PRE-ECLAMPSIA

Pre-eclampsia is a disorder that only happens in

pregnant women – it occurs after 20 weeks
gestation, and in some cases develops up to 6 weeks
after delivery.
 Pre-eclampsia causes new-onset
hypertension and proteinuria (protein in the
urine), which is a marker of kidney damage –
and can also cause damage to other organs
like the brain and liver.
 There could be a wide range of symptoms –
for some women there may be no symptoms
or only mild ones, whereas, for others, it
can turn into a life-threatening illness.
(If a woman with pre-eclampsia develops seizures,
she is said to have eclampsia)
RISK FACTORS
 Pre-eclampsia tends to occur more often
during:
 first pregnancy (primigravida)
 multiple gestations
 Age (younger than 18 and 35 years
or older)
 Other risk factors include having:
 Hypertension
 Diabetes
 Obesity (BMI more than 30)
 family history of pre-eclampsia
 In PRE-ECLAMPISA, these uteroplacental
arteries become fibrous causing them to
narrow, which means less blood gets to the
placenta.
 A poorly perfused placenta can lead
to intrauterine growth restriction
and even fetal death in severe
cases.
 At this point, the hypo-perfused
placenta starts releasing:
pro-inflammatory protein
will go into the mother’s circulation
and cause the endothelial cells that
line her blood vessel to become
dysfunctional.
 Endothelial cell dysfunction
causes vasoconstriction –
narrowing of the blood vessels –
and also affects the kidneys in
a way that makes them retain
more salt, both of which result
in HYPERTENSION.
DIAGNOSIS
When diagnosing pre-eclampsia, hypertension is
defined as a:
 systolic blood pressure of more than 140mmHg
 diastolic pressure of more than 90mmHg

In severe pre-eclampsia
Why do these changes happen in pre-
 systolic blood pressure of more than 160mmHg
eclampsia and eclampsia?
 diastolic pressure of more than 110mmHg
The exact cause is unclear, a key These extreme blood pressures can
pathophysiologic feature is the development of an lead to a hemorrhagic stroke or placental abruption, in
abnormal placenta. which the placenta detaches prematurely from the
uterine wall.
 NORMALLY during pregnancy, the spiral
arteries dilate to 5-10 times their normal
size and develop into large uteroplacental
arteries capable of delivering large
quantities of blood to the developing fetus.
 More than 140/90 mmHg, is one reading
sufficient?

NO, there must be TWO separate readings that

are at least 4 or 6 hours apart.

How is pre-eclampsia different from

gestational hypertension?

They’re both considered hypertensive

disorders BUT gestational hypertension doesn’t cause
injury to organs in the body or proteinuria, and this leads
us to the next criteria.

There could also be local areas of vasospasm – which

means that less blood might reach certain parts of the
body. Such as:

i. Reduced blood flow to the kidneys, which are

particularly susceptible, can cause glomerular
damage leading to oliguria (low amount of urine)
and proteinuria.
 Normally, the glomeruli of the kidneys
do a good job of preventing the protein
from spilling into the urine so,
 Proteinuria can be a sign of glomerular
damage and is a CLASSIS SIGN of pre-
eclampsia.
 Also, due to kidney compromise: uric
acid and creatinine levels INCREASE
and urinary output will DECREASE.

What is considered proteinuria for pre-

eclampsia?

 > +1 with a dipstick test

 > 300 mg with a 24-hour urine
 > 0.3 mg/dL creatinine/protein ratio

ii. Reduced blood flow to the retina can cause:

 blurred vision
 seeing flashing lights
 development of scotoma – when a
small part of the visual field has
slightly worse visual acuity.

iii. Reduced blood flow to the liver can cause severe

liver injury and swelling, which can cause an
elevation in liver enzymes and stretches out the
capsule around the liver.
 Stretching of the liver capsule typically
causes right upper quadrant pain
(epigastric) which is one of the CARDINAL
SYMPTOMS of severe pre-eclampsia.
 Finally, endothelial injury increases vascular
permeability, allowing water to slip out of blood vessels
The endothelial injury also leads to the
between neighboring endothelial cells and get into the
formation of many tiny thrombi in the microvasculature,
tissues.
which is a process that uses up massive amounts of
platelets.  Because there is also a loss of protein from
the blood due to proteinuria, fluid moves
from the blood vessels into the tissue.

