ECLAMPSIA

A Case Analysis Presented to the

Faculty of the Nursing Department
San Pedro College, Davao City
SARAH JANE PAMALOAN, RN

In Partial Fulfillment of the

Requirements in NCM 209 – RLE
OBSTETRICS AND GYNECOLOGY NURSING ROTATION

Submitted by:
MARY JUSTINE AFRICA, St.N
HANS BREGUNDOT, St. N
TRIANAH MARIE ILAGAN, St. N
LIANA CRIS PACIENTE, St. N
ELVEA E. UY, St. N

BSN 2E – GROUP 3 (Subgroup 2)

April 15, 2021

 CRITERIA
NURSING CASE ANALYSIS
Introduction and Objectives 10%
Pathophysiology
• Etiology 10%
• Symtomatology 10%
• Disease Process 5%
• Management 15%
• Prognosis 10%
Discharge Planning 10%
Nursing Theory 10%
Review of Related Studies 10%
Reference 5%
Promptness 5%
Total 100%
 TABLE OF CONTENTS

CRITERIA ........................................................................................................................ 2

I. INTRODUCTION ...................................................................................................... 4

II. OBJECTIVES ........................................................................................................... 6

III. PATIENT INFORMATION ........................................................................................ 7

IV. PATHOPHYSIOLOGY .............................................................................................. 8

a. ETIOLOGY ............................................................................................................ 8
1. Predisposing Factors ......................................................................................... 8
2. Precipitating Factors ........................................................................................ 10

b. SYMPTOMATOLOGY ........................................................................................ 10

c. DISEASE PROCESS .......................................................................................... 13

.................................................................................................................................... 14

V. MANAGEMENT ...................................................................................................... 17

a. Laboratory Tests/Diagnostic Evaluation ......................................................... 17

b. Medical ............................................................................................................... 18

c. Surgical .............................................................................................................. 20

d. Nursing ............................................................................................................... 21

VI. PROGNOSIS .......................................................................................................... 24

VII. DISCHARGE PLANNING ....................................................................................... 25

VIII. RELATED NURSING THEORY ............................................................................. 29

Katharine Kolcaba’s Theory of Comfort ................................................................. 29

Sister Callista Roy’s Adaptation Theory ................................................................ 30

IX. REVIEW OF RELATED STUDIES ......................................................................... 32

X. REFERENCES ....................................................................................................... 34
 I. INTRODUCTION
Obstetrics and gynecology nursing is a specialty area wherein nurses positively
influence women’s health during antepartum, intrapartum, postpartum, and even in their
overall reproductive health. These women, ranging from adolescence through
childbearing to advanced age, seek specialized OB-GYN care for many reasons,
including well-woman care visits, contraceptive concerns, fertility inquiries, and prenatal
checkups. Providing patient-centered care with advocacy, caring, and shared decision-
making is vital for women, especially pregnant ones since they are among the high-risk
populations (Nurse Practitioner Schools, 2020).
Globally, maternal mortality is unacceptably high. Each year, more than 150 million
women become pregnant, and an estimated of 500,000 of them die from pregnancy-
related complications. Due to the medical advancements, most of the complications that
develop during pregnancy are already preventable and treatable. One of the primary
complications that account for nearly 75% of all maternal deaths is high blood pressure
during pregnancy, such as preeclampsia and eclampsia (WHO, 2019).
Preeclampsia, the precursor to eclampsia, has had an evolving definition over
recent years. The definition for preeclampsia initially included proteinuria as a diagnostic
requirement, but this is no longer the case as some patients had the advanced disease
before proteinuria detection. According to the American College of Obstetricians and
Gynecologists (ACOG), preeclampsia is a complex, progressive, multisystem disorder
of pregnancy present in different forms. Some women experiencing unremitting
headaches or severe right upper quadrant pain, while others experiencing no symptoms
before prenatal visits reveal they have elevated blood pressure and protein in their
urine. Preeclampsia may result in the new onset of generalized tonic-clonic seizures,
which is called eclampsia. Eclampsia is a known complication of preeclampsia during
pregnancy and is associated with both the mother and fetus’s morbidity and mortality if
not adequately diagnosed. Preeclampsia and eclampsia are one of the four categories
associated with hypertensive disorders of pregnancy. The other three categories include
chronic hypertension, gestational hypertension, and preeclampsia superimposed on
chronic hypertension.
 The estimated prevalence of eclampsia is reported to be 0.3% globally (Vousden
et al., 2019). In the Philippines, eclampsia was the leading cause of maternal death,
with 284 deaths and 17.6% maternal deaths in 2018, followed by gestational
hypertension with significant proteinuria with 198 deaths and 12.3% of the total maternal
deaths (Epidemiology Bureau Department of Health, 2018). Furthermore, eclampsia
was recorded as the leading cause of maternal mortality rate in the Davao Region, with
11% affected per 100,000 live births in 2017 (PSA, 2018).
Concerning the aforementioned statistical data, the student nurses of BSN-2E
Group 3 Subgroup 2 have perceived how much eclampsia affects innumerable mothers
worldwide. Therefore, this case analysis is highly relevant to nursing education, nursing
practice, and nursing research. For nursing education, this will contribute to the
knowledge and awareness of nurses in order for them to have a wholesome viewpoint
regarding this condition. For nursing practice, nurses will be able to develop proficiency
in handling patients with the said condition. Lastly, this can be utilized to develop
nursing research where it imparts tremendous influence on the current and future
professional nursing practice in the maternity and child area.
 II. OBJECTIVES
Within four weeks of Obstetrics and Gynecology Nursing Rotation, the student
nurses of BSN-2E Group 3 Subgroup 2 will be able to gain knowledge regarding the
nursing problems in maternity, and conduct a comprehensive case analysis that will
enhance their ability to determine accurate nursing managements and nursing theories
that will aid them in providing quality maternal and newborn care when exposed to the
real world of nursing.
Specifically, the student nurses aim to:
a. Present an introduction about the definition and statistical data of the
case;
b. State the implications of the study in the nursing practice, education and
research;
c. Identify the etiology of the disease specifically its predisposing factors and
precipitating factors;
d. Discuss the signs and symptoms of the disease;
e. Trace the pathophysiology through a schematic diagram;
f. Enumerate the possible diagnostic, medical, and surgical managements;
g. Formulate appropriate nursing diagnosis and interventions;
h. Identify the prognosis;
i. Develop a discharge plan;
j. Determine nursing theories that would relate to this case;
k. Gather review of related studies to the disease;
l. Present bibliography in American Psychological Association (APA) format.
III. PATIENT INFORMATION
A. BIOGRAPHICAL DATA
Name of Client: P.M.H.
Gender: Female
Religion: Roman Catholic
Age: 28 years old
Birthday: March 25, 1993
Nationality: Filipino
Home Address: Davao City
Marital Status: Married
Spouse: J.O.

