Model of Advanced Practice:

Nursing Care in Patients with

Preeclampsia & Eclampsia

Djenta Saha, PhD

Physiological changes in pregnancy
• Most women experience a normal pregnancy.
A small percentage of women experience
life-threatening complications that may result
from the pregnancy itself or may be part of a
preexisting condition.
• Nurses must understand the psychological
changes that occur in pregnancy to distinguish
normal from abnormal responses.
 Physiological changes in pregnancy
1. Cardiovascular changes
- Blood volume change (>40%-50%) pregnancy
level (1,450-1,750 ml)
- Red blood cells change >20%, pregnancy level
(250-450 ml)
- Blood pressure: systolic change <5-12 mmHg
- Diastolic change <10-20 mmHg
- Cardiac output change>30%-50%, pregnancy
level 6-7l/min
Physiological changes in pregnancy
• Heart rate change >10%-30% pregnancy level
increased by 15-20 beat/min
• Systemic vascular resistance change
<20%-30% pregnancy level 1, 210 ±266
dynes/sec/cm-5
• Pulmonary vascular resistance change <34%
pregnancy level 78 ±22 dynes/sec/cm-5
• Colloid osmotic pressure change <10%-14%
pregnancy level 22.4 ± 0.5
Physiological changes in pregnancy
2. Respiratory changes
Functional residual capacity change <10%-25%
pregnancy level 1,725-2,070 ml
Tidal volume change >30%-35% pregnancy level
700ml
3. Renal Changes
Renal blood flow change >25%-50% pregnancy level
1,500-1,750ml/min
Glomelural filtration rate change >50% pregnancy
level 140-170mL/min
 Critical care conditions in pregnancy
• During pregnancy normal physiological
changes occur to provide for growth of fetus
& to prepare the mother for birth. Medical
complications may alter an uncomplicated
pregnancy into a critical condition. The most
common complications are severe
preeclampsia.
 Classification
• The hypertension disorders of pregnancy refer
to a variety of conditions in which maternal
blood pressure is elevated with corresponding
risk to maternal and fetal well-being
• Clinically there are two basic types of
hypertension during pregnancy:
- Chronic hypertension
- Pregnancy-induced hypertension (PIH)
 Classification
• Gestational hypertensive disorders:
pregnancy-induced hypertension (PIH) include:
1. Transient hypertension: development of mild
hypertension during pregnancy in previously
normotensive patient without proteinuria or
pathologic edema.
2. Gestational proteinuria: development of
proteinuria after 20 weeks of gestation in
previously nonproteinuric patient without
hypertension
 Classification
3. Preeclampsia: development of hypertension
and proteinuria in previously normotensive
patient after 20 weeks of gestation or in early
postpartum period in presence of
thromboplastic disease it can develop before
20 weeks of gestation
4. Eclampsia: development of convulsions or
coma in preeclamptic patient.
 Classification
Chronic hypertensive disorders
1. Chronic hypertension: hypertension or
proteinuria in pregnant patient with chronic
hypertension
2. Superimposed preeclampsia/eclampsia:
development of preeclampsia or eclampsia in
patient with chronic hypertension.
 Classification
• Preeclampsia: is a pregnancy-specific
condition in with hypertension develops after
20 weeks of gestation in a previously
normotensive women. It is a multisystem
vasospatic diseases process characterized by
hypertension and proteinuria. Preeclampsia is
usually categorized as mild or severe in terms
of management.
 Classification
• Eclampsia: is the onset of seizure activity or
coma in the woman diagnosed with PIH, with
no history of neurologic pathology. The
seizured can be the initial sign for a pregnancy
complicated by PIH
 Etiology
• The etiology of preeclampsia is unknown;
however predisposing risk factors include
nulliparity, multiple gestation, diabetes, age
younger than 18 or older than 35 years, and
chronic hypertension
 Etiology
Risk factors associated with the development of
pregnancy-induced hypertension include:
chronic renal disease, chronic hypertension,
family history of PIH, twin gestation,
primigravidity, maternal age <19 years; >40
years, diabetes, RH incompatibility, obesity.
 Pathophisiology
• Preeclampsia progress along the continuum
from mild to severe preeclampsia, HELLP
syndrom, or eclampsia. The pathofisiology of
preeclampsia reflect alterations in the normal
