CASE PRESENTATION

I. CASE INTRODUCTION
Presenting the case of patient RAS, 34 y/o G6P4 at 38 weeks in AOG by June 4, 2020 LMP who
presented to the emergency department for complaints of shortness of breath, severe headache and
blurring of vision. Upon assessment, her blood pressure was fluctuating from 140/90 to 160/110 mmHg
for the past 8 hours. She mentioned that she has type 2 diabetes and she has missed her daily insulin
shots for 3 consecutive days because they had financial difficulties these past few days. The doctor
ordered to run tests in order to confirm a possible diagnosis of Severe Pre-eclampsia. Laboratory tests
revealed (+) proteinuria, serum creatinine level of 1.5 mg/dl, and serum AST level 75 U/L 2 days after
admission, she complained of pain in her epigastric region. Seizure precautions were initiated and the
physician was immediately notified of her condition.

II. PAST MEDICAL AND FAMILY HISTORY

RAS has recently been experiencing a consecutive increase of blood pressure. Past medical history
shows that she has suffered from Type II Diabetes Mellitus for almost 2 years now. She had an abortion
on her third pregnancy which required a salpingostomy to terminate the pregnancy. On her fourth and
fifth pregnancy, cesarean section was indicated since she developed gestational diabetes on her fourth
pregnancy, and fetal macrosomia secondary to Type II Diabetes Mellitus. She is currently receiving
antidiabetic medications and insulin to improve glycemic control and manage Non-insulin Dependent
Type 2 Diabetes Mellitus.

She has no allergies of any kind. Her family history shows that her father suffers from HTN as well as
TB and her mother has a medical history of HTN and Eclampsia. Both of her maternal grandparents had
a history of Type II DM.

III. PERSONAL SOCIAL HX

Pt. R.A.S is married, lives in Pilar, Capiz, and has been a housewife for almost 5 years. She lives with
her husband and ​4 children. Her husband is very supportive towards her first to present gestation. She
is a smoker at the age of 20 but denies alcohol and drug consumption. She is physically active;
conducts yoga and aerobic exercises 3 times a week. Her favorite exercise is walking early in the
morning together with her sister. Pt. had her first coitus at the age of 17 with a Non-promiscuous Sexual
Partner (NPSP) and there is no history of OCP or IUD and STD’s.

IV. MENSTRUAL HX
The patient had her menarche at age 13 with subsequent periods occurring at regular intervals, lasting
for 5 days, soaking 3 pads per day. Patient usually experiences dysmenorrhea on her first day, which
she described as stabbing pain which lasts for at least 3 hours. LMP was June 4, 2020.
V. OBSTETRIC HX
Pt. R.A.S was married for 5 years, G6P4, First to second pregnancy was Normal Spontaneous Vaginal
Delivery (NSVD) at St. Anthony College Hospital of Roxas City, Inc with no significant problems
however at third pregnancy she had an abortion, developed Gestational Diabetes at her fourth
pregnancy, and at fifth delivery she underwent cesarean section due to fetal macrosomia secondary to
Type II Diabetes Mellitus.

TPAL: 4-0-1-4

A. Abortion (Spontaneous, Induced, Duration of Pregnancy) Once.

● Induced first trimester abortion (medical termination of pregnancy) on 03/16/2016 at St. Anthony
College Hospital of Roxas City, Inc due to Ectopic Pregnancy at 10 weeks AOG.

B. Type of Previous Deliveries (Normal/Instrumental/ LSCS)

● Normal vaginal delivery of 1st and 2nd child on 2011 and 2013 at St. Anthony College Hospital of
Roxas City, Inc .
● Salpingostomy done at first trimester on third pregnancy 4 years back 03/16/2016 at St. Anthony
College Hospital of Roxas City, Inc due to Ectopic Pregnancy at 10 weeks AOG.
● Fourth child was delivered on 05/19/2017 through cesarean birth at 38 weeks AOG due to
Gestational Diabetes Mellitus.
● Fifth child was delivered on 09/23/2019 cesarean section due to fetal macrosomia secondary to
Type II Diabetes Mellitus at 38 weeks AOG.

C. Significant Antenatal Problem/ 3rd Stage Puerperal Complications in Previous deliveries

● No any significant problem during pregnancy and delivery of first and second child.
● Antenatal period complicated by Ectopic Pregnancy on third pregnancy.
● Antenatal period complicated by Hyperglycemia at 15 weeks AOG secondary to Gestational
Diabetes Mellitus on fourth pregnancy.
● Antenatal period complicated by Macrosomia secondary to Type II Diabetes Mellitus at 38 weeks
AOG on fifth pregnancy.

D. Year and Place of Previous Deliveries, Sex of Baby, Living or Not, If neonatal death (Age and Cause
of Death, Congenital Malformation)
● 07/17/2011 at St. Anthony College Hospital of Roxas City, Inc., Male Child, Living.
● 11/27/2013 at St. Anthony College Hospital of Roxas City, Inc ., Male Child, Living
● 05/19/2017 at St. Anthony College Hospital of Roxas City, Inc ., Female Child, Living
● 09/23/2019 at St. Anthony College Hospital of Roxas City, Inc ., Female Child, Living
E. Year of Marriage, Gravida, Para, Abortion, Living Issues.

No. Year ANC Period of Type of Complications

attendance/Pregnancy Gestation Delivery/ in Puerperium
Complication abortions

1 2011 4 visits/ no any 42 weeks AOG NSVD No any

significant significant
complications complications

2 2013 4 visits/ no any 41 weeks AOG NSVD No any

significant significant
complications complications

3 2016 1 visit/ no any 10 weeks AOG Abortion No any

significant significant
complications complications

4 2017 4 visits/ complicated by 38 weeks AOG CS No any

Hyperglycemia significant
complications

5 2019 4 visits/ complicated by 38 weeks AOG CS No any

Macrosomia significant
complications

VI. CLINICAL PRESENTATION

The patient presented to the emergency room with chief complaint of shortness of breath, severe
headache, and blurring of vision.

● General Appearance:
Patient has a weak appearance. During the interview, the patient was confused and disoriented but
was able to converse. Restlessness, irritation, facial grimace, and swelling on her face were observed.
Her gait is uneven and she needed support to stand and walk either assisted or with the use of a
wheelchair. Spine is in midline: slightly curved out from neck inward at the waist.
● Signs noticed by the examiner:
The patient is restless and irritable. Facial grimace is observed. Her skin is cyanotic. Facial edema is
present and bilateral pitting edema of moderate indentation 2+ was palpated on her ankles.
Her blood pressure was fluctuating from 140/90 to 160/110 mmHg for the past 8 hours. She
complained of severe headache and described it as severe and continuous with a gradual onset of 1
to 2 hours prior to admission. 2 days after admission, she complained of pain in her epigastric region.

