ACTION PLAN TO RECOGNIZE PREECLAMPSIA AND PREVENT ECLAMPSIA

R A C H E L W O O D A R D , M S N , R N C - O B

I O W A S T A T E W I D E P E R I N A T A L C A R E P R O G R A M

Iowa State Conference

October 26, 2015

DISCLOSURES

I have nothing to disclose that

would create a conflict of

interest

1)Analyze and

interpret patient

data from

selected case

study

2)Demonstrate the

application of a

preeclampsia tool

kit.

CASE STUDY

• 29 year old G3 P1 @ 29w6d

• History of chronic hypertension

• Previous OB history of preeclampsia

with severe features with NSVD

delivery at 35 weeks

PATIENT HISTORY

PLAN

• Discuss risk of developing PET

• Patient d/c labetalol continue 25mg Atenolol

• Monitor for growth restriction

• Continue ASA

• Weekly NST beginning at 32 weeks

• Delivery in the 39th week of gestation

Severe Nausea and Headaches, concerning for migraines

Plan:

-Use Fioricet PRN.

-previously referred to neurology for chronic management of headache.

PATIENT HISTORY

Obesity- Class 2 BMI 41 (201 lbs., 5ft2in)

Plan:

• recommend <15lb weight gain this pregnancy

• discussed importance of diet and exercise in pregnancy

PATIENT HISTORY

Solitary kidney

-s/p laparoscopic left nephrectomy in 2003

Plan

• Nephrology consult revealed a healthy kidney by both blood tests and US

• Baseline creatinine 0.9 - continue to monitor monthly throughout the pregnancy

PATIENT HISTORY

Depression/Anxiety

Herpetic Whitlow

Plan

• Continue Fluoxetine and Diazepam (previously counseled on risks)

• Referred to women's wellness clinic -continue mood checks

• Continue acyclovir 800 mg daily

PATIENT HISTORY

Palpitations

Subclinical hypothyroidism

Plan

• -EKG and Maternal echo WNL with EF 59%, normal LV wall thickness

• Cardiology diagnosed her with exercise intolerance. No clear etiology. Recommend blood pressure control at this time.

• TSH 3.18, was recommended to start Synthroid 50 mcg,

PATIENT HISTORY

Baseline studies

• 24 hour urine

protein 220mg

• AST/ALT 17/15

• HCT:39 Plt 282

• Cr.0.9

• Continue daily

prenatal vitamin

• Tdap vaccine to

be administered

between 27-36

weeks gestation

• Declined

influenza vaccine

PRENATAL CARE

PRENATAL VITALS WEIGHT AND ULTRASOUND RESULTS

Weeks Blood pressure Weight

7w1d 142/83 mmHg 91.4 kg

11w1d 147/89 mmHg no weight gain

14w3d 148/91 mmHg 91.8 kg

18w1d 143/91 mmHg 91.3 kg

20w1d 134/80 mmHg 91.9 kg

23w3d 122/67 mmHg, 93 kg , EFW:591gm (50%)

136/74 mmHg,

27w1d 139/98 mmHg 97.3 kg, EFW 959gms(41%)

Calls nursing triage with headache from sinus infection

Goes to Quick Care

• Has headache

• Right upper quadrant pain

• SOB

• B/P 180/120

Receives z-pack and albuterol inhaler

ARRIVES IN EMERGENCY DEPARTMENT

G3 P1

29w6d

• Acute Severe

URQ pain

• Head ache

• Blurred

vision

• SBP >200

Transferred to Labor and Delivery

Temp 36.5

HR 80

RR 20

B/P 191/118

TIME

1819

FHR

141

HR 67

B/P 196/97

MD called to bedside

BMTZ given

IV access obtained

Labs drawn

Headache

Blurred

vision

Agitated

FHR

141-

150

1834

1849

1902

40 sec

seizure

Patient rolled to right

side, oral suctioning

done O2 applied via

non re breather face

mask at 10L/min.

MD at bedside

Anes paged 911

Magnesium

Sulfate 4 gram

bolus

1908

60-70

• HR 84

• B/P 196/84

• 20 mg Hydralazine given IVP

Decision to not go to OR until FHR stable.

1922

Fetal heart tones 135 with minimal variability. Patient calm but

remains disoriented. HR 111, B/P 149/59

1925

75 sec

seizure

Patient rolled to right

side, oral suctioning

done O2 applied via

non re breather face

mask at 10L/min.

Magnesium

Sulfate 2 gram

bolus

1941

Primary LTCS

delivery

1026 gm male

Apgars 1,7.

Cord gases

art.6.92

venous 6.91.

EBL 1000.

