10.1c Care Management of Preeclampsia

Question 1

Prevention of Pre-eclampsia

Answer 1

• Low dose aspirin reduces preeclampsia risks

- High risk patients are put on 81mg/day aspirin therapy between 12-28 weeks

Question 2

Preeclampsia High Risk

Answer 2

• History of preeclampsia
• Multifetal gestation
• Chronic hypertension
• Diabetes (1 or 2)
• Renal Disease
• Autoimmune Diseases (Lupus, Antiphospholipid Syndrome)

Question 3

Preeclampsia Moderate Risk

Answer 3

• First Pregnancy
• 35+ age
• BMI >30
• Family History

Question 4

Assessment of Preeclampsia

Answer 4

• BP
• Edema
• DTR
• Proteinuria

Question 5

Edema

Answer 5

• Dependent edema is located in the lowermost dependent parts of the body with the most hydrostatic pressure.
• Pitting edema (pit usually goes away in 10-30 seconds)

GRADING
\+1 = 2mm pit
\+2 = 4mm pit
\+3 = 6mm pit
\+4 = 8mm pit

Question 6

Deep Tendon Reflexes (DTR)

Answer 6

• Bicep and Patellar Reflex are assessed
• Normal is +2
• Normal result (negative clonus) has no rhythmic oscillations
• Abnormal result (positive clonus) has rhythmic oscillations

Question 7

Proteinuria

Answer 7

• Collected from 24 hour urine specimen
• > 300mg
• protein/creatinine ratio larger than 0.3
• Dipstick measurement 1+ on 2 occasions

Question 8

Severe Features of Preeclampsia

Answer 8

• Severe headache (frontal)
• Epigastric pain (heartburn)
• RUQ pain
• Visual Disturbances (scotoma, photophobia, double vision)

Question 9

Problems experienced with Preeclampsia

Answer 9

• Anxiety
• Management Education (assessments, medications, activity restrictions, plans for L&D)
• Financial concerns
• Injuries related to hypertension, CNS irritability secondary to cerebral edema, vasospasm, decreased renal perfusion
• Fetus risk including disrupted oxygen transfer, IUGR, Placental Abruption, Preterm birth

Question 10

Gestational Hypertension and Preeclampsia Without Severe Features INTERVENTIONS

Answer 10

• Prior to 37 weeks close monitoring of maternal/fetal status
• Can safely be managed at home
• Vaginal birth is recommended at 37 weeks
• BP of 155/105 or less can have regular diet with no salt restriction
  SEEK HELP IF
• Abdominal pain
• Significant headache
• Uterine Contractions
• Vaginal Spotting
• Decreased fetal movement

Question 11

Severe Features

Answer 11

• Headaches/Blurred Vision
• Mental Confusion
• RUQ/Epigastric Pain
• N/V
• SOB
• Decreased Urinary Output
• BP monitored twice a week

Question 12

Fetal Evaluations

Answer 12

• Daily Fetal Movement Counts
• NST or BPP 1-2 times a week
• Ultrasound for amniotic fluid status and estimated fetal weight
• Doppler blood flow test if IUGR is suspected

Question 13

Pre-Eclampsia Recommendations

Answer 13

• Activity restriction

- Complete/partial bed rest for the duration of pregnancy

Question 14

Gestational Hypertension and Preeclampsia with Severe Features

Answer 14

• Hospitalized immediately for thorough examination
• Magnesium sulfate to prevent eclamptic seizures
• If this develops after 34 weeks of gestation, prompt birth is recommended

Question 15

Maternal Assessment

Answer 15

• BP
• Urine Output
• Cerebral Status
• Epigastric/RUQ Pain
• Labor/Vaginal Bleeding

LABS

• Platelets
• Liver Enzymes
• Serum Creatinine

Question 16

Fetal Assessment

Answer 16

• FHR
• BPP
• Ultrasound (fetal growth and amniotic fluid volume)
• If Fetal Growth Restriction is seen then Doppler is recommended

Question 17

Expectant Management

Answer 17

• For those who are less than 34 weeks pregnant and no indications for giving birth early
• Hospitalized immediately at a tertiary care facility

Expectant Management

• Oral hypertensive medication (Maintain BP between 140-155/90-105
• Ongoing maternal/fetal assessments
• Corticosteroids to enhance fetal lung maturation
• Betamethasone 12mg IM (2 doses 24 hour intervals)
• Dexamethasone IM 6mg 4 doses 12 hours apart
• Benefits of corticosteroids are best if given before 48 hours of birth

Question 18

Intrapartum Care

Answer 18

• Early identification of FHR abnormalities
• Prevention of complications
• Continuous FHR and UC monitoring