● Initial Assessment by Nurse

 ● Admitting Diagnosis
Possible Severe Pre-eclampsia

● Differential Diagnoses
r/o SLE
r/o acute renal failure
r/o amniotic fluid embolism

VII. TEXTBOOK DISCUSSION

● Description
Preeclampsia is a disorder of widespread vascular endothelial malfunction and vasospasm that occurs
after 20 weeks' gestation and can present as late as 4-6 weeks postpartum. It is clinically defined by
hypertension and proteinuria, with or without pathologic edema.

● Classification of hypertensive disorders:

1. Gestational hypertension
2. Chronic hypertension
3. Preeclampsia/eclampsia
4. Superimposed preeclampsia (on chronic hypertension)
Preeclampsia with severe features is defined as the presence of one of the following symptoms or signs in
the presence of preeclampsia:
● SBP of 160 mm Hg or higher or DBP of 110 mm Hg or higher, on two occasions at least 6 hours apart
while the patient is on bed rest (unless antihypertensive therapy has previously been initiated)
● Impaired hepatic function as indicated by abnormally elevated blood concentrations of liver enzymes
(to double the normal concentration), severe persistent upper quadrant or epigastric pain that does not
respond to pharmacotherapy and is not accounted for by alternative diagnoses, or both.
● Progressive renal insufficiency (serum creatinine concentration >1.1 mg/dL or a doubling of the serum
creatinine concentration in the absence of other renal disease)
● New onset cerebral or visual disturbances
● Pulmonary edema
● Thrombocytopenia (platelet count < 100,000/μL)

Risk factors (Modifiable/ Nonmodifiable)

● History of preeclampsia
● Multiple pregnancy
● Younger than 20 years old or older than 40 years of age
● Women from low socioeconomic backgrounds because of poor nutrition
● Gravida greater than 5
● Polyhydramnios (overproduction of amniotic fluid)
● Underlying disease
● Family history
● Chronic renal disease
● Chronic hypertension
● Antiphospholipid syndrome
● Diabetes mellitus
● High body mass index

Signs and symptoms

Patients with preeclampsia with severe features display end-organ effects and may complain of the
following:
● Hypertension
● Proteinuria
● Headache
● Visual disturbances: Blurred, scintillating scotoma
● Altered mental status
● Blindness: May be cortical or retinal
● Dyspnea and cyanosis
● Edema: Sudden increase in edema or facial edema
● Epigastric or right upper quadrant abdominal pain
● Weakness or malaise: May be evidence of hemolytic anemia
● Clonus: May indicate an increased risk of convulsions
To diagnose preeclampsia, you have to have high blood pressure and one or more of the
following complications after the 20th week of pregnancy:
● Protein in your urine (proteinuria)
● A low platelet count
● Impaired liver function
● Signs of kidney problems other than protein in the urine
● Fluid in the lungs (pulmonary edema)
● New-onset headaches or visual disturbances

Previously, preeclampsia was only diagnosed if high blood pressure and protein in the urine were present.
A blood pressure reading in excess of 140/90 mmHg is abnormal in pregnancy. However, a single high
blood pressure reading doesn't mean you have preeclampsia. If you have one reading in the abnormal
range or a reading that's substantially higher than your usual blood pressure your doctor will closely
observe your numbers. Having a second abnormal blood pressure reading four hours after the first may
confirm your doctor's suspicion of preeclampsia. The doctor may have you come in for additional blood
pressure readings and blood and urine tests.

● Diagnostics

Tests that may be needed If your doctor suspects preeclampsia, you may need certain tests, including:

1. Blood tests - The doctor will order liver function tests, kidney function tests and also measure your
platelets the cells that help blood clot.

2. Urine analysis - Your doctor will ask you to collect your urine for 24 hours, for measurement of the
amount of protein in your urine. A single urine sample that measures the ratio of protein to creatinine a
chemical that's always present in the urine also may be used to make the diagnosis.

● Medical Management

Possible treatment for preeclampsia may include:

Antihypertensives - Medications to lower blood pressure and are used to lower your blood pressure if it's
dangerously high. Blood pressure in the 140/90 millimeters of mercury (mmHg) range generally isn't
treated. Although there are many different types of antihypertensive medications, a number of them aren't
safe to use during pregnancy. Discuss with your doctor whether you need to use an antihypertensive
medicine in your situation to control your blood pressure.

Corticosteroids - If you have severe preeclampsia or HELLP syndrome, corticosteroid medications can
temporarily improve liver and platelet function to help prolong your pregnancy.

Corticosteroids can also help your baby's lungs become more mature in as little as 48 hours an important
step in preparing a premature baby for life outside the womb.
Anticonvulsant medications - If the preeclampsia is severe, your doctor may prescribe an anticonvulsant
medication, such as magnesium sulfate, to prevent a first seizure

● Nursing Management

Nursing Assessment

● Assess vital signs, especially blood pressure. An elevated blood pressure of 140/90 mmHg and above
would indicate hypertension.
● Presence of protein could be determined through urine tests.
● Assess patient for the presence of edema on the face, fingers, and upper extremities.

Nursing Interventions

● Promote bed rest in a recumbent position to aid in the secretion of sodium.

● Promote good nutrition, since the woman has still to continue her usual pregnancy nutrition.
● Provide emotional support to establish a trusting relationship and let the woman voice out her fears.

Evaluation

● Patient must exhibit a normal blood pressure of 120/80 mmHg.

● No presence of protein should be detected on her urine.
● Edema should be confined to the lower extremities only.

VIII. PHYSICAL EXAM

Examination Findings Remarks

General examination

INSPECTION

Observe client’s ability to Pt is confused and Sudden confusion may indicate

respond to verbal commands disoriented. a lack of oxygen in the blood
(hypoxemia), Diabetic
Ketoacidosis, and certain
medications, including, diuretics
Observe client’s Level Of Lowered LOC Eye opening to speech
Consciousness GCS score of 13 Disoriented but converses
Obeys commands.

