A Pregnant Client Is Admitted To The Unit For Preeclampsia

Preeclampsia, a pregnancy-specific hypertensive disorder, demands a meticulous and multifaceted approach when a pregnant client is admitted to the unit. It's characterized by new-onset hypertension and proteinuria, or other signs of end-organ dysfunction, typically after 20 weeks of gestation. The following details the critical aspects of managing a pregnant client admitted with preeclampsia.

Understanding Preeclampsia: A Foundation for Care

Preeclampsia is more than just high blood pressure during pregnancy; it's a complex condition affecting multiple organ systems. Its etiology remains incompletely understood, but it's thought to involve abnormal placental development leading to endothelial dysfunction and widespread vasospasm.

• Incidence: Affects 2-8% of pregnancies worldwide.
• Risk Factors: Nulliparity, multiple gestation, pre-existing hypertension, renal disease, diabetes, obesity, family history of preeclampsia, advanced maternal age.
• Pathophysiology: Abnormal placentation leads to the release of factors that cause endothelial damage, resulting in hypertension, proteinuria, and other systemic complications.
• Classification: Preeclampsia can be classified as either with or without severe features. Recognizing these distinctions is crucial for appropriate management.

Initial Assessment and Stabilization

Upon admission, a comprehensive assessment is essential to determine the severity of preeclampsia and identify any immediate threats to the mother and fetus.

1. Maternal Assessment:
   • Vital Signs: Continuously monitor blood pressure, heart rate, respiratory rate, and temperature.
   • Neurological Status: Assess for headaches, visual disturbances, hyperreflexia, clonus, and any signs of impending eclampsia (seizures).
   • Cardiovascular System: Evaluate for chest pain, shortness of breath, and edema.
   • Respiratory System: Assess for pulmonary edema.
   • Renal System: Monitor urine output and assess for proteinuria using a 24-hour urine collection or spot urine protein/creatinine ratio.
   • Gastrointestinal System: Evaluate for epigastric or right upper quadrant pain, which may indicate liver involvement.
   • Laboratory Tests:
     • Complete Blood Count (CBC) to assess for thrombocytopenia and hemoconcentration.
     • Comprehensive Metabolic Panel (CMP) to evaluate liver and kidney function.
     • Coagulation studies (PT, PTT, fibrinogen) to assess for disseminated intravascular coagulation (DIC).
     • Uric acid levels.
     • Lactate dehydrogenase (LDH) to assess for hemolysis.
   • Edema Assessment: Note the presence and extent of edema, particularly in the face, hands, and lower extremities.
2. Fetal Assessment:
   • Fetal Heart Rate Monitoring: Continuous electronic fetal monitoring to assess fetal well-being.
   • Ultrasound: To assess amniotic fluid volume, fetal growth, and estimated fetal weight.
   • Biophysical Profile (BPP): A combination of ultrasound and fetal heart rate monitoring to assess fetal well-being.
   • Doppler Studies: Umbilical artery Doppler velocimetry to assess placental blood flow.

Pharmacological Management

Pharmacological interventions are crucial in managing preeclampsia, focusing on controlling blood pressure and preventing seizures.

1. Antihypertensive Medications:
   • Labetalol: A beta-adrenergic blocker, commonly used as a first-line agent to lower blood pressure. Administered intravenously or orally.
     • Dosage: Typically starts with 20 mg IV, followed by 40-80 mg every 20-30 minutes, up to a maximum dose of 300 mg.
     • Contraindications: Asthma, heart block, bradycardia.
   • Hydralazine: A direct vasodilator, also used to lower blood pressure. Administered intravenously.
     • Dosage: Typically starts with 5-10 mg IV every 20-30 minutes.
     • Side Effects: Headache, flushing, tachycardia.
   • Nifedipine: A calcium channel blocker, can be administered orally.
     • Dosage: Typically 10-20 mg orally every 30 minutes, up to a maximum dose of 50 mg in the first hour.
     • Side Effects: Headache, flushing, dizziness.
2. Magnesium Sulfate:
   • Mechanism of Action: Primarily used as a seizure prophylactic. It also has a mild antihypertensive effect.
   • Dosage:
     • Loading Dose: Typically 4-6 grams IV over 20-30 minutes.
     • Maintenance Dose: 1-2 grams per hour via continuous IV infusion.
   • Monitoring:
     • Assess for magnesium toxicity: Monitor respiratory rate, deep tendon reflexes, urine output, and serum magnesium levels (therapeutic range: 4-7 mEq/L).
     • Signs of Magnesium Toxicity: Decreased or absent deep tendon reflexes, respiratory depression, altered mental status, cardiac arrest.
     • Antidote: Calcium gluconate (1 gram IV).

