STDENT NAME—Miss Itismita Biswal

HOSPITAL—IMS & SUM HOSPITAL , BBSR.

YEAR OF STUDY—2018

IDENTIFICATION DATA

NAME OF THE PATIENT—Mrs. Satyapriya Paikray

NAME OF THE HUSBAND—Mr. Dillip Ku. Baliarsingh

AGE— 27years

SEX— Female

MARITAL STATUS— Married

HOPITAL REGISTRATION NO— 190117009

WARD/BED NO— 2(maternity Ward) / Bed No- 3

ADDRESS— At- Sastrinagar, P.O – Sastrinagar, PS – Sastrinagar,

Bhubaneswar(unit-IV), Dist - Khurdha

RELIGION— Hindu

EDUCATION— Graduation

ADMISSION DATE— 17/1/19

DISCHARGE DATE— 20/1/19

DIAGNOSIS – Primigravida at 38wk 6day in latent labour with Pre-eclampsia

NAME OF THE DOCTOR— Dr. P. Sujata

OCCUPATION— Housewife

MONTHLY FAMILY INCOME— Rs- 35,000

WEIGHT— 62 kg

HIGHT—5 feet,2 inch

CHIEF COMPLAINS —

 Leaking per vagina since 12 hrs.

 Lower abdominal Pain since 6 hrs
HISTORY OF PAST ILLNESS —

There is no past medical history of TB, HTN, DM

she has not undergone any surgical procedure.

FAMILY HISTORY—

She belongs to a nuclear family having 4 numbers . Her husband is the supporting person in
her family. The monthly income of her family is nearly about Rs 35,000. There is family
history of Hypertension to her Father-in-law; there is no history of any disease like TB, DM ,
hereditary disease , twin pregnancy, Sickle cell anemia & eclampsia in her family.

HEALTHY FACILITY NAR HOME—

UHC is situated at about 2 k.m from her home with adequate tranportation facility available
like bicycle & motorcycle

HOUSING —

She lives in a pucca house having 8 numbers of rooms with adequate ventilation. They use
sanitary latrine for toileting. Electricity supply is available. They use municipality water supply
taps for drinking.

PERSONAL HISTORY—
 PERSONAL HYGIENE – She is maintain her oral hygiene by brushing daily and
taking bath once daily with soap & normal water.
 DIET—She takes both vegetarian & non-vegetarian diet & She takes meals 4 times a
day. she don’t have any addiction of alcohol & tobacco. She drinks about 2-3 lts of
water per day. She takes rest of about 2 hrs at day time & 8 hrs during night time. She
takes no drugs for sleep.
 ELIMINATION—She has a regular bowel & bladder habits
 MOBILITY & EXERCISE—No regular walking habits. Only moderate activity with
normal house hold work

MENSTRUAL HISTORY—
She got menarche at 12 year of age with regular cycles of 28-30 days interval & 3-4 days
duration with average amount of bleeding. Her LMP is 18/4/18 and EDD- 25/1/19.

SEXUAL & MARITAL HISTORY—

She is married since 1 year & She has satisfactory relationship with her spouse. General health
of her spouse is good.
OBSTETRICAL HITORY—
 PAST OBSTETRIC HISTORY—
Nothing significant as she is Primigravida.
 PRESENT OBSTETRIC HISTORY-
She is a registered case . She had attended antenatal clinic 7 times,
Her LMP was 18/4/18 & EDD - 25/1/19 .Thus the Gestational age (GA)
is 38 weeks 6 days.
 FIRST VISIT—
She missed her menstrual period & went to nearby clinic & tested her urine
for pregnancy & become confirm of her pregnancy. On her examination her weight was
48 kg, BP=100/70 mmhg , pulse =78bpm.At that time she suffered from minor
alignments like nausea & vomiting.

 SECOND VISIT-
At about 3 month she went to Antenatal clinic , taken 1 dose of T.T, BP =
112/72 mmhg, Pulse = 80bpm.
 THIRD VISIT –
At about 4 month she went to Antenatal clinic , taken 2 dose of T.T, BP =
106/70 mmhg, Pulse = 78bpm.