Observe facial expression and (+) Facial Grimace Facial grimace, , and irritation
mood (+) Irritation are evident in a patient's
response to pain.

Observe general appearance, Pt needed support to stand D/t blurring of vision and
posture, gait, movement and walk generalized body pain.
Decreased movement
Uneven gait

General state of health Poor health status. Patient developed Type 2

Diabetes Mellitus back in 2019
which complicated 2 of her
pregnancies and had a huge role
in the development of
Pre-eclampsia.

Nutritional status Well nourished

Behavior Restless and disoriented. Restlessness may indicate either

hypoxia or anxiety.
Disorientation may be a
combination of pain and
emotional distress.

Cleanliness Hygiene maintained but not

well groomed

Speech Clear w/ adequate pace

VITAL SIGNS

BP: 140 / 90 and 160 / 110 Normal temperature Tachycardia and Tachypnea d/t
in right and left hand Tachycardia insufficient blood flow caused by
T: 36.5 C Hypertension vasospasm.
HR: 110 bpm ( high blood pressure ) Blood pressure is elevated d/t
RR: 23 bpm Tachypnea vasoconstriction.
Height: 165 cm Weight gain of 3 kg for 6 Weight gain indicates abnormal
weeks tissue fluid retention.
 Weight taken at 32 weeks
AOG- 67 kg
Current Weight: 70 kg

B. Skin Assessment

INSPECTION AND PALPATION

Inspect skin from head to toe Slightly pale and bluish skin Cyanosis indicates poor tissue
color perfusion.

Palpate skin for moisture and Slightly moist, No excessive

texture moisture or dryness
Firm, Smooth, Soft, Elastic
skin

Palpate skin for temperature Warm

Palpate skin for hydration and No sign of dehydration

turgor

Inspect skin for lesions, cut and Skin is intact Moles may either be malignant or
surgical incision Freckles, moles and warts benign.

Press suspected edematous Presence of bilateral pitting Normal discomfort of pregnancy.

areas with the edge of the finger edema with moderate
for 10 seconds and observe for indentation 2+ in ankle
the depression

C. Nail
Inspect and palpate the fingernails
and toenails; note color, shape and
lesion
Check capillary refill
D. Hair and scalp
Inspect hair : note color, texture,
growth distribution
Inspect scales, lumps, nevi or
other lesions
E. Head
Observe the skull for size, shape
and symmetry
Palpate skull for deformities,
depression, lump and tenderness
F. Face
Inspect for abnormal facial
expression, gestures, involuntary
movement , swelling and masses
Pale fingernails and toenails
Normal return of color: 3 sec
No discoloration, ridges,
pitting, thickening or
separation from the edge
Color black, dry and straight
No lumps, lesions, scales and
nevi
Skull Symmetrical, round and
erect on midline
No deformities, depression,
lump and tenderness
Normal facial expression
No involuntary movements
+ Swelling
May indicate low red blood cell
count. White nails can also
signal diabetes, liver disease,
an overactive thyroid, heart
failure, or a lack of nutrients in
the diet.
A delayed capillary refill time
(>2 sec) indicates
hypoperfusion of the skin.
Shunting of blood from the
capillary beds in the skin is an
indication of increased
systemic vascular resistance.
Facial edema is present.
Palpate face for edema, Peri – orbital edema present Unlike edema found in lower
tenderness and depression around eyes extremities, edema that has
progressed to the upper
extremities, or the face is
abnormal.

G. Sinuses

Palpate sinuses for tenderness No tenderness in frontal and

maxillary sinuses

H. Eye

Inspect both eyes for position and No deviation from normal

alignment condition

Eyebrows inspected for distribution Uniform distribution and no

and any scaliness scaliness

Inspect eyelashes for distribution Uniform distribution

Inspect conjunctiva for No redness, discharge,

redness,paleness,discharge, foreign body, dryness and
foreign body, dryness or tearing tearing

Inspect sclera for color change,
injury and dilated blood vessels
Slightly yellowish sclera
Jaundice may develop when
the liver is not functioning well
due to a build-up of red blood
cells otherwise known as
bilirubin.

Inspect cornea for color, abrasion Transparent, no abrasion or

and white spots white spots
 Inspect pupil size, shape and Pupil round, symmetrical and
symmetry comparison uniform

Coordination of eye movement Good eye movement and

coordination

Pupillary reaction to light Reactive to light

Inspect lens for opacity Lens: Transparent

Convergence Test Normal ( Positive )

I. Ear

Location and Size The top of pinna cross the

occiput line
Equal in size bilaterally

Pinna for lump and lesion No lump or lesion

The external auditory canal No discharge, masses or

for ear discharge, mass foreign foreign body, small amount of

body and cerumen cerumen

Palpate for tenderness No tenderness

Weber Test Sound hear equally on both

sides

Rinne Test Air conduction of sound is

greater than bone conduction

J. Nose
Location of nose Located at midline

Nostrils for their size and Symmetrical and uniform in size

symmetry

Nasal septum for polyp No polyp noted

Nasal Canal Pink nasal mucosa, no

discharge

K. Mouth and Throat

Lip for color, moisture, cracks or
ulcer
( + ) Cyanosis , ( + ) Dry w/ (+) cyanosis may indicate poor
cracks tissue perfusion.
Dry mouth also known as
xerostomia happens because
of the normal hormonal
changes during pregnancy.

The mucous membrane of the ( + ) Cyanosis , ( + ) Dry w/

mouth for color, ulcer, nodules cracks
and amount of saliva

Gum for inflammation, swelling, Pink gum, No inflammation, No

redness and bleeding Swelling, No redness and No
bleeding present

Teeth for color, cavities and (+) Cavities, No missing Teeth,

missing teeth White color

Tongue for symmetry, color and Pink, moist, symmetrical,

papillae papillae normal

Pharynx and tonsils observed No inflammation and swelling

and difficulty swelling
L. Neck

INSPECTION

Ask patient to sit straight No tilting of neck

Observe for masses, congenital No masses, No congenital

goiters, scars, distended jugular goiters, No scars or distended
vein jugular vein

Thyroid Gland No enlargement of thyroid gland

Ability to move neck No neck stiffness, smooth

range of motion and no
tenderness

PALPATION

Thyroid gland to exclude goiter, No goiter, masses and

masses and enlargement enlargement

The back of neck along the No abnormal alignment of spine

spine and back

M. Lymph Nodes

Inspection and palpation of No tenderness or enlargement

lymph nodes for enlargement
and tenderness

N. Chest and Lungs

INSPECTION
Shape, size and symmetry Lateral diameter wider than
antero-posterior diameter
Symmetrical, sternum located
at midline

