recoding a pregnant mother-Based case study. thai primegravida multpara.
This essay is about a process recording for a pregnant mother. Process recording is a written record of an interaction with a client. Pregnant mothers are in danger of any disease but there most alarming gestational diseases; these include hypertension, cardiac disease, anemia, diabetes, hyperemis gravidarum and many more. In this essay am only going to dwell in gestational hypertension.
This is a process recording of a case study of a pregnant mother. Mrs. B is a 16 years old primigravida at 30 weeks gestation and has attended the antenatal clinic three times. All finding were within the normal range until her last visit 1 week ago when her blood pressure was 130/90mmHg.On urinalysis there was no proteinuria. The fetal heart sounds were normal, the fetus was active and uterine size was consistent with dates. She has come to clinic today, as requested, for follow up. (www.reproline.jhu.edu/../05-CS-5.2.htm)
According to above case study a diagnosis of hypertension in pregnancy was made. Hypertension in pregnancy is defined as rise in the blood pressure above 130/90mmHg.It is also associated with increased level of protein in urine with or without oedema. Hypertension is mostly called disease of primigravida although it can also occur in multiparous or reoccur in cases where it was present in the 1st pregnancy. Risk factors of hypertension include family history of pre-eclampsia, long standing high blood pressure or kidney disease, pregnancy induced diabetes, auto-immune disease. Hypertension in pregnancy is divided into pre-eclampsia and eclampsia. In pre-eclampsia blood pressure is more than 130/90mmHg, proteinuria with or without oedema while eclampsia is high blood pressure of 130/90mmHg and above, convulsions, with or without proteinuria and oedema. Other signs and symptoms of hypertension includes; hyperreflexion, right upper quadrant pain (tense liver capsule), headache, blurring of vision. (Benson M.D)
The management of hypertension is basically focused towards lowering blood pressure. Mild preeclampsia (BP less than 160/100,no proteinuria, mild oedema),strict bed rest and encourage lying in the left side, check blood pressure 4 hourly if in hospital, daily weight and fetal heart tones check, urine protein measurement after 2 days. Induce labour if no improvement and fetus is term. May sedate with Phenobarbital 30mg 2 times per day. Severe pre-eclampsia (more than 160/100mmHg,proteinuria, oedema), admit, no added salt diet, convulsions precautions, examine eye grounds, daily weights check, BP check after 1-4hr,fetal heart tone recording at least daily. Place Foley catheter and monitor urine input-output chart. Do laboratory testing to evaluate severe hypertension. This includes testing for target organ damage, possible causes of hypertension, and other risk factors. Do urinalysis, full blood count and serum sodium, potassium, creatinine, and glucose levels. Other optional tests include uric acid, creatinine clearance, microalbuminuria, glycosylated hemoglobin, 24-hour urinary protein, serum calcium, thyroid-stimulating hormone, and an electrocardiogram. (Pritchard J.A, P.C MacDonald, and N.F Gant)
Routine tests for eclampsia include: full blood count, urine dip for protein, electrolytes, creatinine, liver enzymes and bilirubin, In full blood count, where platelet count is less than 150,000/µL, 75% are because of dilutional thrombocytopenia of pregnancy, 24% are due to preeclampsia, and about 1% of cases are due to other platelet disorders not linked to pregnancy. Platelets counts less than 100,000/µL suggest preeclampsia. Haemoconcentration is suspected when hemoglobin levels are greater than 13 g/dL while low levels may be as a result of microangiopathic hemolysis or iron deficiency. Urinalysis is used as a screen for proteinuria. Trace levels to +1 proteinuria are acceptable, but levels of +2 are alarming and should be quantified with a 24-hour urine collection or spot urine protein: creatinine ratio. Serum creatinine generally is less than 0.8 mg/dL during pregnancy; higher levels indicate intravascular volume contraction or renal involvement in preeclampsia. A serum uric acid level greater than 5 mg/dL is unusual, but unclear marker of tubular dysfunction in preeclampsia. (http://www.guideline.gov/summary/summary.aspx?doc_id=9338.)
