Princess Levie Ceniza BSN 2A Case study 118

SCENARIO

J. F is an 18 year old woman, gravida 1 para 0, at 36 weeks gestation. She felt fine
until 2 days ago, when she noticed swelling in her hands, feet and face. She complains
of a frontal headache, which started yesterday and has not been relieved by
acetaminophen ( Tylenol ) or coffee. She says she feels irritable and doesn’t want the
“overhead lights on.” Her physician is admitting her for induction of labor. You begin
to asses her.

CHART VIEW

Assessment

VS: BP 152/84 mm Hg
HR: 88 beats/min
Oral temperature: 98.8 F ( 37.1 C )
Weight: 131.4 kg ( 289 lb )
Height: 5’4
Edema: noted in hands, feet, face
Deep tendon reflexes ( DTRs ) +2, no clonus
Urine dipstick reveals proteinuria +3

1. Based on the assessment data you have obtained so far, what do you think is
happening to J.F at this time ?

●Based on the assessment data, J.F has possibly developed pre-eclampsia

●Pre-eclampsia is a hypertensive condition that women develop during the second
half of pregnancy (after 20 weeks of gestation or postpartum). It is characterized by
high blood pressure and protein in the urine. This can occur in the women with or
without pre-existibg high blood pressure.
●Pre-eclampsia presented by hypertension, peripheral and facil edema, proteinuria,
head and light sensitivity and DTR greater than +2 no clonis.

2. As you assess J.F for edema in her ankles, you note that she is closest to letter B in
the figure below; with edema at about 4 mm. How would you document this edema ?

I would document this as anasarca since it is -2+3-4 mm depression, or a slight

indentation.
Anasarca is general swelling of the whole body that can occur when the tissues of the
body retain too much fluid. The condition is also known as extreme generalized
edema.
3. What other assessment questions should you ask her at this time ?

●Any symptoms with previous pregnancy.

If you had preeclampsia in your first or an earlier pregnancy... Research suggests the
risk of having preeclampsia again is approximately 20%, however experts cite a
range from 5% to 80% depending on when you had it in a prior pregnancy, how
severe it was, and additional risk factors you may have.
●History of hypertension, any previous symptoms of pre-eclampsia
but several factors in addition to having a history of preeclampsia can put you at a
higher risk for it, including: having high blood pressure or kidney disease before
pregnancy. family history of preeclampsia or high blood pressure.
●Activity level, any shortness of breath.
Shortness of breath, a racing pulse, mental confusion, a heightened sense of anxiety,
and a sense of impending doom can be symptoms of preeclampsia. If these symptoms
are new to you, they could indicate an elevated blood pressure, or more rarely, fluid
collecting in your lungs (pulmonary edema).
●Have you experienced any vision changes/ visual disturbances?
Vision changes are one of the most serious symptoms of preeclampsia. They may be
associated with central nervous system irritation or be an indication of swelling of the
brain (cerebral edema). Common vision changes include sensations of flashing
lights, auras, light sensitivity, or blurry vision or spots.
●Epigastric pain or vomiting?
Hepatic involvement occurs in 10% of women with severe preeclampsia. The
resulting pain (epigastric or right upper quadrant abdominal pain) is frequently
accompanied by elevated serum hepatic transaminase levels.
● Reduction in fetal movement? Gain weight also and how she will rate the pain n the
scale of 1-10 with 10 being the lowest and 1 being the highest.

4. What information should you obtain from her obstetric record ?

●Information from OB record

It is helpful if the prenatal record provides cues to remind the clinician to order
standard screening tests. As additional information is gathered from ongoing
prenatal visits and laboratory evaluation, risk assessment, education plans, and
management plans should be reviewed and updated as necessary.
Old kab values including:
●Liver enzymes (ALT, AST)
Any elevation in an enzyme level may be a sign of a liver problem, and aspartate
aminotransferase (AST) and alanine aminotransferase (ALT) are two of the enzymes
central to such an investigation. When used in comparison with each other, AST and
ALT can help identify toxins in the liver, liver disease, or liver damage.
●Platelet count
It affects about one pregnant woman in 10 and usually develops in mid to late
pregnancy. Your platelet count is usually checked during a routine blood test, taken at
one of your antenatal appointments. Platelets are cells that help your blood to clot
when it needs to.
●Bloop pressure, vitals urinalysis (proteinuria)

Monitoring your blood pressure is an important part of prenatal care because the first
sign of preeclampsia is commonly a rise in blood pressure. Blood pressure that
exceeds 140/90 millimeters of mercury (mm Hg) or greater — documented on two
occasions, at least four hours apart — is abnormal.