 FOURTH VISIT –
At about 5 month she went to Antenatal clinic, BP = 110/72 mmhg,
Pulse = 78bpm.
 FIFTH VISIT –
At about 7 month she went to Antenatal clinic ,BP = 122/80 mm hg,
Pulse = 82bpm
 SIXTH VISIT –
At about 8 month she went to Antenatal clinic, BP = 134/90 mm hg,
Pulse = 76bpm
 SEVENTH VISIT –
At about 9 month she went to Antenatal clinic, BP = 148/90 mm hg,
Pulse = 74bpm

INVESTIGATIONS—
 Hb=12.3gm%
 FBS = 83mg/dl
 Urine for HCG=positive
 Blood group— B’ positive
 Sickling -- Negative
 Urine test=Albumin- Present
=Sugar---Not Present
 VDRL=Negative
  HIV=Non reactive
 HbsAg =Non reactive
 HCV =Non reactive
 USG= done on 12/1/19 showing single live intra-uterine fetus in cephalic presentation.

OBSERVATION & ASSESSMENT—

 Her general appearance is good
 Patient is conscious & anxious
 She has no foul body odour & foul breath

PHYSICAL EXAMINATION—

VITAL SIGN—
 Temp –98.20 F
 BP— 158/80mm Hg
 Pulse –68 beat/min.
 Resp –20 breath/min.

HEAD TO TOE EXAMINATION—

 Her skin colour is normal
 Hair & scalp are clean & healthy. No dandruff & pediculosis is present
 In eye ,no Jaundice & Pallor is seen
 Mouth is clean
 Tongue is hydrated
 Gum is healthy
 Total no of teeth is 32
 Nose, ear, throat is clear
 In neck no abnormal enlargement of lymph node & glands.
 In breast secondary areola has formed & nipple are normal,.
 Engorged breast is present.
 Liver & spleen are not palpable
 Leg ,spine & back are normal
 pedal oedema is present

OBSTETRICAL EXAMINATION—

INSPECTION—
 No undue enlargement of the Uterus .
 Skin condition—healthy & no discolouration.
 Linea nigra is prominent
  Striae gravidarum visible at lower abdomen
 Episiotomy wound present.

PALPATION—
 Uterus is hard, mobile & globular.
 Fundal height is 24 c.m i.e. at the level of umbilicus.

P/V EXAMINATION—
Vulva – Oedema present over vulva area

Perineal area & Anus – Clean

Lochia rubra present in normal amount

Episiotomy wound - Healthy

DEPENDENCY LEVEL OF PATIENT –

Patient is partially dependent.

CLINICAL EXAMINTION & NOTES

DIAGNOSIS— Primi at 38week 6 day in latent labor with Pre-eclampsia

INTRODUCTION—
During Pregnancy, there are a lot of changes which happen inside the body of a
woman. She gets a number of variations in different parameters of the body. Up to some limit
these changes are normal but when it crosses the threshold, it is termed as disorder.

Such a disorder that may happen in pregnancy is Pre-eclampsia , Which is a

multisystem disorder and it contributes significantly to Maternal & Paternal morbidity &
mortality.

DEFINITION :-
Pre-eclampsia is a multisystem disorder of unknown pathology characterised by development
of hypertension to the extent of 140/90 mm hg or more with Proteinuria after 20th week in a
Previously normotensive and non-proteinuric woman.

INCIDENCE :-
The incidence of Pre-eclampsia in

1. Primigravida – Abt 10%

2. Multigravida - Abt 5%
RISK FACTORS FOR PRE-ECLAMPSIA

IN BOOK IN CLIENT
 Primigravida ( Young or elderly )  She is a
 Family history of Hypertension / Pre-eclampsia primigravida
 Placental abnormalities  Family history of
i. Hyperplacentosis Hypertension
ii. Placental ischaemia
 Pre-existing vascular disease
 Obesity – BMI > 35
 Thrombophilias ( Antiphospholipid syndrome, Protein- c,s
deficiency, Factor v Leiden )