B. ADMISSION HISTORY
Chief complaint: Headache
Diagnosis: Severe Preeclampsia
Date and Time of Admission: April 15, 2021 at 6:45 am
Manner of Admission: Ambulation
Ward & Room/Bed No.: St. Mary Ward, Room 201-2
Attending Physician: Dr. Gray

C. OBSTETRICAL DATA
LMP: August 14, 2020
EDC: May 21, 2021
GPA: G4 P1 A2
TPAL: T1 P0 A2 L1
AOG: 34 weeks and 6 days
Obstetrical History:
o Gravida: G3
o Year: 2019
o AOG: Full term
o Type of Delivery: Caesarean section
o Place of Delivery: Hospital
o Sex/weight: M; 8 lbs.
IV. PATHOPHYSIOLOGY
a. ETIOLOGY
1. Predisposing Factors
FACTORS RATIONALE
Age Preeclampsia is more common at maternal age
extremes, such as in ages less than 18 years or
greater than 35. The increased prevalence of chronic
hypertension and other comorbid medical illnesses in
women older than 35 years may explain the
increased frequency of preeclampsia among older
gravidas (Carson, 2018).

Pregnancy History Most cases of preeclampsia happen in first

pregnancies. Previous pregnancies with poor
outcomes could also increase the risk of developing
eclampsia (Biggers, 2017).

Multiple Gestation It is well-established that the risk of preeclampsia is

greater in twin pregnancies rather than in singleton
pregnancies. This may be due to increased placental
mass that leads to increased circulating levels of
soluble fms-like tyrosine kinase 1 (sFlt1), which is a
circulating antiangiogenic molecule of placental origin
playing a central role in preeclampsia (Endeshaw, et
al., 2016).

Race Black women have higher rates of preeclampsia

complicating their pregnancies compared with other
racial groups, mainly because they have a greater
prevalence of underlying chronic hypertension
(Carson, 2018).
Family History Preeclampsia
A 1st degree relative with a history of pre-eclampsia
(PE) is a well-known risk factor for PE. Moreover, the
risk of a more distant family member or a 2nd degree
relative with a history of PE may be associated with
the development of PE(Shanahan, Goulding,
Johnson, & Aagaard, 2021).

Hypertension
A family history of hypertension was the most
dominant risk factor of preeclampsia. It is concluded
that these factors can be used as a screening tool for
preeclampsia prediction and early diagnosis, allowing
timely interventions to minimize deaths associated
with severe preeclampsia/eclampsia (Endeshaw, et
al., 2016).

Preexisting Medical Having certain conditions before the pregnancy —

Conditions such as obesity, chronic high blood pressure,
migraines, type 1 or type 2 diabetes, kidney disease,
a tendency to develop blood clots, or lupus —
increases the risk of preeclampsia/eclampsia (Mayo
Clinic, 2020).
 2. Precipitating Factors
FACTORS RATIONALE
Lack of Activity Lack of physical exercise during pregnancy posed a
statistically significant relation with preeclampsia.
Exercise of low to moderate intensity is beneficial for
general health reasons to maintain or improve
circulation and physical fitness and reduce the risk of
preeclampsia/eclampsia (Endeshaw, et al., 2016).

