SYSTEMS PLUS COLLEGE FOUNDATION BALIBAGO, ANGELES CITY

In Partial Fulfillment of the Requirement in NCM 102 RLE

CASE REPORT

Pregnancy Induced-Hypertention

Submitted to: Arnel Jay C. Sali RM,RN,MSN

Submitted by: Manlincon Arlyn G.

Submitted on: July 05, 2013

I.

OVERVIEW
A hypertensive disease of pregnancy. Known as pre-eclampsia and eclampsia. Pre-eclampsia = hypertension, proteinuria, edema Eclampsia = other signs plus convulsions It develops between the 20th and 24th week of gestation and disappears after the tenth day postpartum.

Preeclampsia is defined by high blood pressure and excess protein in the urine after 20 weeks of pregnancy.

Often, preeclampsia causes only modest increases in blood pressure. Left untreated, however, preeclampsia can lead to serious even fatal complications for both mother and baby.

The only cure for preeclampsia is delivery of the baby. If preeclampsia develops near the end of your pregnancy, delivery is the obvious solution. If you're diagnosed with preeclampsia earlier in your pregnancy, you and your doctor face the delicate task of prolonging your pregnancy to allow your baby more time to mature, without putting you or your baby at risk of serious complications.

II. SIGNS & SYMPTOMS

The most common symptom and hallmark of preeclampsia is high blood pressure. This may be the first or only symptom. Blood pressure may be only minimally elevated initially, or can be dangerously high; symptoms may or may not be present. However, the degree of blood pressure elevation varies from woman to woman and also varies during the development and resolution of the disease process. There are also some women who never have significant blood pressure elevation. The kidneys are unable to efficiently filter the blood (as they normally do). This may cause an increase in protein to be present in the urine. The first sign of excess protein is commonly seen on a urine sample obtained in your provider's office. Rarely does a woman note any changes or symptoms associated with excess protein in the urine. In extreme cases affecting the kidneys, the amount of urine produced decreases greatly.

Nervous system changes can include blurred vision, seeing spots, severe headaches, , and even occasionally blindness. Any of these symptoms require immediate medical attention. Changes that affect the liver can cause pain in the upper part of the abdomen and may be confused with indigestion or gallbladder disease. Other more subtle changes that affect the liver can affect the ability of the platelets to cause blood to clot; these changes may be seen as excessive bruising. Changes that can affect your baby can result from problems with blood flow to the placenta, and therefore, your baby not getting proper nutrients. As a result, the baby may not grow properly and may be smaller than expected, or worse the baby will appear sluggish or seem to decrease the frequency and intensity of its movements. Call the doctor immediately if the baby's movements slow down.

III. CAUSE
Preeclampsia used to be called toxemia because it was thought to be caused by a toxin in a pregnant woman's bloodstream. This theory has been discarded, but researchers have yet to determine what causes preeclampsia. Possible causes may include:

Insufficient blood flow to the uterus Damage to the blood vessels A problem with the immune system Poor diet

IV. PATHOPHYSIOLOGY
Although the exact cause of preeclampsia remains unclear, many theories center on problems of placental implantation and the level of trophoblastic invasion. It is important to remember that although hypertension and proteinuria are the diagnostic criteria for preeclampsia, they are only symptoms of the pathophysiologic changes that occur in the disorder. One of the most striking physiologic changes is intense systemic vasospasm, which is responsible for decreased perfusion of virtually all organ systems. Perfusion also is diminished because of vascular hemoconcentration and third spacing of intravascular fluids. In addition, preeclampsia is accompanied by an exaggerated inflammatory response and inappropriate endothelial [Link] of the coagulation cascade and resultant microthrombi formation further compromise blood flow to organs.

