Obstetrical Emergency Care of an Eclamptic Patient - Coursework Example

Obstetrical Emergency care of an Eclamptic Patient Introduction Eclampsia is an obstetric emergency with high morbidity and mortality (ACOG, 2002). Failure to act promptly and appropriately on the part of health professionals can lead to negative outcomes for both mother and the fetus. Nurses have an important role to play in the assessment, evaluation, monitoring, diagnosis and management of eclampsia. In this essay, nursing management of an eclampsia in an emergency setting will be discussed through review of appropriate literature and through identification of goals. Methodology The following articles were used to prepare the power point presentation and essay: 1. ACOG (2002). Diagnosis and management of preeclampsia and eclampsia. ACOG practice bulletin, 33, 1-8. 2. Jerry, S.E., Hockenberry, M.J., Lowdermilk, D.L., Wilson, D. , 2010. Pregnancy at risk: Gestational conditions. In Carter, R., and Gower, L.K. (Eds.), Maternal child nursing care (pp. 334-375). Canada: Mosby. 3. White, A. (2006). Emergency Care of Postpartum Patients with Preeclampsia and Eclampsia. Advanced Emergency Nursing Journal, 28(3), 248- 257. Understanding the disease Eclampsia is one of the complications of severe preeclampsia and typically occurs either during or beyond the 20th week of gestation or in the post-partum period, upto 6 weeks. It is infact progression from severe stage of preeclampsia. Preeclampsia is a complication in pregnancy which is clinically defined by hypertension (systolic blood pressure of more than 140mmHg and diastolic blood pressure of more than 90mmHg) and proteinuria. (more than 300 grams in 24 hours) (ACOG, 2002). There are basically 2 types, mild to moderate and severe. Clinical features of mild to moderate preeclampsia include diastolic blood pressure between 90- 110 mmHg, platelet count of more than 1 lakh cells per cmm, reassuring antepartum fetal testing, minimal or absent central nervous system irritability, absence of epigastric pain and normal liver enzymes. Severe preeclampsia manifests with dramatic and persistent symptoms and they are blood pressure of more than 160/110 mmHg, proteinuria of more than 5 grams in 24 hours, oliguria, with less than 500 ml urine in 24 hours, platelet counts of less than one lakh, disseminated intravascular coagulation and intrauterine growth retardation (ACOG, 2002). Other manifestations of severe preeclampsia include HELLP syndrome (hemolysis, elevated liver enzymes and low platelets), oligohydramnios and signs and symptoms of end organ failure. Preeclamsia can cause ischemic encephalopathy, growth retardation and premature birth to the baby. In the mother, preeclampsia can lead to tissue and organ ischemia, seizures, strokes, brain hemorrhage, acute tubular necrosis, coagulopathies, and placental abruption (Jerry, 2010) Severe preeclampsia along with seizures and involvement of the central nervous system is eclampsia. The condition It occurs 20 weeks after gestation and is a disorder of widespread vascular endothelial malfunction and vasospasm. The onset of seizures and altered mental status in preeclampsia is the beginning of eclampsia. Onset of eclampsia is believed to occur because of development of hypertensive encephalopathy, vasogenic edema, ischemia of the cortex and cortical hemorrhage and edema. the exact etiology of preeclampsia and eclampsia is not well understood and some theories which have been put forward in this regard are abnormalities in coagulation, cardiovascular maladaptation, genetic predisposition, abnormal trophoblastic invasion and dietary deficiencies (ACOG, 2002). Eclampsia is associated with high mortality and morbidity. Complications include CNS damage secondary to intracranial bleeding or seizures. Fetal complications that can occur are abruptio placenta, intrauterine growth retardation and placental infarcts (Jerry, 2010). For a nurse to diagnose eclampsia, clinical features and warning signs of eclampsia must be understood. The most common presentation features of eclampsia are hypertension and seizures with or without proteinuria and edema. Eclampsia can occur any time and in more than 90 percent cases, it occurs beyond 28 weeks of gestation. The patients presents with severe preeclampsia before the onset of eclampsia. other associated clinical features include visual disturbances, frontal head