INTRODUCTION:

Pre-eclampsia and eclampsia are the two forms of pregnancy induced hypertensive disorders which usually develops after 20^th week of pregnancy and mostly in multiparous women. Eclampsia is a serious form of preeclampsia, where a pregnant woman who does not have a history of epilepsy experiences convulsions and coma. These convulsions are thought to be caused by cerebral vasospasm and cerebral edema. Seven to fifteen percentage of pregnant women will develop preeclampsia and 1 to 3% will progress to eclampsia.

Eclampsia is one of the major causes for maternal and perinatal mortality and morbidity.

Deaths due to eclampsia commonly occurs in the younger age group of 19 to 24 years and in Primi-gravida women in Developing countries, are seven times more likely to develop Pre-eclampsia, three times more likely to progress to eclampsia and fourteen times more likely to die with eclampsia, compared to developed countries¹.

The risk factors of eclampsia include pregnancy during the teenage, primi gravidae, pregnancy after the age of 35, multiple pregnancy, diabetes, hypertension, kidney disease and history of vascular disease.

Except in rare occasions, an eclamptic client always shows premonitory symptoms like rapid deterioration in the condition of pre-eclampsia with severe hypertension over a short-period of time. The signs of impending eclampsia are – a sharp rise in B.P, severe, persistent frontal headache, drowsiness and confusion, visual disturbances, diminished urinary output with increased proteinuria and upper abdominal pain due to hepatic edema, nausea and vomiting. There is a constant threat of convulsion, cerebral hemorrhage, cardiac failure and placental abruption.

Convulsion in eclampsia has four stages-premonitory stage, tonic stage, chronic stage and coma stage. Convulsions occur commonly in the third trimester and rarely convulsions may occur in early months also. As such convulsions may occur any time during antenatal period, intra-natal period and postnatal period.

The diagnosis of eclampsia is associated with the presence of generalized edema, hypertension, proteinuria abnormal weight gain and convulsions. Though, hypertension is an important diagnostic feature of eclampsia, in 16% of cases, hypertension may be absent.

Pregnancies complicated by eclampsia are also associated with increased rates of maternal morbidities such as, abruptio placenta (7 to 10%), disseminated intravascular coagulation (7 to11%), pulmonary edema (3 to 5%), acute renal failure (5 to 9%), aspiration pneumonia (2 to 3%) and cardio pulmonary arrest (2 to 5%).

The reported perinatal death rate is related to prematurity, abruptio placenta and severe foetal growth restriction. The rate of preterm delivery is approximately 50% with approximately 25% of these occurring before 32 weeks of gestation.

Maternal mortality in eclampsia is very high in India and varies from 2 to 30% more in rural based hospitals than in urban. If treated early and adequately, the mortality will be even less than 2%. The perinatal mortality is very high to the extent of about 30 to 50%.

Calcium supplementation during pregnancy reduces the incidence of pre-eclampsia by as much as 64%. Low dose of aspirin supplementation during pregnancy reduces pre-eclampsia by 17%. In majority of cases, eclampsia is preceded by severe pre-eclampsia. Thus, the prevention of eclampsia depends on early detection and effective institutional treatment with judicious termination of pregnancy during pre-eclampsia. Prophylactic use of magnesium Sulphate lowers the risk of eclampsia².

Nursing Management:

Assessment:

· The patient with eclampsia may appear to cease breathing then suddenly take a deep stertorous breath and resume breathing and then may lapse in to coma, lasting for a few minutes to several hours.

· Systolic B.P. may increase to 180 to 200 mm of Hg.

· Marked edema on inspection.

· Obtain information of previous and present medical and obstetrical history.

· Assess the level of consciousness and orientation. Mental status deteriorates as the Preeclampsia progresses.

· Enquire about nausea, headache, visual disturbances or pain in right upper quadrant.

· Enquire about convulsions and coma.

· Check the weight every day at the same time to assess the fluid retention.

· Check B.P. on right arm both in supine and left lateral position and compare the readings to determine increasing trends.

· Auscultate the lungs to assess for pulmonary edema.

· Measure urine output hourly as the patient may progress to oliguria (urine output of 400ml / day or less, <30ml/hr).

· Oliguria may result in magnesium toxicity as the drug accumulates.

· Check the urine protein every 4 hours.

· Check for hyper reflexia, which indicates cerebral irritability.

· Absence of reflexes indicates CNS depression.

· Check for clonus bilaterally, by dorsiflexing the foot, which indicates CNS involvement.

· Perform vaginal examination to determine ripeness of the cervix, rupture of membranes, show etc.

· Place the patient on electronic foetal monitoring.

· Monitor the signs and symptoms of progressive disease and impending eclampsia like accelerating hypertension, headache, epigastric pain, nausea, visual disturbances, altered sensorium and increased bleeding tendencies.

· Assess for the signs of magnesium toxicity.

· Obtain laboratory data.

· Investigate how the family will function while the expectant mother is hospitalized.

· Determine how the woman is adopting to the sick role and the necessity of depending on others.

· Assess her ability to cope with disorder and how much social support is available and who is willing to participate in her care.

· Determine the major concerns of the family.