Bilateral expansion of lungs Equal expansion of both lungs

PALPATION

Check for expansion, lumps, Equal bilateral expansion of

tenderness and depression lungs, no lumps, tenderness or
along ribs depression noted

PERCUSSION

The front and back of chest Dull sound heard over the Dullness is found over areas of
from apex to base entire chest, anteriorly and decreased air in the lungs
posteriorly (atelectasis, and pneumonia)

AUSCULTATION

The front and back of the chest Crackles heard on bilateral Crackles upon auscultation
to evaluate breath sound using lungs accompanied by shortness of
stethoscope breath are indicative of retained
fluid in the lungs d/t pulmonary
Compare duration of inspiration Inspiration longer than edema.
and expiration expiration

Check for adventitious sounds; Coarse crackles in bilateral Occurs when the patient starts
crackles, rhonchi, wheezes lungs to inhale but diminish after
coughing.

O. Heart

INSPECTION
Enlargement of neck veins No enlargement of of jugular
veins

AUSCULTATION

Aortic area ( 2​nd intercostals Increase heart rate 110/min Tachypnea occurs d/t
space just right of the sternum ) No abnormal S3 heart sound insufficient blood flow caused
present by vasospasm.

Pulmonic area ( 2​nd intercostals

space just left of the sternum )

Tricuspid area ( 5​th intercostals

space

Mitral area ( 5​th intercostals

space at midclavicular line )

Note the clarity and regularity of Regular, Normal heart sound

heart sound S1 and S2 present
No abnormal heart sound like
gallop and murmur present

P. Female Breast

INSPECTION

Size and shape together w/ Breasts and nipples are uniform

nipple condition in shape and size, nipples are
pointed in the same direction
Left breast slightly larger than
right breast

Look for swelling, dimpling or No swelling, dimpling or

retraction of breast retraction of breast

Nipples for cracks and No cracks and discharge

discharge
PALPATION

Both breast were palpated in Soft, non-tender, no masses,

circular motion for masses, lumps and swelling were
swelling detected

Q. Abdomen

INSPECTION

For shape, size, dilated veins, Round shape, no distention,

striae, previous incisional scars,
lesions
lesions, previous incisional
scars or dilated abdominal
veins present
Linea nigra and striae
gravidarum present

AUSCULTATION

For bowel sound Bowel sound present in all

areas in every 20 seconds
Gurgling sound present
Note type of sound

PERCUSSION

Keep Pt in supine position and Tympanic sounds heard over

percuss abdomen in all four gas-filled viscera and dull sound
quadrants over fluid filled viscera

PALPATION
Keep pt in supine and ask pt to
relax abdomen, palpate in all 9
regions. Feel for any masses
and tenderness
No abdominal masses
(+) Tenderness in epigastric
region
.Tenderness in the epigastric
region indicates imminent
progression of severe
pre-eclampsia into eclampsia,
which is accompanied by
seizures.

Palpate the liver ; note Liver is palpable, w/ (+) Liver Damage

enlargement and tenderness enlargement or tenderness

Spleen: note enlargement and Spleen not palpable, no

tenderness enlargement or tenderness

Kidneys: Note enlargement and Kidneys non palpable and non

tenderness tender

R. Anus

INSPECTION

Anus for irritation, hemorrhoids, No irritation, hemorrhoids,

cracks and fissure cracks, fissure

S. Genital Area

INSPECTION

Vulval swelling, condition of (+) Chadwick’s sign

perineum, labia for color, No abnormal vaginal discharge
redness, swelling

Check for urethral orifice for No redness or discharge

redness or discharge
Vaginal discharge or bleeding No abnormal vaginal discharge
from vagina or bleeding from vagina

T. Musculoskeletal System

INSPECTION

Muscles and joints: Ask Pt to Patient was unable to perform D/t deteriorating condition and
perform range of motion ROM exercises. generalized weakness.
exercises, joint movement of
neck wrist, ankle, hip in all
possible direction

Patient’s spine, note placement Spine is in midline: slightly Lordosis is a normal physiologic
and curvature curved out from neck inward at change in pregnancy d/t change
the waist in the center of gravity as a
result of increased uterine size.

PALPATION

Palpate joints for swelling, No joint swelling, or tenderness,

tenderness and temperature normal temperature

Ask pt to perform range of Patient was in no condition to D/t deteriorating condition and
motion exercises, joint perform it weakness.
movement of neck wrist, ankle,
hip in all possible direction

U. Nervous System

Muscle strength, push against Weak muscle strength d/t deteriorating condition and
patient’s hand and ask to resist weakness.
push

Sensation Present
 Coordination of movements Co-ordinated motor activities

V. Reflexes

Biceps Reflex Contraction of the biceps

muscles and flexion of the
forearms

Triceps Reflex Normal Response, extension of

forearm

Knee jerk Extension of lower leg

Plantar Reflex Flexion of all toes and inversion

and flexion of the forefoot

SUMMARY OF FINDINGS

Physical examination was performed from head to toe of Patient RAS, a 34 years old female with
diagnosis of PIH with severe pre – eclampsia on March 1, 2021. The findings obtained are listed below :

Vital Signs
BP: 140 / 90 and 150 / 95 in right and left hand
T: 36.5 C
HR: 110 bpm
RR: 23 bpm
Height: 165 cm
Weight: 75 kg

Findings

General Appearance : Weak appearance

Gait : Imbalanced
Nutritional Status : Well Built
Facial expression : (+) Facial Grimace. (+) Irritation.
Skin : Pale and Yellowish
 Bilateral Pedal Edema Present , Peri – orbital edema present around eyes
Head : Normal contour, No lesions were observed
Chest : No added murmur sounds were head but with coarse crackles
Abdomen : Palpable liver but no splenomegaly noted, no dilated veins over abdomen, Striae gravidarum
and Linea nigra present, No masses but with tenderness
Genitalia : (+) Chadwick’s sign, no swelling or redness, No abnormal vaginal discharge present
Musculoskeletal : Weak muscle strength
Reflexes : Normal reflexes

PREGNANCY ASSESSMENT

● Fundic Height- 38cm below xyphoid process.