BUNDLES AND TOOLKITS

HYPERTENSION AND PREECLAMPSIA

BUNDLE

Weeks Blood pressure

7w1d 142/83 mmHg

11w1d 147/89 mmHg

14w3d 148/91 mmHg

18w1d 143/91 mmHg

20w1d 134/80 mmHg

23w3d 122/67 mmHg

27w1d 139/98 mmHg

25mg Atenolol

Calls nursing triage with headache from sinus infection

Goes to Quick Care

• Has headache

• Right upper quadrant pain

• SOB

• B/P 180/120

Receives z-pack and albuterol inhaler

Sudden increase in

B/P

Headache, epigastric

pain, SOB

QUICK CARE ASSESSMENT

What is it

Why should you care

What should you pay attention to

What should you do if you have signs

Multiple teaching strategies

to accommodate a variety

of cognitive, psychological,

and physical factors that

affect learning

Messages need to be

repeated to be learned

PREECLAMPSIA EARLY RECOGNITION TOOL

C/O headache and blurry vision. Severe right upper quadrant

pain. Patient agitated. Labs : AST 74 ALT 40 HCT 36, PLT 215, PT 9 PTT

25 INR 0.9, CRT1.3.

HR 67, B/P 196/87

23w3d 122/67 mmHg, 93 kg ,

EFW:591gm (50%)

27w1d 139/98 mmHg 97.3 kg,

EFW 959gms(41%)

PREECLAMPSIA EARLY RECOGNITION TOOL

Second RN at bedside, MD called to bedside due to patient

c/o and blood pressure. In- person evaluation

ECLAMPSIA ALGORITHM

Call for help

Magnesium Sulfate 4-6 gram IV loading dose over 15-20 minutes followed by a 2 gram/hr maintenance dose

1.Position patient in left lateral decubitus positon

2. Establish open airway and maintain breathing

3. Check oxygen level

4. Check blood pressure and pulse

5. Obtain IV access: 1 or 2 large bore IVs

Patient begins to have seizure. Patient rolled to right side, oral suctioning done

o2 applied via non re breather face mask at 10L/min. Staff OB at bedside

anesthesia paged 911. Magnesium Sulfate started at 4 grams over 30 minutes

1908 vital signs HR 84, B/P 196/84

SEIZURE

If patient seizes again while on magnesium sulfate maintenance

dose

.Maintain airway and oxygenation

Give a 2nd loading dose of Magnesium sulfate 2 grams over

5 minutes.

Observe for signs of magnesium toxicity

Patient has another seizure that last75 sec. Interventions

done and 2 gm Magnesium bolus given.

RECURRENT SEIZURE AFTER 2ND LOADING DOSE

Re

cu

rre

nt

Se

izu

res

Midazolam

1-2 mg

Lorazepam

4mg

Diazepam

5-10mg

Phenytoin

1000mg

RESOLUTION OF SEIZURES

Maintain Magnesium Sulfate until 24 hours

after last seizure or after delivery, which ever is the

later

Assess for any signs of neurologic injury head

imaging should be considered if neurologic

injury is suspected

Once patient is stabilized preparations should e

made for delivery mode of delivery dependent upon

clinical circumstances

POST DELIVERY CARE TO SNICU AFTER DELIVERY INTUBATED X 24 HOURS.

Continue Magnesium at 2g/hr for 24 hours after delivery

HELLP labs q4 hours overnight

If altered mental status when extubated or persistent severe headaches, consider MRI head with flair to evaluate for PRES.

PRN Hydralazine or Labetalol for systolic >160, diastolic >110.

H/H in AM

Fundal checks per LDR nursing

OVERNIGHT IN SNICU

Overnight on POD#0

Hypotensive and hgb was found to be 7.4 from 12.3 pre-op.

Started on pressors and given 2 units of PRBCs with appropriate rise in Hgb.

0100 ICU MD notified that SBP 90 (91/45) fluid bolus given.

0215 BP continued to drop B/P 77/35, 75/54, 71/40

0340 OB contacted and at bedside due to abdominal distention and tenderness. SBP 80’s

Extubated on POD#1

On POD#2 a CT scan was performed with findings of a rectus sheath hematoma

which was managed conservatively and her hemoglobin was stable thereafter.

Transferred out of the SNICU on POD#3

required several BP medication changes and IV medications for severe range BPs.

On POD#4 she continued to have severe range pressures and renal was

consulted. Her BPs improved with medication changes

Discharged to home on POD#6 on lisinopril 5mg daily, atenolol 50mg BID and

HCTZ 25mg daily.

DISCHARGE INSTRUCTIONS

T Y P I C A L P E T S P E C I F I C

Need to include:

Monitoring B/P at home

Call MD for:

B/P>______

Severe HA or dizziness

Upper right quadrant pain

Visual changes

SOB

Weight gain more than 3lbs in 3days

Maurice L. Druzin, MD; Laurence E. Shields, MD; Nancy L. Peterson, RNC, PNNP, MSN;

Valerie Cape, BSBA. Preeclampsia Toolkit: Improving Health Care Response to Preeclampsia

(California Maternal Quality Care Collaborative Toolkit to Transform Maternity Care) Developed

under contract #11-10006 with the California Department of Public Health; Maternal, Child and

Adolescent Health Division; Published by the California Maternal Quality Care Collaborative,

November 2013. errata5.13.14