ETIOPATHOLOGICAL FACTOR-

IN BOOK IN CLIENT
 Failure of trophoblast invasion ( Abnormal Placentation )  Idiopathic
 Vascular endothelial damage
 Inflammatory mediators ( Cytokinase )
 Immunological intolerance between maternal & fetal tissues
 Co-agulation abnormalities ( Increased thromboxane )
 Increased Oxygen free radicals
 Genetic Predisposition ( Polygenic disorder )
 Dietary deficiency or excess i.e. low protein or dietary salt
overload
PATHOPHYSIOLOGY –

1. PRE-ECLAMPSIA:
Cytotrophoblast Invasion

Immunolgical factor

Poor Placentation Thrombophilia

Acute artherosis Uteroplacental mismatch Multiple Pregnancy

Fetal macrosomia

PBLS Cytokines PGs ROs

Endothelial cell activation ARDS

Cardiomyopathy

Maternal syndrome Eclampsia/Stroke

Oedema

Hypertension Glomerular Liver damage/ Microangiopathic

Endotheliosis/ Haematoma/ Haemolysis/

Proteinuria/ Rupture Thrombocytopenia/

Acute tubular DIC

Necrosis
2. OEDEMA:
Increased Angiotensin –II due to idiopathic cause

Increased Aldosterone level, Increased capillary permeability

Increased sodium retention

Increased Extracellular fluid

Oedema

3. PROTEINURIA :
Spasm of afferent Arterioles

Change to the endothelium / glomerular endotheliosis

Increased capillary permeability

Increased leakage of Protein ( Albumin )

Excretion of albumin in urine

CLINICAL TYPE-

IN BOOK IN CLIENT
1. MILD- My patient comes under severe type,
 Rise of BP above 140/90 mm Hg but because at the time of admission,
less than 160/110 mm Hg  BP – 158/80 mm Hg
 Without significant proteinuria  Protein excretion
11. SEVERE- ( Urine albumin ) – 4 +
 Persistent BP > 160/110 mm Hg ( 10gm/lit/24 hr)
 Protein excretion in urine > 5gm/24 hr
 Oliguria ( < 400 ml/24hr )
 Platelet count ( < 1 lakh/mm3)
 HELLP syndrome
 Visual disturbance
 Persistent epigastric pain
 Retinal Haemorrhage
 Pulmonary oedema
 IUGR

CLINICAL FEATURES—

 SYMPTOMS
i. MILD SYMPTOMS

IN BOOK IN CLIENT
 Swelling of ankles ( slightly ) which My Patient shows mild symptoms
persists on rising from the bed in the  Ankle swelling
morning  Oedema over vulva, face & abdomen
 Tightness of the ring on finger
 Gradually oedema over face, vulva,
abdomen & whole body

ii. ALARMING SYMPTOMS ( A/C ONSET )

IN BOOK IN CLIENT
 Headache ( Occipital/Frontal region )  Headache
 Disturbed sleep  Disturbed sleep
 Oliguria ( < 400 ml/24hr )
 Eye Symptoms ( Blurring vision,
Diminished vision, Blindness, Retinal
infraction)
 Epigastric Pain
 SIGNS

IN BOOK IN CLIENT
 Abnormal weight gain In my patient, wt. gain in last 2 wk is 3 k.g.
i.e wt > 1 lb in 1 wk  BP = 158/80 mm Hg
or wt > 5 lb in 1 month  Oedema – Positive
 Rise of Blood Pressure-
Diastolic Pressure usually tends to
rise first than systolic pressure
 Oedema-
Sudden & generalised oedema
 Pulmonary oedema –
No manifestation of chronic
cardiovascular / Renal pathology
 Abdominal Examination-
IUGR

 INVESTIGATION

IN BOOK IN CLIENT
 Urine test for albumin  Urine albumin – 4+
 Ophthamoscopic Examination ( 10 gm/lit/24 hr)
 Blood values i.e. serum Urea,  Blood values:
Serum creatinine Serum urea – 22 mg/dl
 Serum total Protein Serum creatinine – 0.93 mg/dl
 Total Platelet count Serum bilirubin – 0.25mg/dl
 Liver function test Serum total protein – 5.6gm/dl
 During Antenatal Period – Serum sodium – 138 meq/lit
Fetal monitoring by USG, FHR etc Serum potassium – 3.5meq/lit
R.B.S – 83 mg/dl
 Fetal monitoring by USG-
Single live Intra-uterine fetus in
cephalic presentation
 F.H.R – 134beat/min.