5. What laboratory values should be considered at this time ?

●Lab values considered this time

Normal Pre-eclampsia:
●H&H 12-16g/dl,37-47% may increase
Your body uses iron to make hemoglobin, a protein in the red blood cells that carries
oxygen to your tissues. During pregnancy, you need double the amount of iron that
nonpregnant women need. Your body needs this iron to make more blood to supply
oxygen to your baby.
The normal physiologic range for hemoglobin during pregnancy is 11.5-13.0 (13.5)
g/dl; anemia is, by definition, present when the values are under 11 g/dl and is quite
common in pregnancy.

●Patelets 150,000-400-000mm3 Unchanged

It affects about one pregnant woman in 10 and usually develops in mid to late
pregnancy. Your platelet count is usually checked during a routine blood test, taken at
one of your antenatal appointments. Platelets are cells that help your blood to clot
when it needs to.
There is a normal drop in platelet count during pregnancy. In the first trimester, the
normal count is around 250,000 and decreases to about 225,000 at delivery.
Platelet counts <100,000 were rarely encountered in normal, uncomplicated
pregnancies and should not generally be considered a physiologic change.
●Fibrinogen 200-40mg/dl 300-600mg/dl
A fibrinogen activity test measures the function of fibrinogen and its ability to be
converted into fibrin. It is used: As part of an investigation of a possible bleeding
disorder or inappropriate blood clot formation (thrombotic episode)
Normal blood concentration of fibrinogen in pregnant women in their third trimester
rises close to 500 mg/dL. 19, 20, 21 The minimum amount of fibrinogen necessary
for hemostasis is 40–50% of the normal concentration, whereas the minimum amount
of coagulation factors other than fibrinogen is 20–25%.
●BUN 10-20mg/dl increase
A BUN test is done to see how well your kidneys are working. If your kidneys are
not able to remove urea from the blood normally, your BUN level rises. Heart failure,
dehydration, or a diet high in protein can also make your BUN level higher. Liver
disease or damage can lower your BUN level.
Women and children may have lower BUN levels than men because of how their
bodies break down protein. A low BUN-to-creatinine ratio may be caused by a diet
low in protein, a severe muscle injury called rhabdomyolysis, pregnancy, cirrhosis, or
syndrome of inappropriate antidiuretic hormone secretion (SIADH).
●Creatinine 0.5-1.1mg/dl>1.2mg/dl
The physiologic increase in GFR during pregnancy normally results in a decrease in
concentration of serum creatinine, which falls by an average of 0.4 mg/dl to a
pregnancy range of 0.4 to 0.8 mg/dl.
●AST 4-20 units/L unchanged to minimal increase
●ALT 3-21 units/L unchanged to minimal increase
●Cr. clearance 80-125 ml/min 130-180ml/min
●Uric acid 2-6.6mg/dl>5.9mg/dl
During early pregnancy serum uric acid levels fall, often to 3 mg/dl or below, related
to the uricosuric effects from estrogen and from the increase in renal blood flow. Uric
acid levels then increase during the third trimester, reaching levels of 4–5 mg/dl by
term 
●Biliburin 0.1-1mg/dl unchanged to increase
A common use of this test is to measure bilirubin levels in newborns to check for
infant jaundice. Determine whether there might be blockage in your bile ducts, in
either the liver or the gallbladder. Help detect liver disease, particularly hepatitis, or
monitor its progression.
In the current era, gallstones and preeclampsia-related disorders are the most
common causes of jaundice in pregnant women. Disorders that cause elevated
maternal bilirubin during pregnancy are associated with increased risk for the fetus.

