Predicting the True Cause and Occurrence of Preeclampsia - Term Paper Example

? Preeclampsia      Summary Introduction: Preeclampsia common maternal condition, which is presents high blood pressure in the second or third trimester of the gestational period. The characteristic HBP is accompanied by presence of proteins in urine. It is thus exclusively problem of pregnant women, but it could also affect those in the postpartum period. Diagnosis: The diagnosis of the condition is done by blood pressure measurements. Two separate HBP measurements in a six-hour period is an indication of preeclampsia. The readings have to be at least above 90 for diastolic pressure and more than 140 for systolic pressure for a confirmation of the condition to be made. The HBP readings should at least be accompanied by a confirmatory test of 300 milligrams of protein in urine. As the condition gains severity other symptoms and signs may manifest, and the pressure may reach 160/100. According to evidence based practice these indications do not automatically guarantee the existence of the condition and a measure on platelets has been proposed as a more effective measure (Ekiz et al., 2011). MPV count, which is a platelet measure in predicting the occurrence of preeclampsia is an aspect under debate. This can be seen in the work of Dadeszen who said that the platelet ratio in MPV is more sensitive compared to MPV alone for predicting the adverse maternal outcome related to preeclampsia (Von Dadelszen et al., 2004, p 871-879). Dundar et.al, on the other hand, shows that MPV increases during pregnancy, but is highly prominent during preeclampsia development (Dundar et al., 2008, p 1052-6). As such, MPV provides a good diagnosis tool for the condition. The evidence-based proposal on diagnostics thus implies that MPV is a better measure. This is also cited as a better measure of the condition’s progression-a thing that the other diagnostic measures cannot offer. The evidence-based practice using MPV as a diagnostic measure for the condition is already in clinical practice and has offered a better tool for monitoring the condition. However, it is not widely applicable globally in clinical diagnostics practice. Symptoms: Symptoms of preeclampsia could include irritability, edema, and sudden increase in weight, nausea, decreased urination, belly pain and migraine-like headache. Causes and risk factors: Preeclampsia’s causes are not clearly known, but there are various propositions that point to various probable causes, which include heredity, blood vessel problems, dietary effects and disorders of the autoimmune system. Factors that predispose pregnant mothers to the problem include advanced age (>35 years), kidney diseases, multiple and first pregnancies as well as pre-existent conditions such as diabetes mellitus and hypertension. Pathogenesis: The etiology of preeclampsia and its development are inconclusive. There is some uncertainty with regard to the development and progression of the condition. However, there is potential explanation on the mechanism of preeclampsia. According to David, Laresgoiti-Servitje and Gomez-Lopez (2010), the limitation of blood flow in placenta is cited as a possible trigger for hormone-based reactions, which cause damage to endothelium that lines the vascular system as well as inflammation that characterizes the condition. Alternative explanations from other studies show that alterations in the immune system and maternal. This research-based proposition is supported by evidence, which shows that shifts occur in the immune system in terms of component cells when the condition occurs. Alterations of allorecognition of the fetus have also been cited as a potential causes of inflammation that accompanies preeclampsia (Fonseca et al., 2007). Management and Treatment: The management of preeclampsia heavily relies on a pharmacologic approach aimed at controlling blood pressure levels (Drife, Magowan & Owen, 2009). This is the current common evidence-based clinical practice that is often put to use in the control of preeclampsia. The aim is to keep high blood pressure below 110 mm Hg (diastolic) and 180 mm Hg (systolic). The use of magnesium sulphate, which works as an anticonvulsant in the prevention of seizures that may occur in preeclampsia is also part of the pharmacologic approach in such cases (Pennington et al., 2010). The patients should further be advised to minimize the intake of fluids. The physicians and nurses should also closely monitor the patient regularly before her health status can deteriorate rapidly. In other cases, the doctor may prescribe drugs such as beta-blockers to reduce hypertension. Maternal vital signs should be strictly monitored as well as the heart rate of the fetus. The mental status of the mother should also be assessed regularly. Serial