 COMPLICATION

IN BOOK IN CLIENT
I. IMMEDIATE  No complication seen in my patient
A. Maternal:-
During Pregnancy :-
Eclampsia, Preterm labour, Oliguria,
ARDS, HELLP syndrome
During labour:-
Eclampsia, PPH
Puerperium:-
 Eclampsia usually occurs within 48 hrs,
Shock, sepsis
B. Fetal:-
IUD, IUGR
Asphyxia, Prematurity
II. REMOTE
 Residual Hypertension-
Hypertension persist even after 6 month
following delivery ( Thrombophillias,
CRP, Antiphospholipid syndrome )
 Recurrent Pre-eclampsia
( Family history, Thrombophillias )
 Chronic Renal disease
( Glomerular nephritis )
 HELLP syndrome

SCREENING TESTS FOR PREDICTION & PREVENTION OF PRE-

ECLAMPSIA
 Doppler Ultrasound (2nd trimester)
 Presence of diastolic notch
 Absence of end diastolic frequencies
 Average Mean arterial pressure in second trimester >/ 90 mmHg predict the onset
 Fetal DNA-Free fetal DNA in maternal serum
 Roll over test (28-32 wks)

PROPHYLACTIC MEASURES FOR PREVENTION OF PRE-ECLAMPSIA:-

 Regular Antenatal check up – Detect wt. gain or High B.P
 Antithrombotic Agent – Patient with potential risk i.e. decreased Thromboxane
e.g. Aspirin 60 mg
 Heparin/Low molecular weight heparin – Thrombophillia
 Antioxidants : Vit E, C, Mg, Zinc,Fish oil & low salt diet
 Balanced diet – Rich Protein, low salt

MANAGEMENT—

IN BOOK IN CLIENT
Hospitalization My patient was hospitalized on
17/1/19
Rest Left lateral Position was given
Diet i.e. High protein & low salt diet (Protein High protein & low salt diet was given
100mg/day)
Medication:
i) Antihypertensive –
 Calcium channel Blocker e.g. Nifedipine  Tablet lobet 100mg BD
(10 to 20 mg) B.D
 Anti adrenergic drugs e.g. Methyldopa (250-
500 mg tid or qid)
 α & β blockers e.g. labetalol 100 mg tid or
qid
ii) Prophylactic Anticonvulsant –
 Magnesium Sulphate-  MgSO4 was not given to my
Prophylactic MgSO4 is started when systolic patient
BP >/ 160 diastolic >/ 110, MAP >/ 125 mm
Hg
Loading dose- 4gm IV over 3-5 minute
followed by 10 gm deep I.M (5gm in each
buttock)
Maintainance dose-
5gm I.M 4 hourly in each buttock
iii) Diuretics – iii)Diuretics not given
Frusemide – 10-40 mg/day
iv) Antibiotics- to prevent infection iv) Inj. Ceftriaxone 1gm I.V. B.D
B.P. is checked hourly
B.P check is done atleast 6 hrly or 4 times/day to
know the effectiveness of medication
Opthalmoscopic examination Not done

