PREECLAMPSIA - Nursing Case Study

Pathophysiology

• Primary mechanism: Abnormal placentation leads to impaired remodeling of uterine spiral arteries, resulting in high-resistance, low-flow circulation. This causes placental ischemia and release of antiangiogenic factors into the maternal circulation, contributing to endothelial dysfunction.

• Secondary mechanism: Endothelial dysfunction increases systemic vascular resistance and reduces nitric oxide production, leading to hypertension. The dysfunction also increases vascular permeability, causing proteinuria and edema as proteins and fluids leak into the interstitial space.

• Key complication: These changes can progress to multi-organ dysfunction, including renal, hepatic, and cerebral complications, increasing risks for both the mother and fetus. Early recognition and management are critical to prevent severe outcomes.

Patient Profile

Demographics:

32-year-old female, elementary school teacher

History:

• Key past medical history: Gestational hypertension in previous pregnancy, family history of hypertension

• Current medications: Prenatal vitamins, labetalol

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Severe headache and visual disturbances

• Key symptoms: Swelling in hands and feet, upper abdominal pain, nausea

• Vital signs: Blood pressure 160/110 mmHg, heart rate 92 bpm, respiratory rate 18 breaths per minute, temperature 98.6°F

Section 1

As the healthcare team continues to monitor the 32-year-old patient, further assessments reveal increasing severity of symptoms that warrant immediate attention. Upon initial evaluation, the nurse notes that the patient's edema has become more pronounced, extending from her hands and feet to her face. Additionally, the patient reports escalating intensity of the headache, now accompanied by a sensation of "flashing lights" in her vision, which raises concerns about potential neurological involvement. Fundoscopic examination reveals mild retinal hemorrhages, suggesting possible cerebral involvement.

Laboratory results return, indicating worsening proteinuria with a 24-hour urine collection showing 5 grams of protein, confirming significant renal impairment. Liver function tests reveal elevated transaminases (AST 85 U/L, ALT 95 U/L), suggesting hepatic involvement. Furthermore, her platelet count has dropped to 95,000/mm³, raising suspicion for HELLP syndrome, a severe variant of preeclampsia characterized by hemolysis, elevated liver enzymes, and low platelets.

These findings prompt an urgent multidisciplinary discussion about the need for more aggressive management. The obstetrician recommends close fetal surveillance, given the increased risk of placental insufficiency and fetal distress. Considering the patient's deteriorating condition and the risk of progression to eclampsia or other severe complications, the team contemplates the balance between prolonging the pregnancy for fetal maturity and the necessity of early delivery to prevent further maternal harm. This scenario underscores the importance of timely intervention and the need for careful monitoring of both maternal and fetal well-being as the patient's clinical picture continues to evolve.

Section 2

As the healthcare team closely monitors the patient's condition, a sudden change in her status demands immediate action. During a routine examination, the patient becomes increasingly agitated and confused, displaying signs of disorientation. Her blood pressure has spiked to 180/110 mmHg, a significant increase from previous readings, indicating a potential progression towards eclampsia. The nurse notes that the patient's reflexes have become hyperactive, with clonus observed upon examination, further raising the alarm for imminent seizure activity.

In response to these critical developments, the team initiates magnesium sulfate therapy to prevent seizures, closely monitoring the patient for any signs of toxicity, such as decreased deep tendon reflexes or respiratory depression. The patient is placed on continuous electronic fetal monitoring to assess for any signs of fetal distress, which could necessitate an urgent delivery. Despite the magnesium sulfate administration, the patient's condition remains precarious, and the decision is made to transfer her to the intensive care unit for closer surveillance and more aggressive management.

Throughout this period, the team remains vigilant, balancing the need to stabilize the mother with the potential risks to the fetus. Discussions continue regarding the timing of delivery, weighing the benefits of extending the pregnancy for fetal lung maturity against the increasing risk to the mother. The obstetrician, alongside the neonatologist, prepares for a possible preterm delivery, ensuring that all necessary resources are in place to provide immediate care to the newborn if required. This evolving situation highlights the critical need for ongoing assessment and rapid adaptation of the care plan based on the patient's dynamic clinical status.

