This document discusses the pathophysiology and management of preeclampsia and eclampsia in pregnancy. It begins by outlining the normal physiological changes in pregnancy and then defines preeclampsia and eclampsia. Risk factors and potential causes are described. The pathophysiology involves alterations in the normal vascular adaptations of pregnancy. Care management involves thorough assessment, monitoring of vital signs, labs, and fetal well-being. Treatment focuses on controlling blood pressure and preventing seizures.
This document discusses the pathophysiology and management of preeclampsia and eclampsia in pregnancy. It begins by outlining the normal physiological changes in pregnancy and then defines preeclampsia and eclampsia. Risk factors and potential causes are described. The pathophysiology involves alterations in the normal vascular adaptations of pregnancy. Care management involves thorough assessment, monitoring of vital signs, labs, and fetal well-being. Treatment focuses on controlling blood pressure and preventing seizures.
This document discusses the pathophysiology and management of preeclampsia and eclampsia in pregnancy. It begins by outlining the normal physiological changes in pregnancy and then defines preeclampsia and eclampsia. Risk factors and potential causes are described. The pathophysiology involves alterations in the normal vascular adaptations of pregnancy. Care management involves thorough assessment, monitoring of vital signs, labs, and fetal well-being. Treatment focuses on controlling blood pressure and preventing seizures.
This document discusses the pathophysiology and management of preeclampsia and eclampsia in pregnancy. It begins by outlining the normal physiological changes in pregnancy and then defines preeclampsia and eclampsia. Risk factors and potential causes are described. The pathophysiology involves alterations in the normal vascular adaptations of pregnancy. Care management involves thorough assessment, monitoring of vital signs, labs, and fetal well-being. Treatment focuses on controlling blood pressure and preventing seizures.
Physiological changes in pregnancy • Most women experience a normal pregnancy. A small percentage of women experience life-threatening complications that may result from the pregnancy itself or may be part of a preexisting condition. • Nurses must understand the psychological changes that occur in pregnancy to distinguish normal from abnormal responses. Physiological changes in pregnancy 1. Cardiovascular changes - Blood volume change (>40%-50%) pregnancy level (1,450-1,750 ml) - Red blood cells change >20%, pregnancy level (250-450 ml) - Blood pressure: systolic change <5-12 mmHg - Diastolic change <10-20 mmHg - Cardiac output change>30%-50%, pregnancy level 6-7l/min Physiological changes in pregnancy • Heart rate change >10%-30% pregnancy level increased by 15-20 beat/min • Systemic vascular resistance change <20%-30% pregnancy level 1, 210 ±266 dynes/sec/cm-5 • Pulmonary vascular resistance change <34% pregnancy level 78 ±22 dynes/sec/cm-5 • Colloid osmotic pressure change <10%-14% pregnancy level 22.4 ± 0.5 Physiological changes in pregnancy 2. Respiratory changes Functional residual capacity change <10%-25% pregnancy level 1,725-2,070 ml Tidal volume change >30%-35% pregnancy level 700ml 3. Renal Changes Renal blood flow change >25%-50% pregnancy level 1,500-1,750ml/min Glomelural filtration rate change >50% pregnancy level 140-170mL/min Critical care conditions in pregnancy • During pregnancy normal physiological changes occur to provide for growth of fetus & to prepare the mother for birth. Medical complications may alter an uncomplicated pregnancy into a critical condition. The most common complications are severe preeclampsia. Classification • The hypertension disorders of pregnancy refer to a variety of conditions in which maternal blood pressure is elevated with corresponding risk to maternal and fetal well-being • Clinically there are two basic types of hypertension during pregnancy: - Chronic hypertension - Pregnancy-induced hypertension (PIH) Classification • Gestational hypertensive disorders: pregnancy-induced hypertension (PIH) include: 1. Transient hypertension: development of mild hypertension during pregnancy in previously normotensive patient without proteinuria or pathologic edema. 