V. ASSESSMENT AND DIAGNOSIS

Assessment of the Woman 1. Blood pressure measurement BP 140 mm Hg systolic or 90 mm Hg diastolic with proteinuria (>300 mg/24 hr) after 20 weeks gestation is indication for preclampsia

2. Urine dipstick testing

Urine protein testing is used to detect protein in the urine, to help evaluate and monitor kidney function, and to help detect and diagnose early kidney damage and disease

3. Protein/Creatinine and Urea Nitrogen) Test

BUN(Blood -measure the level of the waste product creatinine in your blood and urine. These tests tell how well your kidneys are working. Normal range in creatine test: The substance creatine is formed when food Female: 0.5 to 1.1 mg/dl, or 44 to 97 is changed into energy through a process mol/L called metabolism. Creatine is broken down into another substance called creatinine, The normal range of urea nitrogen in which is taken out of your blood by the blood or serum : 5 to 20 mg/dl, or 1.8 kidneys and then passed out of your body in to 7.1 mmol urea per liter. urine. -Urea is a waste product made when protein is broken down in your body. Urea is made in the liver and passed out of your body in the urine. A blood urea nitrogen (BUN) test measures the amount of urea in your blood. Like creatinine, it can help your doctor see how well your kidneys are working.

4. 24-hour urine collection

24-hour urine protein measures the amount of protein excreted in urine over a 24-hour period. Proteins are large molecules which help make up our muscles, important parts of our immune system, and many other portions of our bodies. Most proteins are also too large to pass through the filtering system of the kidney. And since they are not supposed to pass into the kidney, there is no mechanism for proteins to be reabsorbed if they make it in there. Therefore, if protein is detected in the urine, it means there is something going on with the filter that is allowing the proteins to pass. Protein is the building block of all life and is essential for the growth of cells and tissue repair. Complete blood count or CBC test is used as a broad screening test to check for such disorders as anemia, infection, and many other diseases. Significant increases in WBCs may help confirm that an infection is present and suggest the need for further testing to identify its cause. Decreases in the number of RBCs (anemia) can be further evaluated by changes in size or shape of the RBCs to help determine if the cause might be decreased production, increased loss, or increased destruction of RBCs. A platelet count that is low or extremely high may confirm the cause of excessive bleeding or clotting.

5. Full blood count

6. Liver function testing

To monitor the activity and severity of liver disorders and it the liver function well. The functions of the liver include: storing glycogen (fuel for the body) which is made from sugars; helping to process fats and

proteins from digested food; making proteins that are essential for blood to clot (clotting factors); processing many medicines which you may take; helping to remove poisons and toxins from the body.

7. Clotting studies/Serum platelet counts Less than 100,000/mm3 in disseminated intravascular(DIC), because platelets adhere to collagen released from damaged blood vessels. DIC leads to the formation of small blood clots inside the blood vessels throughout the body. 8. Monitoring and charting of fluid Fluid balance is maintaining the correct balance amount of fluid in the body. It is the continuance of the fluid input and output of the body. Fluid loss may indicate Increased plasma-urea concentration

9.

Assessment of the Fetus 1. Cardiotocography -is a technical means of recording (-graphy) the fetal heartbeat (cardio-) and the uterine contractions (-toco-) during pregnancy, typically in the third trimester. The machine used to perform the monitoring is called a cardiotocograph, more commonly known as an electronic fetal monitor (EFM). Fetal ultrasound is a test done during pregnancy that uses reflected sound waves to

2. Ultrasound measurement of fetal size

produce a picture of a fetus, the organ that nourishes the fetus (placenta), and the liquid that surrounds the fetus (amniotic fluid). The picture is displayed on a TV screen and may be in black and white or in color. The pictures are also called a sonogram, echogram, or scan, and they may be saved as part of your baby's record. 3. Umbilical artery Doppler Umbilical Artery Doppler is an ultrasound technique that allows one to gauge how much resistance fetal blood encounters during its passage through the placenta. Ideally, fetal blood should encounter very little resistance; with certain placental abnormalities, increased resistance to flow may limit oxygenation transfer to fetal blood.

