Care of the Patient with Mild Preeclampsia, Severe Preeclampsia, Eclampsia & HELLP Syndrome

Fetal Heart Patterns that Suggest Compromise

Late decelerations associated with reduced placental perfusion Decreased variability Interventions tailored to the nonreassuring fetal heart pattern (administer O2, stop oxytocin infusion, alter other IV infusion rates as ordered).

Aspiration

Leading cause of morbidity/mortality in pt with eclampsia Equipment to suction the woman's airway should be immediately available After stabilization, the nurse should anticipate orders for chest x-ray and arterial blood gas to identify aspiration

Uterine Irritability Associated with Eclampsia

Monitor pt for ruptured membranes, signs of labor, and abruption placentae

Increase in liver enzyme levels

Occurs when hepatic blood flow is obstructed by fibrin deposits. Hyperbilirubinemia and jaundice may occur as a result of liver impairment.

Assessment: Headache, epigastric pain, visual problems

Implication: these symptoms indicate increasing severity of condition caused by cerebral edema, vasospasm of cerebral vessels, and liver edema. Eclampsia may develop quickly.

Adverse maternal/fetal outcomes associated with HELLP

-Placental abruption -Acute renal failure -Subcapsular hepatic hematoma (can cause severe internal hemorrhage) -Recurrent preeclampsia -Preterm birth -Fetal and maternal death (maternal death r/t pulmonary edema and eclampsia)

Disease Theories

(1) Abnormal implantation of placenta (2) Autoimmune response (APA)--mom's body sees fetus as foreign object (3) Maternal maladaptation to CV or inflammatory changes of pregnancy (4) Dietary deficiencies (5) Genetic influences

Assessment of edema

+1 minimal edema of lower extremities +2 marked edema of lower extremities +3 edema of lower extremities, face, hands, and sacral area +4 generalized massive edema that includes ascites

Risk factors for Preeclampsia

-Exposed to chorionic villi for first time (Primagravidas)* -Exposed to superabundance of chorionic villi (Multi-fetuses)* -Preexisting CV disease* -Diabetes* -Maternal age older than 35 years* -African American ethnicity* -Those with a positive family or personal history of pregnancy induced hypertension -Those with chronic hypertension or renal disease -Anemia -Obesity

Management of HELLP

-Managed in a setting with ICU -Magnesium sulfate to prevent/control seizures that could increase intraabdominal pressure -Hydralazine to control B/P -Fluid replacement -Cervical ripening with induction usually done if gestation is at least 34wks and woman is stable; steroids given to increase fetal lung maturity *If woman is near term and has a favorable cervix, induction is the preferred method of delivery to avoid bleeding and clotting complications that are more likely to occur with C-section *C-section necessary if woman is far from term or has unfavorable cervix

Hypertensive Disorders in Pregnancy

-Most common medical complication during pregnancy -Contributes to maternal morbidity and mortality -Associated with intrauterine fetal death (IUFD) because of decreased placental perfusion

Other signs of preeclampsia

-Obvious vascular constriction & narrowing of small arteries upon examination of the retina -Hyperreflexia (brisk DTRs) -Cerebral irritability secondary to decreased brain circulation & edema -Labs may identify liver, renal & hepatic dysfunction if preeclampsia is SEVERE -Decreased number of platelets suggests impaired coagulation -Generalized edema may occur (may first manifest as rapid weight gain caused by fluid retention; present in lower legs, hands & face) -Pulmonary edema may occur

Signs of Magnesium Toxicity

-Respiratory rate less than 12 breaths/min -Maternal pulse oximetry reading lower than 95% -Absence of DTRs -Sweating, flushing -Altered sensorium (confusion, lethargic, slurred speech, drowsy, disoriented) -Hypotension -Serum Magnesium value above therapeutic range of 4-8mg/dL *Carbon dioxide accumulates if the respiratory rate is decreased, leading to respiratory acidosis and further CNS depression, which could culminate in respiratory arrest*

Signs that the PP pt is recovering from preeclampsia

-Urinary output of 4-6L/day, which causes a rapid reduction in edema and rapid weight loss -Decreased protein in the urine -Return to normal B/P, usually within 2wks

Preeclampsia

A systolic BP of 140 mm HG or greater or a diastolic of 90 mm HG or greater occurring after 20 weeks of pregnancy that is usually accompanied by significant proteinuria (> or equal to 300mg in 24hr urine collection, dipstick of > or equal to 1+) Women may experience edema; however this is NOT always the case. Only known cure is birth of the fetus.