New Paternity Each pregnancy with a new partner increases the risk
of preeclampsia more than does a second or third
pregnancy with the same partner (Mayo Clinic, 2020).

b. SYMPTOMATOLOGY

SIGNS & SYMPTOMS RATIONALE

Seizures Seizures happen due to cerebral vasospasm and

cerebral edema. Blood flow can be restricted if the
arteries are damaged. It can cause swelling in the
blood vessels of the brain as well as in the developing
baby. Seizures can occur if this irregular blood flow
into veins interferes with the brain's ability to function.
(Macon, 2018)

Elevated blood Hypertension may develop as a result of unhealthy

pressure lifestyle decisions, such as a lack of daily physical
exercise. Diabetes and obesity are two health
problems that can raise the chance of experiencing
elevated blood pressure. (CDC, 2020)
Edema (Generalized, Edema happens as body fluids rise in order to nourish
Pulmonary, Cerebral) both the mother and the baby and collect in the
tissues as a result of increased blood supply and
pressure from the expanding uterus on the pelvic
veins and the vena cava (the large vein on the right
side of the body that returns blood from the lower
limbs to the heart) (O’Connnor, 2020).

Proteinuria This is attributed to proteins that are usually

contained to the blood by your kidney's filtering role
spilling into the urine. This is due to the fact that
eclampsia briefly damages this "filter." Many proteins,
including albumin, are destroyed in this manner.
(Preeclampsia Foundation, n.d)
Headaches Headaches happen due to changes in the brain from
vascular permeability. Preeclamptic or eclamptic
patients complain of headache that cannot be
alleviated with pain relievers (Macon, 2018).
Excessive weight Damaged blood vessels cause more water to escape
gain through and remain in body tissue, rather than
passing through the kidneys and being excreted.
(Preeclampsia Foundation, n.d)

Nausea and Vomiting This is due to the effects of human chorionic

gonadotropin (HCG) (Marnach, 2019).
Visual Disturbances Extreme hypertension causes the neurosensory
retina to separate from the pigmented retinal
epithelium, resulting in vision failure. Among the
visual manifestations, blurring of vision and photopsia
are very common in severe pre-eclampsia and
eclampsia (Radha Bai Prabhu, 2017)

Epigastric Pain Epigastric pain indicates that the liver has been
harmed, this increases the likelihood of HELLP
Syndrome arising. Severe upper-right abdominal pain
is a warning indication that HELLP Syndrome is on
the way. (Preeclampsia Foundation, n.d)
 c. DISEASE PROCESS

PREDISPOSING FACTORS PRECIPITATING FACTORS

• Primigravida • Obesity • Lack of Activity

• Multiple Gestation • Age • New Paternity
• Chronic Hypertension • Family History
• GDM

LEGEND

Shallow/Inadequate Placentation Intrauterine growth
Direction of flow

restriction

Signs

and
Symptoms

Reduced placental perfusion

Managements

Fetal Demise
Pro-inflammatory proteins release
Disease

in mother’s circulation

Endothelial cell dysfunction

Thrombi Vascular
Vaso- Vasospasm Formation Permeability
constriction

Hypertension

(High BP) Generalized

Retina Liver Hemolysis
• Systolic~ Salt- Edema

> 140 mmHg retention in

• Diastolic~ kidneys Swelling & HELLP

> 90 mmHg S/s: Injury Syndrome
• Blurred Pulmonary

• Hemolysis Edema

vision • Elevated
• Flashing

lights Liver Liver
S/s: Enzymes

• Oliguria • Scotoma Enzymes
• Low
• Proteinuria Platelets S/s:

Severe Pre- • Cerebral

eclampsia Liver- Hyperfusion/
• Systolic~ capsule Edema

>160mmHg
stretching S/s:

• Diastolic~ • Headache
>110mmHg S/s: • Vision

Epigastric Problems
pain Seizures

(Eclampsia)

Hemorrhagic Abruptio
Stroke Placenta

LABORATORY TEST/DIAGNOSTIC TEST
• For Hypertension - BP monitoring
• For Oliguria & Proteinuria - Urinalysis
• For Blurred Vision, Flashing Lights, Scotoma - Visual Field Test
• For HELLP - Blood test (eg., CBC)

• For Generalized Edema - Physical Assessment (Pitting Edema Assessment)

• For Pulmonary Edema - Chest X-ray
• For Cerebral Hyperfusion/Edema - CT scan, MRI, and blood test

NURSING DIAGNOSIS
• Ineffective Tissue Perfusion related to vasoconstriction of blood vessels
• Impaired Urinary Elimination related to vasospasm of the kidneys
• Disturbed Sensory Perception related to vasospasm in the retina
• Acute Pain related to the stretching of liver-capsule
• Deficient Fluid Volume related to fluid shifting out of the vascular compartment

IF TREATED IF NOT TREATED

MEDICAL MANAGEMENT Eclamptic seizures

• Anticonvulsants (eg., Magnesium Sulfate, Phenytoin, continue

Diazepam/Lorazepam)
• Antihypertensive drugs (eg.,Hydralazine, Labetalol,
Nifedipine, Glycerin trinitrate)
Coma
SURGICAL MANAGEMENT

• Cesarean Section
NURSING MANAGEMENT
• Monitor vital signs Brain damage
• Monitor I&O

• Position patient on a left lateral position

• Administer O2
• Keep the side rails up and padded
• Assure a dimmed and quiet environment Maternal/Fetal Death
• Administer drugs as ordered
• Watch out for danger signs

• If seizures occur, note the time of seizure, duration,

and body parts involved.

