WHAT IS PREECLAMPSIA

CLASSIFICATION OF PREECLAMPSIA

WHAT ARE THE SIGNS & SYMPTOMS OF PREECLAMPSIA

WHEN DO SYMPTOMS SHOW UP

WHAT CAUSES PREECLAMPSIA (PE)

PREECLAMPSIA RISK FACTORS

PREECLAMPSIA COMPLICATIONS

HOW LONG DOES PREECLAMPSIA LAST

HOW TO TREAT PREECLAMPSIA

PATHOPHYSIOLOGY OF PREECLAMPSIA

CLINICAL ASSESSMENT OF PREECLAMPSIA

WHAT ARE THE NURSING DIAGNOSES FOR PREECLAMPSIA?

NURSING CARE PLAN FOR PREECLAMPSIA

NURSING INTERVENTIONS

EVALUATION

CONCLUSION

REFERENCES

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OBJECTIVES

At the end of the course the students will be able to demonstrate good knowledge

of the following:

1. What Is Preeclampsia

2. Classification of Preeclampsia PE

3. What Are the Signs & Symptoms of Preeclampsia

4. When Do Symptoms Show Up

5. What Causes Preeclampsia (PE)

6. Preeclampsia Risk Factors

7. Preeclampsia Complications

8. How Long Does Preeclampsia Last

9. How to Treat Preeclampsia

10. Nursing care process for preeclampsia

What Is Preeclampsia?

Preeclampsia, formerly called toxaemia, is when pregnant women have high blood

pressure, protein in their urine, and swelling in their legs, feet, and hands. It can range

from mild to severe. It usually happens late in pregnancy, though it can come earlier

or just after delivery.

Preeclampsia can lead to eclampsia, a serious condition that can have health risks for

mom and baby and, in rare cases, cause death. If your preeclampsia leads to seizures,

you have eclampsia.

The only cure for preeclampsia is to give birth. Even after delivery, symptoms of

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preeclampsia can last 6 weeks or more.

Classification of Preeclampsia PE

There are two types of preeclampsia, which have different pathogenesis:

Preeclampsia without proteinuria or other evidence of kidney disease is “isolated

preeclampsia.” It usually develops after 20 weeks of gestation.

Preeclampsia with superimposed pre-existing chronic renal disease is termed “pre-

existing preeclampsia.” It can occur at any time during pregnancy.

Mild Preeclampsia PE

Mild preeclampsia may be diagnosed before 20 weeks of gestation. However, it is a

late-onset form of the disease until 32 to 34 weeks gestation (2) This often happens

with high-risk pregnancies, such as those that are multiples or have had one or both of

their parents develop preeclampsia in a past pregnancy.

The first signs of mild preeclampsia are a discernable increase in blood pressure and a

small amount of protein in the urine.

Preeclampsia can be treated with bed rest, anticonvulsant medications if seizures

develop, and delivery by inducing labour or C-section when it reaches severe forms.

Moderate Preeclampsia PE

Moderate preeclampsia is diagnosed when the systolic blood pressure exceeds 151

mmHg, or the diastolic blood pressure exceeds 100 mm Hg in a female who

previously has been normotensive.

It is sometimes also used as an umbrella term for mild and severe forms of

preeclampsia. It is also used to define women with milder forms of preeclampsia,

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women whose mildness is categorized as early-onset and occurs antepartum.

Proteinuria is always present in the moderate form of preeclampsia, but other

symptoms such as headache and visual disturbances are present. Preeclampsia may be

accompanied by other medical complications, including renal disease, hepatic disease,

thrombocytopenia, and HELLP syndrome.

Preeclampsia is not dangerous to the mother until it is moderate in severity. Once

preeclampsia has reached average levels of severity, and if a pregnant woman’s blood

pressure goes above 160/110, she may develop seizures or myocardial infarction. If

there is no improvement of preeclampsia’s symptoms with bed rest or the control of

blood pressure does not improve within a few days to weeks, delivery by inducing

labour or C-section must occur.

The mild form often improves without treatment, but severe conditions need to be

treated. Complications of severe preeclampsia include seizures if blood pressure is

poorly controlled and liver or kidney dysfunction if the placenta separates from the

uterine wall (placental abruption). In such cases, an emergency cesarean section may

be necessary.