Nursing Diagnosis, Planning, Intervention and Evaluation:

1. Nursing diagnosis – High risk for seizures in pregnant women associated with decreased organ function.

Planning:

· Perform actions to lessen the risk for seizures

· Prevent maternal and foetal injuries if seizures occur

· Monitor the signs of impending seizures

· Psychological support to the woman and the family

Interventions:

Seizures will be precipitated by visual or auditory stimuli. Reduce external stimuli by:

Admiting the woman in a quietest room and keep the door closed, reduce the noise, apply eye pads, have optimum level of light in the room, block the incoming calls, no visitors, perform all the nursing care activities at one given time to give periods of undisturbed quietness, move calmly around the room.

Monitor B.P. every 4 hours, record the level of consciousness, assess for signs of impending eclampsia, monitor the signs of labour or uterine contractions, administer anti hypertensives as per the prescription.

Nurse the patient in a low level cot with side rails; pad the hard side of the rails, lock the wheels of the cot to prevent trauma during convulsions, keep the oxygen and suction equipment ready to use, maintain a patent I/V line preferably in a central vein, keep a tracheostomy tray ready, keep the supplies like a medium airway, ambubag with mask, endotracheal tubes in different sizes, ophthalmoscope, a tourniquet, reflex hammer, syringes and needles ready in a separate tray, keep medications like magnesium sulphate, sodium bicarbonate, heparin, epinephrine, phenytoin and calcium gluconate, keep the patient in left lateral position as much as possible, understand that the patient receiving magnesium sulphate will be lethargic.

During convulsions – remain with the woman and press the emergency bell for assistance, state the location, provide identity of the caller, give priority to prevent maternal injury and to support respiratory and cardiovascular functions, prevent serious maternal injury and aspiration, maintain maternal oxygenation; elevate the padded side rails of the bed during the convulsions; prevent tongue biting, turn the mother on her side when the tonic phase begins to improve the circulation through the placenta and to prevent the aspiration, note the time of onset of the seizures, progress, body involvement, signs of cyanosis and presence of incontinence at the time of cessation.

Suction the woman’s month and nose after the convulsion, maintain oxygenation by supplemental oxygen administration through the face mask during the convulsion, connect the patient to transcutaneous pulse oximeter, do not restrain the woman during the convulsion.

Observe foetal monitor patterns for non-assuring signs like bradycardia, tachycardia or decreased variability, which usually resolve as maternal oxygenation is restored, administer medications and prepare for additional medical interventions as directed by the obstetrician.

Explain to the family what has happened without minimizing the seriousness of the situation. Make them understand that the convulsion indicates worsening of the condition. Give emotional support to the patient and the family. Educate the family on the environment and care given in the NICU, as there are chances of delivering a premature baby.

Evaluation:

Deep tendon reflexes remains within normal limits of +1 to +3; The woman is free of visual disturbances, severe head ache and epigastric on right upper quadrant pain; remains free of seizures or free of preventable injury if a seizure occurs.

2. Nursing Diagnosis: High risk for fetal distress (Compromise/ non-assuring foetal heart rate) related to changes in the placenta:

Planning:

Monitor foetal heart rate; review the foetal growth; explain the signs of abruptio placenta; collaborate with the ultra sound and NST.

Interventions:

Monitor the foetal heart rate and notify the changes; assess the foetalgrowth to identify growth retardation; explain the signs of abruptio placenta like abdominal pain, bleeding, uterine tension, decreased foetal activity; use ultra sound and NST for continuous foetal heart monitoring; If the bradycardia or late decelerations persist beyond 10 to 15 minutes despite of all resussitative efforts, then diagnosis of abruptio placenta or non-reassuring foetal status should be considered.

Evaluation:

Foetal heart rate maintains at a normal range; no symptoms of abruptio placenta

3. Nursing diagnosis: Impaired sense of comfort (pain) related to uterine contractions.

Planning:

Relieve the pain and discomfort

Interventions:

Assess the patient’s pain intensity level; intervention depends upon the patient’s response to pain; explain the causes of pain to the mother to make her understand; teach deep breathing and relaxation techniques, which leads to vasodilatation and optional lung expansion; massage the painful areas; administer the systemic opioids or epidural anaesthesia as recommended.

Evaluation:

Pregnant woman understands the causes of pain; learns to adopt to the pain; intensity of pain reduces.

4. Nursing diagnosis: Risk of magnesium toxicity related to magnesium therapy.

Planning:

Monitor the signs of magnesium toxicity like nausea, feeling of warmth, flushing, double vision, slurred speech, muscular paralysis, respiratory arrest, absence of knee jerks and hypotension; consult the obstetrician; perform actions that minimize the magnesium toxicity.

Interventions:

Magnesium excess depresses the entire CNS including the brain stem, which controls respirations and cardiac function and the cerebrum which controls memory, mental process and speech. Discontinue magnesium if the respiratory rate is less than 12 breaths/mt, a low pulse oximeter level (<15%) persists or if deep tendon reflexes are absent; notify the physician; magnesium is excreted by kidneys and if the urinary output falls below 30 ml/hr, the physician should be notified. Calcium opposes the effects of magnesium at the neuromuscular junction. Magnesium toxicity can be reversed by slow intravenous administration of 1 gm (10ml of 10%) calcium gluconate at the rate of 1ml/mt.

