Case Study: Eclampsia and Pre Eclampsia Severe

ECLAMPSIA

I. Definition

Eclampsia is a Greek word meaning 'bolt from the blue'. It describes one or more convulsions occurring during or immediately after pregnancy, as a complication of pre-eclampsia. Eclampsia has been recognized since ancient times, but it wasn't until the mid-nineteenth century that doctors began to realize that the fits were normally preceded by a collection of circulatory disturbances now known as pre-eclampsia. Confusingly, however, very few cases of pre-eclampsia culminate in eclampsia, while eclampsia can sometimes precede pre-eclampsia.

II. Causes

Several factors are probably involved, including:

·         reduced blood flow to the brain, caused by a combination of small clots and spasm of the small arteries;

·         swelling in the brain (cerebral edema), possibly as a complication of excessive fluid retention;

·         Bleeding from small arteries ruptured by the intensity of the blood pressure.

III. Risk Factors

The following are considered risk factors for eclampsia:

• Nulliparity
• Family history of preeclampsia, previous preeclampsia and eclampsia
• Poor outcome of previous pregnancy, including intrauterine growth retardation, abruptio placentae, or fetal death
• Multifetal gestations, hydatid mole, fetal hydrops, primigravida
• Teen pregnancy
• Primigravida
• Patient older than 35 years
• Lower socioeconomic status

IV. Signs and symptoms

Typically patients show signs of pregnancy-induced hypertension and proteinuria prior to the onset of the hallmark of eclampsia, the eclamptic convulsion. Other cerebral signs may precede the convulsion such as nausea, vomiting, headaches, and cortical blindness. In addition, with the advancement of the pathophysiological process, other organ symptoms may be present including abdominal pain, liver failure, signs of the HELLP syndrome, pulmonary edema, and oliguria. The fetus may already have been compromised by intrauterine growth retardation, and with the toxemic changes during eclampsia may suffer fetal distress. Placental bleeding and placental abruption may occur.

V. Pathophysiology

     The etiology of eclampsia remains unclear. It is thought that the underlying factor is hypoperfusion of the placenta. This may be due to the abnormal formation of uteroplacental spiral arteries, making them highly susceptible to vasoconstriction. Vasoconstriction of the placental vessels promotes ischemia or infarction. The hypoperfusion state of the placenta is thought to lead to the release of vasoactive substances causing an inflammatory response, vasoconstriction, coagulation disorders, an increase in capillary permeability and platelet dysfunction. All of these will contribute to organ dysfunction and clinical signs of the disease process.

VI. Treatment

The treatment of eclampsia requires prompt intervention and aims to prevent further convulsions, control the elevated blood pressure and deliver the fetus.

·         Prevention of seizure convulsion is usually done using magnesium sulfate.

·         Antihypertensive management at this stage in pregnancy may consist of hydralazine (5–10 mg IV every 15-20 min until desired response is achieved) or labetalol (20 mg bolus iv followed by 40 mg if necessary in 10 minutes; then 80 mg every 10 up to maximum of 220 mg).

·         If the baby has not yet been delivered, steps need to be taken to stabilize the patient and deliver her speedily. This needs to be done even if the fetus is immature as the eclamptic condition is unsafe for fetus and mother. As eclampsia is a manifestation of a multiorgan failure, other organs (liver, kidney, clotting, lungs, and cardiovascular system) need to be assessed in preparation for a delivery, often a cesarean section, unless the patient is already in advanced labor. Regional anesthesia for cesarean section is contraindicated when a coagulopathy has developed.

·         Invasive hemodynamic monitoring may be useful in eclamptic patients with severe cardiac disease, renal disease, refractory hypertension, pulmonary edema, and oliguria.

VII. Nursing Management:

The responsibilities of nursing staff in the management of preeclampsia and eclampsia include patient education and monitoring of patient compliance with the physician's instructions as well as assisting with emergency care. Patients resting at home should be visited and assessed periodically by a home health nurse. These functions are essential to good management of high-risk patients. Providing emotional support to patients with complications during pregnancy is also a critical function. If the patient requires hospitalization, a calm and quiet environment can help decrease the risk of seizure.

PRE ECLAMPSIA SEVERE

I. Definition

A condition in pregnancy characterized by abrupt hypertension (a sharp rise in blood pressure), albuminuria (leakage of large amounts of the protein albumin into the urine) and edema (swelling) of the hands, feet, and face. Preeclampsia is the most common complication of pregnancy. It affects about 5% of pregnancies. It occurs in the third trimester (the last third) of pregnancy.

Severe preeclampsia can be determined by a blood pressure reading of 160/110.

II. Causes

Preeclampsia used to be called toxemia because it was thought to be caused by a toxin in a pregnant woman's bloodstream. This theory has been discarded, but researchers have yet to determine what causes preeclampsia. Possible causes may include:

• Insufficient blood flow to the uterus
• Damage to the blood vessels
• A problem with the immune system
• Poor diet

III. Risk Factors

Preeclampsia develops only during pregnancy. Risk factors include:

• History of preeclampsia.
• First pregnancy.
• New paternity.
• Age. The risk of preeclampsia is higher for pregnant women younger than 20 and older than 40.
• Obesity.
• Multiple pregnancies.
• Prolonged interval between pregnancies.
• Diabetes and gestational diabetes.

IV. Signs and symptoms

• High blood pressure (hypertension) — 140/90 millimeters of mercury (mm Hg) or greater — documented on two occasions, at least six hours but no more than seven days apart
• Excess protein in your urine (proteinuria)
• Severe headaches
• Changes in vision, including temporary loss of vision, blurred vision or light sensitivity
• Upper abdominal pain, usually under your ribs on the right side
• Nausea or vomiting
• Dizziness
• Decreased urine output
• Sudden weight gain, typically more than 2 pounds (0.9 kilogram) a week

V. Pathophysiology:

VI. Treatment

The only cure for preeclampsia is delivery.

·         Medications

                                -Use of antihypertensives

                                -Corticosteroids-corticosteroid medications can temporarily improve liver and platelet                                   functioning to help prolong your pregnancy.

                                -Anticonvulsive medications such as magnesium sulfate to prevent a first seizure.

·         Bed rest

·         Delivery
If you're diagnosed with preeclampsia near the end of your pregnancy, your doctor may recommend inducing labor right away. After delivery, expect your blood pressure to return to normal within a few weeks.

VII. Nursing Management

• Monitor blood pressure every 4 hours
• Record the patient's level of consciousness
• Assess signs of eclampsia (hyper active, the patellar reflexes, decreased pulse and respiration, epigastric pain and oliguria)
• Monitor for signs and symptoms of labor or uterine contractions.