Preeclampsia and Eclampsia Nursing

Pregnancy-Induced Hypertension (PIH)

• Hypertension: Defined by consistent high blood pressure (BP) readings (at least 140/90 mmHg) or a notable increase from pre-pregnancy levels (30 mmHg systolic and 15 mmHg diastolic).
• Readings should be confirmed on two separate occasions, 4-6 hours apart.
• Gestational Hypertension: High BP (140/90 mm/Hg) develops during pregnancy without proteinuria.
• BP returns to normal within 12 weeks postpartum.
• PIH: Hypertension after the 20th week in previously normotensive women, includes preeclampsia, eclampsia, and gestational hypertension.
• Preeclampsia: Hypertension (BP 140/90) after 20 weeks, accompanied by proteinuria (>300 mg/24 hours) and edema.
• Superimposed Preeclampsia/Eclampsia: When a woman with chronic hypertension develops preeclampsia or eclampsia during pregnancy.
• Chronic Hypertension: Hypertension before pregnancy or before the 20th week (excluding H-mole) that persists beyond 12 weeks postpartum.

Risk Factors for PIH

• Primiparity: First pregnancies have a higher risk.
• Age: Women under 20 or over 40 face increased risk.
• Preexisting Conditions: Diabetes, collagen vascular disease, chronic hypertension, or renal disease.
• Socioeconomic Factors: Low socioeconomic status and inadequate prenatal care.
• Nutritional Deficiencies.
• Pregnancy Complications: H-mole, diabetes, multiple pregnancy, polyhydramnios, Rh incompatibility, renal or heart disease.
• Hereditary Factors.
• Race: Black women are at higher risk.

Causes and Pathophysiology of PIH

• Cause of PIH is largely unknown.
• It has correlations with antiphospholipid syndrome and the presence of antiphospholipid antibodies.
• Endothelin Theory: Excess endothelin production leads to vasoconstriction, which elevates blood pressure.
• Normal Pregnancy: Plasma volume increases and systemic vascular resistance decreases without increasing blood pressure.
• Vasospasm: The presence of abundant chorionic villi from multiple fetuses or H-mole can cause overabundance.
• Decreased Kidney Blood Supply: Results in decreased GFR & decreased ability to remove waste, leading to sodium retention and edema.
• Damage to the Endothelium: Promotes coagulation and increases sensitivity to pressor agents.
• Reduced Synthesis of Vasodilators: The body will produce less Prostaglandin PGE2, which will help with vasodilation.

Effects of Preeclampsia

• Hemoconcentration: Plasma volume decreases, leading to higher hemoglobin and hematocrit levels.
• Kidney: Poor kidney perfusion causes decreased glomerular filtration rate & excretion of waste products.
• Edema and Hypertension: Elevated blood pressure contributes to fluid retention.
• Vasospasms: Worsening of vasoconstriction and vascular changes, resulting in end-organ disturbances.
• Elevated laboratory values of blood urea nitrogen, creating & uric acid result in acidosis & low urine output proteinuria occurs due to protein passage to the urine.
• Brain: Decreased blood supply causes cerebral ischemia and vasogenic edema, leading to hyperreflexia & seizures.
• Placenta: Diminished blood supply resulting in Intrautine Growth Restriction (IUGR), fetal hypoxia and distress, and abruptio placentae.

Mild vs. Severe Preeclampsia Signs and Symptoms

• Mild Preeclampsia:

  • BP: 140/90.

• Proteinuria: +1 to +2 by dipstick testing (>300 mg/24hr urine collection).

• Liver enzymes: Slightly elevated.

• Edema: Digital and dependent, weight gain of ≤2 lb/week, urine output ≥400 ml/24 hours.

• Cerebral disturbances include headache and reflexes range 1+ to 3+.

• Severe Preeclampsia:

  • BP: 160/110 (diastolic 30 mm Hg above pre-pregnancy levels).

• Proteinuria: Marked, 3+ or 4+ (or >5 g in a 24-hour sample).

• Liver enzymes: Markedly elevated.

• Increased Hematocrit & Thrombocytopenia.

• IUGR: Present.

• Edema: Pitting (4+) & generalized, rapid weight gain, urine output <400 ml/24 hours.

• Cerebral disturbances: severe frontal headache, photophobia, blurred vision, nausea & vomiting, hyperreflexia (4+), right upper quadrant pain.

