pre eclampsia

nursing

1. PREECLAMPSIA 1

2. INTRODUCTION Hypertension is one of the most common disorders of pregnancy and contributes significantly to the maternal and perinatal morbidity. Hypertension may appear for the first time during pregnancy as a direct result of the gravid state or a sign of underlying pathology , which maybe pre-existing 2

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4. Classification of hypertension in pregnancy A. PREGNANCY INDUCED HYPERTENSION (PIH) With proteinuria and or oedema Preeclampsia Eclampsia Without gross oedema or proteinuria Gestational hypertension 4

5. B. CHRONIC HYPERTENSION IN PREGNANCY Essential hypertension Reno vascular hypertension Pheochromocytoma Coaction of aorta Thyrotoxicosis Connective tissue disease systemic lupus erythematous 5

6. C. HYPERTENSION WORSENED BY PREGNANCY Superimposed preeclampsia Superimposed eclampsia 6

7. DEFINITION Preeclampsia is a multisystem disorder of unknown aetiology characterized by development of hypertension to the extent of 140/90 mm of hg or more with proteinuria induced by pregnancy after the 20thweek in a previously normotensive and proteinuric woman. (International society for study of hypertension in pregnancy, 1998) 7

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9. INCIDENCE According to the new guidelines given by American Congress Of Obstetricians and Gynaecologist (ACOG) in 2013. In INDIA, the incidence of preeclampsia is reported to be 8-10%. It occurs more frequently in young primigravidae and in mothers over 35yrs of age. 9

10. It is known to be associated with HYDATIFORM MOLE, MULTIPLE PREGNANCY AND MATERNAL DIABETES. The incidence in primigravidae is about 10% and in multigravidae 5%. 10

11. AETIOLOGY Failure of trophoblastic invasion mediators (abnormal placentation). Vascular endothelial damage. Inflammatory mediators. Immunological intolerance between maternal and foetal tissues. Coagulation abnormalties . Increased oxygen free radicals. Genetic pre disposition. Dietary deficiency or excess. 11

12. Other Factors Abnormal lipid metabolism (results in more oxidative stress). Mutation of factor V Leiden increase risk. 12

13. PATHOPHYSIOLOGY UTEROPLACENTAL BED KIDNEY BLOOD VESSELS LIVER HEART LUNGS HAEMATOLOGICAL CHANGES HORMONES 13

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15. CLINICAL TYPES The clinical classification of preeclampsia is arbitrary and in principally dependent on the level of blood pressure for management purpose. 1) MILD 2 ) SEVERE 15

16. MILD This includes cases of sustained rise of blood pressure of more than 140/90 mm of hg but less than systoloic or 110 diastolic without significant proteinuria . SEVERE: A systolic blood pressure of more than 160 mm of hg or diastolic more than 110 mm of hg. 16

17. CLINICAL FEATURES The clinical manifestation appears usually after the 20 th week. ONSET: The onset is usually insidious and the syndrome runs a slow course. 17

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19. MILD SYMPTOMS Slight swelling over the ankles (on rising from bed in morning). Tightness of the ring on the finger. Swelling may extend to face abdominal wall, vulva and even the whole body. 19

20. ALARMING SYMPTOMS Headache( occipital or frontal region). Disturbed sleep Diminished urinary output Epigastric pain Eye symptoms 20

21. INVESTIGATION History collection Physical examination Urine analysis: proteinuria is the last feature of preeclampsia to be appear.(there may be few hyaline cysts, epithelial cells or even few red cells ). Opthalmoscopic examination Blood values or CBCs Liver Function Test Non stress test or biophysical profile Renal Function Test 21

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23. MANAGEMENT So, As long as the aetiology of preeclampsia remains obscure, the treatment is mostly empirical and symptomatic. 23

24. PHARMACOLOGICAL MANAGEMENT 1. ANTIHYPERTENSIVE AGENTS Methyl D opa : central and peripheral anti adrenergic action:250/500mg/ tid / qid . Labetalol : adrenoceptor antagonist (alpha and beta blockers):250mg tid / qid . 24

25. Nifedipine : calcium channel blockers: 10-20mg/bid. Hydralazine : vascular smooth muscle relaxant: 10-25mg bid. 25

26. IN HYPERTENSIVE CRISIS : 26 DIURETICS : The diuretics should not be used injudiciously as they cause harm to the baby by diminishing placental perfusion. FRUSEMIDE (LASIX) 40 MG give orally after breakfast for 5days in a week.

27. SEDATIVES: To cut down the emotional factors mild sedatives may be given orally as PHINOBARBITONE 60mg or DIAZEPAM 5mg at bed time. 27

28. Monitoring of a patient with severe preeclampsia on MgSo4. 28 Pulse, blood pressure, respiratory rate, SaO2 Temperature, lung sounds Deep tendon reflexes, level of consciousness, assessment of headache, visual disturbances, epigastric pain Intake and output record Foetal wellbeing (ante and intrapartum) Every 10 to 30 minutes Every 2 hour every 4 hour Intake IV crystalloids (normal saline), colloids (albumin, blood), total less than or equal to 125 mL/h Continuous EFM

29. SURGICAL MANAGEMENT Depending on the response to the treatment, the patients are grouped into the following. GROUP A: Preeclampsia features completely subside. GROUP B: Partial control of the preeclampsia features but the blood pressure maintains a steady high level . GROUP C: Persistently increasing BP to severe level. 29

30. METHODS OF TERMINATION 1. Induction of labor 2. Caesarean section 30

31. MANAGEMENT DURING LABOR Blood pressure tends to rise during labor and convulsions may occur. The patient should be in bed Antihypertensive drugs may be given. Blood pressure should be monitored along with urinary output. Careful monitoring of Foetus also. 31

32. PUERPERIUM: The patient is to be watched closely for at least 48 hours, the period during which convulsions usually occur. 32

33. NURSING MANAGEMENT 1. Continue monitoring of vitals sings . 2. Rest 3. Position 4. Diet 5. Fluids 33

34. PREDICTION AND PREVENTION Screening tests for prediction and prevention of preeclampsia are not helpful. The following steps that helps are: Regular antenatal check-up for early detection. Anti thrombotic agents Calcium supplementations Antioxidants Nutritional supplements 34

35. COMPLICATIONS The complications may be considered are more likely to occur if the patients are left untreated from the following points of view; 1. IMMEDIATE a. Maternal b. Foetal 2. Remote 35

36. IMMEDIATE (Maternal) Eclampsia Accidental haemorrhage Oliguria and anuria Dimness of vision even blindness Preterm labor HELLP syndrome Shock Sepsis 36

37. (Foetal) Intra uterine death Intra uterine growth restriction Asphyxia Prematurity 37

38. REMOTE Residual hypertension Recurrent preeclampsia C hronic renal disease 38

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40. the end special thanks to: mrs. Snehlata parashar (lecturer) 40