibronectin, plasminogen activator inhibitor-1, and altered
prostacyclin/thromboxane profile.Evidence to date suggests that oxidative stress; circulatory
maladaptation; inflammation; and humoral, mineral, and metabolic abnormalities may all
contribute to endothelial dysfunction and pathogenesis of preeclampsia.
Furthermore, it shows that persisting symptoms will make patient’s body sensitive to
AngiotensinII thus presenting manifestations occurs.
Many investigators believe that the placenta is the trigger for endothelial cell injury.
Evidence suggests that hypoperfused placentas produce various factors that are capable of
injuring endothelial cells. Recent data suggest that circulating factors that interfere with the
action of vascular endothelial growth factor (VEGF) and placental growth factor (PlGF) play a
major role in maternal manifestation of the disorder.
Endothelium regulates vascular permeability, vassal tone, and coagulation cascade. While
not all the factors produced by the placenta responsible for endothelial dysfunction have been
characterized, recent data show that an imbalance of pro- and anti-angiogenic factors produced
by the placenta may play a major role in mediating endothelial dysfunction. The circulating
proangiogenic factors secreted by the placenta include VEGF and PlGF. Other substances that
have been proposed, but not proven, to contribute to this process include tumor necrosis factor,
interleukins, various lipid molecules, and syncytial knots.
Angiogenesis is critical for successful placentation. Both VEGF and PlGF promote
angiogenesis by interacing with the VEGF receptor family. While both growth factors are
produced by placenta, the serum level of PlGF rises much more significantly in pregnancy.
Taylor et al demonstrated that the serum level of PlGF decreased in women who later developed
preeclampsia. The fall in serum level was notable as early as the second trimester in women who
developed preeclampsia and intrauterine growth restriction. In 2003, Maynard et al observed that
the serum levels of both VEGF and PlGF were decreased in women with preeclampsia.
However, the magnitude of decrease was less pronounced for VEGF since its serum level was
not as high as PlGF, even in normal pregnancy. Others have confirmed this finding and showed
that the serum level of PlGF decreased in women before they developed preeclampsia.
The normal expansion of blood volume by 50% that occurs with pregnancy is decreased
by 15-20% in patients with preeclampsia. This is the result of diminished plasma volume,
leading to the relative hemoconcentration observed in preeclampsia. The plasma volume
abnormality involves a redistribution of extracellular fluid, such that interstitial fluid volume is
increased while the plasma volume is decreased. The hematocrit increases as the severity of
preeclampsia increases. Circulating blood volume is maintained by the increased vascular tone.
Whether the vasospasm is the cause or effect of the vascular endothelial injury is not known.
Regardless, this injury likely results in the microangiopathic hemolysis and disseminated
intravascular coagulation that accompanies severe preeclampsia.
The increased circulating blood volume and cardiac output of normal pregnancy results in
increased renal blood flow and glomerular filtration rates (GFRs). Women with preeclampsia
have markedly decreased renal blood flow and GFRs. Renal biopsies of these women show a
constellation of lesions, termed glomerular capillary endotheliosis. Some consider glomerular
capillary endothelial swelling that is accompanied by deposits of fibrinogen degradation products
within and under the endothelial cells as pathognomonic of the disease. These lesions resolve
within a month of delivery.
The exact cause of HELLP is unknown, but general activation of the coagulation cascade
is considered the main underlying problem. Fibrin forms crosslinked networks in the small blood
vessels. This leads to a microangiopathic hemolytic anemia: the mesh causes destruction of red
blood cells as if they were being forced through a strainer. Additionally, platelets are consumed.
As the liver appears to be the main site of this process, downstream liver cells suffer ischemia,
leading to periportal necrosis. Other organs can be similarly affected. HELLP syndrome leads to
a variant form of disseminated intravascular coagulation (DIC), leading to paradoxical bleeding,
which can make emergency surgery a serious challenge.
HELLP syndrome is a rare but serious illness in pregnancy. This illness can start quickly,
most often in the last 3 months of pregnancy (the third trimester). It can also start soon after you
have your baby. HELLP stands for Hemolysis, Elevated Liver enzyme levels and a Low Platelet
count. These are problems that can occur in women who have this syndrome.
