PREECLAMPSIA

*Case Notes:

Ms. Alyana Dalisay, is a 34 y/o, G2 P1001 with a history of previous normal

spontaneous vaginal delivery 10 years ago. By last menstrual period, the
patient’s pregnancy is approximately 15 weeks. This is Ms. Dalisay’s first
prenatal visit; she states that that she knew she was pregnant but did not
present earlier for care because she had lost her health insurance and wasn’t
sure when she could go. On review of the patient’s history, she reports a 5-
year history of hypertension and denies any other medical problems. She
reports taking lisinopril (an ACE inhibitor) for her hypertension since her initial
diagnosis. She also says that she has been taking prenatal vitamins since
taking an at-home pregnancy test.

On physical examination, she is an obese (BMI of 35) woman who appears to

be in no distress. Her blood pressure is 140/80 mm Hg, her pulse if 85 bpm,
and she is afebrile. Her cardiac examination reveals a grade III/VI systolic
murmur heard best in the left sternal border. Her lungs are clear. She has mild
pedal edema. Her uterus is 15 weeks in size, and fetal heart tones are
auscultated with a Doppler at 155 bpm.

At Ms. Dalisay’s first prenatal visit, her OB-GYN, Dra. Dalubhasa S.

Pagpapaanak discontinued her current anti-hypertensive medication. As a
nurse, you explain to Ms. Dalisay that ACE inhibitors are contraindicated
during pregnancy because they have been associated with neonatal
hypotension, fetal growth retardation, oligohydramnios, neonatal anuria, renal
failure, and neonatal death. Dr. Pagpapaanak replaced her medication with
methyldopa because, as she explained to her, continued BP control during
pregnancy is very important. You assured her that methyldopa has been
extensively used in pregnancy and appears to be safe for both her and her
fetus. In addition, the following prenatal labs were ordered by the doctor,
namely, CBC, HepBsAg, rubella, gonorrhea/chlamydia, and HIV status as well
as chemistry panel and 24-hour urine collection.

As a nurse, you made a diet regimen for Ms. Dalisay and you told her to limit
foods with added sugars and those that are high in fat and to eat a variety of
fruits, grains, vegetables, low-fat or fat-free dairy, and proteins, avoiding such
sources of mercury as shark, swordfish, mackerel, and tilefish, and limiting the
consumption of another source, tuna, to less than six ounces per week.

Ms. Dalisay continued her prenatal visits with Dr. Dalubhasa S. Pagpapaanak.
Her fundal height growth is appropriate and her BP control remains adequate
on her methyldopa. Her 24-hour urine protein excretion is 147 mg/24 hours,
and her second trimester serum screen predicts a low risk for fetal Down
syndrome and trisomy 18. A fetal anatomy survey performed at 20 weeks is
normal. At her 22-week visit, you notice that her BP has dropped significantly.
Currently, it is 110/72 mm Hg.
At the 22-week visit, Ms. Dalisay is taking 250 mg of methyldopa twice daily.
Given that this is a minimal dose, you elect not to change her medication at
this time. At 26 weeks fundal growth is appropriate and the fetus is active.
Ms.Dalisay is working as an office employee and reports that her employer is
requesting an estimate of the frequency of her prenatal visits, so that they can
plan her duties.

Ms. Dalisay continues her care and initiates weekly NST and AFI at 34 weeks
of gestation. At 35 weeks and three days' gestation, Ms. Dalisay developed a
persistent headache. Although she knew this was a warning sign of
preeclampsia, she believes she was in denial. She wanted to hold onto her
pregnancy as long as possible and thought she could put off telling the
maternal-fetal medicine specialist until her appointment two days later. At her
39-week visit, her BP is elevated (155/96 mm HG) and she has 2+ proteinuria.
She also complains of a headache that is not relieved with acetaminophen
(Tylenol). Dra. Pagpapaanak send her to labor and delivery for further
evaluation. Her BPs continue to remain elevated while in triage. A diagnosis
is made of new-onset superimposed preeclampsia, and the decision is made
to induce her labor. As she is having uterine contractions every 5 to 8 minutes,
the decision is made to proceed with oxytocin induction, and there, IV line was
initiated and started to infuse 1 liter of Lactated Ringer’s solution at 10-11
gtts/min with a side drip of magnesium sulfate (loading dose: 4g IV infused
over a period of 20 minutes, followed by a maintenance dose of 2g IV per
hour) for seizure prophylaxis. After 14 hours of induction (6 hours of active
labor), Ms. Dalisay delivers a 3,150 g male infant with APGAR scores of 8 and
9 at one and five minutes. Her elevated blood pressure resolves in the first 24
hours postpartum on her usual dose of methyldopa. She and the infant are
discharged on the second day after delivery.

Given the case scenario above, construct the following:

1. Charting (SOAPIE)
2. Case Analysis (with at least 3 NCPs)
3. Patient Education Form

Prepared by:

Anne Myrtle M. Lorenzo, RN, MAN

Clinical Instructor