Chapter 11: Preeclampsia/ Eclampsia Flashcards
What is Preeclampsia?
pregnancy-specific syndrome
- increase in BP (i.e. systolic BP greater than or equal to 140 mm Hg and diastolic greater than or equal to 90 mm Hg, respectively, occurring twice, 4 hours apart) after 20 weeks gestation
- accompanied by proteinuria (excretion of greater than or equal to 300 mg protein/24 hours)
Pathophysiology
-disease of the placenta, have a distinctive lesion in the placenta termed “acute atherosis” (fat accumulation in the placental arteries)
-placentas also exhibit greater degree of infarction (necrosis r/t decreased blood supply)
-the pathophysiological changes can lead to decreased placental perfusion and placental hypoxia
>vasospasm and endothelial cell damage are the major underlying pathophysiological events in preeclampsia
-vasospasm may be associated with an elevation in arterial blood pressure and resistance to blood flow
SPASMS Pneumonic
S- Significant blood pressure changes may occur without warning
P- Proteinuria is a serious sign of renal involvement
A- Arterioles are affected by vasospasms that result in endothelial damage and leakage of intravascular fluid into the interstitial spaces. Edema result
S- Significant Laboratory changes (most notably, liver function tests (LFT) and the platelet count signal worsening disease
M- Multiple organ systems can be involved: cardiovascular, hematological, hepatic, renal, and central nervous system
S- Symptoms appear after 20 weeks of gestation
Risk Factors for Preeclampsia
- primigravida (6-8 times greater risk)
- age extremes (less than 19, greater than 40)
- pregestational diabetes
- preexisting hypertension, renal disease, or collagen disease
- multiple gestation
- fetal hydrops
- hydatidiform mole
- preeclampsia in a previous pregnancy
- family history
- obesity
- periodontal disease
- antiphospholipid antibody syndrome
- Rh incompatibility
- African American ethnicity
- pregnancies that result from donor insemination, oocyte donation, and embryo donation
Signs of Severe Preeclampsia
- systolic BP greater than or equal to 160 mm Hg or diastolic BP greater than or equal to 110 mm Hg on 2 occasions at least 4 hours apart while patient is on bed rest
- thrombocytopenia (platelets less than 100 x 10/L)
- impaired liver function, as indicated by abnormally elevated blood concentrations of liver enzymes
- severe persistent right upper quadrant or epigastric pain unresponsive to medication and not accounted for by alternative diagnoses
- progressive renal insufficiency (serum creatinine greater than 1.1 mg/dL or a doubling of the serum creatinine concentration in the absence of other renal disease)
- pulmonary edema
- new-onset visual or CNS disturbances
What is the cure for Preeclampsia
delivery of the fetus is the only cure
Nursing Interventions
- preeclampsia without severe features can be managed at home after patient had careful assessment of her S/S, physical examination, lab tests, and evaluation of fetal well-being
- patients with new-onset preeclampsia, initial examination should be performed in the hospital
- get adequate rest
- maintain lying in the lateral side position
Clinical Actions for Severe Preeclampsia
- seizure prophylaxis with magnesium sulfate
- antihypertensive medications
- invasive hemodynamic monitoring may be required if any are present: oliguria unresponsive to a fluid challenge, pulmonary edema, hypertensive crisis refractory to conventional therapy, cerebral edema, disseminated intravascular coagulation (DIC), and multisystem organ failure
Magnesium Sulfate
-anticonvulsant in severe preeclampsia or eclampsia
>plays an important role in neurotransmission and muscular excitability
>therapeutic: resolution of eclampsia
>contraindicated: hypermagnesemia/ hypocalcemia/ anuria/ heart block/ active labor or within 2 hours of labor (unless used for preeclampsia or eclampsia)
>side effects: drowsiness, Decreased respirations, arrhythmias, hypotension, bradycardia, diarrhea, flushing, sweating, hypothermia
>usually piggybacked
Nursing Implications for Magnesium Sulfate
- may feel warm and become flushed and experience nausea and vomiting, visual blurring, and headaches
- always use an infusion pump for administration and run the medication piggyback, not as main line
- monitor pulse, blood pressure, respirations, and ECG frequently throughout administration; Respirations should be at least 16 breaths/min before each dose
- monitor neurological status before and throughout therapy
- institute seizure precautions; keep room quiet and darkened to decrease the likelihood of triggering seizure activity
- Patellar reflexes should be tested before each dose; if absent, no additional dose should be administered until a positive response returns
- Monitor intake and output; output maintained at 100 mL/4 hours
- serum magnesium levels and renal function should be monitored
- have 10% calcium gluconate available if toxicity occurs; 10mL IV over 1 to 3 minutes until symptoms reversed
- after delivery, monitor newborn for hypotension, hyporeflexia, and respiratory depression
Perform a daily cardiovascular assessment on patients with preeclampsia
- auscultation of heart sounds, lungs, and breath sounds
- presence and degree of edema
- early signs or symptoms of pulmonary edema, such as tachycardia and tachypnea
- daily weight taken at the same time of the day and on the same scale
- skin color, temperature, and turgor
- capillary refill, which may indicate decreased perfusion or vasoconstriction if > 3 seconds
Grading reflexes and checking for clonus
4+ = very brisk, hyperactive; often indicative of disease; often associated with clonus
3+ = brisker than average; possibly but not necessarily indicative of disease
2+ = average; normal
1+ = somewhat diminished
0 = no response
>if reflexes are hyperactive, test for ankle clonus; support the knee in a partly flexed position. With your other hand, dorsiflex and plantar flex the foot a few times while encouraging the patient to relax, and then sharply dorsiflex the foot and maintain it in dorsiflexion; look and feel for rhythmic oscillations between dorsiflexion and plantar flexion. Normal is no reaction to the stimulus. Sustained clonus indicates upper motor neuron disease.
Significance of Proteinuria
excretion of 300 mg or more of protein every 24 hours
-if 24-hour urine is not available, protein concentration of 300 mg/L or more (greater than or equal to 1+ on dipstick) in at least 2 random urine samples taken at least 4 to 6 hours apart and no more than 7 days apart
(24-hour urine is best to test)
The purpose of the Renal Assessment in Preeclampsia
to identify renal compromise
-as a result of the vasospasm that accompanies preeclampsia, the expected increases in the glomerular filtration rate and renal blood flow may not occur, nor the expected decrease in serum creatinine
>preeclampsia may be associated with profuse swelling in the kidney glomerular endothelial cell cytoplasm; this pathological change causes glomerular endotheliosis, a lesion that correlates with proteinuria
Important hospital care for patients with preeclampsia
-assess urine output every 1 to 4 hours to confirm adequate renal perfusion and oxygenation
>output of 30 mL/hr or 100 mL/4 hours = normal; a decrease should be reported
>a urimeter attached to a Foley catheter tubing is useful in the assessment of hourly output
>24-hour urine test for total protein; increased = increasing kidney impairment; if it shows protein, a dipstick is not required; once protein is present in the 24-hour urine, protein will always be preset when the urine is tested by dipstick
-24-hour yields more accurate information and shows whether or not the urine protein is increasing, decreasing, or staying the same
>when indicated, a high protein diet may be needed to replace the protein excreted in the urine