Women who have HELLP syndrome may have bleeding problems, liver problems and
blood pressure problems that can hurt both the mother and the baby.
Infections of the urinary tract are the second most common type of infection in the body.
Urinary tract infections (UTIs) account for about 8.3 million doctor visits each year. Women are
especially prone to UTIs for reasons that are not yet well understood. One woman in five
develops a UTI during her lifetime. UTIs in men are not as common as in women but can be very
serious when they do occur. Pregnant women are at increased risk for UTIs. Beginning in week 6
and peaking during weeks 22 to 24, approximately 90 percent of pregnant women develop
ureteral dilatation, which will remain until delivery (hydronephrosis of pregnancy). Increased
bladder volume and decreased bladder tone, along with decreased ureteral tone, contribute to
increased urinary stasis and ureterovesical reflux. Additionally, the physiologic increase in
plasma volume during pregnancy decreases urine concentration. Up to 70 percent of pregnant
women develop glycosuria, which encourages bacterial growth in the urine. Increases in urinary
progestins and estrogens may lead to a decreased ability of the lower urinary tract to resist
invading bacteria. This decreased ability may be caused by decreased ureteral tone or possibly by
allowing some strains of bacteria to selectively grow.These factors may all contribute to the
development of UTIs during pregnancy.
The urinary tract, from the kidneys to the urethral meatus, is normally sterile and resistant
to bacterial colonization despite frequent contamination of the distal urethra with colonic
bacteria. Mechanisms that maintain the tract's sterility include urine acidity, emptying of the
bladder at micturition, ureterovesical and urethral sphincters, and various immunologic and
mucosal barriers.
About 95% of UTIs occur when bacteria ascend the urethra to the bladder and, in the case
of acute uncomplicated pyelonephritis, ascend the ureter to the kidney. The remainder of UTIs
are hematogenous. Systemic infection can result from UTI, particularly in the elderly. About
6.5% of cases of hospital-acquired bacteremia are attributable to UTI.
The etiology of preeclampsia and HELLP Syndrome is unknown. At present, 4 hypotheses are
the subject of extensive investigation, as follows:
SYMPTOMATOLOGY
-Visual disturbances typical of preeclampsia are scintillations and scotomata. These disturbances
are presumed to be due to cerebral vasospasm.
-Headache is of new onset and may be described as frontal, throbbing, or similar to a migraine
headache.
-Epigastric pain is due to hepatic swelling and inflammation, with stretch of the liver capsule.
Pain may be of sudden onset, is typically constant, and may be moderate to severe in intensity.
-While mild lower extremity edema is common in normal pregnancy, rapidly increasing or
nondependent edema may be a signal of developing preeclampsia. Edema is no longer included
among the criteria for diagnosis of preeclampsia.
-Rapid weight gain is a result of edema due to capillary leak as well as renal sodium and fluid
retention.
-Retinal vasospasm is a severe manifestation of maternal disease; consider delivery.
-Retinal edema is known as serous retinal detachment. This can manifest as severely impaired
vision if the macula is involved. It generally reflects severe preeclampsia and should lead to
prompt consideration of delivery. The condition typically resolves upon completion of pregnancy
and resolution of the hypertension and fluid retention.
-Right upper quadrant (RUQ) abdominal tenderness stems from liver swelling and capsular
stretch. Consider delivery.
-Brisk, or hyperactive, reflexes are common during pregnancy. Clonus is a sign of
neuromuscular irritability that usually reflects severe preeclampsia.
-In most normal pregnancies, the woman has some lower extremity edema by the third trimester.
In contrast, a sudden worsening in dependent edema, edema in nondependent areas (such as the
face and hands), or rapid weight gain suggest a pathologic process and warrant further evaluation
for preeclampsia. Common symptoms in women with the HELLP syndrome include a general
feeling of feeling unwell (malaise), nausea and/or vomiting, and pain in the upper abdomen.
Increased fluid in the tissues (edema) is also frequent. Protein is measurable in the urine of most
women with the HELLP syndrome. Blood pressure may be elevated. Occasionally, coma can
result from seriously low blood sugar
Urinary Tract Infection
Lower urinary tract infection (cystitis): The lining of the urethra and bladder becomes inflamed
and irritated.
Upper urinary tract infection (pyelonephritis): Symptoms develop rapidly and may or may not
include the symptoms for a lower urinary tract infection.