2. Gestational proteinuria: development of proteinuria after 20 weeks of gestation in previously nonproteinuric patient without hypertension Classification 3. Preeclampsia: development of hypertension and proteinuria in previously normotensive patient after 20 weeks of gestation or in early postpartum period in presence of thromboplastic disease it can develop before 20 weeks of gestation 4. Eclampsia: development of convulsions or coma in preeclamptic patient. Classification Chronic hypertensive disorders 1. Chronic hypertension: hypertension or proteinuria in pregnant patient with chronic hypertension 2. Superimposed preeclampsia/eclampsia: development of preeclampsia or eclampsia in patient with chronic hypertension. Classification • Preeclampsia: is a pregnancy-specific condition in with hypertension develops after 20 weeks of gestation in a previously normotensive women. It is a multisystem vasospatic diseases process characterized by hypertension and proteinuria. Preeclampsia is usually categorized as mild or severe in terms of management. Classification • Eclampsia: is the onset of seizure activity or coma in the woman diagnosed with PIH, with no history of neurologic pathology. The seizured can be the initial sign for a pregnancy complicated by PIH Etiology • The etiology of preeclampsia is unknown; however predisposing risk factors include nulliparity, multiple gestation, diabetes, age younger than 18 or older than 35 years, and chronic hypertension Etiology Risk factors associated with the development of pregnancy-induced hypertension include: chronic renal disease, chronic hypertension, family history of PIH, twin gestation, primigravidity, maternal age <19 years; >40 years, diabetes, RH incompatibility, obesity. Pathophisiology • Preeclampsia progress along the continuum from mild to severe preeclampsia, HELLP syndrom, or eclampsia. The pathofisiology of preeclampsia reflect alterations in the normal adaptations of pregnancy. Normal adaptations to pregnancy include increased blood plasma volume, vasodilatation, decreased systemic vascular resistance, elevated cardiac output, and decreased colloid osmotic pressure. Pathophisiology • Pathologic changes in the endothelial cells of glomeruli are uniquely characteristic of preeclampsia, particulalry in nulliparous women. • The main pathogenic factor is not an increase in blood pressure but poor perfusion as a result of vasospasm. Arteriolar vasospam disminishes the diameter of blood vessels. • Function in organs such as placenta, kidneys, liver, and brain is depressed by as much as 40%-60%. Care management Assessment : hypertensive disorders of pregnancy can occur without warning or with the gradual development of symptoms. A key goal is early identification of pregnant women at risk for development of preeclampsia. Interview: reviews the woman’s admission form and prenatal record. When the nurse & pregnant woman are comfortable, the nurse begins with the interview to clarify, expand, or complete the form. Care management Medical history is reviewed, especially the presence of diabetes mellitus, renal disease, and hypertension. Family history is explored for occurrence of preeclamptic or hypertensive conditions. The social & experimental history provides information about woman’s marital status, nutritional status, cultural beliefs, activity level, and health habits such as smoking, drug use, and alcohol consumption. Care management Physical examination: accurate and consistent blood pressure assessment is important for establishing a baseline and monitoring subtle changes throughout pregnancy. Observation on edema in additional to hypertension warrants additional investigation. Edema is assessed for distribution, degree, and pitting. If periorbital or facial edema is not obvious, the pregnant woman is asked if it was present when she awoke. Care management Edema may be described as dependent or pitting. Dependent edema is edema of the lower or dependent part of the body, where hydrostatic pressure is greatest. If a pregnant woman is ambulatory the edema may be first evident in the feet or ankles. If the woman confined to bed the edema is more likely to occur in sacral region. Care management Pitting edema is edema that leaves a small depression or pit after finger pressure is apply to the swollen area. The pit caused by movement of fluid away from point of pressure to adjacent tissues within 30 seconds. Care management Symptom reflecting CNS & visual system involvement usually accompany facial edema. Although it is not routine assessment during prenatal period, evaluation of the fundus of the eye yield valuable data. An initial baseline finding of normal eyegrounds assists in differentiating a preexisting from a new disease process. Care management The woman may report no other symptom such as epigastric pain or oliguria. Respirations are assessed for crackles, which may indicate pulmonary edema. Deep tendon reflexes (DTRs) are evaluate if preeclampsia is suspected. The biceps & patellar reflexes and ankle clonus are assessed and findings recorded. Care management An important assessment is determination of fetal status, uteroplacental perfusion decreased in women with preeclampsia placing fetus in jeopardy. Biophysical or biochemical monitoring such as nonstress testing, contraction testing, biophysical profile and serial ultrasonography is to assess fetal status. Care management The fetal heart rate (FHR) is assessed for baseline rate & the presence of variability accelerations, which indicate