Case Study of Chronic

Hypertension with
Superimposed
Preeclampsia
(Obstetrical Complex)
Submitted by:
Aira Marie N. Gonito BSN
2101

Presented To:

Ma’am Leonida Carolino

(Clinical Instructor)
I. Introduction
Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of
damage to another organ system, most often the liver and kidneys. Preeclampsia usually begins
after
20 weeks of pregnancy in women whose blood pressure had been normal. Left untreated,
preeclampsia can lead to serious — even fatal — complications for both you and your baby. If you
have preeclampsia, the most effective treatment is delivery of your baby. Even after delivering the
baby, it can still take a while for you to get better.

Hypertensive disorders of pregnancy, an umbrella term that includes preexisting and

gestational hypertension, preeclampsia, and eclampsia, complicate up to 10% of pregnancies and
represent a significant cause of maternal and perinatal morbidity and mortality. Despite the
differences in guidelines, there appears to be consensus that severe hypertension and non-severe
hypertension with evidence of end-organ damage need to be controlled; yet the ideal target ranges
below 160/110 mmHg remain a source of debate. The prevalence of hypertension in
reproductiveaged women is estimated to be 7.7%.

Preeclampsia is a pregnancy-specific syndrome that affects many organ systems and is

recognized by new onset of hypertension and proteinuria that occur after 20 weeks’ gestation. It is
estimated to complicate 2 to 8% of all pregnancies. Although the precise cause is unknown, the
pathophysiologic processes underlying this disorder are described in two stages. The first stage is
characterized by reduced placental perfusion possibly related to abnormal placentation with
impaired trophoblast invasion and inadequate remodeling of the uterine spiral arteries. The second
stage refers to the maternal systemic manifestations with inflammatory, metabolic, and thrombotic
responses converging to alter vascular function which can result in multi-organ damage.

Precise classification of the various hypertensive disorders of pregnancy has remained

challenging due to the changing nomenclature as well as the geographic variation in accepted
diagnostic criteria. For example, terms such as “toxemia” and “pregnancy-induced hypertension”
are now considered outdated. Furthermore, varying diagnostic criteria are used in different regions
of the world with disagreement regarding the degree of hypertension, presence/absence of
proteinuria, and classification of disease severity. These inconsistencies have led to challenges in
comparing and generalizing epidemiologic and other research findings.

The classification system based on the Working Group Report on High Blood Pressure in
Pregnancy is most commonly used in the United States in which four major categories are defined:
gestational hypertension, preeclampsia- eclampsia, chronic hypertension, and superimposed
preeclampsia on chronic hypertension. Preeclampsia is defined as new onset of sustained elevated
blood pressure (≥140mmHg systolic or ≥90mm Hg diastolic on at least two occasions 6 hours apart)
and proteinuria (at least 1+ on dipstick or ≥300mg in a 24-hour urine collection) first occurring after
20 weeks of gestation.
 As a leading cause of maternal mortality, preeclampsia and related hypertensive disorders of
pregnancy claim the lives of nearly 76,000 mothers and 500,000 babies worldwide every year. To
raise awareness about preeclampsia as a life-threatening complication of pregnancy, maternal
health organizations around the world are joining forces to host the first-ever World Preeclampsia
Day on 22 May.

II. Patient’s History

Name: B.M
Age: 41 years old
Sex: Female
Birthday: October 28, 1977
Address: San Benito, Lipa City

Obstetrical Findings:
G7P6 (6005) PU 31 47 weeks AOG
Not in labor, Chronic Hypertension with superimposed Preeclampsia elderly Grand multigravida

Present Illness

The client has preeclampsia as evidenced by 180/100 mmHg blood pressure and edema on
her ankles.

Past Health History

The client had hypertension since 2017.

Family Health History

There was nobody in the family who had cardiovascular, respiratory, neurologic and
metabolic disorder.

