Page 742 - ACCCN's Critical Care Nursing

Pregnancy and Postpartum Considerations 719

Clinical Presentation and Diagnosis specific sign of preeclampsia, though women who develop
The clinical presentation of preeclampsia is often subtle, non-dependent oedema, such as facial oedema, should
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resulting in delayed diagnosis and treatment. Common be investigated for evidence of preeclampsia. Common
symptoms include feeling ‘generally unwell’, headache, investigations include urea, creatinine and electrolytes,
heartburn, nausea and vomiting, and oedema; all non- full blood examination, liver function tests, serum uric
specific symptoms experienced by many pregnant women acid, spot urine protein/creatinine ratio and 24 hour
who do not have preeclampsia. Severe preeclampsia is urine collection. Additional tests, such as coagulation
associated with severe headache, hypereflexia, vision dis- studies, may be required as indicated by the clinical con-
turbances, severe epigastric pain, right upper quadrant dition. Intra-uterine fetal growth restriction is a sign of
pain and even blindness. There is also evidence of placental involvement (i.e. impairment) and investiga-
impaired systolic and diastolic myocardial function. tion into fetal wellbeing, including an ultrasound for
Diagnosis is made when the woman has hypertension fetal growth estimation and amniotic fluid volume, and
(BP ≥140/90), in association with evidence of multisys- umbilical artery Doppler flow patterns should be done
tem involvement (Box 26.2). Severe preeclampsia is diag- routinely following a diagnosis of severe preeclampsia.
nosed when the BP is ≥160/110, in association with The presentation of preeclampsia is usually restricted to
multisystem involvement. Additionally, eclampsia and women ≥20 weeks’ gestation unless they have a co-existing
HELLP syndrome are considered severe variants of pre- condition that is known to be associated with the <20
eclampsia even if the woman is normotensive. weeks presentation of preeclampsia including hydatidi-
form mole, multiple pregnancy, fetal triploidy, severe
This clinical diagnosis has replaced the traditional triad
of signs of hypertension, proteinuria and oedema, in maternal renal disease or antiphospholipid antibody
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accordance with the increased understanding of the mul- syndrome.
tisystem nature of the disease. Raised blood pressure is The old adage is that approximately one-third of eclamp-
commonly, but not always, the first sign of the condition. sia occurs during pregnancy, one-third during labour and
Although proteinuria is the most commonly recognised one-third postpartum; the UKOSS study found 45% of
additional feature after hypertension, it is not mandatory first eclamptic fits were during pregnancy, 19% during
to make a clinical diagnosis. Oedema is no longer a labour and 36% postpartum. The majority of post-
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partum eclampsia occurs in the first 48 hours, although
late-onset eclampsia may occur at two to three weeks
postpartum. Despite the nomenclature, eclampsia can
BOX 26.2 Diagnostic features of occur without any preceding signs and symptoms of pre-
preeclampsia eclampsia. In the UKOSS eclampsia study, only 38% of
women had established hypertension and proteinuria in
Hypertension ≥140/90 accompanied by one or more of the the week preceding the eclamptic fit and 21% of women
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following: had no sign or symptom prior to the first eclamptic fit.
l Renal involvement: HELLP syndrome commonly presents during pregnancy
l Significant proteinuria: dipstick proteinuria subsequently with about 30% postpartum. 78
confirmed by spot urine protein/creatinine ratio Most women admitted to ICU with a diagnosis of pre-
≥30 mg/mmol or >300 mg protein in a 24 hour urine eclampsia have usually delivered prior to transfer, and
collection require support for complications of preeclampsia, e.g.
l Serum or plasma creatinine >90 µmol/L acute renal failure, disseminated intravascular coagula-
l Oliguria (<500 mL/24 hours) tion (DIC), pulmonary oedema and fluid management.
l Haematological involvement Once the placenta is delivered, most women improve
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l Thrombocytopenia (<100 × 10 /L) within 24–48 hours, however, women with HELLP syn-
l Haemolysis drome may experience a worsening of condition in the
l Disseminated intravascular coagulation first 48 hours postpartum. Uncontrolled hypertension
l Liver involvement remains a major concern and is associated with cerebral
l Raised serum transaminases haemorrhage, one of the dominant causes of death in
l Severe epigastric or right upper quadrant pain. women with preeclampsia.
l Neurological involvement
l Convulsions (eclampsia) Management Priorities
l Hyperreflexia with sustained clonus
l Severe headache Women with mild preeclampsia at term may be managed
l Persistent visual disturbances (photopsia, scotomata, with induction of labour and delivery and experience few
cortical blindness, retinal vasospasm) complications. The management of women with severe
l Stroke preeclampsia is focused on stablising the woman’s condi-
l Pulmonary oedema tion, optimal timing of delivery of the baby (and pla-
l Fetal growth restriction centa) and preventing complications of the condition.
l Placental abruption Women with eclampsia and HELLP syndrome require
the same treatments as other women with severe pre-
Adapted from (66 and 71). eclampsia, even though they may or may not have the
same degree of hypertension. 69,79