laboratory tests should be conducted, including the collection of urine to test proteinuria and creatinine clearance (Drife et al., 2010). Delivery is considered the ultimate solution for preeclampsia. This is due to the need of the mother to deliver safely. After delivery, the preeclampsia manifestations rapidly resolve. The patient is required to rest in bed and take food rich in calcium (Von Dadelszen et al., 2004). This will help in reducing the risks associated with preeclampsia. When the patient’s health becomes unstable, many hospital facilities provide expectancy management such as caesarean section when preeclampsia becomes severe and uncontrollable. The patients with preeclampsia should be advised to take a sodium restricted diet. Additionally, they should be advised to take food, such as, vegetables, cabbage, and bananas. The patient is advised to lie on the left lateral position. The environment has to be favorable and quiet with limited visitors (Fonseca et al., 2011). The above practices currently form the bulk of clinical management and treatment options, and they supported the cited respective evidence-based studies. Abstract Preeclampsia is a condition that affects pregnant women. The condition is characterized by high blood pressure and the presence of protein in urine. The condition commonly occurs in the third trimester of pregnancy. Preeclampsia leads to several neonatal and maternal adverse effects. Severe preeclampsia takes place when the systolic blood pressure goes up to 160 mm Hg and diastolic pressure reaches 100mmHg. Moderate preeclampsia, on the other hand, occurs when there is 140mmHg (systolic) by 90mmHg (diastolic). The most common severe effects of preeclampsia included preterm delivery and retarded growth for the fetus. The risk factors to preeclampsia are well known, but the exact predictor of this condition are not well understood. There is conflicting information and data that shows the existence of multiple predictors. Part of this information relates to the mean platelet value (MPV) indicating the presence of platelet ratio. This paper will present the signs, diagnosis, symptoms, pathophysiology and treatment of preeclampsia. The presentation considers its risk factors by use of MPV. The first part of the paper will examine the evidence –based guidelines for nursing practice from various scholarly sources on Preeclampsia in the form of a literature review. The second part is on the disease process. This research will help in educating other nurses on the management of patients with preeclampsia. Preeclampsia Preeclampsia, alternatively referred to as toxemia, is initiated either by the fetal system, or the maternal system. It is a syndrome that occurs during pregnancy, and it is characterized by the onset of hypertension and occurrence of proteinuria. It is a condition that affects the placental and hinders the growth of the fetus. The condition poses an obstetrical challenge that contributes to neonatal and maternal mortality and morbidity (Preeclampsia foundation, 2012). The common effects of preeclampsia are hypertension, high density lipo-protein (HDL) or low density lipo-protein (LDL). The adverse effects of this condition on the unborn include retarded growth and premature birth. Severe preeclampsia is characterized by a high rate of stillbirths (Fonseca et.al., 2007, p 462-469). The common risk factors of preeclampsia include nulliparity, stress, high blood pressure, lifestyle habits, advanced age, family history, self history diabetes mellitus, and lack of prenatal ultrasound check ups. Though most studies have examined preeclampsia and its causes, the method of prevention and treatment as well as its pathogenetic mechanism are not well-known. It is necessary to know how to predict the severity of this disease in order to prevent neonatal and maternal complications. This is because there is a high rate of morbidity and mortality in severe preeclampsia compared to its mild form. Overview of the Problem Preeclampsia occurs within 20 weeks of pregnancy and can manifest as late as four to six weeks before delivery. The condition can be accompanied by pathologic edema, but this may at times no appear. Research shows that in the United States, there are about 2% to 6% incidences of preeclampsia among healthy women. According to the estimations one in every 12 pregnant women is likely to be affected by preeclampsia (Preeclampsia foundation, 2012). Over 50,000, women die of preeclampsia. In the United States, preeclampsia is among the leading causes of prenatal and maternal death. Approximately 5% to 8% of American women are affected by preeclampsia (Newstead et. al., 2007). The diagnosis of preeclampsia is often done when hypertension is detected during pregnancy. The detection of proteinuria is also a reason