an intact oxygenated fetal CNS. Abnormal baseline rate, decreased or absent variability, & late or variable decelerations are indications of fetal intolerance to the intrauterine environment. Care management Laboratory test: obtain a number of blood and urine specimens to aid in the diagnosis of pre eclampsia, HELLP syndrome, or chronic hypertension. Baseline laboratory test information is useful in the early diagnosis of preeclampsia for comparison with result obtained to evaluate progression & severity of disease. Care management Laboratory test: the hematocrit, hemoglobin, and platelet level are monitored closely for changes indicating a worsening of a patient status. Because hepatic involvement is a possible complication, serum glucose levels are monitored if liver function tests indicate elevated liver enzymes. Care management Laboratory test: proteinuria is determined from dipstick testing of a cleancatch or catherizad urine specimen. A reading 2+ on two or more occasions, al least 6 hours apart, shoud be followed by a 24-hour urine collection. Care management • Laboratory test: renal laboratory assessments include monitoring trends in serum creatinine and BUN levels, as renal function becomes compromised, renal excretion creatinine or other waste products including magnesium sulfate, decreases. As renal excretion decreases, serum level for creatinine, BUN, uric acid, & magnesium rise. Medical Management • Medical management The only cure for severe preeclampsia is delivery of the fetus. The decision to deliver the fetus versus expectant management is individual. Management is focused on preventing seizures and respiratory complications, monitoring cardiovascular status, and maintaining fluid status. If the women does not deliver, fetal monitoring is necessary. The goal of therapy are to ensure maternal safety and to deliver a healthy newborn, as close to term as possible. Nursing diagnoses Nursing diagnoses for the woman with hypertensive disorder in pregnancy include: • Anxiety related for: preeclampsia and its effect on woman and infant • Ineffective individual/family coping related to: the women's restricted activity and concern over a complicated pregnancy • The women's inability to work outside the home Nursing diagnoses • Powerless related to: inability to prevent or control condition & outcomes • Altered tissue/organ perfusion, decreased related to: hypertension, cyclic vasospasms, cerebral edema, hemorrhage • Risk injury related to: uteroplacental insufficiently, preterm birth, abruption placenta. Nursing interventions Nursing interventions Nurse must assess the patient for increased risk of seizures by evaluating neurological symptoms. To reduce the risk of seizures, decrease the light and sound stimulation to the patient. If seizures occur, protect the patient from injury, ensure patent airway, provide adequate oxygenation, and evaluate possible aspiration. After stabilizing the patient, uterine & fetal activity quickly assessed. Expected outcomes Expected outcomes for care of the patients with hypertensive disorders of pregnancy include that woman will be doing the following: ▪ Recognize & immediately report abnormal signs & symptoms to prevent worsening of her condition ▪ Adhere to the medical regimen to minimize risk to her & her fetus ▪ Identify and use available support system Expected outcome • Verbalized her fears and concerns to cope with the condition and situation. • With her fetus will not suffer adverse sequelae from preeclampsia or its management • Develop no signs of preeclamsia and its complications • Give birth to a healthy infant. Exclampsia Tonic- clonic convulsion signs Stage of invasion: 2 to 3 seconds; eye fixed, twitching of facial muscles Stage of contraction: 15 t0 20 seconds, eye protrude and bloodshot, all body muscle in tonic contraction Stage of colvusions: muscles relax and contract alternately (clonic). Respiration are halted and then begin again with long deep stertorous inhalation, coma may be ensure. Exclampsia Interventions: ▪ Keep airway patent, turn head to one side, place pillow under one shoulder or back if possible ▪ Call for assistance ▪ Protect with side rails up and padded ▪ Observe and record convulsion activity Exclampsia After convulsion/seizure: • Observe for the postconvulsion, coma and incontinence • use suction as needed • Administer oxygen via face mask at 10l/min • Start IV fluid and monitor for potential fluid overload • Give MgSO, or anticonvulsant drug as order Exclampsia ▪ Insert indwelling catheter ▪ Monitor blood pressure ▪ Monitor fetal and uterine status ▪ Expedite laboratory work as ordered to monitor kidney function, liver function, coagulation system, and drugs levels; ▪ Provide hygiene and quiet environment ▪ Support and keep woman and family informed ▪ Be prepared for birth when woman is stable. ▪ Transfer of the woman to a tertiary center for more intensive management. End Section