Preeclampsia Management: Screening and Hospitalization

• Roll-over Test (Supine-Pressor Test): Conducted at 28-32 weeks' gestation & measures BP changes when supine.
• Positive indicator: ≥20 mmHg rise diastolic BP which means it is likely that the woman will develop Preeclampsia.
• Initial Hospitalization: Necessary for signs of preeclampsia to assess status:
• Thorough Labs: Complete blood count, BUN, creatinine, uric acid & liver function.
• Urine Assesment: A 24-hour urine collection measures creatinine clearance and protein.
• Diagnostics: Weights, UTZ for fetal size and amniotic fluid volume.
• Reflex Assesment: Deep tendon reflexes (patellar site) graded 0 to 4: Ranges of assessment 0= none, 1+= diminished, 2+= normal, 3+= brisker than average, 4+= brisk with clonus.
• Clonus Assessment: Dorsiflex the foot and observe for jerking movements. Evidenced by a rhythmic jerking which indicates hyperreflexias.

Preeclampsia Evaluation and Home Management

• Severe Preeclampsia: Hospitalization is a must for management.
• Home Management (Mild Preeclampsia, Normal Labs): Depends on the following guidelines:
• Has BP ≤140/90, low proteinuria, normal fetal growth, and confirmed fetal well-being with movement.
• Bed rest (LLP): Must be physical & emotional stress free.
  • Avoids Vena Cava Compression: Lying on the woman’s left side so that there is shifting of weight off of it in order to optimize the uteroplacental flow and increase diuresis in order to bring down BP
  • Include diversional activities (every two weeks) & clinic visits to prevent prolonged rest.
• Diet is high in protein and high carbohydrates with moderate sodium restriction. Diet includes:
  • High protein (≥1.5 g/kg of body weight daily) and moderate sodium (≤2 g/day).
  • Discourage the consumption of alcohol.
• Provide education by:
  • Monitor/record blood pressure twice a day.
• 8-10 glasses of water
• Daily Weights: Fetal movement, testing for protein, report preeclampsia symptoms such as rising BP, epigastric pain, etc.

Hospital Management of Preeclampsia

• Condition Considerations: Requires hospitalization for the following (BP ≥ to 160/100 mmHg), proteinuria (3+ or 4+).
• Weight increase, Oliguria, visual issues, and/or abnormal fetal movements.
• Cure depends on Gestational age of the fetus.
• Betamethasone is prescribed in order to help with the development of babies' lungs.
• Intravenous Fluid Consideration: Expertly monitored fluid therapy, such as a crystalloid infusion (100-125 ml/hour) of lactated ringers solution or normal saline.
• Magnesium Sulfate Prescribed Considerations : CNS depressant that prevents seizures by blocking acetylcholine.
  • Before Administering Magnesium Sulfate Nurse must check resperations (Should be > at least 14 CPM, output at least 100 ml/hour and DTR must test positive).
  • Monitor Magnesium level and know toxicity level (> at least 9-12 mg/dl and be versed on admin of Calcium Gloconate as an antidote.
  • After delivery, administer magnesium post 24 hours of the last seizure/convulsion and monitor atony because it could cause uterine relaxation.
  • Side effects cause hypo-tension, or can cause maternal - CNS depression, hyporeflexia, flushing, and/or confusion and fetal tachycardia, hypoglycemia, or hypocalcemia).
• BP Prescribed Medications: Hydralazine (Apresoline) & IV labetolol (Normodyne).
• Bedrest Guidelines: Promote rest, dim the lights, and limit visitors and disturbances.

Ongoing Monitoring of Preeclampsia

• Continuous v/s and fht monitoring for blurring of vision & epigastric pain.
• Continue laboratory diagnostics and note proteinuria, creatinine, hematocrit
• Counting fetal movement testing: Nonstress, biophysical studies and doppler flow studies for safety
• Raise padded side rails to prevent convulsion from reoccurring. Put bed at lowest position (with emergency equipment in place).
• Provide Eclamptic Convulsion Care - Stages include:
• Stage of 1st or Aura stage includes eye rolling/twitching, the Tonic involves eyes protruding and flexion, The Clonic involves eyes opening violently (foaming at the mouth).

Seizure/Convulsion Protocols

• Always Watch for S/S: Maintain patient airway and avoid trauma.
• Note Turning of the head on the woman’s side in order to help avoid aspiration and head injury.
• After Concluding seizure, Look abruption
• Give Magnesium at least 4 grams
• Provide sedation if magnesium cannot help
• Continue monitoring all the time if electronic and auscultate for pulmonary edema
• Administer oxygen and check catheter
• Stabilize before Commencing with deliveries (vaginal/cesarean)

Postpartum and Delivery Recommendations

• Danger After delivery is still present (until 24 hrs), monitor with Magnesium & Hydrazine.
• Observe New Born in toxicity cases where MgSO4 was administered.
  • Continue monitoring during the puerperium cycle and be knowledgeable about the process.
• Recommend Two years should elapse before conception again.