Nursing Care and Monitoring

Nursing care is paramount in the management of preeclampsia, requiring vigilant monitoring and timely intervention.

1. Continuous Monitoring:
   • Blood Pressure: Monitor blood pressure frequently (e.g., every 15-30 minutes) during acute phases and every 1-4 hours once stabilized.
   • Fetal Heart Rate: Continuous electronic fetal monitoring to assess fetal well-being and detect any signs of distress.
   • Intake and Output: Strict monitoring of fluid intake and urine output to assess renal function and fluid balance.
   • Weight: Daily weights to assess for fluid retention.
2. Neurological Assessment:
   • Assess for signs and symptoms of impending eclampsia: Headache, visual disturbances, hyperreflexia, clonus.
   • Implement seizure precautions: Padded side rails, oxygen and suction equipment readily available.
3. Medication Administration:
   • Administer antihypertensive medications and magnesium sulfate as prescribed.
   • Monitor for side effects and toxicity.
4. Fluid Management:
   • Carefully manage fluid administration to avoid fluid overload and pulmonary edema.
   • Monitor for signs of pulmonary edema: Shortness of breath, crackles in the lungs.
5. Patient Education:
   • Educate the patient and her family about preeclampsia, its potential complications, and the plan of care.
   • Explain the importance of reporting any new or worsening symptoms.
6. Emotional Support:
   • Provide emotional support and reassurance to the patient and her family.
   • Address any anxiety or concerns they may have.

Managing Severe Features of Preeclampsia

Preeclampsia with severe features indicates a higher risk of complications and requires more intensive management. Severe features include:

• Severe hypertension (systolic blood pressure ≥160 mmHg or diastolic blood pressure ≥110 mmHg)
• Thrombocytopenia (platelet count <100,000/µL)
• Impaired liver function (elevated liver enzymes)
• Progressive renal insufficiency (serum creatinine >1.1 mg/dL or doubling of serum creatinine)
• Pulmonary edema
• New-onset cerebral or visual disturbances

1. Aggressive Blood Pressure Control:
   • Use intravenous antihypertensive medications to rapidly lower blood pressure.
   • Maintain blood pressure within the target range (systolic 140-150 mmHg, diastolic 90-100 mmHg).
2. Monitoring for End-Organ Damage:
   • Closely monitor laboratory values (CBC, CMP, coagulation studies) to assess for end-organ damage.
   • Assess for signs and symptoms of liver involvement (epigastric or right upper quadrant pain), renal dysfunction (decreased urine output), and neurological complications (seizures, stroke).
3. Consideration for Delivery:
   • Delivery is often the definitive treatment for preeclampsia, especially with severe features.
   • The decision to deliver depends on gestational age, maternal and fetal status, and the presence of complications.
   • If the patient is remote from term, a course of corticosteroids may be administered to promote fetal lung maturity.
4. HELLP Syndrome:
   • HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count) is a severe complication of preeclampsia.
   • Management includes:
     • Stabilization of the patient.
     • Transfusion of blood products as needed.
     • Prompt delivery, regardless of gestational age.

Delivery Considerations

The timing and mode of delivery depend on several factors, including gestational age, maternal and fetal status, and the presence of complications.

1. Gestational Age:
   • At or near term (≥37 weeks): Delivery is generally recommended.
   • Preterm (<37 weeks): The decision to deliver depends on the severity of preeclampsia and the presence of fetal distress.
     • If the patient is stable, expectant management may be considered until 34 weeks, with close monitoring.
     • Corticosteroids should be administered to promote fetal lung maturity.
2. Mode of Delivery:
   • Vaginal Delivery: May be attempted if the patient is stable and there are no contraindications.
   • Cesarean Delivery: May be necessary if there is fetal distress, maternal complications, or contraindications to vaginal delivery.
3. Postpartum Management:
   • Continue to monitor blood pressure and administer antihypertensive medications as needed.
   • Magnesium sulfate is typically continued for 24 hours postpartum to prevent seizures.
   • Monitor for postpartum complications: Postpartum hemorrhage, infection, thromboembolism.

Eclampsia Management

Eclampsia, the occurrence of seizures in a woman with preeclampsia, is a life-threatening emergency.

1. Immediate Actions:
   • Protect the patient from injury during the seizure.
   • Maintain airway and administer oxygen.
   • Administer magnesium sulfate to control seizures.
     • If seizures persist despite magnesium sulfate, consider other anticonvulsants (e.g., lorazepam, phenytoin).
   • Monitor maternal and fetal status closely.
2. Post-Seizure Management:
   • Assess for complications: Aspiration, hypoxia, trauma.
   • Obtain laboratory tests to assess for end-organ damage.
   • Expedite delivery once the patient is stabilized.