(*Having all of these tiny blood clots in the blood is a bit This CAUSES generalized edema which is often seen in
like having dozens of boulders in the middle of a fast- the:
moving river*)
a) Legs
b) Face and hands

It becomes treacherous for red blood cells Pulmonary edema

(RBC) to navigate through, and because of that RBCs slam
up against a clot and get destroyed – which is a process a) Cough
called HEMOLYSIS. b) Shortness of breath

Cerebral edema

a) Headache
b) Confusion
c) Seizures – SEIZURES DEFINE THE ONSET
OF ECLAMPSIA.

Because all of the problems of pre-eclampsia and

eclampsia stem from placental dysfunction.

TREATMENT
TOGETHER these make up the HELLP syndrome:
I. Delivery of the fetus and placenta
i. H = hemolysis
 The decision to induce delivery depends
ii. EL = elevated liver enzymes
heavily on the:
iii. LP = low platelets
 gestational age of the fetus
 severity of the disease
 and how it’s affecting both
Overall, HELLP syndrome develops in about 10% maternal and fetal health.
to 20% of women with severe pre-eclampsia or
eclampsia.
 II. If the onset of symptoms comes after delivery, Evaluate blood pressure for hypertension: monitored at
then the goal is to manage the symptoms which every prenatal visit and educate the mother to monitor at
slowly subside on their own. home.

 Remember hypertension criteria: >140/90 two

Additional measures are aimed at managing any end-organ separate times at least 4 or 6 hours apart.
damage by offering:
Edema monitoring (watch for and educate mother about
 supplemental oxygen this):
 medication to manage seizures and
 weight gain of 2 lbs. or more in a week and weigh
other complications like stroke or
self-daily.
placental abruption.
 Edema can be in the face, eyes, and extremity
swelling.
NURSING INTERVENTION: PRE-ECLAMPSIA
 Monitor urinary output.
Proteinuria monitoring: check urine for protein at every
prenatal visit (some women may be taught to do this at
 Lung sounds (pulmonary edema - short of breath)

home with a dipstick test):
 Labs to remember:
 >1+ dipstick test (if hypertension is
present along with protein in the urine
the physician may order the woman to
complete 24-hour urine)
 24-hour urine: >300 mg
 >0.3 mg/dL creatinine to protein ratio
 Other prenatal labs that may
be ordered: CBC (platelets
<100,000, red blood cells or
peripheral smear to check for
hemolysis, creatinine, BUN),
liver enzymes (AST or ALT), if
preeclampsia suspected
Reflexes hyperactive (deep tendon reflexes - patellar
and bicep)
 Watch for exaggerated reflexes called
“hyperreflexia” like 4+
 Indicates the CNS is stressed out and
at risk for seizures:
Calcium gluconate: antidote for magnesium sulfate
toxicity (be sure to have it handy).
Left side-lying position (helps prevent placenta ischemia
and increases blood flow to baby), bed rest/limit
stimulation, fetal heart rate monitoring (report decrease
in fetal activity)
Assess for seizure activity “eclampsia”: there is a risk
during and after labor (up to 48 hours)
 Follow the hospital’s protocol: have seizure
precautions in place beforehand if there is a risk
(suction, airway management supplies, padded
side rails, etc.)
 checks reflexes and clonus per protocol:
 To check for ankle clonus:
quickly dorsiflex the patient’s
foot (point toes upward) and
see the response. If positive
(clonus) foot will start to
bounce back and forth (it
attempts to plantarflex) >3
bounces or more is positive

 assess neuro status, vision

changes, headaches, and ankle
 Seizure interventions:
clonus (check out the lecture to
see how to check for this)  Eclampsia - early may
see facial twitching,
 Magnesium Sulfate may be
changes in neuro
ordered to decrease the risk of
status, followed by full
seizure activity: Watch for
body tonic-clonic
decreased or absent reflexes
seizure (contraction
because this could
and stiffening of body
indicate Magnesium Sulfate
followed by jerking of
Toxicity
muscles)
  Stay with patient and
get help, don’t restrain
patient, get on left
side (helps prevent
aspiration, opens
airway, and helps with
blood flow to placenta),
oxygen 8 to 10 L,
monitor baby, timing
and characteristics of
seizure, may need
medication and delivery
of baby - delivery of
baby tends to be the
treatment to help but
can have seizures after
delivery)