Preeclampsia is dangerous in that the mother may have a stroke due to uncontrolled

blood pressure. However, women with severe preeclampsia are not in danger of dying

from the disease.

Severe Preeclampsia

Severe Preeclampsia Pregnancy Induced Hypertension (PIH) occurs in severe

preeclampsia and HELLP syndrome. To identify the severity of preeclampsia, a

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physician would look at these features: headaches, visual disturbances, seizures, and

pulmonary oedema.

What Are the Signs and Symptoms of Preeclampsia?

Preeclampsia can be defined as the onset of new-onset hypertension and proteinuria

after the 20th week of gestation.

Hypertension: Most women with preeclampsia present with new-onset hypertension

(systolic BP > 140 or diastolic BP > 90 mm Hg) damaged endothelial cells lose their

tone, therefore, vasospasm (contraction of the vessel) starts to occur and this leads to

increase pressure within the vessel…hence causes hypertension

Proteinuria: (> 300 mg in 24 hours) this is due to kidney injury…the kidneys are

being deprived of proper blood flow and endothelial cells that line the glomerulus

(this structure filters the blood and it normally does NOT filter large molecules like

protein) are damaged. The damaged cells of the glomerulus start to leak protein from

the blood into the urine causing proteinuria. Note: this also drops protein levels in the

blood (why the woman needs a protein-rich diet)

Also due to kidney compromise: uric acid and creatinine levels INCREASE and

urinary output will DECREASE

Oedema: (eyes, face, extremities, pulmonary oedema, increase weight gain, cerebral

oedema): the increase in permeability of the endothelial cells causes the protein to

escape the vessel. Remember protein helps regulate oncotic pressure…so where

protein goes, so does water. Therefore, water will leave the intravascular area and

shift to the interstitial tissue and cause swelling. This further complicates things

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because it decreases blood volume. So, there is less blood volume being used to

perfusion the organs and this cause further organ injury.

Lungs: fluid can start to accumulate in the lungs leading to difficulty breathing

Brain: due to brain swelling and decreased perfusion the woman may experience

headache, vision changes, hyperreflexia, clonus (if this is present there is a HIGH risk

for seizures due to central nervous system irritability)

Upper abdominal pain and increase in liver enzymes (AST and ALT): the liver is

affected due to decreased perfusion and swelling

Decreased platelets (leading the DIC), hemolysis (rupture of red blood cells)…

leading to HELLP Syndrome: the damaged endothelial cells cause red blood cells to

rupture and it causes the body to want to repair the cells…so platelets start to

congregate at these cells (note in severe cases there are many damaged endothelial

cells in the body so that requires a lot of platelets)…this depletes the platelet stores

and cause micro-clot development with the vessels, which decreases perfusion even

more.

When Do Symptoms Show Up

Preeclampsia can happen as early as 20 weeks into pregnancy, but that’s rare.

Symptoms often begin after 34 weeks. In a few cases, symptoms develop after birth,

usually within 48 hours of delivery. They tend to go away on their own.

What Causes Preeclampsia (PE)?

Preeclampsia is an autoimmune disease that results from a failure of maternal-fetal

tolerance. The exact cause remains unknown, but risk factors include: being over 35

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years old, having previous preeclampsia/eclampsia, abnormal placentation, multiple

gestations (twins and triplets), Black race, preterm labour, intrauterine growth

restriction, and abnormal maternal liver function.

Preeclampsia Risk Factors

-Smoking: Smoking triggers constriction of peripheral blood vessels, which reduces

blood supply to tissue in the body. This causes hypertension, elevated pulse rate, and

increased respiratory rate. These increase the chances of preeclampsia occurring in a

woman; when it does happen, it usually develops earlier than normal

-Being overweight or obese before conception: Being overweight or obese is a risk

factor for preeclampsia and gestational diabetes. Overweight mothers are exposed to

this condition because of an increase in circulating estrogen in the body. This causes a

shift in blood volume, which leads to hypertension.

-Having a personal or family history of thrombophilia (blood clotting disorders):

The exact mechanisms behind this are unknown, but it has been suggested that

elevated levels of factor VIII and von Willebrand factor may lead to increased risk for

preeclampsia.

-Prior history of preeclampsia, eclampsia, or gestational hypertension: Women

who have experienced any of the above are at greater risk to develop the condition

again during subsequent pregnancies than those with no prior histories. This could be

due to genetic factors, but the mechanism behind this has not yet been determined.