Evaluation:

Respiratory rate remains at least 12 breaths /mt; deep tendon reflexes are present and maternal serum levels of magnesium remain within therapeutic range.

5. Nursing diagnosis: Excess fluid volume related to increased salt retention; impaired urinary elimination related to decreased renal function.

Planning:

Measures to improve the renal perfusion and to minimize the fluid retention and circulatory overload.

Intervention:

Catheterize the patient with Foley’s catheter and record the urinary output every hour; notify the physician if the urinary output is less than 30 ml/hr, Test the urine for protein, if it is more than 2 to 4 and the specific gravity is more than 1.40, suspect proteinuria and inform the physician. Haemodynamic monitoring with a central venous pressure catheter or a pulmonary artery catheter may be initiated to regulate the fluid balance. Prescribed diuretics should be administered in time, if there is pulmonary edema. Maintain strict intake and output chart, which aids in calculation of I/V fluids. At any cost, excess of I/V fluids should not be infused, as it leads to tissue over load. (There is intravascular dehydration and extra vascular over hydration). Check the weight daily or more frequently and notify, if it increases.

Evaluation:

Urinary output maintains above 30 ml/hr No increase in the weight and no symptoms of pulmonary edema.

6. Nursing diagnosis: Impaired nutritional status

Planning:

Maintain nourishment either by oral or parenteral supplements.

Interventions:

High protein and moderate sodium diet should be given if the patient is alert and is not sedated, if not maintain the nourishment through I/V fluids. Low salt diets are not indicated.

Evaluation:

Nutritional needs are met. Patient doesn’t show the signs of impaired nourishment.

7. Nursing diagnosis: Ineffective tissue perfusion – cerebral and peripheral related to arterial spasm and obstruction in the flow

Planning:

Reduce the hypertension by medical and nursing interventions.

Interventions:

Check the B.P. hourly, intimate the doctor about variation in it; administer the prescribed anti hypertensive drugs and sedatives; provide calm, quite and relaxing environment to soothen the patient and to curtail the emotional factors. Maintain the systolic B.P. between 140 and 160 mm of Hg and diastolic pressure between 90 and 110 mm of Hg. The rationale for keeping maternal B.P. at these levels is to avoid potential reduction in either placental blood flow or cerebral perfusion pressure.

Evaluation:

B.P. maintains in an acceptable range of 140 to 160 mm of Hg systolic and 90 to 100 mm of Hg diastolic. No signs of cerebral irritation.

8. Nursing diagnosis:

9. Activity intolerance related to altered function of body systems.

Planning:

Improve the activity level, minimize the activities.

Intervention:

Strict bed rest in the left lateral position. Allow long rest periods by completing all the nursing interventions at a time. Avoid visitors. Keep a calling bell near the patient. Maintain optimum nutrition level to maintain the energy levels.

Evaluation:

No exertion and tiredness.

9. Nursing diagnosis:

Anxiety and fear related to the outcome of pre-eclampsia and eclampsia. In effective coping related to the unexpected hospitalization.

Planning:

Reduce the anxiety and fear. Help the pregnant mother to cope up with the unexpected hospitalization.

Intervention:

Give a balanced explanation about the condition of the patient. Tell about the possible outcome of the pregnancy, introduce the health team members to eliminate the anxiety. Explain the procedures and their purpose. Inform about the possible symptoms like changes in the vision like blurring and blindness. Assure that these changes are reversible. Prepare her psychologically for premature delivery. Involve her in making the decisions about her treatment. Find out her worries about her family members, work, care of children, economic problems etc. Talk to the family members about these issues and see that the arrangements are made; inform her about this; be nonjudgmental.

Evaluation:

Mother understands the condition. Gets relieved form anxiety and tension. Copes up with the unexpected hospitalization.

Management during Postnatal Period:

Monitor vital signs; symptoms; intake and output for at least 48 hours. These women are at risk for pulmonary edema and exacerbation of hypertension during postnatal period. Continue parenteral magnesium sulphate for 24 hours after the delivery. Oral anti hypertensive drugs should always be continued.

CONCLUSION:

Eclampsia remains a major cause of maternal and fetal morbidity and mortality. The diagnosis needs to be considered in any patient more than 20 wks gestation with any suspicious features. Prompt recognition and appropriate management minimizes mortality and morbidity for both the mother and the child.

REFERENCES:

1. https://www.ncbi.nlm.nih.gov>articles

2. Myles ‘Text book of Midwifery’, 14^thedition, Churchill livingstone publication, pg no: 365-364.

3. D.C Dutta ‘textbook of obstetrics’, seventh edition, jaypee publications, pg no: 233-237

4. www.academia.edu

5. Annama jacob ‘A comprehensive Text book of Midwifery’ second edition, jaypee publications, pg no: 317-319

Received on 29.03.2018 Modified on 11.04.2018

Int. J. of Advances in Nur. Management. 2019; 7(3): 289-293

DOI: 10.5958/2454-2652.2019.00068.4