6. Name at least three possible maternal and three possible fetal complications with
J.F’s diagnosis.

FETAL; MATERNAL:
●Fetal Hypoxia. ●Seizures
●Prenature Birth. ●Hemorrhage of subcapssular to liver
●Intrauterine Growth Restriction from. ●Cerebral edema
hypoperfusion an/or oligohydramnios. ●Disseminated Intravascular
●Renal Insufficiency
FETAL HYPOXIA
Intrauterine hypoxia (also known as fetal hypoxia) occurs when the fetus is deprived
of an adequate supply of oxygen. It may be due to a variety of reasons such as
prolapse or occlusion of the umbilical cord, placental infarction, maternal diabetes
(prepregnancy or gestational diabetes) and maternal smoking.
PREMATURE BIRTH
premature birth is a birth that takes place more than three weeks before the
baby's estimated due date. In other words, a premature birth is one that occurs
before the start of the 37th week of pregnancy. Premature babies, especially those
born very early, often have complicated medical problems.
INTRAUTERINE
There is an association between oligohydramnios and both intrauterine growth
restriction and increased perinatal mortality. Normal amniotic fluid volume changes
with gestational age and ways of accurately estimating it have changed over the years.
Chronic hypertension is the most common cause of IUGR
MATERNAL
SEIZURES
Damage to your arteries may restrict blood flow. It can produce swelling in the
blood vessels in your brain and to your growing baby. If this abnormal blood flow
through vessels interferes with your brain's ability to function, seizures may occur.
HEMORRHAGE
In preeclampsia there is releasing of different mediators from liver and blood
vessel endothelium (fibronectin, thrombomodulin, endothelin-l, thromboxane), which
causes vasoconstriction and liver hypoxia. Hypoxia increases the level of ALTA
subcapsular hematoma of the liver is an accumulation of blood between Glisson's
capsule and the liver parenchyma; rupture into the peritoneum has a 75% mortality
rate [1, 2]. The hematoma is usually located around the right lobe of the liver (in 75%
of patients).
CEREBRAL EDEMA
It is common for the increased blood pressure associated with pre-eclampsia to cause
leakage of fluid from the blood vessels supplying the brain. Under these
circumstances the brain can become swollen with fluid, a condition known as
cerebral edema.

7. What risk factors does J.F have that cause her to be at risk for this condition ?
( Select all that apply. )

A. Obesity
B. Nulliparity
C. Single - fetus pregnancy
D. Age less than 20 years
E. Coffee drinker

ANSWER:A&B
since the J.F. is 131.4kg with the height of 163cm she is considered obese because her
BMI 49.8
If the vasculature of obese women is inflamed, the additional oxidative burden of
pregnancy imposed by the placenta and the increase in the number of neutrophils
during pregnancy could result in vascular inflammation sufficient to cause the clinical
symptoms of preeclampsia.
Having a high BMI can harm your fertility by inhibiting normal ovulation. Even
in women who regularly ovulate, the higher the BMI , the longer it appears to take to
become pregnant. Some research also suggests that as your BMI increases, so does
the risk of unsuccessful in vitro fertilization (IVF).
NULLI
since it is her first pregnancy
Early in pregnancy, new blood vessels develop and evolve to efficiently send blood
to the placenta. In women with preeclampsia, these blood vessels don't seem to
develop or function properly.

8. Identify eight measures that would likely be implemented.

●Update Anesthesiologist if epidural desired

A baseline determination of maternal blood pressure, pulse, and fetal heart rate
should be made prior to inserting the epidural catheter. Continuous fetal monitoring is
essential to determine any fetal distress which may result from anesthesia-induced
hypotension.
●Limit fluids to prevent pulmonary edema
The treatment of pulmonary edema in PE is similar to those of non-pregnant patients:
oxygen therapy, water restriction, intravenous furosemide (80 mg initially) and
central hemodynamic monitoring. Reduction in afterload is obtained with the use of
vasodilators (hydralazine, nifedipine)
●Normal Admission labs, with special emphasis on obtaining platelet count
Preeclampsia occurs in 3-4% of pregnancies and accounts for 5-21% of cases of
maternal thrombocytopenia. Thrombocytopenia is usually moderate, and platelet
count rarely decreases to < 20,000/μL. Thrombocytopenia in patients with
preeclampsia always correlates with the severity of the disease.