Maternal History

The client had her Last Menstrual Period last March 15, 2019. It is her seventh pregnancy
with all her children delivered in full term through normal delivery. Her first child was born on 2001,
her second child was born on 2002, her third child was born on 2004, her fourth child was born on
2006, her fifth child was born on 2008 and her sixth child was born on 2011. All of her children have
the same father.

Nutritional History

The mother was fond of eating snacks high in sodium and fat.
III. Physical Assessment

IV.
Part Method Use Findings

Skin Inspection Normal

Face Inspection Normal

Chest Inspection Normal

Abdomen Inspection Wound along the umbilicus

Upper limbs and extremities Inspection , Palpation Normal

Lower limbs and extremities Inspection, Palpation Edema in the ankle

Anatomy and Physiologyy

The external genitalia, also called the vulva, includes the mons pubis (a fatty mound which
covers the pubic bone), the labia majora (outer lips of the vagina), the labia minora (the inner lips of
the vagina), the vaginal opening, the urethral opening (opening of the urethra, a tube which carries
urine from the bladder outside of the body), the clitoris (a small structure with sensitive nerve
endings located within the labia minora, the sole purpose of which is for sexual arousal and
pleasure), and the perineum (the space between the anus (the rectal opening), and the vaginal
opening).

The internal reproductive anatomy includes the uterus, two ovaries, two fallopian tubes, the
urethra, the pubic bone, and the rectum. The uterus contains an inner lining called the
endometrium (which builds ups and sheds monthly in response to hormonal stimulation). The lower
portion of the uterus is called the cervix, which contains a small opening called the os. Menstrual
blood flows through the os into the vagina during menstruation. Semen travels through the os into
the uterus and the fallopian tubes following ejaculation during sexual intercourse. The cervical os
dilates (opens) during childbirth.

The ovaries, two small almond-shaped structures located on each side of the uterus, are the
female gonads (reproductive glands). Female babies are born with over 400,000 ova (the gametes,
also referred to as egg cells or oocytes), which are stored in the ovaries. The female body does not
produce any additional ova. The ovaries produce estrogen and progesterone. The ovaries are close
to,
but not actually connected to the fallopian tubes, thin tube-like structures that are the site of
fertilization, the fusion of the male and female gametes.
V. Pathophysiology
 Predisposing Factors
Predisposing Factors
- Age (41 y/o )
- High salt, high fat diet
- Past Health History HTN

Activation of
Sympathetic Nervous
System

- increased heart rate

-increased cardiac contractility

- produces widespread vasoconstriction in the

peripheral arterioles

Decrease renal
Endothelial damage Vasospasms
perfusion

Decrease uterine
Decrease N.O, decrease Juxtaglomerular cells
placental blood flow
Prostacylin, increase
Endothelin
renin
Premature delivery

Abnormal clotting
occurs

Angiotensinogen A-C-E Angiotensin I

 Increase Peripheral Arteriolar
resistance vasoconstriction Angiotensin II

-severe Adrenal Cortex

headache
Increase IOP - blurring of vision
Increase
ELEVATED BP - dizziness Aldosterone
Acute Cerebellar
Compression of
Hemorrhage - vomiting
brain
Increase Na
- loss of normal Reabsorption
balance

-muscle strength Increase H2O

reabsorption
-unable to sit
without support
VI. Laboratory and Diagnostic Procedures
 Test Result Reference Range

HEMATOLOGY
Complete Blood Count
ERYTHROCYTES 4.01 4.2 - 5.4
Hemoglobin 112 120 - 140
Hematocrit 0.335 0.38 - 0.47
LEUKOCYTE 10.30 4.5 - 11.0
Differential Count
Neutrophils 0.833 0.37 - 0.72
Lymphocytes 0.148 0.20 - 0.50
Monocytes 0.013 0.0 - 0.14
Eosinophils 0.005 0.0 - 0.06
Basophils 0.001 0.0 - 0.01
THROMBOCYTE 174 150.0 - 400.0
MCH 27.9 27.0 - 31.0
MCV 83.5 80.0 - 96.0
MCHC 0.33 0.32 - 0.36
RDW 14.5 11.5 - 14.5
MPV 10.6 RNF
Blood Typing
ABO TYPE “O”
RH TYPE POSITIVE