HELLP Syndrome

• Overview: A severe variant of PIH named for Hemolysis, Elevated Liver enzymes & Low Platelets.
• Causes unknown issues such as 4- to 12% PIH patients with high rates of mortality and high risk factor of fatality.
• S/S: Look elevated, nausea, right upper quadrant inflammation) and pain plus edema.
• Diagnostics through RBC blood smear in blood.
• Monitor LFT’s for elevated liver enzymes and platelets
• Treatment: Can use blood, proteins bedrest with monitoring and medication and possible assistance with steroid medication.

Multiple Pregnancy

• Definition: Simultaneous conception and development of two or more fetuses.
• Multifetal Pregnancy: When two, three, four, or even five are growing at the same time.
  • Twins: are 2
  • Triplets: 3 fetuses
  • Quadruplets: 4 fetuses
  • Quintuplets: 5 fetuses

Types of TWinning

• Monozygotic/Identical:
  • from ovum & one sperm.
  • Same genetic traits.
  • Same Sex.
  • Two amnions (diamniotic) & two chorions (dichorionic).
  • Two amnions: one chorion is (monochorionic) and two embryos.
  • With amnions: one chorion and 2 embyros.
• Dizygotic/Fraternal:
  • 2 sperm cells that are also sperm at teh same cell.
• Sperm cells can have different traits and must have separate placenta

Risk and Signs of Multiple Twinning

• Race risk - highest in blacks
• Hereditary - more frequent in females
• Fertility Med - high incidence
• Monitor signs such as growth, alpha protein lab , quickening ausculation (Ultra Sound).

Pregnancy Complications from Multiple Twinning

• Abortion/Premature labor. Can cause PIH rth defects from transfusion pregnancy issues.
• Nursing managments and education for mothers is important
• Promote frequent vsits (diet, and nutrition)
• Monitor rest activity through the 2nd trimester

HIGH-RISK Considerations: POST TERM/POLY

• Post/POLY-High risk Pregnancy includes factors associated with longer pregnancies.
• Occurs at a high rate if you are past due in history, woman hase menstrual cycles and triggers
• Risk increases with cord compression and possible amniotic fluid compression. Infection can also be present.
• Nurse can help assess fetal well-being and monitor delivery

Polyhydramnios

• A condition marked by excessive level.
• This may lead to additional increased space w/ fluid and premature risk with infection
• Can be caused by many factors (DM & spina defects w/ increased urinations)
• Size of the uterus is larger than life, monitor the breath, weight, and perform a ultra sound.

Oligohydramnios

• Opposite to hydro (low amniotic fluid)
• Can occur at a rate of 4%
• It can be renal problems from lack of fluid + infection
• Continue to monitor, observe abnormal and note anything different

Hypermesis Gravidarum

• Nausea and vomiting for to long and if severe look for dehydration.
• Causes are from hormone HCG elevatoins but also look to bacteria.
• S/S dehydration, less urine, and weight loss
• May require the adminstartion of Ringer’s Lactate in order to improve blood
• Assess any additional and administer small meals

PICA

• Eating disorder when woman craves for nonfood subsatnces.
• Unknown cause for adaptive behavior.
• Make sure to make regular check-ups

Pseuedocyesis

• Sickness signs but with no fetus Take care to refer when needed

Anemia of Pregnancy

• Number of red blood cells are too Low (most common issue is deficiency iron)
• Mild-Moderate - Severe class
• Factors are poor, heavy, nutrition intake
• Note - if RBC are to small and low ferritin then it may effect pretenancy and effect labor and puerperium.
• Always increase VItamine, vitamin and encourage iron rich diet.

Folid Acid Deficiency

• Folate from the B family prevents tube incidents and are important
• This is a common deficiency that causes miscarriage
• Manage with a milligram and educate what can be taken.

SICKLE-CELL

• Occurs during certain condition
• Oxygen is reduced in red blood cells
• Monitor the pain.
• Increase hydration

Thalassemia

• Leads to poor red blood cells and severe anemia
• fragile RBC blood cells/ anemia
• Folic supplementation is recommended

Coagulation disorders

• Von wille (is from shortage and VWD is lack protien)
• Bleeding will continue
• Always replacement the factors

Hypoglycemia

• Often because dilation will occur for the urine or glucose
• In prentancy there is a greater medium
• Make sure there is prevention

Discomfort in Pregancy

• Bladder is over active
• Give Antipasomdatic if the risk is lower than the overweights

Pregnancy Respiratory Disorders

• Pregnancy can be cause Ensure simple prevention measures Take acetaminophen

TB/Respiratory Infections

• Always perform an TB test in lung tissue

Thyroid in Pregnancy

• When this occurs there is can be enlarged vascular or blood flow
• May increase pregnancy transition as it can cause still births

HIV/AIDS

• Mode: sexual, needles, contact, blood
• At Risk: People that have hemophilia, sharing needles, and multiple sex partners.
• First is conducted an Elisa Test

Infection Torch

• A infection that transmits cross placenta
• There are certain things such as, avoid changing litter box, contact veterinarian.