Magnesium sulfate was administered to prevent seizures

during and after labor (risk for seizures up to 48 hours
after delivery)

 Monitor for toxicity: Early pt may report feeling

warm or note flushing, RR: <12, DTRs:
decreased/absent, UOP: <30 cc/hr., EKG changes
etc.

Protein-rich diet (remember there may be low protein in

blood due to proteinuria - protein leaks into the urine and
leaves blood)

 watch salt intake (sodium levels can increase due

to renal dysfunction and start to keep sodium in
the blood)

Severe complications to watch for:

 HELLP Syndrome: hemolysis (rupture of RBCs),

elevated liver enzymes, low platelets,
 DIC
 Placental abruption
 Stroke
 Fetal distress or restriction of growth

I & Os: strict monitoring (may need Foley catheter),

abnormal sign: low urinary output less than 30 cc/hour
(kidneys aren’t being perfused very well)

Antihypertensives (labetalol, hydralazine)

 There is a fine line that has to be followed when

using blood pressure medication on a pregnant
woman because blood flow must be maintained to
the placenta and baby. They are used with
caution.
 A. 1600: blood pressure 144/100, 1700:
blood pressure 120/80
B. 3+ dipstick urine protein
C. 1r glucose tolerance test 90 mg/dL
D. 0800: blood pressure 142/92, 1230:
blood pressure: 144/98
E. <300 mg/dL 24-hour urine protein

2. You’re providing an in-service to a group of new

labor and delivery nurse graduates about the
pathophysiology of preeclampsia. Which
statement by one of the group participants
demonstrates they understood how this
condition develops?
A. The basal arteries of the myometrium
fail to widen to support blood flow to
the placenta.”
B. “The placenta experiences ischemia
because the spiral arteries of the
uterus fail to reshape and increase in
diameter.”
C. The cardiovascular system of the
mother fails to compensate for the
increased blood flow from the fetus and
placental ischemia occurs.”
D. “If the mother experience uncontrolled
hypertension and proteinuria, it
compromises blood flow to the placenta
and leads to preeclampsia.”

3. A 37-year-old female patient who is 36 weeks

pregnant is diagnosed with mild preeclampsia.
The nurse will include what information in the
patient’s education? Select all that apply:
A. Report weight gain of >4 lbs in one week
to physician
B. Follow a no salt diet
C. Headache and vision changes are
expected side effects of this condition
and cause no reason for concern.
D. Importance of monitoring urine protein
at home
E. Lying on left-side is recommended along
with rest
F. Report a decrease in fetal activity
immediately

LET’S ANSWER!

1. A patient is currently 34 weeks pregnant with

4. The signs and symptoms of preeclampsia are
her first baby. Which findings below could
mainly occurring because substances released by
indicate the development of preeclampsia in this
the ischemic placenta cause damage to the
patient that would need to be reported to the
_________________ in mom’s body, which
physician? Select all that apply:
injures organs.
 A. spiral arteries C. Monthly visits until 20 weeks, then bi-
B. epithelial cells monthly visits
C. endothelial cells D. Bi-monthly visits until 36 weeks, then weekly
D. juxtaglomerular cells
9. The nurse is developing a plan of care for a
5. A 37 week pregnant patient is admitted with woman who is pregnant with twins. The nurse
severe preeclampsia. The patient begins to includes interventions focusing on which of the
experiences a tonic-clonic seizure. Which of the following because of the woman's increased risk?
following would the nurse AVOID during the A. Oligohydramnios
seizure? Select all that apply: B. Preeclampsia
A. Placing the patient in a supine position C. Post-term labor
B. Holding down the patient’s head to D. Chorioamnionitis
prevent injury
C. Staying with the patient and activating 10. The nurse knows that pre-eclampsia tends to
the emergency response team occur during what time in a pregnancy?
D. Timing the seizure A. before 20 weeks
E. Providing 8 to 10 L of oxygen B. in the third trimester and postpartum
C. after 20 weeks
6. A 39-week pregnant patient is in labor. The D. in the first and second trimester
patient has pre-eclampsia. The patient is
receiving IV Magnesium Sulfate. Which finding
below indicates Magnesium Sulfate toxicity and
requires you to notify the physician?
A. A. Deep tendon reflex 4+
B. Respiratory rate of 13 breaths per
minute
C. Urinary output of 600 mL over 12 hours
D. Clonus presenting in the lower
extremities.
E. Patient reports flushing or feeling hot.