adaptations of pregnancy. Normal
adaptations to pregnancy include increased
blood plasma volume, vasodilatation,
decreased systemic vascular resistance,
elevated cardiac output, and decreased
colloid osmotic pressure.
 Pathophisiology
• Pathologic changes in the endothelial cells of
glomeruli are uniquely characteristic of
preeclampsia, particulalry in nulliparous women.
• The main pathogenic factor is not an increase in
blood pressure but poor perfusion as a result of
vasospasm. Arteriolar vasospam disminishes the
diameter of blood vessels.
• Function in organs such as placenta, kidneys,
liver, and brain is depressed by as much as
40%-60%.
 Care management
Assessment : hypertensive disorders of pregnancy
can occur without warning or with the gradual
development of symptoms. A key goal is early
identification of pregnant women at risk for
development of preeclampsia.
Interview: reviews the woman’s admission form
and prenatal record. When the nurse & pregnant
woman are comfortable, the nurse begins with
the interview to clarify, expand, or complete the
form.
 Care management
Medical history is reviewed, especially the
presence of diabetes mellitus, renal disease,
and hypertension. Family history is explored
for occurrence of preeclamptic or
hypertensive conditions. The social &
experimental history provides information
about woman’s marital status, nutritional
status, cultural beliefs, activity level, and
health habits such as smoking, drug use, and
alcohol consumption.
 Care management
Physical examination: accurate and consistent
blood pressure assessment is important for
establishing a baseline and monitoring subtle
changes throughout pregnancy.
Observation on edema in additional to
hypertension warrants additional investigation.
Edema is assessed for distribution, degree, and
pitting. If periorbital or facial edema is not
obvious, the pregnant woman is asked if it was
present when she awoke.
 Care management
Edema may be described as dependent or
pitting.
Dependent edema is edema of the lower or
dependent part of the body, where
hydrostatic pressure is greatest. If a pregnant
woman is ambulatory the edema may be first
evident in the feet or ankles. If the woman
confined to bed the edema is more likely to
occur in sacral region.
 Care management
Pitting edema is edema that leaves a small
depression or pit after finger pressure is apply
to the swollen area. The pit caused by
movement of fluid away from point of
pressure to adjacent tissues within 30
seconds.
 Care management
Symptom reflecting CNS & visual system
involvement usually accompany facial edema.
Although it is not routine assessment during
prenatal period, evaluation of the fundus of
the eye yield valuable data. An initial baseline
finding of normal eyegrounds assists in
differentiating a preexisting from a new
disease process.
 Care management
The woman may report no other symptom such
as epigastric pain or oliguria. Respirations are
assessed for crackles, which may indicate
pulmonary edema.
Deep tendon reflexes (DTRs) are evaluate if
preeclampsia is suspected. The biceps &
patellar reflexes and ankle clonus are
assessed and findings recorded.
 Care management
An important assessment is determination of
fetal status, uteroplacental perfusion
decreased in women with preeclampsia
placing fetus in jeopardy. Biophysical or
biochemical monitoring such as nonstress
testing, contraction testing, biophysical profile
and serial ultrasonography is to assess fetal
status.
 Care management
The fetal heart rate (FHR) is assessed for
baseline rate & the presence of variability
accelerations, which indicate an intact
oxygenated fetal CNS. Abnormal baseline rate,
decreased or absent variability, & late or
variable decelerations are indications of fetal
intolerance to the intrauterine environment.
 Care management
Laboratory test: obtain a number of blood and
urine specimens to aid in the diagnosis of pre
eclampsia, HELLP syndrome, or chronic
hypertension. Baseline laboratory test
information is useful in the early diagnosis of
preeclampsia for comparison with result
obtained to evaluate progression & severity
of disease.
 Care management
Laboratory test: the hematocrit, hemoglobin,
and platelet level are monitored closely for
changes indicating a worsening of a patient
status. Because hepatic involvement is a