VI. COMPLICATIONS

Lack of blood flow to the placenta. Preeclampsia affects the arteries carrying blood to the placenta. If the placenta doesn't get enough blood, your baby may receive less oxygen and fewer nutrients. This can lead to slow growth, low birth weight, preterm birth and breathing difficulties for your baby. Placental abruption. Preeclampsia increases your risk of placental abruption, in which the placenta separates from the inner wall of your uterus before delivery. Severe abruption can cause heavy bleeding and damage to the placenta, which can be lifethreatening for both you and your baby. HELLP syndrome. HELLP which stands for hemolysis (the destruction of red blood cells), elevated liver enzymes and low platelet count syndrome can rapidly become life-threatening for both you and your baby. Eclampsia. When preeclampsia isn't controlled, eclampsia which is essentially preeclampsia plus seizures can develop.

VII. MEDICAL MANAGEMENT:

1. Magnesium Sulfate (Pregnancy risk category B) - muscle relaxant, prevent seizures loading dose 4-6g, maintenance dose 1-2g/h IV infuse IV dose slowly over 15-30 min.

Always administer as a piggy back infusion. Assess PR, urine output, DTR, and clonus every hour. Observe for CNS depression and hypotonia in infant at birth.

2. Hydrazaline (Apresoline) Pregnancy risk category C -anti hypertensive (peripheral vasodilator) use to decrease hypertension 5-10mg/IV Administer slowly to avoid sudden fall of BP Maintain diastolic pressure over 90 mmHg to ensure adequate placental filling. 3. Diazepam (Valium) Pregnancy risk category D - halt seizures 5-10mg/IV administer slowly. Dose may be repeated every 1015 min. (up to 30mg/hr) Observe for respiratory depression for both mother and infant at birth.

4. Calcium Gluconate (Pregnancy risk category C) -antidote for Magnesium Sulfate 1g/IV (10 mL of a 10% solution) have prepared at bed side when administering Magnesium Sulfate administer at 5mL/min.

VIII. NURSING INTERVENTIONS:

Intervention for mild PIH: Rationale: 1. Assess maternal VS and fetal heart rate. -to detect any increase which is warning that a womens condition is worsening. 2. Encourage elevation of edematous -to increase venous blood return. arms and legs. 3. Encourage compliance with bed rest in -to increase evacuation of sodium and encouraging a lateral recumbent position. diuresis and lateral recumbent position can avoid uterine pressure on the vena cava and prevent supine hypotension syndrome. 4. Provide emotional support. -this can make a women underestimate the severity of the situation. 5. Support patient with bed rest and -because a bright light can trigger seizures. darken the room if possible. 6. Obtain daily hematocrit levels as -to monitor blood concentration and help to the extent ordered. of plasma loss to interstitial space or extent of the edema. 7. Obtain blood studies (CBC, platelets -to assess for renal and liver function and the count, liver function, BUN and creatinine, development of disseminated intravascular coagulation and fibrin degregation). which often accompanies severe vasospasms. 8. Obtain daily weights at the same time -to evaluate tissue fluid retention. each day. 9. Raise side rails. -to help prevent injury if seizure should occur. 10. Support nutritious diet of moderate to -to compensate for protein she is losing in her urine. high in protein and moderate in sodium. 11. An indwelling catheter may be -to allow accurate recording of output and comparison inserted as ordered. with intake. 12. Oxygen administration to the mother -to maintain adequate fetal oxygenation and prevent may be given as ordered. fetal bradycardia. 13. Administer medication for seizures -to prevent seizures and hypertension. and hypertension episodes as ordered.

Intervention for severe PIH: 1. Maintain patients airway by not putting a tongue blade between a womens teeth during seizures. 2. Turn a woman on her side.

Rationale: -to prevent broken of teeth which could then be aspirated. -to allow secretions to drain from her mouth.