Assessment: Level of consciousness

Implication: drowsiness or dulled sensorium indicates therapeutic effects of mag; no responsive behavior or muscle weakness is associated with mag excess

Assessment: Respiratory rate, SPO2

Implication: drug therapy (mag sulfate) causes respiratory depression, and drug should be withheld and HCP notified if respiratory rate is <12. SPO2 should be 95% or greater

Assessment: DTRs

Implication: hyperreflexia indicates increased cerebral irritability and edema; hyporeflexia is associated with magnesium excess

Assessment: Urine protein

Implication: normal protein in random dipstick urine sample is negative or trace; higher levels suggest greater leaking of protein secondary to glomerular damage with worsening with preeclampsia; a 24hr urine sample is most accurate for quantitative urine protein level

Assessment: Urinary output

Implication: output of at least 30mL/hour indicates adequate perfusion of the kidneys; magnesium levels may become toxic is urinary output is inadequate

Assessment: Daily weight

Implication: provides estimate of fluid retention

Assessment: Edema

Implication: provides estimation of interstitial fluid

Assessment: Fetal heart rate and baseline variability

Implication: rate should be between 110-160 bpm in a term fetus; decreasing baseline variability may be caused by therapeutic magnesium level or by inadequate placental perfusion

Hydralazine

Antihypertensive given in severe preeclampsia Vasodilator that increases cardiac output and blood flow to the placenta *Use with caution when pt is on Magnesium Sulfate (hypotension may occur reducing placental perfusion)

Postpartum Management of Preeclampsia

Assessment of blood loss and signs of shock (hypovolemia caused by preeclampsia may be aggravated by blood loss during birth) Assessment for S&S of preeclampsia must be continued for at least 48hrs and administration of magnesium with its associated care usually is continued to prevent seizures for 24hrs.

Inpatient Management of Severe Preeclampsia

B/P > 160/110 & multisystem involvement Goals: improve placental blood flow and fetal oxygenation; prevent seizures and other maternal complications such as stroke Bed rest in lateral position with very minimal environmental stimulation Continuous electronic fetal monitoring Pt at higher risk of stroke or CHF

Severe Preeclampsia

B/P > or equal to 160/110 Proteinuria > or equal to 5g/24hr or dipstick > or equal to 3+ Serum creatinine > 1.2 mg/dL Platelets <100,000 Hepatic involvement (Elevated ALT or AST) Persistent headache or other cerebral or visual problems Persistent epigastric pain (RUQ pain) Urine output <20ml/hr or <500ml/24hr Pulmonary edema may be present Fetal growth restriction; reduced amniotic fluid

S&S of pulmonary edema

Chest Pain SOB Crackles especially at bases of lungs

Nursing Implications when giving Magnesium Sulfate

Closely monitor B/P during administration Assess RR, want above 12 breaths/min Presence of DTRs Urinary output > 30mL/hr before administering Mag Resuscitation equipment in room & readily available for use (suction & O2) Calcium gluconate available and ready for use

Assessment: Laboratory data

Implication: significant signs of increasing severity of disease are elevated serum creatinine level, elevated levels of liver enzymes, or decreased number of platelets (thrombocytopenia); serum magnesium levels should be in therapeutic range designated by HCP.