7. Your patient with pre-eclampsia is started on

Magnesium Sulfate. The nurse knows to have
what medication on standby?
A. Acetylcysteine
B. Calcium carbonate
C. Oxytocin
D. Calcium gluconate

8. When preparing a schedule of follow-up visits

for a pregnant woman with chronic hypertension,
which of the following would be most
appropriate?
A. Monthly visits until 32 weeks, then bi-
monthly visits
B. Bi-monthly visits until 28 weeks, then weekly
visits
 2. The answer is B. This is the only correct
statement. When preeclampsia occurs it is
because the spiral arteries of the uterus failed
to widen in diameter due to poor trophoblast
invasion during the beginning of the pregnancy.
Overtime, this causes problems (usually after 20
weeks gestation) and the placenta experiences
ischemia. When the placenta becomes ischemic is
releases substances into mom’s circulation that
are very toxic to her endothelial cells, which
causes all the signs and symptoms seen in
preeclampsia. Severity varies in patients.

3. The answers are: B, E, F, and G. These

options are topics the nurse wants to include in
the patient’s teaching with preeclampsia. Option
A is wrong because the patient should report a
weight gain of >2 lbs (NOT 4 lbs) in one week.
Option C is wrong become it is no longer
recommended the patient restrict salt in diet
but limit it. Option D is wrong because a
headache and vision changes are serious
complications that may indicate the development
of eclampsia, and the patient should report it
immediately.

4. The answer is C: The signs and symptoms of

preeclampsia are mainly occurring because
substances released by the ischemic placenta
cause damage to the ENDOTHELIAL CELLS in
mom’s body, which injures organs.

5. The answers are A and B. The nurse would want

to place the patient on their side (preferably the
left-side - not supine) to help prevent the tongue
from obstructing the airway, preventing
aspiration, and improving blood flow to the
placenta.  In addition, the nurse would NOT want
to restrain the patient, which can cause injury.
Option C, D, and E are steps the nurse would
want to take.

6. The answer is E. The nurse should monitor for

Magnesium Sulfate toxicity. Signs of this
include: EARLY: flushing or feeling hot/warm,
later on: decreased or absent reflexes (finding

ANSWERS with RATIONALE

1. The answers are B and D. Signs and symptoms

of preeclampsia include: proteinuria (>1+ dipstick
urine protein or >300 mg/dL 24 hour urine
protein, hypertension >140/90 - two reading at
least 4-6 hours apart), swelling in face, eyes,
extremities, headaches, vision changes, etc.
of 4+ Deep tendon reflex is considered
HYPERreflexia), Respiratory rate less than 12
breaths per minute, Urinary output of less than
30 mL/hr, EKG changes.
7. The answer is D: The antidote for Magnesium
Sulfate is Calcium Gluconate. The nurse should
have this on hand in case Magnesium toxicity
occurs.

8. The answer is B: For the woman with chronic

hypertension, antepartum visits typically occur
every 2 weeks until 28 weeks' gestation and then
weekly to allow for frequent maternal and fetal
surveillance.

9. The answer is B: Women with multiple

gestations are at high risk for preeclampsia,
preterm labor, hydramnios, hyperemesis
gravidarum, anemia, and antepartal hemorrhage.
There is no association between multiple
gestations and the development of
chorioamnionitis.

10. The answer is C. Preeclampsia tends to occur

AFTER 20 weeks gestation.