GOOD PROGNOSIS
Narrative
Although the exact etiology of preeclampsia is unknown, a combination of
predisposing factors (e.g. primigravida, multiple gestation, chronic hypertension, GDM,
Obesity, mothers aged >35 years old, family history) and precipitating factors (e.g. lack
of activity and new paternity) are considered to play a part in the development of the
disease. These factors lead to shallow or inadequate placentation, resulting in reduced
placental perfusion. The narrowing of the utero-placental arteries, instead of the normal
dilation that should occur, causes the reduced placental perfusion. A poorly perfused
placenta may lead to intrauterine growth restriction and even fetal demise.
The hypo-perfused placenta causes the release of pro-inflammatory proteins in
the mother’s circulation, leading to endothelial cell dysfunction or damage. Endothelial
cell dysfunction causes vasoconstriction and increases salt-retention in the kidneys,
leading to hypertension. Hypertension in pre-eclampsia is usually defined as having a
systolic blood pressure 140mmHg or above or a diastolic blood pressure 90mmHg or
above. However, in severe pre-eclampsia, systolic blood pressure may reach 160mmHg
or greater and the diastolic blood pressure may become 110mmHg or higher. The
extreme blood pressures in severe pre-eclampsia can lead to hemorrhagic stroke or
abruptio placenta. Hypertension is first detected during routine blood pressure
monitoring and can be managed using the nursing diagnosis “Ineffective tissue
perfusion related to vasoconstriction of blood vessels”.
Endothelial cell dysfunction also causes vasospasm or reduced blood flow in
local areas of the body. If vasospasm occurs in the kidneys, it leads to glomerular
damage, causing oliguria and proteinuria. Both of these conditions can be diagnosed
using urinalysis and can be managed using the nursing diagnosis “Impaired Urinary
Elimination related to vasospasm of the kidneys”. Reduced blood flow in the retina
causes blurring of the vision, creates the sensation of flashing lights, and the
development of a scotoma. These conditions are firstly detected via verbalizations from
the patient and are confirmed by conducting a visual field test. Moreover, they can be
managed using the nursing diagnosis “Disturbed Sensory Perception related to
vasospasm in the retina”. Vasospasm in the liver causes swelling and injury, leading to
an elevation of the liver enzymes and stretching of the capsule on the liver. This
stretching of the liver typically causes epigastric pain, one of the cardinal symptoms of
severe pre-eclampsia. This pain can be managed using the nursing diagnosis “Acute
pain related to the stretching of the liver capsule”.
Endothelial cell injury also leads to the formation of thrombi in the
microvasculature. This process uses up a lot of platelets, leading to a difficulty for the
red blood cells to navigate the bloodstream, increasing the risks for hemolysis. These
phenomena make up the HELLP syndrome, which stands for Hemolysis, Elevated Liver
Enzymes, and Low Platelets. This syndrome occurs in about 10-20% of women with
severe pre-eclampsia or eclampsia and is detected using blood tests such as complete
blood counts.
Lastly, endothelial cell dysfunction increases vascular permeability. Combined
with the loss of protein in the blood due to proteinuria, these factors increase the fluids
that move into the tissues, causing generalized edema, pulmonary edema, and cerebral
edema. Generalized edema can be detected with the use of the “Pitting Edema
Assessment” while pulmonary edema is usually observed with the use of chest x-rays.
These can be managed using the nursing diagnosis “Deficient Fluid Volume related to
fluid shifting out of the vascular compartment”. In addition, the diagnostic/ imaging tests
used to detect cerebral hyperfusion or edema are CT scans, MRIs, and blood tests. The
occurrence of cerebral edema causes headaches, confusion and seizures. The onset of
seizures in pre-eclampsia marks the progression of the disease to eclampsia.
Medical management for eclampsia includes the use of anticonvulsants (e.g.
Magnesium sulfate, Phenytoin, Diazepam/Lorazepam) and antihypertensive drugs (e.g.
Hydralazine, Labetalol, Nifedipine, Glycerin trinitrate), while surgical management
includes performing a caesarian section. The nursing management for eclampsia
includes regular monitoring of the vital signs and the intake and output, positioning the
patient in left- lateral position, administering oxygen as prescribed during episodes of
dyspnea, keeping the side rails up and padded, assuring a dimmed and quiet
environment, administering prescribed medications, monitoring medication adverse
effects or danger signs, and noting the time, duration, and areas involved should
seizures occur. There is a good prognosis if eclampsia is properly treated. However, if
not treated, eclamptic seizures may continue, leading to coma, brain damage, and
ultimately maternal or fetal death.

V. MANAGEMENT

a. Laboratory Tests/Diagnostic Evaluation

Laboratory Tests/
Rationale
Diagnostic Evaluation
Urine Test The physician may order urine tests to check for the
presence of protein and its excretion rate.
Proteinuria is typically one of the presenting
symptoms in patients with eclampsia. The degree of
proteinuria or change in proteinuria is helpful in
diagnosing preeclampsia/eclampsia (Ross, 2019).