-Viral diseases during pregnancy: It is known that viruses can trigger preeclampsia

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in some women, but the exact mechanism through which they do so remains to be

discovered. A recent study has suggested that viral infection of the placenta may

increase levels of interleukin-6 (IL-6), a cytokine that plays an essential role in the

development of preeclampsia. It has also been suggested that virus particles can be

transferred from the mother to her child and lead to infection, which may trigger

preeclampsia.

Preeclampsia Complications

Preeclampsia is a severe complication that can affect fetal growth and survival. This

condition may cause abruption placenta, abruption placentae, placental infarction,

preterm labour (before 37 weeks), fetal distress, uterine rupture, or perforation.

Premature infants are at a high risk of developing respiratory distress syndrome

(RDS) and intrauterine growth restriction. Pre-eclampsia also increases the risk of

maternal complications, including renal failure, disseminated intravascular

coagulation, hepatic coma, stroke, myocardial infarction, and death.

HELLP SYNDROME

HELLP syndrome is a complication of preeclampsia. It occurs in about 5% of cases,

and the symptoms include:

Hemolysis. This is when the red blood cells that carry oxygen through your body

break down.

Elevated liver enzymes. High levels of these chemicals in your blood mean liver

problems.

Low platelet counts. This is when you don’t have enough platelets, so your blood

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doesn’t clot the way it should.

HELLP syndrome is a medical emergency.

Preeclampsia can also cause your placenta to suddenly separate from your uterus,

which is called placental abruption. This can lead to stillbirth.

How Long Does Preeclampsia Last?

Preeclampsia can last for weeks or even months in some cases. Eventually, a woman

with the condition will go into labour and give birth. After delivery, symptoms usually

disappear. However, sometimes they do not fade right away, and a woman may have

high blood pressure for weeks or even months after giving birth. If this is the case, she

may need to take blood pressure medication or other drugs such as corticosteroids

regularly (e.g., until her blood pressure returns to normal).

How to Treat Preeclampsia

If a woman’s blood pressure becomes dangerously high, she will be hospitalized and

placed on medications that lower the pressure (diuretics or other drugs) and deliver

her baby as soon as possible.

Newer treatments include magnesium sulfate given intravenously or calcium channel

blockers.

Magnesium sulfate helps prevent seizures, which may develop in severe cases of

preeclampsia. Women with milder signs and symptoms who are not at risk for

seizures may be treated with calcium channel blockers or antihypertensive drug

therapy such as labetalol.

After delivery, magnesium sulfate treatment is continued until 24 hours after the

blood pressure has returned to normal.

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PATHOPHYSIOLOGY OF PREECLAMPSIA

The pathophysiology of preeclampsia is due to the resistance of the hypertrophied

placenta to general vasodilation. This causes placental hypoperfusion with alterations

in fetal-placental perfusion. The role of maternal factors (e.g., age, excess weight

gain) and fetal factors (e.g., sex and elevated unconjugated bilirubin concentration)

has recently been reevaluated to determine those factors that may predispose women

to the condition.

Clinical assessment of preeclampsia

Patients with preeclampsia require close monitoring. A thorough initial assessment of

the woman with possible preeclampsia should include a complete history, a complete

physical exam with close attention to preeclampsia symptoms including unremitting

headaches, oedema, visual changes, and epigastric pain, fetal activity, and vaginal

bleeding.

The patient’s history about their maternal age, gestational age, previous gestational

history, medication reconciliation of antihypertensive agents and any other condition

which may have been associated with preeclampsia such as oedema or hypertension,

had been reviewed.

Preeclampsia has been diagnosed by the criteria of systolic blood pressure (SBP) ≥ 

140 mm Hg or diastolic blood pressure (DBP) ≥ 90 mm Hg, on two occasions at least

4 h apart in a previously normotensive patient with positive urine protein (at least 1+

of dipstick urine protein)

The gestational age was calculated by using the date of the last menstrual period and

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then confirmed by ultrasonography of the fetus before the consideration for pregnancy

termination.