Blood for haematrocrit, platelet count, uric Platelet count -1,24000/mm3

acid, creatinine, liver function test at least once a week Serum uric acid – 7.30 mg/dl
Serum creatinine – 0.93 mg/dl
Liver function test –
Albumin- 2.84 mg/dl
Total Protein- 5.61gm/dl
Fetal well being assessment Fetal well being assessed by USG,
Doppler study, Cardiotocography,
Non stress test
SPECIAL OBSTETRICAL MANAGEMENT
I) During Labour –
 Fetal well being is monitored carefully During admission the findings of my
 B.P & urine output is recorded client are
 Labour duration is curtailed by low rupture of  B.P- 158/80 mm Hg
the membranes in the first stage and foreceps  Urine albumin – 4+
nd
or ventouse in 2 stage  P/V – Vulval oedema
 Caesarean section is the ultimate choice for Cervix – soft, 50% effaced
pre-eclampsia 1.5 c.m dilated,
 Intravenous ergometrine following the  As the cervical dilatation was
delivery of anterior shoulder is withheld as it only 1.5 c.m, tab Misoprostol
may cause further rise of Blood Pressure 25µg was given on posterior
fornix of vagina, then after 4
hour cervical dilatation was 6
c.m., then after 4 hr full
 dilatation occur,
 Patient was undergone normal
II) During Puerperium – vaginal delivery with right
 Patient is closely observed for 48 hr after medio-lateral episiotomy
delivery with all the managements to prevent
complication

Post Delivery Day – 1 (17/1/2019)

GENERAL CONDITION OF ADVICE NURSING

MOTHER-- INTERVENTION

Patient conscious Inj. Xone 1gm I.V. Bed making done

Afebrile B.D Low salt diet given
Pallor (-- ve) Inj. Diclofenac 1 amp Mouth care given
Pulse= 82bpm I.V. B.D Vital sign checked
BP= 110/70mmhg Inj. Pan (40mg) IV I/O chart maintained
Chest/CVS== NAD O.D Bleeding P/V checked
P/A= Soft, Uterus Tab. Calcigard (R) 10 Medication given in due
contraction present mg B.D time
BP/V= Lochia rubra Tab. Chymoral forte 1 Perineal care given
U/O= Adequate tab B.D Catheter care given
Catheter in situ Syp. Duphalac 15 ml
HS

GENERAL CONDITION OF ADVICE NURSING

BABY-- INTERVENTION

Active & Alert Exclusive breast Baby is kept warm by warm

Reflex – well developed feeding clothes
Pulse – 134 bpm, Resp- Immunization Eye care given
30breath/min Mouth care given
Temp – 98.60f Cord care given
Urine passed Napkin changed
Stool passed Rooming-in of mother &
baby maintained

Post Delivery Day – 2 (18/1/2019)

GENERAL CONDITION OF ADVICE NURSING

MOTHER-- INTERVENTION

Patient conscious Bed making done

Afebrile Inj. Pan (40mg) IV O.D Low salt diet given
Pallor (-- ve) Tab. Calcigard (R) 10 mg Mouth care given
Pulse= 86bpm BD Vital sign checked
BP= 130/80mmhg Tab. Chymoral forte 1 tab I/O chart maintained
 Chest/CVS = NAD B.D Bleeding P/V checked
P/A= Soft, Uterus Tab. Lizolid 600 mg B.D. Medication given in due
contraction present time
BP/V= Lochia Rubra Perineal care given

GENERAL CONDITION OF ADVICE NURSING

BABY-- INTERVENTION

Active & Alert Exclusive breast feeding Baby is kept warm by

Reflex – well developed Immunization warm clothes
Pulse – 130 bpm, Eye care given
Resp- 30breath/min Mouth care given
Temp – 990f Cord care given
Urine passed Napkin changed
Stool passed Rooming-in of mother &
baby maintained

Post Delivery Day – 3 (19/1/2019)

GENERAL CONDITION ADVICE NURSING

OF INTERVENTION
MOTHER--

Patient conscious Bed making done

Afebrile Tab. Pan (40mg) IV O.D Low salt diet given
Pallor (-- ve) Tab. Calcigard (R) 10 mg Mouth care given
BD
Pulse= 86bpm Vital sign checked
Tab. Chymoral forte 1 tab
BP= 110/60mmhg B.D I/O chart maintained
Chest/CVS = NAD Tab. Lizolid 600 mg B.D. Bleeding P/V checked
P/A= Soft, Uterus Medication given in
well contracted due time
BP/V= Lochia Breast care given
Rubra
Engorged Breast