CLINICAL
MICROSCOPY

URINALYSIS
Physical Examination
Color YELLOW
Transparency SLIGHTLY TURBID
Chemical
Examination
Glucose NEGATIVE
Protein PLUS 2
Bilirubin NEGATIVE
Urobilinogen NORMAL
pH 6.5
Specific Gravity 1.020
Blood PLUS 2
Ketone PLUS 2
Nitrite NEGATIVE
Leukocyte PLUS 2
Microscopic
Examination
Pus Cells (WBC) 25-50
Red Blood Cells 25-50
(RBC )
Epithelial Cells MODERATE
Mucus Thread FEW
Bacteria FEW
Crystal NONE SEEN
Casts NONE SEEN
 RANDOM BLOOD 4.40 - 7.80
SUGAR
FASTING BLOOD 4.10 - 5.90
SUGAR

IX. Prognosis
Most women with mild preeclampsia have good pregnancy outcomes. Eclampsia is a serious
condition with about a 2% mortality (death) rate.

The recurrence risk for preeclampsia varies according to the onset and severity of the
condition. Women with severe preeclampsiawho had an onset of the conditionearly in pregnancy
have the highest recurrence risk. Studies show recurrence rates of 25% to 65% for this population.
Only 5% to 7% of women with mild preeclampsia will have preeclampsia in a subsequent pregnancy.

Preeclampsia typically goes away after the baby is delivered. Sometimes, blood pressure can
remain high for a few weeks after delivery, requiring treatment with medication. Your healthcare
provider will work with you after your pregnancy to manage your blood pressure. Patients with
preeclampsia, particularly those who develop the condition early in pregnancy, are at greater risk
for high blood pressure (hypertension) and heart disease later in life. Knowing this information,
those patients can work with their primary care provider to take steps to reduce these risks.

X. Discharge Planning
Medication

-Advise the patient to follow home medication as prescribed.

-Blood pressure medicine helps lower your blood pressure and protects your heart, lungs,
brain, and kidneys. Take your blood pressure medicine exactly as directed.

-Steroid medicine helps your baby's lungs develop. These may be given if you have to deliver
before 37 weeks of pregnancy.

-Low doses of aspirin may be recommended after 12 weeks of pregnancy if you are at high
risk for preeclampsia. Aspirin may help prevent preeclampsia or problems that can happen from
preeclampsia. Do not take aspirin unless directed by your healthcare provider.

-Take your medicine as directed. Contact your healthcare provider if you think your medicine
is not helping or if you have side effects. Tell him or her if you are allergic to any medicine. Keep a
list of the medicines, vitamins, and herbs you take. Include the amounts, and when and why you
take them. Bring the list or the pill bottles to follow-up visits. Carry your medicine list with you in
case of an emergency.

Exercise

-Encourage mild aerobic exercise

Treatment

-Inform the patient of fall and infection precautionary measures

Health Teachings

-Rest as directed. Your healthcare provider may tell you to rest more often if you have mild
symptoms of preeclampsia. You may need to be in the hospital if your condition worsens.

-Do not drink alcohol or smoke. Alcohol, nicotine, and other chemicals in cigarettes and
cigars, can increase your BP. They can also harm your baby. Ask your healthcare provider for
information if you currently drink alcohol or smoke and need help to quit. E-cigarettes or smokeless
tobacco still cont2ain nicotine. Talk to your healthcare provider before you use these products.

Outpatient

-Instruct patient’s family of follow-up check-up

-Give emphasis on family roles during medication administration

Diet

-Introduce soft diet

-ensure low fat and low salt diet

XI. Proposed Outcome and Recommendations

After 8 hours of nursing intervention the client will be able to have a normal Blood Pressure
of 120/80mmHg. Alleviate the pain she is having due to her headache. And have adequate rest,
enough to reduce stress during her pregnancy.