Blood Test Blood tests include a complete blood count, which is

ordered to look for changes in the blood associated
with preeclampsia, such as low platelet counts (Lab
Tests Online, 2020).

BP Monitoring Since high blood pressure (HBP) is one of the

hallmark signs of preeclampsia and eclampsia, the
best way to diagnose HBP is through the blood
pressure monitoring.

Chest X-ray Chest X-ray is usually done to evaluate for

pulmonary edema in the setting of dyspnea or
hypoxia occurring in a woman with preeclampsia
(Carson M. P., 2018).
CT Scan Computed tomography (CT) scanning of the head,
with or without contrast, can exclude cerebral
venous thrombosis, intracranial hemorrhage, and
central nervous system lesions, all of which can
occur in pregnancy and present with seizures.
Although obtaining a CT scan in eclampsia is not
routine, abnormalities have been observed in up to
50% of women imaged (Ross, 2019).

MRI Abnormal magnetic resonance imaging (MRI)

findings of the head have been reported in up to
90% of women imaged. These include an increased
signal at the gray-white matter junction on T2-
weighted images, as well as cortical edema and
hemorrhage. The syndrome of posterior reversible
encephalopathy (PRES), indicative of central
vasogenic edema, has been increasingly recognized
as a component of eclampsia (Ross, 2019).

b. Medical

Medical Rationale
Management

Cessation of Magnesium Sulfate is utilized as a seizure prophylaxis in showing

Seizures by symptoms of severe preeclampsia and controls the seizures
administering during eclampsia. It is given intramuscularly or through an
Magnesium intravenous route. If Magnesium Sulphate is contraindicated or
Sulfate has failed in taking its effect, phenytoin and diazepam/lorazepam
are administered.
 Prophylaxis 4 g in 100 ml 0.9% NaCl

1st Seizure 4 - 6 g in 100 ml 0.9% NaCl (15-

20mins)

Maintenance 1 - 2 g in hourly as a continuous IV

solution for 24 hours

Recurrent Seizures or Further bolus of 2 g

when MgSO4 is
contraindicated Lorazepam (Ativan; 2 - 4 mg over 2 - 5
minutes)

Diazepam (Valium; 5-10 minutes mg

IV slowly)

Benzodiazepine (Midazolam)
A loading dose of 0.05 mg/kg in 100
ml of isotonic saline. May be given
when seizures are taking too long and
for sedation.

Control of If there is presence of severe hypertension it must be addressed

Hypertension by after the cessation of seizure. Hydralazine or labetalol is
administering recommended to maintain the blood pressure within the normal
antihypertensive ranges. The goal of lowering the blood pressure is to decrease the
agents risk for cerebral hemorrhage, cardiac failure, myocardial infarction
and placental abruption.

IV bolus of • 5 mg every 20 minutes up to a

hydralazine maximum dose of 20mg
 Labetalol • with an initial dose of 20 mg IV
escalating to 80 mg every 10
minutes up to maximum dose of
300 mg

Oral nifedipine • (10 mg) may be administered as

capsule an alternative. Although it can
elevate the hypotensive response.

Glyceryl • (10 mg) administered to control

Trinitrate high blood pressure

Considerations:

• The lowering of blood pressure must be gradual.

c. Surgical

Surgical Rationale
Management

Delivery of The only treatment for Eclampsia is the delivery of Fetus. The patient
Fetus should have stabilized the seizure, oxygenation and hemodynamic
status before going through delivery. Delivery should take its place as
soon as the mother has been stabilized because delaying delivery will
risk the lives of both the mother and the fetus.
 Cesarean Delivery

• This surgical approach is considered for patients with

unfavorable cervix and with a gestational age of 30 weeks or
less. It is necessary for deteriorating maternal conditions. It
should be based on fetal gestational age, fetal condition,
presence of labor and cervical bishop score.

d. Nursing

Nursing Managements Rationale

1. Check for the involvement of the Central Cerebral edema and vasoconstriction
Nervous System and report immediately if can be evaluated in terms of
there are any signs or symptoms of CNS symptoms, behaviors or retinal
involvement. changes. Delayed treatment or
progressive onset of symptoms may
result in convulsions or eclampsia

2. Ensure seizure precautions as per To be prepared when seizure occurs

protocol and reduce the risk for injury.

3. When seizure occurs: Maintains airway by reducing risk of

a. Protect the mother from maternal aspiration and preventing tongue

injury and secure airway from from occluding airway. It maximizes

aspiration oxygenation. Be aware that aspiration

i. Position patient on side or on
left lateral position;
ii. Elevate and pad the bed’s side
rails and insert padded tongue
blade. Insert airway/bite block
can occur when the padded tongue
blade is forced to the back of the
throat, stimulating the gag reflex and
resultant vomiting.
 only if mouth is relaxed;
iii. Suction nasopharynx, as
indicated;
iv. Administer oxygen as ordered
by a physician
v. Avoid restrictive clothing; do not
restrict movement.
vi. Document motor involvement,
duration of seizure, and post
seizure behavior.