GENERAL CONDITION ADVICE NURSING

OF BABY-- INTERVENTION

Active & Alert Exclusive breast feeding Baby is kept warm by

Reflex – well Immunization warm clothes
developed Eye care given
Pulse – 132 bpm, Mouth care given
Resp- 30breath/min Cord care given
Temp – 990f Napkin changed
Urine passed Rooming-in of mother &
Stool passed baby maintained
Post Delivery Day – 4 (20/1/2019)

GENERAL CONDITION ADVICE NURSING

OF INTERVENTION
MOTHER--

Patient conscious Bed making done

Afebrile Tab. Pan (40mg) IV O.D Low salt diet given
Pallor ( - ve) Tab. Calcigard (R) 10 mg Mouth care given
BD
Pulse= 84bpm Vital sign checked
Tab. Chymoral forte 1 tab
BP= 110/70mmhg B.D I/O chart maintained
Chest/CVS = NAD Tab. Lizolid 600 mg B.D. Bleeding P/V checked
P/A= Soft, Uterus Medication given in
well contracted due time
BP/V= Lochia Breast care given
serosa
Engorged Breast
GENERAL CONDITION ADVICE NURSING
OF BABY-- INTERVENTION

Active & Alert Exclusive breast feeding Baby is kept warm by

Reflex – well Immunization warm clothes
developed Eye care given
Pulse – 134 bpm, Mouth care given
Resp- 30breath/min Cord care given
Temp – 990f Napkin changed
Urine passed Rooming-in of mother &
Stool passed baby maintained
ADVICE ON DISCHARGE :

MOTHER-
Low salt diet
Adequate fluid to drink
Regular health visit
To seek immediately the medical attention in case any complication arises.
To avoid heavy lifting & climbing upstairs
To maintain personal hygiene
To take highly nutritious diet .
Iron & calcium to be continued
Follow up check after 15 days
Avoid coitus up to 3 months

BABY-
Handwashing should be done before handling the Baby
Minimizing the handling of the baby which protect the infant from infections
Exclusive Breastfeeding for upto 6 month
Nothing should be put into the cord
Advised regarding Skin care, Mouth care, Cord care
Baby should be immunized according to the National Immunization Schedule

SUMMARY—
Mrs Satyapriya is a Primigravida aged 27 yrs admitted to IMS & SUM Hospital on dt. 17/1/19
at 4.00 am. She was diagnosed as a case of Primigravida at 38wk 6day in latent labour with Pre-
eclampsia . After induction of labor there was full dilatation & effacement of the cervix and she
was undergone Normal vaginal delivery with Right medio-lateral episiotomy. She was given
proper care by administration of I.V fluids, Antihypertensive drug , Antibiotic & symptomatic
management. Gradually improvement occur in her general condition.

CONCLUSION—
Effect of my care—

After providing nursing care, the client has improved her self confidence .She feels relaxed
& no anxiety is there. The client & family members are very co-operative & they have trust on
me.
BIBLIOGRAPHY—

1. Bhaskar Nima. Midwifery & Obstetrical Nursing: High Risk Pregnancy – Assessment
and Management. 2nd ed. Bangalore: EMMESS Medical Publishers, 2015.P- 347 – 52
2. Dutta DC. Text Book of Obstetrics including Perinatology and Contraception:
Hypertensive Disorders In Pregnancy. In:Konar Hiralal editor.7th ed.London.New
Central Book Agency (P ) Ltd:2011.P.219-32
3. Jacob Annamma. A Comprehensive Text Book of Midwifery & Gynecological
Nursing : Hypertensive Disorders Of Pregnancy, 3rd ed.Karnataka : JAYPEE Brothers
Medical Publishers (P) Ltd,2012.P.295-302
 CASE PRESENTATION
ON
“PRE-ECLAMSIA”

SUBMITTED TO- SUBMITTED BY-

Mrs.Gomathi B. Mahalingam Itismita Biswal
Assosciate Professor M.Sc.Nursing 1st yr Student
Obstetrics & Gynaecological Nursing Obstetrics & Gynaecological Nursing
SUM Nursing College, BBSR SUM Nursing College, BBSR