-Nausea
-Vomiting
-Flank pain: pain in your back or side, usually on only one side at about waist level
V. NURSING ASSESSMENT
Neurologic:
LOC: drowsy to stuporous, 3-4 mm pupil size anisocoric, with brisk reaction to light; GCS – 9
(E4- Spontaneous eye opening V1- none/mechanical ventilation M4 – withdraws to pain) (+)
doll’s eye reflex (+) babinski on right foot (-) corneal reflex, no visual threat
Respiratory
Patient is hooked to a mechanical ventilator through a tracheostomy. Ventilator set-up:
350/30/14/AC/5. (+) crackles on both lung fields. With equal breath sounds.
Cardiac
With atrial fibrillation; fine course, with occasional unifocal PVC’s. HR = 97 BP= 120’s-
130’s/60’s-70’s.
Musculo-Skeletal
No contractures noted but there was stiffness noted at the right wrists and both ankle joints; with
normal muscle tone and non-spontaneous movement; with severe weakness on both upper and
lower extremities.
Hematologic
Latest PTPA: INR = 1.02 Act = 98%
NURSING THEORY
Florence Nightingale
Environmental Theory
Jean Watson
Jean Watson as one of our n ursing theorist emphasized the value of our
profession as being able to assist and help our patients in attaining there
optimal level of health. She adopts a view of the human being as: “….. a valued person in
and of him or herself to be cared for, respected, nurtured, understood and assisted; in general a
philosophical view of a person as a fully functional integrated self. He, human is viewed as
greater than and different from, the sum of his or her parts”.
A. MANAGEMENT
MEDICAL CARE
Among infants born to women with preeclampsia who exhibited absent or reverse end-
diastolic umbilical artery Doppler flow velocity on fetal monitoring, an increased frequency of
hypoglycemia and polycythemia that is independent of the degree of gestational age and fetal
growth restriction has been found.
CNS effects of headache, dizziness, tinnitus, altered mental status, visual changes, and
seizures are thought to result from the increased vascular resistance and vasospasm of
preeclampsia. Although total cerebral blood flow and cerebral oxygen metabolism generally are
not altered in preeclampsia, regional changes certainly do occur. One third of patients who died
from eclampsia experienced cerebral hemorrhages of varying degrees. The visual changes may
result from vasospasm, ischemia, and hemorrhage in the occipital cortex, or from retinal artery
spasm, edema, or retinal detachment.
The therapy for this condition is to improve the platelet count by transfusion of fresh
frozen plasma or platelets. Complications associated with the syndrome are subcapsular liver
hematoma, hyponatremia, renal failure, and hypoglycemia. If hypoglycemia is present, this is
corrected by an intravenous dextrose infusion. Maternal hemorrhage may occur at birth because
of poor clotting ability. Epidural anesthesia is not possible because of a low platelet count and
possible bleeding in the site. Laboratory result returns to normal after birth.
B. SURGICAL CARE
-Peritoneal washing is a procedure used to look for malignant cells, i.e. cancer, in the
peritoneum. Peritoneal washes are routinely done to stage abdominal and pelvic tumours e.g.
ovarian cancer.
-Tubal ligation or tubectomy (informally known as getting one's "tubes tied") is a form of
female sterilization, in which the fallopian tubes are severed and sealed or "pinched shut", in
order to prevent fertilization
C. NURSING CARE
> Monitor v/s and report to the doctor if there is an abnormal findings.
> Give due medicines as ordered. Monitor therapeutic effect and side effects.
> Implement no added no salt diet.
> Provide educational teaching related to the disease.
PREVENTION
There currently are no well-established measures for preventing preeclampsia. Both low-
dose aspirin therapy and daily calcium supplementation have been studied as preventive
measures but have not been shown to be beneficial in the general pregnant population and are not
recommended for primary prevention of preeclampsia. Some evidence does support the use of
low-dose aspirin therapy and daily calcium supplementation in certain high-risk women.
Calcium supplementation has been shown to produce modest blood pressure reductions in
pregnant women who are at above- average risk for hypertensive disorders of pregnancy and in
pregnant women with low dietary calcium intake. An optimum calcium dosage for these women
has not been established. Low-dose aspirin therapy (100 mg per day or less) has been shown to
reduce the incidence of preeclampsia in women who were found to have an abnormal uterine
artery on Doppler ultrasound examination performed in the second trimester.