●PO or IV Labetalol of hydralizine

Hydralazine and Labetalol both were found to be equally efficacious in reducing
blood pressure in cases of severe hypertension in pregnancy. Labetalol achieved the
target blood pressure faster than Hydralazine. The adverse effects of both the drugs
were comparable.
●IV magnesium sulfate
Magnesium sulfate can help prevent seizures in women with postpartum preeclampsia
who have severe signs and symptoms. Magnesium sulfate is typically taken for 24
hours.
●Initiate seizures precautions
Damage to your arteries may restrict blood flow. It can produce swelling in the blood
vessels in your brain and to your growing baby. If this abnormal blood flow through
vessels interferes with your brain's ability to function, seizures may occur.
●Hourlymeasurement of Intake and Urine Output
Because of this, serum creatinine levels in preeclamptic patients rarely increase above
normal pregnancy levels (. 8 mg/dL). Close monitoring of urine output is necessary in
patients with preeclampsia, because oliguria (defined as less than 500 cc/24 hours)
may occur because of renal insufficiency.
●Limit Actvity to bathroom privileges

CASE STUDY PROGRESS

The physician orders a magnesium sulfate infusion. As you monitor J.F, you observe
for signs of magnesium sulfate toxicity.

9. What are potential signs of magnesium sulfate toxicity ? ( Select all that apply. )

A. Absent DTRs
B. Increased respiratory rate
C. Oliguria
D. Muscle rigidity
E. Severe hypotension

ANSWER: E
Magnesium also indirectly affects vascular contractility by inhibiting the release of
catecholamines both from the adrenal medulla and peripheral adrenergic terminals
resulting in decreased vasoconstriction. In obstetrics, Mg decreases uterine tone
through relaxation of uterine blood vessels and uterine smooth muscle.
Increased toxicity:maternal hypotension,bradycardia,bradypnea,cardiac arrest

Magnesium toxicity as a cause of hypotension and hypoventilation. Occurrence in

patients with normal renal function.

10. Four hours later, a serum magnesium level is drawn, and the results show 7.8
mEq/L. Does this result need to be reported to the physician ? If so, what would you
prepare to do ?

Yes it should be reported. (Therapeutic level=4-7mEq/L)

●Stop the infusion
Patients can experience facial flushing and possibly transient hypotension,
especially with overly-rapid infusions- so feel free to slow the rate down if any of
these side effects occur. In conclusion, be very mindful of each magnesium order's
indication.
●Assess for the signs of Mg toxicity
The patient should be assessed for signs of toxicity (e.g., visual changes,
somnolence, flushing, muscle paralysis, loss of patellar reflexes) or pulmonary
edema. If these signs are observed, a physician must be notified.
●Administer calcium gluconate (usually administered by the MD) as necessary.
Calcium Gluconate should be administered intravenously either directly or by
infusion. The dose is dependent upon the individual requirements of the patient.
Calcium Gluconate may also be administered by intermittent infusion at a rate not
exceeding 200 mg/min, or by continuous infusion.
11. Is there an antidote for magnesium sulfate ?

●Antidote: Calcium gluconate (10ml of a 10% solution or 1g. Slow IV push over
atleast 3 mins)
Treatment of Hypermagnesemia

Why is calcium gluconate The antidote for magnesium toxicity?

Treatment of severe magnesium toxicity consists of circulatory and respiratory
support and administration of 10% calcium gluconate 10 to 20 mL IV. Calcium
gluconate may reverse many of the magnesium-induced changes, including
respiratory depression.

CASE STUDY PROGRESS

The magnesium sulfate infusion rate is reduced, and an oxytocin infusion has been
ordered by the physician and is being given IV in increments to achieve an adequate
contraction pattern. You notice on the fetal monitor strip that J.F. is experiencing
seven uterine contractions in a 10 - minute period over a 30 minute window, with a
few FHR decelerations noted.

12. What is happening at this time ?

●Oxytocin is used for both the induction and augmentation of labor. The most
common adverse effect of oxytocin is fetal heart rate deceleration due to uterine
tachysystole and resultant uteroplacental hypoperfusion.
Uterine tachysystole with Oxytocin:
●More than 5 contractions
According to the "411 Rule" (commonly recommended by doulas and midwives), you
should go to the hospital when your contractions are coming regularly 4 minutes
apart, each one lasts at least 1 minute, and they have been following this pattern for
at least 1 hour. You may also hear about the 511 rule.
●A series of single contractions lasting more than 2 minutes
Labor is often more intense and faster with subsequent pregnancies and after you
break your bag of water. In active labor, your contractions will be every 2-3 minutes
apart. At this time, you can expect your cervix to start dilating.

●Contractions of normal duration hapening within 1 minute of each other

Prodromal labor consists of contractions that can be fairly regular (between 5-10
minutes apart) and can be painful like active labor contractions, more so than Braxton
Hicks contractions. Typically each contraction will last just shy of one minute.