High levels of hepatic trans aminases may be a sign of liver involvement in preeclampsia and may take place in the absence of epigastric pain. Higher levels of urine, more than 300mg/d are abnormal and may be a sign of renal involvement in preeclampsia. Creatinine levels less than 100 mL/min may be because of renal dysfunction that is either chronic or due to preeclampsia.
Imaging studies should not be done in an unstable patient and should not delay rapid facilitated delivery in a pregnant woman. A new convulsion in pregnancy is a sign of hypertension but primary neurological disorders must be excluded. Obtain chest x-ray to evaluate for pulmonary oedema if there is dyspnoea or hypoxia taking place in a woman with preeclampsia. The x-ray shows a diffuse increase in lung markings with no cephalization or vascular redistribution seen in patients with pulmonary oedema from systolic dysfunction. Computer topography scan of the brain is performed to rule out cerebral hemorrhage in case of convulsions, severe headache, or altered level of consciousness. Computer topography scan will show hypo dense areas involving white matter of occipital lobes and high frontal/parietal lobes in eclampsia. They signify focal and reversible areas of oedema that are the result of capillary leak or focal areas of impaired venous flow. (http://www.guideline.gov/summary/summary.aspx?doc_id=9338)
Magnetic resonance imaging of the brain may be done to assess for defects in the cerebral cortex such as hemorrhage, oedema, and infarction in preeclamptic women with convulsions, severe visual disturbance, or altered mental status. The result of preeclampsia is bilateral occipital bright spots that signify focal oedema (posterior reversible leukoencephalopathy syndrome). Result is the same as the changes observed when a non-pregnant patient has hypertensive encephalopathy. Computer topography scan or ultrasonography of the liver may be used to assess for sub-capsular hemorrhage or infarction in constant severe epigastric pain or distinctly elevated hepatic trans aminases. Echocardiography may be necessary to rule out left ventricle hypertrophy in chronic hypertension and cardiomyopathy or occult valvular disease in pregnant women with pulmonary oedema.
Other tests performed include; Electroencephalogram to assess recurrent convulsions activity, constant altered level of consciousness, or changed mental status. Fetal monitoring with the assistance of an obstetrician is necessary in pregnant women with preeclampsia.
Preeclampsia is a disease of the placenta, hence if the placenta is severely affected, subtle hypoperfusion of the fetus can occur, which may at first manifest as a reduced levels of the amniotic fluid, intrauterine fetal death, and fetal growth restriction as an effect of placental insufficiency. In sever hypertension; consider advising the obstetrician to obtain a fetal ultrasound at 18 weeks' gestation to document growth. Sequential ultrasounds may be essential to document fetal growth velocity and to monitor amniotic fluid volume. Histological findings indicate that incomplete decidualization of the spiral arterioles, which may be part of the pathogenesis of preeclampsia. The kidneys may show glomerular endotheliosis or, rarely acute tubular necrosis or cortical necrosis. (Chobanian AV, Bakris GL, Black HR,).
For treatment, give magnesium sulphate Intramuscular (load with 4-6g IV over 20 minutes and 4-5g IM, then 4g IM after 4 hours) or Intravenous (4-6g IV stat over 20 minutes, then constant infusion of 1-3g per hour in 100cc 5%dextrose). Hydralazine 5-10mg IV or IM after 2-4hours for blood pressure control. Complications include acute renal failure, malignant hypertension, disseminated intravascular coagulation, pulmonary oedema, cerebrovascular accident (Catherine Wolf, Dennis Palmer D.O)
In conclusion, all pregnant mothers should be closely monitored especially primigravidas because she might not be aware of the danger signs of pregnancy. Hypertension being among the most dangerous diseases in pregnancy so pregnant mothers are advised to visit clinics frequently in case they notice anything unusual. If possible, a pregnant mother should have weekly recording of blood pressure and for pregnant mothers already diagnosed with gestational hypertension should have daily recording of blood pressure. Gestational hypertension in most cases subsides after delivery but in some cases it extends after delivery. In such cases the mother should be thoroughly investigated…