Section 3

The patient's condition continues to evolve as she is closely monitored in the intensive care unit. Despite the initiation of magnesium sulfate therapy, she remains at high risk for further complications. Her vital signs are reassessed, revealing a persistent elevation in blood pressure at 185/115 mmHg. The nurse notes an increased respiratory rate of 24 breaths per minute, and her oxygen saturation has dropped to 92% on room air, prompting the application of supplemental oxygen. Auscultation of lung sounds reveals fine crackles at the bases, which raises concern for pulmonary edema, a known complication of severe preeclampsia.

A new set of laboratory results arrives, providing additional insight into the patient's condition. Her serum creatinine has risen to 1.6 mg/dL from a baseline of 0.8 mg/dL, indicating potential renal impairment. Liver function tests are also abnormal, with elevated AST and ALT levels of 95 U/L and 100 U/L, respectively, suggesting liver involvement. Proteinuria remains significant, with a 24-hour urine collection showing protein levels of 5 grams, further confirming the severity of her preeclampsia. The healthcare team must now consider the implications of these findings, balancing the need for aggressive treatment with the potential risks of further deterioration.

As the patient remains at a critical juncture between maternal stabilization and fetal safety, the decision is made to administer corticosteroids to enhance fetal lung maturity, anticipating the possibility of preterm delivery. The team continues to evaluate the patient's response to ongoing interventions, ready to adapt the treatment plan as necessary. The obstetrician and intensive care specialists consider the timing of delivery, weighing the potential benefits for the fetus against the increasing threat to the mother's health. With the patient's condition remaining unstable, the team prepares for various scenarios, ensuring that both maternal and neonatal resources are readily available for any emergent developments.

Section 4

As the healthcare team continues to monitor the patient closely, a new complication arises that demands immediate attention. Despite the ongoing administration of magnesium sulfate and other supportive measures, the patient begins to exhibit signs of deteriorating neurological status. She complains of a persistent headache that has intensified over the past hour and now rates as a 9 out of 10 in severity. Additionally, she reports visual disturbances, describing seeing flashing lights and blurred vision, which are concerning for worsening cerebral edema or impending eclampsia.

Recognizing these alarming symptoms, the team acts swiftly to reassess the patient's neurological status. On examination, the nurse notes that the patient is increasingly lethargic and responds sluggishly to verbal stimuli. Her deep tendon reflexes are brisk, a change from the previous assessment, and she now demonstrates clonus, indicating heightened neuromuscular irritability. These findings strongly suggest a progression towards eclamptic seizures, necessitating urgent intervention to protect both the mother and the fetus.

In response to the escalating situation, the team reevaluates the treatment plan. Additional antihypertensive therapy is considered to achieve more effective blood pressure control, while the magnesium sulfate infusion rate is reassessed to ensure therapeutic levels are maintained to prevent seizures. The obstetrician consults with the neonatology team, preparing for the possibility of expedited delivery if maternal stabilization efforts prove insufficient. With the patient teetering on the brink of a critical event, the healthcare team remains vigilant, ready to implement advanced life support measures and ensure the availability of comprehensive neonatal care should the need arise.

Section 5

As the healthcare team intensifies monitoring efforts, a new set of diagnostic results provides further insights into the patient's condition. Laboratory tests reveal significant proteinuria with a urine protein-to-creatinine ratio exceeding 0.3, consistent with severe preeclampsia. Her liver function tests show elevated liver enzymes, with AST and ALT levels rising to 75 and 80 IU/L, respectively, suggesting hepatic involvement. Additionally, a complete blood count indicates a drop in platelet count to 95,000/mm³, raising concerns about the possibility of HELLP syndrome, a severe form of preeclampsia that necessitates immediate action.

These alarming laboratory findings prompt the team to reassess the balance between maternal and fetal risks. The patient's blood pressure remains elevated at 170/110 mmHg despite ongoing antihypertensive therapy, indicating the need for additional or alternative medications to achieve better control. Given the potential for rapid deterioration, the obstetrician considers the risks and benefits of immediate delivery, especially as fetal heart rate monitoring begins to show signs of distress, with late decelerations suggestive of uteroplacental insufficiency.

In light of the evolving clinical picture, the healthcare team prioritizes stabilizing the mother while preparing for potential delivery. Magnesium sulfate infusion is carefully titrated to maintain therapeutic serum levels, and intravenous labetalol is administered to address the refractory hypertension. The interdisciplinary team maintains constant communication, ensuring that all necessary resources and personnel are ready to support both a safe delivery and prompt neonatal care. This coordinated effort is crucial as the patient navigates this critical phase, with every decision made to maximize outcomes for both mother and child.