● Fetal Presentation- Cephalic
● Fetal Position- Right Occipital Anterior (ROA)
● Fetal Lie- Longitudinal Lie
● FHR- 110 bpm, heard on LLQ
● Decelerations- Late Decelerations were present during uterine contraction d/t placental insufficiency
● No S & S/X of RDS.

IX. ASSESSMENT

Inspection:

❖ Surgical Scars from Previous Cesarean Section, Visible Striae Gravidarum And Linea Nigra
❖ Genitalia : (+) Chadwick’s sign, no swelling or redness, No abnormal vaginal discharge present

Palpation:

❖ Abdomen: Palpable liver with tenderness

❖ Fundal Height: 38 cm below Xiphoid Process
❖ Fetal Presentation: Cephalic
❖ Fetal Position: ROA (Right Occiput Anterior)
❖ Fetal Lie: Longitudinal
❖ Fetal Movement: Present
❖ Fetal Station: 0

Auscultation:

❖ Fetal Heart Rate: Present (110 bpm - LLQ)

❖ Decelerations: Late Decelerations were present during uterine contraction d/t placental
insufficiency
Obstetric Data:

❖ AOG: 38 weeks
❖ LMP: June 4, 2020
❖ EED: March 11, 2021

X. SHORT TERM PLAN

● Tests to be ordered

If the physician suspects pre-eclampsia, these are the tests that need to be done:

1. Complete Blood Count (CBC) – to assess if there is development of Disseminated Intravascular

Coagulation
▪ Red blood cell count (RBC or erythrocyte count)- Normal values are : 4.2-5.4
▪ White blood cell count (WBC or leukocyte count)- Normal values are: 5,000-10,000 mm3 Platelet
count- <100,000/ mm3
▪ Hematocrit- >33%. ​This level will rise if increased fluid is leaving the bloodstream for interstitial
tissue (edema).
▪ BUN- Normal values are: 10-20 mg/dL or 3.6-7.1 mmol/L.
>100mg/dL indicates serious impairment of renal function.

2. Urinalysis
Normal Findings
▪ Appearance: clear. ​Cloudy urine may be caused by the presence of pus (necrotic WBCs), RBCs,
or bacteria; however normal urine also may be cloudy because of ingestion of certain foods (e.g.,
large amounts of fat, urates, phosphates)
▪ Color: amber yellow. ​Abnormally colored urine may result from a pathologic condition or the
ingestion of certain foods or medicines.
▪ Odor: aromatic. ​Urine of patients with diabetic ketoacidosis has the strong, sweet smell of
acetone. In patients with a UTI, the urine may have a foul odor. Urine with a fecal odor may
indicate an enterovesical fistula.
▪ pH: 4.6-8.0 (average, 6.0) ​An alkali pH is observed in a patient with alkalemia. Acidic urine is
also observed in patients with academia, which can result from metabolic or respiratory acidosis,
starvation, dehydration, or a diet high in meat products or cranberries.
▪ Protein: 0-8 mg/dL. ​Proteinuria (most commonly albumin) is probably the most important
indicator of renal disease. The urine of pregnant women is routinely checked for proteinuria,
which can be an indicator of pre-eclampsia
50-80 mg/24 hr (at rest)
<250 mg/24 hr (during exercise)
▪ Specific Gravity: 1.005-1.030 (usually, 1.010-1.025). ​Used to evaluate the concentrating and
excretory power of the kidneys. Renal disease tends to diminish concentrating capability. High
specific gravity indicates concentrated urine while low specific gravity indicates dilute urine.
▪ Leukocyte esterase: negative. ​Positive results indicate UTI.
 ▪ Nitrites: none. ​A screening test for the identification of UTI. A positive test result indicates the
need for urine culture.
▪ Ketones: none. ​Normally, no ketones are present in the urine; however, a patient with poorly
controlled diabetes and hyperglycemia may have massive fatty acid catabolism. This test for
ketonuria is also important in evaluating ketoacidosis with alcoholism, fasting, starvation,
high-protein diets, and isopropanol ingestion.
▪ Bilirubin: none. ​Elevated bilirubin concentration can indicate previously unsuspected liver injury
because of disease gallstones, or drug toxicity.
▪ Urobilinogen: 0.01-1 Ehrlich unit/mL. ​If bilirubin levels are high because of overproduction, which
may result from RBC lysis (hemolysis), urobilinogen levels will be elevated.
▪ Crystals: none. ​Crystals found on the urinary sediment on microscopic examination indicate that
renal stone formation is imminent, if not already present.
▪ Casts: none. ​Casts are usually associated with some degree of proteinuria and stasis within the
renal tubules.
▪ Glucose: fresh specimen-none. ​Glucose elevations indicate Diabetes Mellitus.
24-hour specimen: 50-300 mg/24 hr or 0.3-1.7 mmol/day
▪ White blood cells (WBCs): 0-4 per low-power field. ​The presence of 5 or more WBCs in the urine
indicates a UTI involving the bladder or kidneys, or both.
▪ WBC casts: none. ​WBCs are more frequently found in infections of the kidney (e.g.,acute
pyelonephritis) and are also seen in poststreptococcal glomerulonephritis or inflammatory
nephritis (e.g., lupus nephritis).
▪ Red blood cells (RBCs): ≤ 2. ​Bladder, ureteral, and urethral disease are the most common cause
of RBCs in the urine. ​Pathologic conditions (e.g., tumors, trauma, stones, infection) that involve
the mucous membrane in the mucous membrane can also cause hematuria.
▪ RBC cast: none. ​RBC casts suggest glomerulonephritis.

3. Fetal ultrasound
4. Biochemistry/ Biophysical profile

Legend:
Blue​ - Decreased
Red​ ​- Elevated

INVESTIGATIONS NORMAL VALUES PATIENT’S RESULT

Blood Pressure 120/80mmHg 180/120mmHg
Hematology
● Platelet count 150,000 – 400,000/uL 100,000/uL
● Hemoglobin 12- 16 g/DL 20 g/DL
● Hematocrit 37 – 48 % 72%
● WBC 4000-10,000/µL 20,000/µL
● Lymphocytes 25– 30 % 44%
● Eosinophils 1-3 % 5%

● Blood Urea Nitrogen test 7-20 mg/dl 28mg/dl

● Uric Ac 2.7-7.3 mg/dl 8.5 mg/dl

Biochemistry
● Urea 10-40mg/dl 25mg/dl
● Creatinine 0.8-1.3 mg/dl 2mg/dl
● Sodium 135-145 mmol/L 200mmol/L
● Potassium 3.5-5.mmol/L 2mmol/L
● Bilirubin 0.2-1.9mg/dl 5mg/dl
● Lactate Dehydrogenase <480IU/L 500IU/L
Liver Function test
● Serum Alanine Aminotransferase 0-40U/L 55U/L
● Aspartate Aminotransferase 0-40U/L 60U/L

Urine Analysis
● Color Yellow to amber Yellow
● Transparency Transparent Foamy urine
● Sugar Negative Positive
● Pus cells 0-5/hpf 6/hpf
● Epithelial cells Moderate Moderate

● Albumin Negative +3
 Note: Patient also had 3+ in the Urine dipstick test. Patient’s urine output is 200ml/day. Patient’s urine
calcium is 200mg/24h.