possible complication, serum glucose levels
are monitored if liver function tests indicate
elevated liver enzymes.
 Care management
Laboratory test: proteinuria is determined from
dipstick testing of a cleancatch or catherizad
urine specimen. A reading 2+ on two or more
occasions, al least 6 hours apart, shoud be
followed by a 24-hour urine collection.
 Care management
• Laboratory test: renal laboratory assessments
include monitoring trends in serum creatinine
and BUN levels, as renal function becomes
compromised, renal excretion creatinine or
other waste products including magnesium
sulfate, decreases. As renal excretion
decreases, serum level for creatinine, BUN,
uric acid, & magnesium rise.
 Medical Management
• Medical management
The only cure for severe preeclampsia is delivery of the
fetus. The decision to deliver the fetus versus
expectant management is individual. Management is
focused on preventing seizures and respiratory
complications, monitoring cardiovascular status, and
maintaining fluid status. If the women does not
deliver, fetal monitoring is necessary.
The goal of therapy are to ensure maternal safety and to
deliver a healthy newborn, as close to term as possible.
 Nursing diagnoses
Nursing diagnoses for the woman with
hypertensive disorder in pregnancy include:
• Anxiety related for: preeclampsia and its
effect on woman and infant
• Ineffective individual/family coping related to:
the women's restricted activity and concern
over a complicated pregnancy
• The women's inability to work outside the
home
 Nursing diagnoses
• Powerless related to: inability to prevent or
control condition & outcomes
• Altered tissue/organ perfusion, decreased
related to: hypertension, cyclic vasospasms,
cerebral edema, hemorrhage
• Risk injury related to: uteroplacental
insufficiently, preterm birth, abruption
placenta.
 Nursing interventions
Nursing interventions
Nurse must assess the patient for increased risk of
seizures by evaluating neurological symptoms. To
reduce the risk of seizures, decrease the light
and sound stimulation to the patient.
If seizures occur, protect the patient from injury,
ensure patent airway, provide adequate
oxygenation, and evaluate possible aspiration.
After stabilizing the patient, uterine & fetal
activity quickly assessed.
 Expected outcomes
Expected outcomes for care of the patients with
hypertensive disorders of pregnancy include
that woman will be doing the following:
▪ Recognize & immediately report abnormal
signs & symptoms to prevent worsening of her
condition
▪ Adhere to the medical regimen to minimize
risk to her & her fetus
▪ Identify and use available support system
 Expected outcome
• Verbalized her fears and concerns to cope
with the condition and situation.
• With her fetus will not suffer adverse sequelae
from preeclampsia or its management
• Develop no signs of preeclamsia and its
complications
• Give birth to a healthy infant.
 Exclampsia
Tonic- clonic convulsion signs
Stage of invasion: 2 to 3 seconds; eye fixed,
twitching of facial muscles
Stage of contraction: 15 t0 20 seconds, eye
protrude and bloodshot, all body muscle in tonic
contraction
Stage of colvusions: muscles relax and contract
alternately (clonic). Respiration are halted and
then begin again with long deep stertorous
inhalation, coma may be ensure.
 Exclampsia
Interventions:
▪ Keep airway patent, turn head to one side,
place pillow under one shoulder or back if
possible
▪ Call for assistance
▪ Protect with side rails up and padded
▪ Observe and record convulsion activity
 Exclampsia
After convulsion/seizure:
• Observe for the postconvulsion, coma and
incontinence
• use suction as needed
• Administer oxygen via face mask at 10l/min
• Start IV fluid and monitor for potential fluid
overload
• Give MgSO, or anticonvulsant drug as order
 Exclampsia
▪ Insert indwelling catheter
▪ Monitor blood pressure
▪ Monitor fetal and uterine status
▪ Expedite laboratory work as ordered to monitor
kidney function, liver function, coagulation
system, and drugs levels;
▪ Provide hygiene and quiet environment
▪ Support and keep woman and family informed
▪ Be prepared for birth when woman is stable.
▪ Transfer of the woman to a tertiary center for
more intensive management.
 End Section

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