to elicit a diagnostic procedure to determine whether the involved expectant mother has developed preeclampsia. The onset of proteinuria and hypertension is characterized by vasoconstriction, systematic endothelial dysfunction, and reduced organ performance in organs such as the kidney. Early deliveries as a result of preeclampsia in 2008 were approximately, 12.3% in the United States, which indicates increases by 20% from 1990 (Hamilton et al., 2006). There are various well known risk factors to preeclampsia. These include the presence of diabetes mellitus, hypertension before pregnancy, advanced age, obesity, and nulliparity as well as family history, and self history of preeclampsia. These are the well known factors that contribute to preeclampsia. Though this paper presents a discussion on preeclampsia and the pathogenesis of this condition, its exact treatment and prevention as well as pathogenesis mechanisms are still not well understood. This results from the fact that preeclampsia has various supposed causes. As such, there is need for further research that can develop understanding of the condition and appropriate methods of treatment. The condition is akin to heart failure and cancer, which are caused by a combination of various aspects. The increasing rate of morbidity and mortality because of severe preeclampsia, elicits the need to predict the severity of the disease progression so as to prevent both neonatal and maternal complications because the causes are not clear, and therefore, comprehensive prevention cannot be tailored. The analysis of platelets provides a significant mode of monitoring the progression of the condition. Platelet function is marked by the Mean platelet volume (MPV) through the analysis of the whole blood count. Many physicians in their daily practice, however, tend to take less consideration of to the values from MPV in platelet count (Pennington et al., 2012, p 9-18). A slight increase in platelet aggregation found in normal pregnancies, according to a common belief is replaced with an increase in platelet synthesis. This involves the sensitivity of MPV marker more than the platelet counts in defining these changes at an early stage (Ekes et al., 2011, p 162-165). Recent studies have indicated that the increase of MPV causes severe inflammation such as chronic hepatitis B, rheumatoid arthritis, Crohn’s diseases, myocardial infarction and metabolic syndrome (Y?uksel et al., 2009, p. 281). The same effect is anticipated in the case of preeclampsia. The use of MPV in the prediction of severe preeclampsia has been shown through various conflicting data. Prediction of severe preeclampsia, on the other hand, is necessary because of the high incidence of mortality and morbidity rate. The paper will show the risk factors of preeclampsia and the likely role of MPV values in the prediction of the severity of preeclampsia. Part I Literature Review The emergence of hypertensive complications in pregnant women is due to severe systolic BP of more than 160 mm Hg and severe diastolic BP of more than 110mm Hg. This can last for over 15 minutes. In these patients, severe systolic hypertension will act as a vital predictor of infarction and cerebral hemorrhage and if not immediately treated it can cause maternal death. In the clinical setting, the first-line drugs used for the management of severe and acute hypertension in preeclampsia include hydralazine and intravenous labetalol. The nursing staff and the physician should monitor closely the fetal and maternal condition. The emergence of severe hypertension can be treated with the use of hydralazine and labetolol in pregnant women with preeclampsia. Nurses are required to ensure risk reduction so as to achieve successful and safe clinical outcomes and management among these patients. Their main goal should be to avoid the progression of this condition from becoming severe preeclampsia or even eclampsia. The current challenge that nurses and physicians face in the United States is to integrate a standardized set of orders in the daily practice aimed at providing safe and successful care to women with preeclampsia. Evidence shows that patient’s outcomes are greatly improved with the provision of standardized care (Kirkpatrick & Burkman, 2010). A standardized obstetric practice and clinical guidelines based on evidence in patients with eclampsia and preeclampsia management has shown a reduction of incidence related to adverse maternal cases (Menzies et. al., 2007, p 121-7). The nurses are also required to provide antihypertensive therapy whenever there is an onset of severe diastolic or systolic hypertensions to postpartum or pregnant women. Their main goal will not be to normalize blood pressure but to stabilize BP at a range of 140–160/90–100 mmHg. This will mean that prolonged and repeated