Women with preeclampsia with severe features OR women on magnesium sulfate

need vital signs, including pulse ox every 30 minutes (should be done every 5 minutes

during loading dose of magnesium sulfate). These women need lung sounds assessed

every 2 hours. Level of consciousness, oedema and assessment for headache, visual

disturbances, epigastric pain should occur every 8 hours. Strict (hourly) intake and

output should be monitored, and intake should be ≤ 125 mL/hour. Fetal monitoring

should be continuous as ordered.4

-Rest, reassurance, frequent monitoring of vital signs and fluid intake, administration

of antihypertensive medications, prevention or management of seizures, and

preparation for delivery.

– Monitor BP daily

– Monitor urine output

-Provide IV fluids if needed

What Are the Nursing Diagnoses for Preeclampsia?

The only way to prevent preeclampsia is by early diagnosis and management. A good

history and physical exam are essential for accurate diagnosis. If signs and symptoms

of preeclampsia are present, the patient should be seen every 4 hours until delivery.

According to the AACN Synergy Model for Critical Analysis and Resolution of

Clinical Problems, six interrelated diagnoses may be applicable in planning care for a

patient suffering from preeclampsia. They include:

-Deficient Knowledge

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-Impaired Physical Mobility

–Risk for Injury

–Imbalanced Nutrition: Less than body requirements

–Deficient Fluid Volume

-Disturbed Energy Field

Nursing Care Plan for Preeclampsia

OBJECTIVES:

Prevent maternal renal failure.

Minimize fetal distress

ACTIVITY GOALS:

Remain in a semi-Fowler’s position as much as possible. Maintain normal fluid

intake, minimum 64 oz. daily, unless contraindicated by symptoms or lab values.

Remember that normal urine output is generally defined as 1.5 litres per day;

however, the amount of fluid these patients drink does not correlate with their urine

output.

ACTIONS:

Encourage the patient to remain in semi-Fowler’s position as much as possible

because this reduces the risk of renal failure. Encourage to drink 1/2 cup fluid with

each meal and at least 64 oz. daily unless contraindicated by her symptoms or lab

values [e.g., increased thirst; decreased output].

Assess the client’s condition regularly to ensure that her health has not worsened.

Monitor the client’s blood pressure regularly using an appropriate device.

If any changes are noticed or significant sudden weight gain, then medication may

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need adjusting accordingly.

Manage vomiting using anti-emetics to reduce nausea and vomiting

Educate on dietary measures should be given as appropriate, for example, low salt,

low fat intake, and regular consumption of fresh fruit and vegetables

PATIENT GOALS:

Remain as comfortable as possible during the disease and delivery.

Encourage to use comfort measures such as changing position, relaxing in a warm

bath or shower, listening to music, watching TV, etc. [comfort measures can help

reduce nausea and fatigue].

Preeclampsia: Nursing Interventions

Deficient Knowledge:

As preeclampsia is a disease that affects the mother’s cardiovascular system, it should

be managed by obstetricians or midwives. However, since these professionals are not

with the patient on a day to day basis, they should provide the patient with written

instructions on what behaviours to avoid or take precautions for the condition. The

nurse should also warn her about when to seek medical attention and emphasize the

importance of doing so.

Interventions:

Instructing the pregnant women on what actions to take based on her diagnosis.

Outcome Criteria: The patient will demonstrate positive knowledge of the condition,

its symptoms, and how to care for herself prior to discharge from the hospital.

Impaired Physical Mobility:

It is vital that the patient does not strain during labor or while carrying out any

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activities at night or in the day. The patient should be made aware of when she

requires help with her daily activities. She also needs to be educated on how to handle

her medical equipment, i.e., BP cuff, continuous fetal monitor, etc.

Outcome Criteria: The patient will not strain during labor or while participating in

daily activities, and she will not need extra assistance from family members for this

purpose. She will follow all instructions provided by the nurse on how to use her

medical equipment properly.

Risk for Injury: The patient is at risk of physical damage while in labor because of

the high BP and blood volume loss. She may also sustain injuries that interfere with

her maternal-fetal attachment if she has frequent seizures.

Impaired Physical Mobility will be assessed through observations and by obtaining a

history from the patient on how she perceives her physical mobility.

Outcome Criteria: The patient will not sustain any injuries while in labor or

throughout her hospital stay.

Impaired Physical Mobility and Risk for Injury diagnoses will be evaluated through

clinical observations and by obtaining a history from the patient on how she perceives

her physical mobility.

