Pre-eclampsia @MAk.pptx

SCIENCE

1. PRE-ECLAMPSIA BY MAKERERE UNIVERSITY

2. CASE A 34 year old G5P3+1 Female is diagnosed with preeclampsia during pregnancy. Discuss the nursing assessments, interventions, and monitoring required to manage preeclampsia and ensure a safe birth. Outline ; Definition Nursing assessment Nursing diagnosis Interventions Monitoring

3. DEFINITION Pre-eclampsia This is a condition where the BP is greater than or equal to 160/110mmHg confirmed within 15 minutes with or without proteinuria after 20 weeks of gestation in a previously normotensive mother. Do atleast 2 readings to confirm pre-eclampsia. Pre- eclampsia can occur upto 6 weeks post partum

4. Pre-eclampsia with severe features Severe pre-eclampsia is high-blood pressure of systole >160 mmHg or diastole >110 mmHg on 2 occasions and significant proteinuria and has atleast 2 of the features below: Low –blood platelet count <100 ×106/l Haemolysis Elevated Liver enzymes and Low Platelet count (HELLP) syndrome Pulmonary edema Epigastric pain Severe headache Visual disturbance (flashing light similar to migraine)

5. RISK FACTORS Maternal factors Primipaternity ( Ist pregnancy with a new partner) Extremes of maternal age (<20 >40 years Family history Obesity Pre-existing diabetes Chronic HTN Pre-existing medical conditions, e.g. renal disease Pregnancy related factors First pregnancy Multiple pregnancy Developing a medical disorder during pregnancy, gestational diabetes, gestational HTN

6. NURSING ASSESSMENTS Maternal assessments; History of headache, visual and hearing disturbances, palpitations Blood pressure Vital sign assessments i.e. heart rate, respiratory rate, weight, temperature Assess pulmonary edema i.e. oxygen saturation, crackles, dyspnea, respiratory rate Urinalysis; Urine output for amount and proteinuria Blood tests; CBC, RFTs, LFTs, coagulation time Neurological status Indications for an earlier delivery Obstetric assessment for mode of delivery

7. ASSESSMENTS CONTINUED.... Fetal assessment Heart rate Movements Liquor Growth( fundal height) NB ; And ensure continuous monitoring of all these aspects of fetus to ensure fetal welbeing

8. NURSING DIAGNOSIS Impaired breathing pattern RT increased fluid retention as evidenced by pulmonary edema, crackles Impaired vision RT disease process as evidenced by photophobia,visual disturbance Imbalanced fluid volume RT decreased kidney function, plasma protein loss as evidenced by pulmonary edema Decreased cardiac output RT decreased venous return as evidenced by edema, dyspnea

9. INTERVENTIONS Goals/ nursing concerns Prevention or and control of convulsions Control blood pressure ( target 135/85mmHg) Plan for delivery within 24 hours NB, Interventions to the mother will also aim at maintaining fetal welbeing

10. 1. PREVENTION & /CONTROL OF CONVULSIONS Admit all mothers with severe pre- eclampsia Give Magnesium sulphate Loading dose( 14g) IV 4g of 20% followed by IM 5g of 50% with 1ml of 2% Lignocaine in each buttock Maintenance dose IM 5g of 50% with 1ml of 2 % Lignocaine in alternate buttock 4 hourly for 24 hours after delivery or last fit depending on what occurs first. If convulsions happens again before the maintenance dose; Give IV 2g of 20% and continue with maintenance for 24 hours after delivery or last fit depending on what occurs first. If mother convulses, give IV Phenytoin 1g in 500mls of saline and consult critical care team.

11. Cont ……… Observe the mother for Magnesium toxicity Hyporeflexia Respiratory depression; RR< 6bpm. Oliguria, < 100 mls in 24 hours Management Stop Magnesium sulphate Give Calcium gluconate IV Calcium gluconate 1 g of 10% over 10 minutes NB: Ensure proper reconstitution of MgSO4 as;

12. Dose of MgSO4 20% (g) Volume of 50% of MgSO4 Volume of water for injection Total volume of 20% MgSO4 2g 4ml 6ml 10ml 4mg 8ml 12ml 20ml

13. 2. CONTROL OF BLOOD PRESSURE Target BP 135/85mmHg (130-139/80-89 mmHg) If BP is > 160/110mmHg ; IV hydralazine 5mg , repeat every 30 minutes until BP<160/110 mmHg ( max dose : 30mg in 24hrs) OR IV Labetalol 20mg every 10mins, double the dose to 40mg then 80mg as needed ( max dose: 300mg in 24 hours)

14. CONTROL OF BP CONT….. Oral immediate release Nifedipine 10mg, Max 3 doses. If BP remains >160/110mmHg, at 20 mins, give 10 or 20 mg orally, depending on the initial response. If BP <160/110 , oral Nifedipine starting at 20 mg 12 hourly, methyldopa at 250mg 8 hourly, labetalol starting 200mg 12 hourly OR a combination of doses. N.B Dosing should be adjusted according to the response observed.

15. 3. PLAN FOR DELIVERY If >=37 weeks; Consider immediate delivery after stabilization within 24 hours If 34-<37 weeks; Expectantly manage the mother if there's no indication for immediate delivery; These signs include; Lab findings in severe range Uncontrolled blood pressure>160/110 Pulmonary edema or SPO2 <90% HELLP syndrome Placental abruption Preterm labour PPROM Oligohydramnios IUGR Abnormal neurological features,stroke

16. EXPECTANT MANAGEMENT Admit in hospital till delivery Daily assessment of mother and fetus Daily lab tests; CBC, LFT, RFT Administer corticosteroid ie IM dexamethasone 6mg 12hourly for 48 hours ( lung maturation, neuroprotection) Control BP with oral Nifedipine or methyldopa Complete maintenance dose of MgSO4

17. INTRA-PARTUM CARE Do obstetric assessment Determine the method of delivery ( ie SVD or C- section) Continuous maternal and fetal monitoring Treat severe HTN promptly with anti- hypertensives Limit fluid intake to 60-80mL/hr. Monitoring maternal Fetal Blood pressure •Fetal heart rate ,movement, Urine output and input • Liqour Proteinuria

18. POST- PARTUM CARE AND FOLLOW UP IMMEDIATE & INTERMEDIATE • Monitor vital signs 2 hourly then 4- 6 hours for atleast 3 days Complete MgSO4 dose Repeat lab tests daily till 2 consecutive normal results Do urinalysis Monitor urine output and input SHORT $ LONG TERM Review Postpartum within 1 week, 2 weeks till 6 weeks and monthly till 3 months Repeat lab tests each review Assess for depression, Postpartum blue Screen for other causes of HTN

19. REFERENCE Myles textbook of Midwifery 16 th edition Maternal and Newborn Critical Care Guidelines 2022

20. SEVERE PRE ECLAMPSIA $ ECLAMPSIA IS MISSED WHEN THE SIGNS $ Symptoms ARE DISMISSED 👁👁