ache, abdominal pain, nausea, amnesia, altered sensorium and coma. Physical findings include moderate to severe hypertension, tachycardia and tachypnea, hyperreflexia and clonus, oliguria, edema, and papilledema (ACOG, 2002). Risk factors for preeclampsia and eclampsia are less than 20 years of age and more than 35 years of age, promigravida, hydatidiform mole, multiple pregnancy, urinary tract infection, black race, nulliparity, presence of chronic diseases like diabetes, obesity, chronic hypertension and renal disease, and positive family history of preeclampsia. patients with these risk factors must be monitored for development of eclampsia (ACOG, 2002). Nursing evaluation Patients presenting with eclampsia must be assessed and evaluated appropriately. Physical examination must include vital signs, vision, cardiovascular system, respiratory system, abdomen, neuromuscular and extremities (reflexes, clonus and edema). Detailed fetal examination also must be done (ACOG, 2002). Investigations which are required to be sent in eclampsia include complete blood picture, peripheral smear, serum bilirubin, serum haptoglobin, lactate dehydrogenase, serum creatinine, liver function tests, coagulation profile, urine protein and albumin, serum albumin and blood sugar. These tests are done to evaluate for liver failure, HELLP syndrome, renal failure and hypoglycemia. Further investigations may be decided upon based on complications and physical findings (ACOG, 2002). Nursing Management Restriction of activity is very important in preeclampsia. The mother and the fetus must be monitored closely. Investigations like complete blood picture and urine albumin must be done weekly.In severe eclampsia, hypertension must be treated with labetolol, hydralazine, nifedipine or methyldopa. Labetalol is the drug of choice. The dose of labetalol is 10-20 mg IV every 20 minutes, that of hydralazine is 5-10 mg iv every 20 minutes, for nifedipine is 10 mg sublingually or orally every 20 min and for methyldopa is 200- 500mg orally every eight hours (White, 2006). Nursing management of eclampsia includes securing of a large bore intravenous line, initiation of mornitoring of cardiorespiratory status and administration of oxygen, transporting the patient to left decubitus position, initiation of airway support and termination of seizures. The patient must be monitored continuously. magnesim sulphate is the drug of choice for termination of seizures and lowering of blood pressure. Diazepam also can be given for control of seizuresThe loading dose of magnesium sulphate is 6 grams which must be adminstered ove 15- 20 minutes and thereafter, maintenance dose of 2g per hour must be administered as continuous infusion. However, it is important to give appropriate doses of the drug because magnesium toxicity can lead to coma. Hypertension usually settles down once seizures cease (White, 2006). The goals of management include control of seizures and seizure related morbidity, decrease in blood pressure, delivery of viable and health neonate and safe recovery of mother. Termination of pregnancy is the only definite for eclampsia. However, termination before 34 weeks of gestation is associated with high neonatal morbidity and mortality. Also, prior to delivery, patient must be stabilized. Stabilization includes control of fits, control of hypertension and hydration (White, 2006). In the postpartum period, magnesium sulphate must be continued and the patient must be monitored for onset of diuresis (White, 2006). Conclusion Eclampsia is an obstetric emergency demanding immediate attention for good outcomes. It is associated with high mortality and morbidity. While delivery is the only cure for eclampsia, nurses play an important role in stabilizing the patient. The goals of nursing intervention are safe and health outcomes for both mother and baby through control of seizures, oxygen therapy, hydration and control of hypertension. References ACOG (2002). Diagnosis and management of preeclampsia and eclampsia. ACOG practice bulletin, 33, 1-8. Jerry, S.E., Hockenberry, M.J., Lowdermilk, D.L., Wilson, D. , 2010. Pregnancy at risk: Gestational conditions. In Carter, R., and Gower, L.K. (Eds.), Maternal child nursing care (pp. 334-375). Canada: Mosby. White, A. (2006). Emergency Care of Postpartum Patients with Preeclampsia and Eclampsia. Advanced Emergency Nursing Journal, 28(3), 248- 257. Read More