The natural tendency is to try and

b. Do not try to stop the first convulsion
interrupt the convulsion, but this is not
recommended. Do not give a drug to
shorten or stop the convulsion,
especially if the patient lacks an
intravenous line and no one skilled in
intubation is immediately available. If
diazepam is given, do not exceed 5
mg over 60 seconds. Rapid
administration of this drug may lead
to apnea or cardiac arrest, or both.

4. Considerations after Administering Magnesium Sulfate is excreted

Magnesium Sulfate as ordered by a through the kidneys. If the patient’s
physician: output is high, an increase in
a. Monitor by hourly measurement of Magnesium Sulfate may be indicated.
patellar reflex and respiratory rate. If the output is low a lower dose may
b. If there are signs of toxicity, stop the be needed. The patient with a low
medication until symptoms are gone output is at an increased risk for
 c. Monitor the serum levels as Magnesium Sulfate toxicity
magnesium is being secreted by the
kidneys if there is presence of renal
disease.
5. Monitor intake and output. Note for the Urine output is a sensitive indicator of
urine color and measure specific gravity circulatory blood volume. Oliguria and
as indicated. specific gravity of 1.040 indicate
severe hypovolemia and kidney
involvement. Administration of
magnesium sulfate (MgSO4) may
cause transient increase in output.

6. Check Blood Pressure and Pulse rate Rise in BP may happen in response
to catecholamines, vasopressin,
prostaglandins, and, as recent
findings suggest, decreased levels of
prostacyclin.

7. After administering antihypertensive Side effects like tachycardia,

agents: headache, nausea, palpitations and
a. Check on BP and side effects of vomiting can be treated with
antihypertensive drugs propranolol.

b. Fetal heart rate monitoring is Fetal distress may precipitate.

necessary.

8. Observe for any signs and symptoms of Convulsions can elevate uterine
labor irritability and cause uterine
contractions.

9. Assess the fetus and note the FHR Helps evaluate fetal well-being. An
elevated FHR may show a
 compensatory response to hypoxia,
prematurity, or abruptio placentae.

10. Prepare for Cesarean birth if placental
functioning is compromised and the cervix
is not responsive to induction.
When fetal oxygenation is severely
reduced owing to vasoconstriction
within malfunctioning placenta,
immediate delivery may be necessary
to save the fetus. If conservative
treatment is ineffective and labor
induction is ruled out, then surgical
procedure is the only means of
halting the hypertensive problems.

VI. PROGNOSIS

Due to the improvement of healthcare facilities, the possibility of the occurrence

of eclampsia has decreased. According to the Centers for Disease Control and
Prevention, the overall pre-eclampsia and eclampsia case fatality rate is 6.4 per 10,000
cases at delivery. Study shows that serious complications among patients with
eclampsia may be predicted by the use of a model that incorporates gestational age,
chest pain or dyspnea, oxygen saturation, platelet count and creatinine and aspartate
transaminase concentrations.

Eclampsia and preeclampsia account for approximately 63,000 maternal deaths

on a yearly basis worldwide. In developed countries, the maternal death rate is
reportedly 0-1.8% and the maternal mortality rate is as high as 14% in developing
countries. The Fetal mortality rate depends and varies from 13% to 30 % because of
premature delivery and the complications it brings. Failure to address properly may
result in Permanent Central Nervous System damage due to the seizures or intracranial
bleeding, disseminated intravascular coagulopathy, renal insufficiency, pulmonary
edema and cardiopulmonary arrest. If the mother recovers from the acute illness she is
likely to recover rapidly in weeks and recurrence of eclampsia is uncommon with a
chance of 30%.

If pre-eclampsia is detected early and treatment is ongoing prior to the eclamptic

episode or if eclampsia is immediately managed, then the general prognosis is good.
However, if left untreated, continued eclamptic seizures may continue and lead to coma,
brain damage, and eventually, maternal or fetal death.