● Differential Diagnoses to rule out

1. Systemic lupus erythematosus – Some of the common signs and symptoms of SLE are
fatigue, fever, swelling, shortness of breath, chest pain, and headache. Lupus can also be
associated with high blood pressure and weight gain.
Symptoms that were experienced by the patient that could indicate SLE include:
● Shortness of breath, edema(swelling), headache, blood pressure of 180/120mmHg and weight
gain of 3lbs for the past 2 weeks.
Systemic Lupus Erythematosus Preeclampsia
Leukopenia Leukocytosis
Low uric acid levels High Uric Acid
Positive Urinary Sediment Negative Urinary Sediment
Urinary Calcium <195 mg/24h Urinary Calcium >195mg/24h
Hematuria No Hematuria

The Physician in charge ordered a complete blood count, the results showed that the
patient has Leukocytosis which is evident in Preeclampsia and not in SLE. The patient also
underwent Urinalysis and had high uric acid which is evident in Preeclampsia and not in SLE.
The patient has High Uric acid and a Urinary calcium of 200mg/24h and is negative for any
urinary sediment, which also fits the criteria for preeclampsia and not SLE. SLE was ruled out
based on the lab results of the patient.

2. Amniotic Fluid Embolism – The signs and symptoms in amniotic fluid embolism that was
evident in the patient was shortness of breath, altered mental status as evidence of the patient
being confused and disoriented and had inappropriate responses, and a rapid heart rate of 110
BPM. Amniotic fluid embolism was ruled out because it contradicts the blood pressure of the
patient, Amniotic fluid embolism causes low blood pressure and it is accompanied by seizure
and bleeding which is not visible in the patient.

Amniotic Fluid Embolism Preeclampsia

Shortness of breath ✔ ✔

Altered Mental Status ✔ ✔

Rapid Heart rate ✔ ✔

Pulmonary Edema ✔ ✔

Blood Pressure Low High

Bleeding ✔ ❌
Seizure ✔ ❌
Cardiovascular Collapse ✔ ❌
3. Acute Renal failure – The patient experienced shortness of breath and severe headache,
edema. These are some of the signs and symptoms of Acute renal failure. The attending
physician ordered blood tests, and imaging tests. Acute renal failure was ruled out because the
laboratory findings for CBC shows that the patient has Thrombocytopenia, and in Acute renal
failure the patient should have elevated platelet count.

Acute Renal Failure Preeclampsia

Shortness of Breath ✔ ✔

Headache ✔ ✔

Decreased Urine Output ✔ ✔

Fluid Retention (swelling) ✔ ✔

Seizures ✔ ❌
Abnormal Heart rate ✔ ✔

Platelet Count Thrombocytosis Thrombocytopenia

Nausea ✔ ❌
STAT concerns that need TX

● Risk For Seizure -

1. Provide therapeutic environment: (Eliminate noise, bright lights and other harsh stimuli)
2. Consider drug of choice, 20gm of MgSo4 SIVP, OD as prescribed; observe for signs of
toxicity, prepare Calcium gluconate (antidote)
3. Administer 02 therapy as ordered.
● Pleural Edema-
1. Suction PRN to remove excess fluid in lungs
2. Administer 84g of Mannitol for 30-60 min, IV, Q6 as ordered
3. Provide O2 Therapy as ordered
● Cerebral Edema-
1. Administer 84g of Mannitol for 30-60 min, IV, Q6 as ordered
● Hypertension-
1. Administer 500mg of methyldopa,PO Q6 as prescribed
2. Administer 25mg of hydralazine, PO Q6 as ordered
3. Monitor VS, specifically BP
 ● Tachycardia-
1. Administer 2 mg of digoxin, PO Q6 as ordered

X. LONG TERM PLAN

Patient is given a Chest x ray as necessary to diagnose pulmonary edema since there is SOB and
adventitious sound.
CT scan is necessary in order to diagnose cerebral edema since there is a presence of headache and
blurring of vision.
A secondary Urine Protein Dipstick test to confirm presence of Proteinuria, as there is a need for two tests
before it can be confirmed, and the initial results showed a +3 result.

INVESTIGATIONS NORMAL FINDINGS PATIENT’S RESULTS

Chest X-Ray Dark and clear, no regions Cephalization of pulmonary

of density, or presence of
swelling.
veins that indicate
dilation/inflammation of veins
due to increased pressure
secondary to fluid
accumulation, Presence of
Kerley B lines

CT Scan No presence of tumors, There is an increased

blood clots, fractures, or pressure within the cerebral
other abnormalities in the ventricles due to fluid
images accumulation

Urine Dipstick Test Trace, less than 150 mg 3+, over 2500 mg

● Medical Management

Magnesium sulfate – Administered loading dose: 5g Intravenously, followed by 10g intramuscularly.

Maintenance Dose: 5 g intramuscularly every 4 hours in alternating buttocks.
Methyldopa – Given 500 mg Q6hrs, orally.
Mannitol — Administer 84g FOR 30-60 min, IV Q6 as ordered

● Surgical Management
Caesarean section, also known as C-section, or caesarean delivery, is the surgical procedure by which a
baby is delivered through an incision in the mother’s abdomen.
Caesarean section is to be done as indicated by associated obstetric indications, such as previous
C-sections.

Preoperative
•The consent must be informed, and the risks and benefits of the procedure must be explained in a
language that the woman understands
•Upon admission, the woman is provided with a clean hospital gown and her hair is pulled into a ponytail.
•The woman’s nails should be free from nail polish or any acrylic fingernails because nails are used to
assess capillary refill.
•To decrease stomach secretions, a gastric emptying agent is used before surgery, because the woman
would be lying on her back during surgery which makes esophageal reflux and aspiration highly possible.
•To ensure that the woman is fully hydrated, an intravenous solution such as Ringer’s can be given.
•Upon transport to surgery, ensure that the woman is lying on her left side to prevent supine hypotension.
•Ensure that the side rails are up, and the woman is covered with a blanket.

