Chapter 4 Sophie Bloom: Preeclampsia

Sophie Bloom Sophie is 23 years old. She had been in a non- exclusive relationship that recently ended. She and her ex-boyfriend used condoms but they weren’t very careful. She has recently discovered she is pregnant.

Risk Factors for Preeclampsia #1 Maternal risk factors: Age ≥20 or ≤35 African descent Low socioeconomic status Family history of preeclampsia First pregnancy or pregnant with a new partner Type 1 or gestational diabetes Obesity Chronic hypertension Kidney disease Thrombophilia (an increased tendency to clot)

Risk Factors for Preeclampsia #2 Pregnancy risk factors: Chromosomal abnormalities of fetus (such as trisomies 18 and 21) Hydatiform mole Hydrops fetalis Multifetal pregnancy Donated eggs or sperm Structural congenital abnormalities of the fetus

Preeclampsia During Pregnancy Preeclampsia is high blood pressure in pregnancy with at least one of the following: Decreased platelets Impaired liver function New-onset renal insufficiency Pulmonary edema New-onset cerebral disturbances (such as seizures) New-onset visual disturbances There is no clear cause of preeclampsia. Preeclampsia involves multiple organ systems. Preeclampsia progresses at different rates in different women. Preeclampsia is associated with cardiovascular disease later in life.

Question #1 Is the following statement true or false? Preeclampsia progresses from mild to severe before eclampsia begins.

Answer to Question #1 False. Preeclampsia is a hypertensive disease that progresses at different rates in different women.

Monitoring Preeclampsia During Pregnancy Teach patient to notify provider if they experience: Reduced fetal movement Vision changes Increased swelling (usually rapid onset) Epigastric pain Severe headache Monitor patients: Blood pressure Lab tests (platelets and liver function tests) Nonstress tests or biophysical profiles

Preeclampsia During Labor and Delivery #1 Assessments: Head-to-toe assessment every 4 hours should include: Headache Vision changes (floaters or spots) Shortness of breath/breath sounds Epigastric pain Urine output Edema Deep tendon reflexes (patellar) Clonus Vital signs every 15 minutes Continuous pulse oximetry Fetal monitoring

Preeclampsia During Labor and Delivery #2 Precautions: Minimal stimuli (to reduce the risk of seizure) Laboratory tests: Comprehensive metabolic panel Liver function tests Complete blood count with platelets

Magnesium Sulfate for Preeclampsia Management Magnesium sulfate is given to help prevent seizures. Common magnesium sulfate dosing: 4-6 gram loading dose over 15-30 minutes 1-3 grams/hour maintenance dose Therapeutic goal: a serum (blood) level of 4-7 mEq/L Signs of magnesium sulfate toxicity: Respiratory depression (under 12 breaths/min) Oliguria Absent reflexes Lethargy Slurred speech Muscle weakness Loss of consciousness

Nursing Intervention for Magnesium Sulfate Toxicity Stop the magnesium sulfate infusion immediately. Notify the primary healthcare provider. Administer calcium gluconate if ordered.

Question #2 Four hours ago, a patient with preeclampsia on magnesium sulfate had hyperreflexes and clonus present in both legs. She is now slurring her words, moving slowly, and has no reflexes or clonus. What should you do first? A. Obtain a set of vital signs. B. Turn off the magnesium sulfate. C. Administer calcium gluconate. D. Call the provider to notify about the patient’s changes.

Answer to Question #2 B. Turn off the magnesium sulfate. Slurred speech, lethargy, and hyporeflexes are signs of magnesium toxicity. The nurse should turn off the magnesium sulfate immediately. Then, the nurse should obtain vitals and notify the provider. Calcium gluconate has not been ordered at this time.

Preeclampsia During Postpartum Magnesium sulfate is to be infused at least 24 hours after delivery. Patient may seize after delivery. May take several weeks for blood pressure and other symptoms to return to baseline. Nursing should continue preeclampsia assessments along with assessments needed for a postpartum mother.

Management of Preeclampsia Routine bed rest is not advised in pregnancy for the treatment of preeclampsia. Patient should eat a high-protein, low-sodium diet. Patient may be monitored at home if mild-preeclampsia. Patient taught to report symptoms of preeclampsia Blood pressure checks twice weekly Weekly assessment of platelets and liver function tests Fetal movement assessed by mother daily Patients are often induced at 37 weeks for mild-preeclampsia. If pre-eclampsia becomes severe, or the patient develops eclampsia (seizures), patient should be hospitalized before 37 weeks. Magnesium sulfate should be given to prevent seizures.

Question #3 A nurse has just finished teaching a patient about preeclampsia symptoms that should be reported to the provider. The nurse knows teaching has been effective when the patient states: “I should report…” A. “…leaking of fluid, contractions, and increased fetal movement.” B. “…increased need to urinate, fatigue, and shortness of breath.” C. “…epigastric pain, shortness of breath, and weight gain of 1 pound per week.” D. “…severe headache, vision changes, and decreased fetal movement.”

Answer to Question #3 D. Severe headache, vision changes, and decreased fetal movement. Patients should be taught to report the preeclampsia symptoms of epigastric pain, shortness of breath, severe headache, vision changes, and decreased fetal movement. Leaking of fluid and contractions should be evaluated but are signs of labor. Increased fetal movement is not a concern. Weight gain of 1 pound per week is expected in the second and third trimester.

Role of the Nurse Patient teaching regarding preeclampsia Frequent maternal assessments to monitor changes Assess fetal well being, often by continuous electronic fetal monitoring Report changes or worsening of symptoms to provider Administer medications as ordered Monitor for signs of magnesium sulfate toxicity Ensure minimal stimuli in the patient environment

Psychosocial Stressors in Unplanned Pregnancies Informing partner or family Support/lack of support from partner or family Financial concerns Concerns about school or work Access to healthcare Keeping or terminating the pregnancy Readiness/ability to parent Keeping the child or adoption