VII. DISCHARGE PLANNING

Discharge
Health Teachings
Planning Area
• Anti-hypertensive
medications as prescribed
(e.g. nifedipine, labetalol)
• Aspirin/ Paracetamol
MEDICATION
• Stool softeners (e.g.
Colace)
• Perform abdominal
exercises. (e.g. belly
breathing)
• Perform seated Kegel
ENVIRONMENT/
exercises.
EXERCISE
• Perform caesarian
delivery scar tissue
Rationale
• Maintains lowered blood
pressure levels.
• Helps manage pain (e.g.
headache, incision site).
Aspirin also helps prevent
blood clots.
• Helps relieve constipation
after C-section.
• Strengthens muscles in
the abdominal area after
C-section.
• Activates and strengthens
pelvic floor muscles after
urinary catheter is
removed post C-section.
• Facilitates proper scar
tissue healing and
 massage (with physicians’ improves range of motion
discretion) after skin and fascia
adhesion.
• Participate in low-impact • Builds up core and overall
exercises 6-8 weeks after body strength gradually
C-section delivery/ with but effectively.
physicians’ discretion
(e.g. yoga, Pilates, leg
slides)
• Avoid lifting objects • Prevents unnecessary
heavier than the baby. exertion which may cause
the incision to reopen.
• Maintain a clean and • Lowers the risk of
organized room/ contracting microbes from
environment environmental dirt/debris.
• BP Monitoring • Helps detect post-partum
pre-eclampsia. Additional
treatment is required if
blood pressure levels
exceed the normal levels.
• Blood tests (e.g. platelet • To monitor platelet levels
TREATMENT
counts, liver and kidney and liver and renal
enzyme levels) function.
• Urinalysis • To check for persistence
of proteinuria and checks
for presence of bacterial
infection.
• Keep incision area clean • Prevents infection.
HYGIENE
and dry.
 • Refrain from soaking in
bath tubs/ pools.
• Regular handwashing
with warm, soapy water
for 20 seconds, especially
before and after handling
the wound dressing.
• If with abdominal binder,
ensure its cleanliness.
• Regularly change sanitary
pads, especially if it is
soaked with lochia.
• Seek medical advice if
blood pressure levels are
continuously elevated or if
hypotension occurs.
OUTPATIENT • Refer immediately to the
REFERRAL health care provider if
redness, pain, or if there
is purulent discharge at
the incision site.
• Seek medical advice if
neurologic condition is
altered or if there are
residual deficits (e.g.
• Keeps the incision dry
and also prevents
infection.
• To deter the spread of
microorganisms.
• Prevents microorganisms
from coming into contact
with the incision site.
• Reduces the risk of
developing urinary tract
infections.
• Continuously elevated
blood pressure levels may
indicate possible chronic
hypertension. Severe
hypotension is an adverse
effect of anti-hypertensive
medications.
• May indicate possible
infection.
• Reassessment is required
to identify proper
management for these
conditions.
 poor coordination,
speech difficulties) from
the eclamptic episode.
• Registered Dietitian
• Instruct to limit foods rich
in salt.
• Consume nutrient- dense
foods (e.g. whole grain,
fiber) and low-fat dairy
products or alternatives
• Incorporate enough
protein (e.g. meat,
DIET
poultry, fish, tofu, and
nuts) in the diet
• Eat enough fruits (e.g.
bananas) and green leafy
vegetables.
• Avoid alcoholic and
caffeinated beverages.
• Provides individualized
nutrition plans, reviews
food intake, and ensures
adequate protein and
other nutrients to address
specific needs during
puerperium.
• Prevents water- retention
and helps maintain
reduced blood pressure
levels.
• Helps lowers systolic
blood pressure.
• Replenishes proteins lost
due to proteinuria.
Increases RBC and
platelet counts since
proteins are required to
produce these blood
cells.
• Helps lower tension in
blood vessel walls.
• Alcohol and caffeine can
be transferred to the baby
 through the breast milk.

• Drink plenty of fluids (e.g. • Prevents dehydration and

water, low-salt broth, replenishes lost fluids.
clear soups) frequently

VIII. RELATED NURSING THEORY

Katharine Kolcaba’s Theory of Comfort

Katharine Kolcaba was born on December 8, 1944 in Cleveland Ohio. She
received a diploma in nursing from St. Luke’s Hospital School of Nursing in 1965. She
graduated in 1987 from the Frances Payne Bolton School of Nursing, Case Western
Reserve University. She graduated with a PhD in nursing and got a certificate of
authority as a clinical nursing specialist in 1997. She is now an associate professor in
nursing at the University of Akron College of Nursing and published “Comfort Theory
and Practice: a Vision for Holistic Health Care and Research.”
Kolcaba’s theory of care was first developed in the 1990s. She described comfort
as 3 forms: relief, ease, and transcendence. These comforts come in four contexts,
namely physical, psychospiritual, environment, and sociocultural. Relief comfort comes
from pain management through medication. For example, feeling a sense of relief from
the patient after administering medication for pain. Ease comfort focuses on the
environment and psychological condition of the patient. For example, after addressing
or dealing with the anxiety of the patient or the watchers, they feel an ease of mind.
Lastly, transcendence comfort is a state in which a patient rises above trials in care and
recovery.
In relation to this case analysis, Kolcaba’s Theory of Care would be helpful to the
student nurses in the mitigation of eclampsia. Most patients that we might encounter are
pregnant women who are in extreme pain and are uncomfortable with their situation.
These women, especially those who are diagnosed with eclampsia and are
considerably younger, would most likely feel scared since they do not know what to
expect. The partners or their family might feel anxious since eclampsia is a very serious
condition. Thus, it is important for the student nurses to initiate comfort to the patient
prior and after delivery and for them and their partners to feel less anxiety. Providing
comfort to the patient will help improve her condition for a faster recovery. As comfort is
given to the patient, partners, or family, they will become more engaged in seeking
advanced health behaviors that will improve the quality of life of the patient and their
family.

