CASE STUDIES
Proceedings of the 2019 AWHONN Convention
Rosemarie Cervantes, MSN/Ed, Background
RN, St. Francis Medical Center,
Lynwood, CA
Mary Favre, BSN, RNC,
St. Francis Medical Center,
Lynwood, CA
Corrisa Carson-Romero,
St. Francis Medical Center,
Lynwood, CA
Keywords
Epigastric
HELLP
Obstetric
Preeclampsia
Ruptured liver
Obstetric
Poster Presentation
Neonatal
Angelique I. Silva, MS, BSN,
RN, RNC-OB, C-EFM,
University of California Davis
Medical Center, Sacramento,
CA
Michelle Duncan, BSN, RN,
RNC-OB, University of
California Davis Medical
Center, Sacramento, CA
JOGNN 2019; Vol. 48, Supplement 3S
Epigastric Pain as a Potential Indicator of
Hemolysis–Elevated Liver Enzymes–Low Platelet
Count (HELLP) Syndrome in Pregnant Women
E
pigastric pain is a common pregnancy
symptom. True clinical symptoms are less
evident and more challenging during pregnancy.
The incidence of HELLP (hemolysis–elevated liver
enzymes–low platelet count) is rare but life threat-
ening. Liver rupture is rare and associated with a
maternal mortality rate of 16.4% and a perinatal
mortality rate of 31.3%. Early diagnosis and treat-
ment have a profound effect on patients’ prognosis.
Obstetric nurses should have a heightened
awareness of HELLP syndrome in patients pre-
senting with epigastric pain. Expedited in-
terventions geared toward rapid diagnosis and
treatment should be implemented to help decrease
maternal and neonatal morbidity and mortality.
Case
A gravida 2 para 0 term patient presented to triage
complaining of severe epigastric pain and uterine
contraction for the previous 3 hours. Her cervix
was closed; the fetal heart rate was tachycardic at
170 beats per minute (Category II). Intravenous
therapy was begun, and a preeclampsia labora-
tory panel was obtained. The lab results were
suggestive of HELLP syndrome. An abdominal
ultrasound was performed; findings included a
Creating a Multidisciplinary Palliative Plan of
Care for Conjoined Twins
Background
W hen parents receive a diagnosis of a life-
threatening condition, integrating a peri-
natal palliative plan of care should be considered.
Palliative care emphasizes the importance of
planning for the limited amount of time families
may have with their baby.
Case
A cesarean birth was planned at 34-weeks
gestation for a woman who was pregnant with a
conjoined set of twin female fetuses. The physical
nature of the anomaly was incompatible with life
because they shared major organs, including the
heart. In anticipation for this case, multidisci-
plinary team meetings were held to ensure that
anticipatory guidance could be provided to the
woman, her family, as well as all members of the
health care team. After birth, the newborns were
large subcapsular liver hematoma with right upper
quadrant and perisplenic fluid. The obstetrician
consulted with the trauma surgeon, and the deci-
sion was made to do an emergency cesarean and
exploratory laparotomy. The patient gave birth to a
viable newborn. The trauma surgeon proceeded
with a laparotomy and found a large, right-lobe,
subcapsular hematoma; disruption of Glisson’s
capsule; and active hemorrhage from the liver. The
liver was sutured; Class 3 hemorrhagic shock and
disseminated intravascular coagulation were
noted. The patient required multiple blood trans-
fusions and interventions to resolve blood loss.
She required two subsequent trips to the oper-
ating room and was intubated for 5 days. She
recovered and was discharged home after 12
days in the hospital.
Implications for Nursing Practice
Epigastric pain occurring in pregnant and post-
partum patients requires diligent assessment.
Epigastric pain is the most common symptom of
HELLP syndrome, and it can precede abnormal
bloodwork changes by several hours. Because of
the life-threatening potential of HELLP syndrome,
epigastric pain should always be considered a
serious symptom.
dried and swaddled; the focus was to monitor the
newborns’ comfort, support the woman and her
husband, answer questions, and allow complete
bonding to take place among the four of them.
During the multidisciplinary meetings, a plan had
been created to tie in other disciplines to assist in
the plan of care. A hospital-based photographer
captured candid moments during the birth as well
as during the recovery period. After being bathed
by the nursery nurse, the photographer captured
beautiful photos of the newborns wearing special
outfits that had already been carefully chosen by
the parents. Footprints, handprints, and locks of
hair were collected for a memory box that, once
completed, was given to the family. Child life
specialists and the palliative care team provided
emotional support as well as entertainment for the
family’s 2-yr-old daughter. Shortly after birth, the
newborns took their last breath; all of the family’s
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