ASSESSMENTS

• Placental abruption (tense and tender uterus)
• CNS, Cardiovascular, Pulmonary, Hepatic, Renal systems
• VS

Question 19

Intrapartum Care Preeclampsia (Severe)

Answer 19

• Bed rest with side rails up
• Quiet and dark environment
• Emergency drug/oxygen/suction available
• Reduce risk of pulmonary edema by keeping IV and oral fluids less than 125 mL/hr

Question 20

Swan-Ganz

Answer 20

• This is a pulmonary artery catheter to evaluate central venous and pulmonary artery pressure
• Used for intensive hemodynamic monitoring
• Only used for select women with preeclampsia (severe) such as those with oliguria

Question 21

Risks of Preeclampsia (severe)

Answer 21

Maternal

• Eclampsia
• Acute Tubular Necrosis
• Oliguria
• Pulmonary Edema
• Coagulopathy
• Cardiac/Liver Failure
• Subcapsular Hematoma (Hematoma in Liver)
• Cerebral Edema/Hemorrhage

Baby

• IUGR
• Decreased Amniotic Fluid Volume
• Abnormal Fetal Oxygenation
• LBW
• Preterm Birth

Question 22

Nursing Intervention Preeclampsia (Severe)

Answer 22

• IV line
• Magnesium Sulfate and Antihypertensives (as prescribed)
• Assess BP/Pulse/RR/DTR/LOC/Fetal Status
• Indwelling catheter to measure urine output accurately
• Monitor Headache/Visual/Epigastric Pain

Question 23

CNS Irritability Outcomes/Interventions

Answer 23

• Woman will maintain DTR 2+ with absence of clonus and no seizures
• Assess VS/LOC/DTR/IV Rate/I&O/Proteinuria
• Initiate seizure precautions with magnesium sulfate.
• Make sure oxygen and suction is readily available
• Report signs of worsening conditions (headache, visual changes, RUQ pain)

Question 24

Decreased Tissue Perfusion Outcome/Interventions

Answer 24

• Women should maintain good perfusion (adequate urine output, normal HR)
• Assess BP, IV Fluid Intake, Indwelling Catheter, Breath Sounds, Edema, FHR
• Administer Antihypertensives as prescribed
• Bed Rest in Side Lying Position

Question 25

Decreased Gas Exchange Outcome/Interventions

Answer 25

• Exhibit Normal Gas Exchange (normal breath sounds, RR, full orientation to person/place/time)
• Assess color, capillary refill, breath sounds, increased RR, dyspnea, oxygen saturation
• Notify HCP for signs of impaired gas exchange where oxygen and diuretics will be administered
• Educate women on doing turn-cough and taking deep breaths

Question 26

Magnesium Sulfate

Answer 26

• Prevents seizures (CNS Depressant)
• Loading dose 4-6g infused over 15-30 minutes
• Maintenance dose diluted into IV fluid (40g in 1000mL lactated ringer)
• Administered via Infusion Pump 2-3g an hour
• Does not affect BP
• Magnesium Sulfate works through vasodilation in peripheral and cerebral circulation which prevents cerebral edema and acts as an anticonvulsant

Question 27

Magnesium Sulfate Side Effects and Toxicity

Answer 27

Side Effects

• Warm/Flushing/Diaphoresis
• Burning at IV site
• Magnesium is secreted in urine so I&O is important to monitor. Renal failure will cause magnesium toxicity

TOXICITY

• Absent DTR
• Decreased RR
• Decreased LOC

Question 28

What to Monitor for Magnesium Sulfate

Answer 28

Maternal V/S
FHR
I&O
DTR (Ankle Clonus)

Question 29

Magnesium Sulfate Toxicity

Answer 29

• Discontinue medication

- Administer calcium gluconate slowly

Question 30

Control of BP

Answer 30

• Medications used if BP exceeds 160/110
• Goal is to keep BP 140-150/90-100

Medications

• Hydralazine (Apresoline)
• Labetalol (Trandate)
• Nifedipine (Procardia)

Question 31

PreEclampsia Post-Partum Care

Answer 31

• VS, I&O, DTR, LOC, Magnesium Sulfate Prophylaxis continued for 24 hours
• Preeclampsia usually resolves within 48 hours after birth
• Signs that preeclampsia is resolving is diuresis and reduced edema
• Baby may be taken to NICU
• BP should continue to be monitored for 72 hours because hypertension takes longer to resolve
• BP should be re-assessed 7-10 days after
• If BP remains at 150/100 or greater, antihypertensives should be prescribed