Sister Callista Roy’s Adaptation Theory

Sister Callista Roy (October 14, 1939 - present) is a nursing theorist, a member
of the Sister of St. Joseph of Carondelet, a professor and chairperson at Mount St.
Mary’s College, and an author. After being challenged by Dorothy Johnson in a
seminar, Roy developed the basic concepts of her theory while she was a graduate
student, earning her master’s degree at University of California-Los Angeles. In 1970,
the Roy adaptation model was published as literature in an article titled “Adaptation: A
Conceptual Framework of Nursing” (Roy, 1970).
 In the Adaptation Model, there are four adaptive modes which are: physiologic
needs, self-concept, role function, and interdependence. Physiologic needs are
associated with the physical and chemical processes involved in the function and
activities of living organisms. Self-concept is defined as the composite beliefs and
feelings about one self at a given time and is formed from internal perception and
perception of others reactions. Role function, it is defined as a set of expectations about
how a person occupying one position behaves toward a person occupying another
position. It is the need to know who one is in relation to others so that one can act.
Interdependence involves the willingness and ability to give others and accept from
them the aspects of all that one has to offer such as love, respect, value, nurturing,
knowledge, skills, commitments, material possessions, time, and talents. In addition, the
goal of nursing is to promote adaptation in these four adaptive modes, thus contributing
to health, quality of life, and dying with dignity by assessing behaviors and factors that
influence adaptive abilities and by intervening to enhance environmental interactions.
Correlating the theory to our study, this would definitely help us widen our
perspectives with regards to the management of eclampsia. As a student nurse, we
should give quality service to our patients. By applying Sr. Callista Roy’s Adaptation
Model, we are able to provide for the patient’s physiologic needs, especially for medical
management since this is directly associated with the chemical processes that involve
the function and activities of the patient, thus promoting overall adaptation. By figuring
out patients’ coping needs and by setting goals to promote their adaptation, we can then
effectively perform the nursing interventions aimed at promoting the patients’ overall
health and well-being.
IX. REVIEW OF RELATED STUDIES

Determinants Of Pre-Eclampsia/Eclampsia Among Women Attending

Delivery Services In Selected Public Hospitals Of Addis Ababa, Ethiopia: A
Case Control Study
A study conducted by Grum, et.al. (2017) stated that preeclampsia has both
prevention and risk factors. Any risk factors for pre-eclampsia/eclampsia included
primigravida, twin pregnancies, a history of pre-eclampsia, and drinking alcohol
during pregnancy. Since identifying risk factors improves the capacity to detect
and track women who are at risk of developing preeclampsia before the start of
illness, early treatments and improved maternal and fetal results are possible.
Receiving dietary therapy during breastfeeding and following up with an ANC was
shown to be effective against pre-eclampsia/eclampsia. It is suggested that health
professionals use primigravida, preeclampsia in prior pregnancy, and women with
twin pregnancy causes as a screening method for preeclampsia detection and
early diagnosis. During ANC appointments, health care professionals can offer
dietary therapy to pregnant mothers, providing advice on avoiding alcohol use.

Acute Cardiac Effects in Severe Pre-Eclampsia

A study conducted by Vaught, et. al. (2018) stated when compared to
normotensive pregnant monitoring patients, women with extreme pre-eclampsia
have higher right ventricular systolic pressure levels, diastolic instability, lower right
ventricular pressure, and irregular cardiac remodeling. Despite the fact that
nonpregnant patients' mean RVSP levels are in the slightly elevated range, 13% of
PEC patients had echocardiographic signs of diastolic dysfunction, 39% had
irregular RV pressure, and 10% developed pulmonary edema. Future research
should look at the timeframe for the occurrence of the pathological
echocardiographic findings associated with pre-eclampsia, as well as whether they
are linked to short- and long-term cardiovascular consequences.
Folic Acid Supplementation in Pregnancy and the Risk of Pre-Eclampsia—A
Cohort Study
A study conducted by Wen, et. al. (2016) stated that In this major
prospective cohort study, they discovered that folic acid supplementation during
pregnancy was associated with a lower risk of PE, though the correlation was only
statistically meaningful in women at high risk of developing PE. Large-scale
randomized controlled trials are desperately required to unequivocally confirm or
disprove the effect of folic acid supplementation in pregnancy on PE.

Effect Of Vitamin D3 Supplementation In Pregnancy On Risk Of Pre-

Eclampsia – Randomized Controlled Trial
A study conducted by Ali, et. al. (2019) stated that vitamin D is important for
placental decidualization and implantation. According to recent studies, a reduced
level of vitamin D3 “25-hydroxyvitamin D (25[OH]D)” in serum is a risk factor for
pre-eclampsia. The most recent research confirms the importance of vitamin D3
deficiency therapy in lowering the risk of pre-eclampsia. Vitamin D
supplementation decreases the risk of pre-eclampsia and IUGR in the deficient
population in a dose-dependent way. However, broader clinical trials are needed
to investigate the optimal vitamin D3 dosage in this population.

Human Chorionic Gonadotropin And Risk Of Pre-Eclampsia: Prospective

Population-Based Cohort Study
A study conducted by Barjaktarovic, et. al. (2019) stated that early
pregnancy abnormal placentation may play a role in the pathogenesis of
preeclampsia. Human chorionic gonadotropin (hCG) controls placental production
and angiogenesis and can influence the serum ratio of soluble fms-like tyrosine
kinase 1 (sFlt1) to placental growth factor (PlGF). Early in pregnancy, a high
overall hCG concentration is associated with an elevated risk of preeclampsia. The
effect of high hCG concentration on the balance of pro and antiangiogenic factors
during pregnancy may play a role in preeclampsia pathophysiology.
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