Long-Term Considerations

Women with a history of preeclampsia have an increased risk of future cardiovascular disease, including hypertension, stroke, and heart disease.

1. Postpartum Follow-Up:
   • Monitor blood pressure and cardiovascular risk factors.
   • Provide education on lifestyle modifications to reduce cardiovascular risk: Healthy diet, regular exercise, weight management.
2. Future Pregnancies:
   • Advise women with a history of preeclampsia to discuss their risk with their healthcare provider before future pregnancies.
   • Low-dose aspirin may be recommended in subsequent pregnancies to reduce the risk of recurrent preeclampsia.

The Role of Interprofessional Collaboration

Effective management of preeclampsia requires a collaborative approach involving obstetricians, nurses, anesthesiologists, neonatologists, and other healthcare professionals.

1. Team Communication:
   • Regular communication among team members to ensure coordinated care.
   • Multidisciplinary rounds to discuss the patient's condition and plan of care.
2. Standardized Protocols:
   • Use of standardized protocols and guidelines to ensure consistent and evidence-based care.
3. Simulation Training:
   • Regular simulation training to prepare for emergencies such as eclampsia and postpartum hemorrhage.

Ethical Considerations

Managing preeclampsia can present ethical dilemmas, particularly when considering the timing of delivery and the potential risks to both the mother and the fetus.

1. Informed Consent:
   • Ensure that the patient is fully informed about the risks and benefits of different treatment options.
   • Obtain informed consent before initiating any interventions.
2. Balancing Maternal and Fetal Well-Being:
   • Strive to balance the well-being of the mother and the fetus when making decisions about delivery.
   • Involve the patient in the decision-making process, respecting her values and preferences.

The Importance of Education

Educating both healthcare providers and pregnant women is essential for improving outcomes in preeclampsia.

1. Healthcare Provider Education:
   • Provide ongoing education and training to healthcare providers on the diagnosis and management of preeclampsia.
   • Promote the use of evidence-based guidelines and protocols.
2. Patient Education:
   • Educate pregnant women about the signs and symptoms of preeclampsia.
   • Encourage them to seek prompt medical attention if they experience any concerning symptoms.

Preeclampsia: Frequently Asked Questions (FAQ)

1. What is preeclampsia?
   • Preeclampsia is a pregnancy-specific condition characterized by high blood pressure and signs of organ damage, typically occurring after 20 weeks of gestation.
2. What are the risk factors for preeclampsia?
   • Risk factors include nulliparity, multiple gestation, pre-existing hypertension, renal disease, diabetes, obesity, family history of preeclampsia, and advanced maternal age.
3. How is preeclampsia diagnosed?
   • Preeclampsia is diagnosed based on elevated blood pressure and the presence of proteinuria or other signs of organ damage.
4. What are the complications of preeclampsia?
   • Complications include eclampsia (seizures), HELLP syndrome, stroke, pulmonary edema, placental abruption, and fetal growth restriction.
5. How is preeclampsia treated?
   • Treatment includes blood pressure control with antihypertensive medications, seizure prophylaxis with magnesium sulfate, and delivery of the baby.
6. What is HELLP syndrome?
   • HELLP syndrome is a severe complication of preeclampsia characterized by hemolysis, elevated liver enzymes, and low platelet count.
7. What is eclampsia?
   • Eclampsia is the occurrence of seizures in a woman with preeclampsia.
8. Can preeclampsia be prevented?
   • Low-dose aspirin may reduce the risk of preeclampsia in women at high risk.
9. What are the long-term risks for women with a history of preeclampsia?
   • Women with a history of preeclampsia have an increased risk of future cardiovascular disease.
10. What should I do if I think I have preeclampsia?
    • Seek immediate medical attention if you experience symptoms such as severe headache, visual disturbances, abdominal pain, or swelling.

Conclusion

The admission of a pregnant client with preeclampsia necessitates a comprehensive and vigilant approach. From initial assessment and stabilization to pharmacological interventions, meticulous nursing care, and consideration for delivery, every step must be carefully executed to ensure the best possible outcome for both mother and baby. Understanding the complexities of preeclampsia, recognizing its severe features, and fostering interprofessional collaboration are key to providing optimal care. By staying informed, adhering to evidence-based guidelines, and prioritizing patient education, healthcare providers can make a significant difference in the lives of women affected by this challenging condition.