13. What are your priority actions ?

●Reposition or maintain patient in side-lying position

It improves circulation, giving nutrient-packed blood an easier route from your heart
to the placenta to nourish your baby. Lying on the left side also keeps your expanding
body weight from pushing down too hard on your liver. While either side is okay, left
is best.
●Administer IV fluid bolus with 500ml of LR solution
●Continue monitoring FHR
Fetal heart rate monitoring measures the heart rate and rhythm of your baby
(fetus). This lets your healthcare provider see how your baby is doing. Your
healthcare provider may do fetal heart monitoring during late pregnancy and labor.
●Decrease oxytocin by one hf if uterine activity has not returned to normal after10
mins
A lack of oxytocin in a nursing mother would prevent the milk-ejection reflex
and prevent breastfeeding. Low oxytocin levels have been linked to autism and
autistic spectrum disorders (e.g. Asperger syndrome) – a key element of these
disorders being poor social functioning.
Asperger syndrome (AS), also known as Asperger's, is a neurodevelopmental disorder
characterized by significant difficulties in social interaction and nonverbal
communication, along with restricted and repetitive patterns of behavior and interests.
●If uterine activity has not returned to normal after another 10 mins, discontinue
oxytocin until fewer than 5 contractions occur in 10 mins]
Conclusion: In singleton gestations with cephalic presentation at term undergoing
induction, discontinuation of oxytocin infusion after the active phase of labor at
approximately 5 cm is reached reduces the risk of cesarean delivery and of uterine
tachysystole compared with continuous oxytocin infusion.
●Notify the physician

CASE STUDY PROGRESS

K. F. progress in labor, and at 4 cm dilation, her membranes spontaneously rupture.

The small amount of amniotic fluid is green.

14. What does the green amniotic fluid indicate ? What are the risks ?

Meconium Aspiration Syndrome

●Green Amniotic fluid usually means the baby has passed his first bowel movement
in the uterus (MSAF=Meconium stained amniotic fluid). It is dangerous because the
baby exercises the lungs and “breaths” amniotic fluid in utero. The fetal matter can
enter the lungs and cause meconium aspiration syndrome.

CASE STUDY PROGRESS

Five hours later, J.F. delivers a 6 pound, 8 - ounce boy, with Apgar scores of 6 and 7.

15. What are your responsibilities at this time ?

Do these immediately after birth

For the baby:
●Assess the baby’s respiratory efforts, heart rate, and muscle tone.
The Apgar score helps find breathing problems and other health issues. It is part of
the special attention given to a baby in the first few minutes after birth. The baby is
checked at 1 minute and 5 minutes after birth for heart and respiratory rates, muscle
tone, reflexes, and color.
●Suction only the baby’s mouth and nose, using either a bulb syringe or a 12 or 14
french suction catheter if the baby has:
STRONG RESPIRATORY EFFORTS
Breathing effort should be nonlabored and in a regular rhythm. Observe the depth of
respiration and note if the respiration is shallow or deep. Pursed-lip breathing, nasal
flaring, audible breathing, intercostal retractions , anxiety, and use of accessory
muscles are signs of respiratory difficulty.
GOOD MUSCLE TONE
Most babies enter the world with good muscle tone. It lets them flex and flail their
little limbs. Newborns with hypotonia won't have strong arm and leg movements. As
they get older, “floppy” babies will miss important milestones, like being able to lift
their heads when they're on their tummies
Hypotonia is the medical term for decreased muscle tone.
Healthy muscles are never fully relaxed. They retain a certain amount of tension and
stiffness (muscle tone) that can be felt as resistance to movement.
HEART RATE> 100 beats/ min
●Suction below the vocal cords using an endotracheal tube to remove any meconium
present before many spontaneous respirations has been initiated if the baby has:
DEPRESSED RESPIRATIONS
Newborn respiratory distress syndrome (NRDS) happens when a baby's lungs are
not fully developed and cannot provide enough oxygen, causing breathing
difficulties. It usually affects premature babies. It's also known as infant respiratory
distress syndrome, hyaline membrane disease or surfactant deficiency lung disease.
DECREASED MUSCLE TONE
Hypotonia means decreased muscle tone. It can be a condition on its own, called
benign congenital hypotonia, or it can be indicative of another problem where there is
progressive loss of muscle tone, such as muscular dystrophy or cerebral palsy. It is
usually detected during infancy.
HEART RATE<100 beats/min