Imbalanced Nutrition:

Less than body requirements: The patient’s nutritional intake will be evaluated at the

start of her hospital stay regarding eating habits and food preferences.

Outcome Criteria:

The patient will have a good appetite for healthy foods high in vitamins, minerals,

protein, and low-fat content. She will follow all recommendations from dieticians

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regarding sugar levels and protein content under her care plan.

Imbalanced Nutrition: Less Than Body Requirements diagnosis will be investigated

through clinical observations and patient interviews. Based on the findings, the

nutrition status of the mother will be evaluated by dieticians to prevent any

complications for the mother and baby during the postpartum period.

Deficient Fluid Volume:

The patient may become dehydrated because of decreased fluid intake, and therefore

she should be supplied with a sufficient volume of fluids.

Outcome Criteria: The patient will follow all instructions given to her by the nurses

on how much fluids she requires each day (8 glasses) and will access the taste of

different foods that are high in liquid content. She will carry out her daily activities

while using a urine dipstick to check for proper hydration levels.

Balanced Fluid Volume: The client requires sufficient fluids throughout her hospital

stay and during labor to help maintain her blood volume and avoid dehydration.

Outcome Criteria: The pregnant woman will follow all instructions given by the

nurses and dieticians on how much fluids she requires each day (8 glasses). She will

assess the taste of different foods that are high in liquid content. She will carry out her

daily activities while using urine dipsticks to check for proper hydration levels.

Impaired Physical Mobility, Imbalanced Nutrition, and Deficient Fluid Volume

diagnoses will be evaluated through clinical observations and by obtaining a history

from the patient on how she perceives her physical mobility, nutritional intake, and

hydration levels. The findings will then be used to develop strategies to meet the

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patient’s needs and ensure she is in good condition after labor.

Effective Protection from Pain:

The patient has been informed about the pain experienced during childbirth before her

hospitalization to cope with the pain emotionally.

Outcome Criteria: The patient will not have an increased heart rate or respiratory

rate during delivery under the supervision of nurses to prevent any problems. To

further address her fear and anxiety, she will be taught relaxation techniques that

involve breathing exercises such as alternate nostril breathing and diaphragmatic

breathing.

The Ineffective Protection from Pain diagnosis will be investigated through clinical

observations and patient interviews. Based on the findings, relevant nursing care

interventions will be implemented to reduce pain before, during, and after delivery

under the supervision of nurses.

Deficient Knowledge: The patient’s knowledge of preparing for labor will be

assessed based on her educational level and whether she has given birth before.

Outcome Criteria: The patient will be taught how to cope with labor contractions

through relaxation exercises and breathing techniques by nurses. She may then use

her skills at home after she has been discharged from the hospital. She will be taught

about the different pain-relieving methods available during labor, such as gas and air,

water therapy (immersion), injection, etc.

The Deficient Knowledge diagnosis will be investigated through clinical observations

and patient interviews. Based on the findings, relevant nursing care interventions will

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be implemented to provide the patient with information regarding labor, pain

management methods, and her postpartum recovery period

NURSING EVALUATION

The client is in good condition and that a case is not worsening

The client’s blood pressure is within the range

If any changes are noticed or significant sudden weight gain, then medication may

need adjusting accordingly.

Manage vomiting using anti-emetics to reduce nausea and vomiting

Educate on dietary measures should be given as appropriate, for example, low salt,

low fat intake, and regular consumption of fresh fruit and vegetables

CONCLUSION

The study enabled the synthesis of specific nursing care to women with pre-

eclampsia, which can reduce complications and mortality rates. Nursing care

described in this review covers mainly thorough physical examination, early detection

of signs of pre-eclampsia/eclampsia, monitoring laboratory tests, fetal assessment,

professional training, including the need for continuing education, standardization of

care from instruments, BP measurement with an appropriate cuff for arm

circumference, slow speed deflation of the mercury column (mmHg ≤2), the need for

standardization of the measurement technique of BP, early identification and

treatment of hypertensive crisis through institutional protocols, as well as a review of

cases and work processes.

Creating and following care protocols guided by scientific evidence in daily clinical

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nursing practise can be helpful to guide the decision-making process and ensure the

provision of quality and safe care.

We highlight the need for studies on the thematic subject of this review with

methodological rigour, seeking to provide the nurse subsidies for nursing care.

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