Deep tendon reflexes (DTR)

Brachial Patellar Clonus Rating scale: 0--reflex absent +1--reflex present, hypoactive +2--Normal reflex +3--brisker than average reflex +4--hyperactive reflex; clonus may also be present Hyperreflexia--exaggerated reflexes Hyporeflexia--diminished reflexes

Magnesium Sulfate

CNS depressant used to prevent seizures Blocks neuromuscular transmission and decreases the amount of acetylcholine liberated NOT AN ANTIHYPERTENSIVE--relaxes smooth muscle thus reducing vasoconstriction & possibly resulting in a reduction of B/P Decreased vasoconstriction promotes circulation to vital organs of the expectant mother and increases placental circulation. Increased circulation to the maternal kidneys leads to diuresis as interstitial fluid is shifted into the vascular compartment and is excreted. Administered via IV infusion through a secondary line so that the medication can be discontinued at any time while the primary line remains functional. Two qualified nurses should check orders to ensure the ordered grams per hour of magnesium are infused and that the total volume when added to plain IV fluids totals the correct infusion volume ordered. Therapeutic Serum Level: 4-8 mg/dL Adverse reactions occur if serum level becomes to high. Magnesium Sulfate is excreted solely by the kidneys. The reduced urine output that often occurs with preeclampsia allows magnesium to accumulate to toxic levels. Frequent assessment of serum level, DTRs, respiratory rate, and SPO2 are VITAL to identifying CNS depression before it progresses to respiratory depression or cardiac dysfunction.

Antidote for Magnesium Sulfate Overdose

Calcium Gluconate

Low Platelets

Caused by vascular damage resulting from vasospasm; platelets aggregate at sites of damage, resulting in thrombocytopenia, which increases the risk for bleeding, usually in the liver

Nursing Assessment for Preeclampsia and Magnesium Toxicity

Daily weight Blood Pressure Respiratory Rate, Pulse oximeter reading Breath Sounds Deep Tendon Reflexes Edema Urinary output Urine protein Level of consciousness Headache, epigastric pain, visual problems Fetal heart rate and baseline variability Laboratory data

Cure to preeclampsia

Delivery of baby

Preventive Measures/Prenatal Care

Early & regular prenatal care with attention to pattern of weight gain, monitoring of B/P and urinary protein level--EARLY DETECTION! Prevention in high-risk women--low dose aspirin, calcium and magnesium supplements, and fish oil supplements

Four categories of hypertensive disorders that occur in pregnancy

Gestational Hypertension Preeclampsia* Eclampsia* Chronic Hypertension

Symptoms of Preeclampsia

Headache, drowsiness, or mental confusion indicate poor cerebral perfusion & may be precursor of seizures. Visual disturbances indicate arterial spasms and edema in the retina. Numbness or tingling of the hands or feet occurs when nerves are compressed by retained fluid. Epigastric (RUQ) pain indicates distention of the hepatic capsule; seizure is imminent. Decreased urinary output indicates poor perfusion of the kidneys and may precede acute renal failure.

HELLP Syndrome

Hemolysis Elevated Liver enzymes Low Platelets (less than or equal to 100,000) *most severe type of PREECLAMPSIA

Signs of Impending Seizures

Hyperreflexia, possibly accompanied by clonus Increasing signs of cerebral irritability (headache, visual disturbances) Epigastric or RUQ pain, nausea, or vomiting

Classic Signs of Preeclampsia

Hypertension & Proteinuria

Leading cause of infant and maternal morbidity and mortality

Hypertensive disorders in pregnancy

Assessment: B/P

Implication: determines worsening condition, response to treatment, or both

Seizure Safety/Prevention

PREVENTION -Quiet, dark room with as little stimulation as possible -Group nursing tasks -Move carefully and calmly around room trying to avoid bumping into the bed or startling the woman SAFETY -Keep bed in lowest position with brakes on -Side rails up, padded if possible -Oxygen and suction available and ready to use -Preeclampsia tray in room (medium plastic airway, ambu bag w/ mask, ophthalmoscope, tourniquet, reflex hammer, syringes & needles) -Medications that should be readily available: magnesium sulfate, sodium bicarbonate, heparin, epinephrine, phenytoin, and calcium bicarbonate -Remain with pt throughout seizure, press call bell for assistance -Turn pt on her side when tonic phase begins -Note time and sequence of seizure -Insert an airway after the seizure, and suction pt mouth/nose -Administer oxygen by mast at 8-10L/min -Notify physician -Administer medications and prepare for additional medical interventions as directed by physician