Although preeclampsia is not preventable, many deaths from the disorder can be
prevented. Women who do not receive prenatal care are seven times more likely to die from
complications related to preeclampsia-eclampsia than women who receive some level of prenatal
care. Some studies indicate that preeclampsia-related fatalities occur three times more often in
black women than in white women. Although the precise reasons for the racial differences
remain elusive, the differences may be indicative of disparities in health status, as well as access
to, and quality of, prenatal care. To decrease preeclampsia-related mortality, appropriate prenatal
care must be available to all women. Early detection, careful monitoring, and treatment of
preeclampsia are crucial in preventing mortality related to this disorder.
Because of the variable nature of the clinical presentation, the diagnosis of HELLP
syndrome is generally delayed for an average of eight days. Many woman with this syndrome are
initially misdiagnosed with other disorders, such as cholecystitis, esophagitis, gastritis, hepatitis
or idiopathic thrombocytopenia. In this one, early detection is a must especially in pregnancy
with complete blood count and liver test.
For Urinary Tract Infection, teach the patient about proper hygienic activities.
Encouraged to increase oral fluid intake and let the patient urinate every 4 hours in order to
prevent stasis of the urine. Wiping from the front to back when moving her bowels or urinating
must be practice. Wear cotton undergarment.
TREATMENT
Delivery remains the ultimate treatment for preeclampsia and HELLP. Although maternal
and fetal risks must be weighed in determining the timing of delivery, clear indications for
delivery exist. When possible, vaginal delivery is preferable to avoid the added physiologic
stressors of cesarean delivery. If cesarean delivery must be used, regional anesthesia is preferred
because it carries less maternal risk. In the presence of coagulopathy, use of regional anesthesia
generally is contraindicated.
Women with preeclampsia, HELLP Syndrome, UTI and preterm pregnancy can be
observed on an outpatient basis, with frequent assessment of maternal and fetal well-being.
Women who are noncompliant, who do not have ready access to medical care, or who have
progressive or severe preeclampsia should be hospitalized. Women whose pregnancy is remote
from term should be cared for in a tertiary care setting or in consultation with an obstetrician or
family physician who is experienced in the management of high-risk pregnancies.
During labor, the management goals are to prevent seizures and control hypertension.4
Magnesium sulfate is the medication of choice for the prevention of eclamptic seizures in women
with severe preeclampsia and for the treatment of women with eclamptic seizures. One
commonly used regimen is a 6-g loading dose of magnesium sulfate followed by a continuous
infusion at a rate of 2 g per hour. Magnesium sulfate has been shown to be superior to phenytoin
(Dilantin) and diazepam (Valium) for the treatment of eclamptic seizures.Although magnesium
sulfate commonly is used in women with preeclampsia, studies to date have been inadequate to
show that it prevents progression of the disorder.
Antihypertensive drug therapy is recommended for pregnant women with systolic blood
pressures of 160 to 180 mm Hg or higher24 and diastolic blood pressures of 105 to 110 mm Hg
or higher. The treatment goal is to lower systolic pressure to 140 to 155 mm Hg and diastolic
pressure to 90 to 105 mm Hg. To avoid hypotension, blood pressure should be lowered
gradually.
Although evidence about the potential adverse effects of most antihypertensive drugs has
been poorly quantified, use of many of these agents is contraindicated during pregnancy.
Hydralazine (Apresoline) and labetalol (Normodyne, Trandate) are the antihypertensive drugs
most commonly used in women with severe preeclampsia Nifedipine (Procardia) and sodium
nitroprusside (Nitropress) are potential alternatives, but significant risks are associated with their
use. Note that labetalol therapy should not be used in women with asthma or congestive heart
failure. Use of angiotensin-converting enzyme inhibitors is contraindicated in pregnant women
In women with preeclampsia, blood pressure usually normalizes within a few hours after
delivery but may remain elevated for two to four weeks. As previously noted, a diagnosis of
chronic hypertension is made if blood pressure remains elevated at 12 weeks postpartum.