Intraoperative
•While anesthesia is being administered, a surgical nurse will assist the woman first to move from the
transport stretcher to the operating table.
•Encourage the woman to remain on her side or insert a pillow under her right hip to keep her body slightly
tilted to the side to prevent supine hypotension.
•For the skin preparation, shaving away abdominal hair and washing the skin over the incision site with
soap and water could reduce the bacteria on the skin.
•The woman is then positioned with a towel under her right hip to move abdominal contents away from the
surgical field and lift her uterus away from the vena cava.
•The woman would be covered by a sterile drape to block the flow of the bacteria from her respiratory tract
to the incision site and also block the woman’s and support person’s lines of sight from the incision site.
•The incision area is scrubbed by an antiseptic, and additional drapes are placed around the area so that
only a small area of the skin is exposed.
•Prepare the woman and the support person for the sights they might see.

Postpartal
•The postpartal care period of a woman who has undergone emergent cesarean birth is divided into two:
immediate recovery period and extended postpartal period.
•After surgery, the woman would be transferred by stretcher to the postanesthesia care unit.
•Pain control is a major problem after birth because it was so intense that it interfered with the woman’s
ability to move and deep breathe.
•This may lead to complications such as pneumonia or thrombophlebitis.
•Use a pain rating scale to allow a woman to rate her pain.
•Some women may need patient controlled analgesia or continued epidural injections to relieve the pain.
•Supplement the analgesics with comfort measures such as change in position or straightening of bed
linen.
•Instruct the woman to ambulate because this is the most effective method to relieve gas pain.
•Inform the woman that she should not take acetylsalicylic acid or aspirin because this can interfere with
blood clotting and healing.
•Instruct the woman to place a pillow on her lap as she feeds the infant to deflect the weight of the infant
from the suture line and lessen the pain.
•Football hold for breast feeding is a way to keep the infant’s weight off the mother’s incision.
•During the extended postpartal period, the woman most commonly experiences gastrointestinal function
interference.
•Note carefully the woman’s first bowel movement after surgery because if no bowel movement has been
observed, the physician may order a stool softener, a suppository, or an enema to facilitate stool
evacuation.
•Teach the woman to eat a diet high in roughage and fluid and to attempt to move her bowels at least every
other day to avoid constipation.
•Incisional pain may interfere with the woman’s ability to use her abdominal muscles effectively, so the
physician may prescribe a stool softener.
•Caution the woman not to strain to pass stools because this puts pressure on their incision.
•Advice the woman to keep their water pitcher full as a reminder for her to drink fluids.
•Reassure the woman that it is normal not to have bowel movements for 3 to 4 days postoperatively,
especially if there is enema administered before surgery

XII. NURSING CARE PLAN

NURSING MANAGEMENT

❏ (+) Edema
❏ Weigh daily: @morning before breakfast, only with hospital gown
❏ Discontinue or lessen levels of IVF
❏ Conduct perineal care and insert foley catheter as indicated
❏ Compression stockings for edema on the ankles
❏ Put in bed rest:
a. If able encourage ambulation or movements
b. If not, reposition patient every 2 hours
❏ (+) Pleural edema:
❏ Put patient on sitting position if tolerated
❏ If not, put in semi-fowler’s position
❏ Suction PRN to remove excess fluid in lungs
❏ Auscultate and percuss bilateral lung fields
❏ Administer 84g of Mannitol for 30-60 min, IV, Q6 as ordered
❏ Provide O2 Therapy as ordered

❏ (+) Cerebral edema:

❏ Administer 84g of Mannitol for 30-60 min, IV, Q6 as ordered
-Weigh before and after administration
-Measure I & O
-Monitor maternal VS, specifically BP then FHR
❏ (+) HTN
❏ Administer 500mg of methyldopa,PO Q6 as prescribed
❏ Administer 25mg of hydralazine, PO Q6 as ordered
❏ Monitor VS, specifically BP
❏ Collaborate with the dietician: DASH Diet
❏ Encourage smoking cessation

❏ (+) Tachycardia
❏ Administer 2 mg of digoxin, PO Q6 as ordered
❖ Before Administration:
a. Monitor Apical Pulse
b. Check dosage and preparation
c. Avoid food intake
❖ During Administration:
a. Hold dose if pulse is < 60 BPM
b. Use cardiac monitor to asses electrical activity of heart
❖ After Administration:
a. Observe for signs and symptoms of toxicity
b. Monitor drug therapeutic levels
c. Notify physician immediately if signs of toxicity are present
d. Administer antidote (Digibind)

❏ (+) Type 2 Diabetes Mellitus

❏ Monitor Blood Sugar level through glucometer
❏ Encourage low intake of sugar
❏ Administer 500mg of metformin, PO,Q12
❏ Administer 14 units of Humulin R, PO, Q12

❏ Precautions for seizures:

❏ Administer MgSo4
❖ Before administration:
a. Monitor Mg level
❖ During administration:
a. Administer slowly to avoid hypotension
b. Use cardiac monitor to asses electrical activity of heart
❖ After administration:
a. Monitor Bp, respiration, pulse, and DTR
b. Monitor BUN, creatinine and urine output
c. Observe for adverse effects and signs of toxicity
d. Notify physician immediately if signs of toxicity are present
e. Administer antidote (calcium gluconate)
❏ Admit patient in a room with least noise and stressors
 ❏ Remove tight clothes and jewelries specially necklace
❏ Keep sharp and hard object aways from patient (Knife, glasses, blades, scissors)
❏ Eliminate bright lights; avoid assessing the eyes using penlight
❏ Avoid touching/handling patient if not necessary
❏ Minimize number of personnel giving care as well as the frequency of care
❏ Avoid making unnecessary noise when entering the room of patient (opening and closing the door
loudly)
❏ Position bed at the lowest and raise the side rails or if possible put the mattress at the floor to avoid
injury if seizure occurs
❏ Limit visitors

❏ Things to remember when seizure occurs:

a. Do not try to stop the movements of the patient
b. Put nothing in the mouth of the person.
c. Do not attempt to provide rescue breaths or CPR
d. Put in a lateral position
e. Keep folks and visitors away from the patient
f. Time duration of seizure