Systemic Pathophysiology of Preeclampsia

Platelet aggregation & deposition of fibrin--low platelets Glomerular damage--proteinuria, increased plasma uric acid & creatinine, oliguria, and increased Na retention Cortical brain spams--headache, hyperreflexia, & seizure activity Pulmonary edema--dyspnea Hepatic microemboli; liver damage--increased epigastric pain, RUQ pain, increased enzymes, N/V, liver rupture

Pathophysiology of Preeclampsia

Poor perfusion d/t arteriolar VASOSPASM which leads to POOR PLACENTAL PERFUSION and a DECREASED DIAMERTER OF BLOOD VESSELS which impeded blood flow to ALL ORGANS and INCREASES B/P

Management of Mild Preeclampsia at Home

Prescribed treatment plan that includes modified bed rest, home blood pressure monitoring, and follow-up visits to the physician every 3-4 days. Pt education on self assessment of B/P Report symptoms that indicate diagnosis is worsening: visual disturbances, severe headache or epigastric pain Teach pt about symptoms that suggest nonreassuring fetal status (i.e. reduced fetal movement) Bedrest in lateral position to decrease pressure on the vena cava and increase circulation/perfusion Pt should weigh herself every morning on the same scale with similar weight clothes on Daily urine dipstick test for protein should be done using first voided midstream specimen; 24hr urine collections might also be done Fetal Assessment--"kick counts", ultrasound, BPP, amniocentesis Diet should have ample protein and calories. A regular diet without salt or fluid restrictions is usually prescribed.

Eclampsia

Progression of preeclampsia to generalized seizures that cannot be attributed to other causes. Seizures may occur postpartum.

When to D/C magnesium sulfate infusion

RR <12 SPO2 <95% Absent DTRs *After D/C notify physician for further orders

Intrapartum Management of Preeclampsia

Seizures most likely to occur during labor or first 24hrs after birth. Woman kept in lateral position to promote circulation through placenta Focus on controlling pain that may cause agitation and precipitate seizures Oxytocin to stimulate uterine contractions and magnesium sulfate to prevent seizures are administered simultaneously during labor. Opiate analgesics or epidural analgesia to provide comfort/reduce pain Continuous electronic fetal monitoring

B/P Measurement

Should be measured uniformly at each office visit Woman seated in semifowlers position Arm supported at the level of the heart Use appropriate cuff size Take in left arm

Characteristics of Generalized Seizures in Eclampsia

Start with facial twitching, followed by rigidity of the body Tonic-clonic movements then begin and last for about 1 minute Breathing stops during a generalized seizure but resumes with a long, noisy inhalation The woman is temporarily in a coma and is unlikely to remember the seizure when she resumes consciousness

Postictal

The unresponsive state after a seizure *Keep pt on her side to prevent aspiration of gastric contents & improve placental circulation *Side rails should be raised *Fetal delivery is usually done once maternal and fetal conditions have been stabilized--induction if cervix is favorable/C-Section if further from term

Assessing clonus

The woman's lower leg should be supported, and the foot well dosiflexed to stretch the tendon. Hold the flexion. If no clonus is present, no movement with be felt. When clonus (indicating hyperreflexia) is present, rapid rhythmic tapping motions of the foot are present.

Effects of Seizures on the Fetus

Transient fetal heart rate patterns such as bradycardia, loss of variability, or late decelerations may be nonreassuring. Fetal tachycardia may occur as the fetus compensates for the period of maternal apnea during the seizures.

Assessing brachial and patellar reflexes

Use reflex hammer

Scotomata

Visual changes

Hemolysis

believed to occur as a result of the fragmentation and distortion of erythrocytes during passage through small damaged blood vessels

Arteriolar Vasospasm

can lead to organ ischemia

Symptoms of HELLP

pain in the RUQ, the lower right chest, or mid-epigastric pain Tenderness may occur because of liver distention Nausea, vomiting, severe edema *avoid traumatizing liver by abdominal palpation & use care when transporting pt; sudden increase in intraabdominal pressure could lead to rupture of a subcapsular hematoma, resulting in internal bleeding and hypovolemic shock *hepatic rupture can lead to fetal and maternal mortality