Usually the high blood pressure, protein in the urine, and other effects of preeclampsia
and HELLP Syndrome go away completely within 6 weeks after delivery. However, sometimes
the high blood pressure will get worse in the first several days after delivery.
A woman with a history of preeclampsia and HELLP Syndrome is at risk for the
condition again during future pregnancies. Often, it is not as severe in later pregnancies.
Women who have high blood pressure problems during more than one pregnancy have an
increased risk for high blood pressure when they get older.
One of the leading causes of maternal death is pre-eclampsia and HELLP Syndrome —
the rapid elevation of blood pressure during pregnancy—which, if untreated, can lead to seizures
(eclampsia), kidney and liver damage, and ultimately, death. Eclampsia and severe pre-eclampsia
claim the lives of an estimated 63,000 women each year, as well as the lives of many of their
babies. The infant's risk of death depends on the severity of the preeclampsia and how
prematurely the baby is born.
Superimposed Preeclampsia can develop into eclampsia if the mother has seizures. There
can be other severe complications for the mother, including bleeding problems, premature
separation of the placenta from the uterus before the baby is born (placental abruption), rupture
of the liver, stroke, death (rarely). However, these complications are unusual. Severe
preeclampsia may lead to HELLP syndrome.
Patients who have had HELLP syndrome should be counseled that they have a 19 to 27
percent risk of developing the syndrome in subsequent pregnancies. They also have up to a 43
percent risk of developing preeclampsia in another pregnancy. Patients with class I HELLP
syndrome have the highest risk of recurrence. When the syndrome recurs, it tends to develop
later in gestation and is generally less severe after two episodes. Patients who have had HELLP
syndrome may subsequently use oral contraceptive pills safely.Patients who develop atypical
early-onset preeclampsia or HELLP syndrome should be screened for the presence of
antiphospholipid antibodies. Urinary Tract Infection patient who has a good compliance in
medical intervention can be treated easily especially if early diagnosed. Possible recurrence can
be, depending on some factors mentioned above, severity and damage of the previous UTI.
IX. DISCHARGE PLANNING (METHODS)
MEDICATION
• Reinforce importance of medication compliance to patient and her relatives; its time,
frequency, duration dosage and route.
• Advice to report unusual manifestations and side effects of drugs to physician.
• Monitor and evaluate effectiveness of medication regimen.
ENVIRONMENT/ EXERCISE/ADL
• Instruct patients watcher to provide calm and non stressful environment to prevent stimuli that
could lead to seizures and an increase in Intracranial Pressure
• Advice to limit visitors
• Provide environment within normal room and body temperature.
• Maintain safe environment.
• Institute seizure precaution.
• Initiate positional precaution to prevent increase in intracranial pressure.
• Teach patient’s relative to perform passive range of motion exercises on patient’s extremities.
• Encouraged proper hygienic practices to avoid infections and further complications.
Diet
• Refer to dietician for dietary instructions.
SPIRITUAL / SEXUAL
• Encourage patient’s relatives to seek spiritual support.
• Encourage patient’s husband on alternative ways on showing affections such as hugs and
kisses.
X. INSIGHTS
XI. Bibliography
Maternal And Child Health Nursing, 4th Edition 2003. Adelle Pilliteri
http://www.nhlbi.nih.gov/resources/hyperten_preg/index.html
http://www.capefearvalley.com/outreach/outreach/peapods/hypertension Pregnancy/
American College of Obstetrician & Gynecologist (2001). ACOG practice bulletin; Chronic
hypertension in pregnancy (No. 29). Washington D.C.
http://3.bp.blogspot.com/E4VRTHYYpkY/5025
DUsKKKI/AAAAAAADmuw/kdJj8udoY7A/S1600-h/Patho+Preeclampsia.JPG
http:///emedecine. Medscape.com/article/1476919-overview
http://stevestakeshisfirststep.wordpress.com/2008/03/12/pathohysiology-of-preeclampsia
http://hb4110.net/wpcontent/uploads/KIT_MATERNAL%20HEALTH_BASIC
%20STATS.doc.
http://www.ncbi.nlm.nih.gov/pubmed/9822529
hypoglycemia).http://www.medicinenet.com/script/main/art.asp?articlekey=8430
http://emedicine.medscape.com/article/261435-overview
http://www.docstoc.com/docs/8981344/Case-Study-Pre-Eclampsia