❏ Prepare for possible surgery:

a. Call for additional help
b. Draw and send blood for type and crossmatch as ordered
c. Ensure MD ordered for blood products
d. Insert foley catheter, and complete shave prep
e. Remove jewelries, dentures, clothing
f. Place ID bands on pt
g. Confirm allergies
h. Prepare consent form

❏ Discharge
Provide instructions​ ​with regards to​:
1. Follow-up check ups
2. Medications or maintenance
3. Diet Therapy and activities (do’s and don’ts)

● PRIORITIZATION OF NURSING PROBLEMS

Nursing Diagnosis Priority Intervention

Risk For Seizure High Priority ❏ Remove tight clothes and jewelries specially necklace
❏ Keep sharp and hard object aways from patient
(Knife, glasses, blades, scissors)
❏ Provide therapeutic environment:
(Eliminate noise, bright lights and other harsh stimuli)

Ineffective cerebral tissue perfusion
related to progressive vasospasm
secondary to severe preeclampsia
Impaired gas exchange related to
excessive fluid in the interstitial
tissues of lungs aeb SOB
❏ Position bed at the lowest or if possible put the
mattress at the floor
❏ Position in left lateral
❏ Raise side rails
❏ Limit visitors
❏ Administer 20gm of MgSo4 SIVP, OD as prescribed;
observe for signs of toxicity, prepare Calcium
gluconate (antidote)
❏ Administer 02 therapy as ordered
High Priority ❏ Monitor VS
❏ Conduct GCS scoring
❏ Conduct Deep Tendon Reflex Test
❏ Position in left lateral
❏ Raise side rails
❏ Provide therapeutic environment:
(Eliminate noise, bright lights and other harsh stimuli)
❏ Instruct folks and visitors to avoid touching the pt. As
much as possible
❏ Provide o2 therapy as ordered
❏ Administer 500mg of methyldopa,PO Q6 as
prescribed
❏ Administer 20gm of MgSo4 SIVP, OD as prescribed;
observe for signs of toxicity, prepare Calcium
gluconate (antidote)
❏ Administer 25mg of Hydralazine, PO Q6 as ordered
❏ Administer 2 mg of Digoxin, PO Q6 as ordered;
observe for signs of toxicity, prepare digibind
(antidote)
High Priority ❏ Monitor VS, especially RR and O2Sat
❏ Monitor fetal well being (EFM and Biophysical profile)
❏ Instruct deep breathing exercises
❏ Encourage proper coughing technique:
-Sitting position if tolerated if not semi-fowlers
-Lift chin lightly and open mouth
-Breathe slowly and deep
-Hold breath for 2-3 sec
-Exhale firmly but slowly (2x)
-Release a strong cough
❏ Gather sputum specimen for laboratory analysis
 ❏ Position in sitting position if tolerated, if not put in
supine position with the head of bed elevated at 30
degrees
❏ Conduct ET suctioning PRN
❏ Administer 02 therapy as ordered
❏ Administer 84g of Mannitol for 30-60 min, IV, Q6 as
ordered

Impaired urinary elimination related
to decreased glomerular filtration
secondary to altered tissue
perfusion
High Priority ❏ Conduct perineal care then insert Foley catheter as
indicated
❏ Encourage less sodium intake
❏ Position in dorsal recumbent
❏ If tolerated encouraged movements if not reposition
pt. Every 2 hours
❏ Measure I&O
❏ Observe urine output; consistency, color, odor
❏ Gather urine specimen for laboratory analysis
❏ Discontinue or decrease level of IVF
❏ Monitor BUN, creatinine

Diabetes Mellitus High Priority ❏ Monitor VS, specifically BP

❏ Assess Blood Sugar level through glucometer
❏ Monitor presence of sugar in urine; urine analysis test
❏ Encourage low intake of sugar
❏ Instruct Antidiabetic Diet; low sugar intake
❏ Administer 500mg of metformin, PO,Q12
❏ Administer 14 units of Humulin R, PO, Q12

● NURSING RESPONSIBILITY

1. Upon arrival at the emergency room, place the woman flat in bed.
2. History Taking: gather chief complaints, past medical, family, personal social, menstrual and
obstetric history
3. Conduct cephalocaudal assessment/examination (DO NOT use penlight)
4. Conduct monitoring/investigations: Vital Signs and GCS. Laboratories: Blood Test, Urine Analysis
Chest X-ray, Ct Scan. UTZ and Biophysical Profile or Nonstress Test for fetal condition
5. Assist patient in transfer from emergency department to admitting room (away from area of activity)
6. Explain all interventions or procedures before administration
7. Provide patient education and psychological support throughout hospitalization
8. Create plan of care both for mother and her unborn child before and after delivery
9. Collaborate with the physician specifically to an OB-Gyne for prescribed medications and treatment
10. Collaborate with the dietician for the diet therapy suited for patient’s condition
11. Provide physical, emotional and mental care throughout hospitalization
 12. Notify physicians if interventions aren’t effective or the condition of pt. continues to decline
13. Prepare for an emergency surgical procedure (cesarean section) and provide care after wards.
14. Closely monitor patient and newborn’s condition until time of discharge to prevent further
complications and recurrence of the disease
15. Lastly, prior to discharge provide health teachings and instructions towards do’s and don’ts at
home both for mother and newborn

● HEALTH EDUCATION PRN

-Provide health teaching and emotional support to establish a trusting relationship and let the woman voice
out her fears.
-Describe the situation to the mother and the expected results
-Educate the mother about the drug maintenance and medical management details
-Educate the patient and family on how to avoid a recurrence of severe preeclampsia in the future
-Educate the patient to change her lifestyle and avoid foods that might trigger her condition
-​Educate the husband and other family members at home to monitor the condition of the patient
-The mother needs to know their risks and signs and symptoms to look for, such as headache, visual
changes, shortness of breath, or altered level of consciousness.
-The mother needs to understand that they must call their provider or go to the emergency department with
any of these symptoms.
-Treated with medications for elevated BPs should have a visit to their provider 3 days after discharge for a
blood pressure check.
-The mother also needs to know the long-term consequences of preeclampsia and the importance of
seeing their family physician.
-Mothers with preeclampsia should see their physician or a visiting nurse within 3-5 days after delivery and
again in 7-10 days after delivery. Some of these pregnant mothers may see nephrologists in the outpatient
setting.