In areas where dietary calcium intake is low, calcium supplementation during pregnancy (at
doses of 1.5–2.0 g elemental calcium/day) is recommended for the prevention of pre-eclampsia in
all women, but especially those at high risk of developing pre-eclampsia.

Low-dose acetylsalicylic acid (aspirin, 75 mg) is recommended for the prevention of

preeclampsia in women at high risk of developing the condition.

Low-dose acetylsalicylic acid (aspirin, 75 mg) for the prevention of pre-eclampsia and its
related complications should be initiated before 20 weeks of pregnancy.

Women with severe hypertension during pregnancy should receive treatment with
antihypertensive drugs.

The choice and route of administration of an antihypertensive drug for severe hypertension
during pregnancy, in preference to others, should be based primarily on the prescribing clinician's
experience with that particular drug, its cost and local availability.
 Magnesium sulfate is recommended for the prevention of eclampsia in women with severe
pre-eclampsia in preference to other anticonvulsants.

Magnesium sulfate is recommended for the treatment of women with eclampsia in

preference to other anticonvulsants.

The full intravenous or intramuscular magnesium sulfate regimens are recommended for the
prevention and treatment of eclampsia.

For settings where it is not possible to administer the full magnesium sulfate regimen, the
use of magnesium sulfate loading dose followed by immediate transfer to a higher level health-care
facility is recommended for women with severe pre-eclampsia and eclampsia.

Induction of labour is recommended for women with severe pre-eclampsia at a gestational

age when the fetus is not viable or unlikely to achieve viability within one or two weeks.

In women with severe pre-eclampsia, a viable fetus and before 34 weeks of gestation, a
policy of expectant management is recommended, provided that uncontrolled maternal
hypertension, increasing maternal organ dysfunction or fetal distress are absent and can be
monitored.

In women with severe pre-eclampsia, a viable fetus and between 34 and 36 (plus 6 days)
weeks of gestation, a policy of expectant management may be recommended, provided that
uncontrolled maternal hypertension, increasing maternal organ dysfunction or fetal distress are
absent and can be monitored.

In women with severe pre-eclampsia at term, early delivery is recommended.

In women with mild pre-eclampsia or mild gestational hypertension at term, induction of

labour is recommended.

In women treated with antihypertensive drugs antenatally, continued antihypertensive

treatment postpartum is recommended.

Treatment with antihypertensive drugs is recommended for severe postpartum hypertension.

XII. References
Epidemiology of preeclampsia: Impact of obesity. Jeyabalan, A. 2014, October 01. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3871181/

Hypertension in pregnancy: Pathophysiology and treatment. Braunthal, S., Brateanu, A. 2019 April
10. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6458675/

Preeclampsia. 2018, November 16. Retrived from

https://www.mayoclinic.org/diseasesconditions/preeclampsia/symptoms-causes/syc-20355745

Preeclampsia during Pregnancy. 2019, September 24. Retrieved from

https://www.drugs.com/cg/preeclampsia-during-pregnancy-discharge-care.html

Preeclampsia:Outlook/Prognosis. (n.d). Retrieved from

https://my.clevelandclinic.org/health/disease/17952-preeclampsia/outlook-prognosis

Pregnancy: Preeclampsia and Eclampsia. Stoppler, M.C., Davis, C.P. 2018, September 05. Retrieved
from https://www.medicinenet.com/pregnancy_preeclampsia_and_eclampsia/article.html

Reproductive Anatomy and Physiology. (n.d). Retrieved from

http://www.columbia.edu/itc/hs/pubhealth/modules/reproductiveHealth/anatomy.html

WHO Recommendations for Prevention and Treatment of Preeclampsia and Eclampsia. (n.d).
Retrived from https://www.ncbi.nlm.nih.gov/books/NBK140555/

World Preeclampsia Day:Reducing Preventable Deaths From Preeclampsia. Tsigas, E. 2017, May 22.
Retrieved from https://www.mhtf.org/2017/05/22/world-preeclampsia-day-reducing-
preventabledeaths-from-preeclampsia/