occurrence of severe hypertension in patients is prevented. The nurses should first make the patients stable before delivery even in critical condition (Lyons, 2008). The nurses are responsible for providing education programs for patients in their health facilities so as to address the aptitude and cultural diversity in relation to preeclampsia. Through an informative approach, they should educate patients. Evidence indicates that through ongoing preeclampsia support and prenatal patient education, such as through credible online resources and support groups, reduced anxiety, improved health outcome, and increased compliance among patients with preeclampsia has been attained. Section 11 Preeclampsia Disease Process Preeclampsia complicates about 10% of most first pregnancies. The condition is rare before 20 weeks of gestation and many cases occur towards the end of pregnancy between week 38 and 40. Despite the many proposed theories and investigations, the etiology of preeclampsia is poorly understood. However, what is known concerning preeclampsia is that its process is likely to start towards the end of gestation. This has been determined through autopsy research done on women whose death is a result of preeclampsia. These studies, have proven that throphoblastic implementation in the maternal endometrium does not take place in the normal way among the affected. Particularly, these studies showed that the interface between fetal and maternal circulatory system among women with preeclampsia is less intensive compared to those who do not have the condition. Various preeclampsia manifestations are perceived to be related to the placenta’s ischemia. Still, much has to be done to understand the process and its causes. There is also need to understand the manifestation of placental ischemia and the way it happens (Olson & Laresgoiti-Servitje, 2010, p 510–534). . Pathophysiology Preeclampsia occurs during the second half of gestation, and it is a multisystem disease. This condition is characterized by endothelial damage and diffuse vasospasm at a pathophysiological examination. The affected organs pathology shows, micro-hemorrhage, micro-infarctions, endothelial swelling, and edema. The affected organs mainly include the heart, lungs, liver, brain, ankle, and kidney (Copstead & Banasik, 2010). Preeclampsia, just like other hypertensive disorders during pregnancy, shares the common theme of high blood pressure resulting from vasoconstriction. The physiological derangements of preeclampsia are the disseminated or local intravascular coagulation, intense vasospasm, and the contraction of plasma volume. The common disorder found in preeclampsia involves the enlargement of the placental mass such as abnormal or twin placentae. The modern hypotheses on the cause of this disorder are that a toxic factor is released from the placenta, leading to the alternation of the functions of maternal endothelia cells (David, Laresgoiti-Servitje & Gomez-Lopez, 2010). This hypothesis is however, not proven. The sensitivity of vasoconstrictors such as, endothelia, serotonin II, and angiotensin II lead to vasospasm. These vasoconstrictors hormones are released in large quantities leading to the decreased sensitivity and production of vasodilators. The vasolidators are the nitric oxide and prostacyclin. Platelet activation and thrombocytopenia result to intravascular coagulation. This is because of the low production of anti-thrombin III. The contraction of plasma volume is then followed by capillary leakage, vasospasm, and reduced pressure in plasma in severe cases (Drife, Magowan & Owen, 2010). There is also fluid redistribution in the intravascular to the interstitial fluid regions, but the volume of the intravascular volume will remain unchanged. The correction of intravascular volume may result to pulmonary edema whenever there is a high capillary permeability and a low pressure of the plasma oncotic. This cycle of abnormal physiology result to organ hypoperfusion. The most affected organs are the kidney, liver, brain and the placenta. These effects can cause death (David et al., 2010). Signs and symptoms The main symptoms and signs of preeclampsia include severe persistent headaches, poor clarity of vision, rapid weight gain, edema, discomfort and lack of concentration. The patient can also experience vomiting and nausea. The headache experienced is by nature migrainious. Poor vision clarity due to preeclampsia is due to scotomas and scintillations, which are considered to be advanced cerebral vascular spasms. The epigastric discomfort experienced is as a result of liver enzymes abnormality to a certain degree. Approximately 30% of pregnant women develop edema. This makes edema not to be a differential diagnostic consideration. However, it can be considered when it is accompanied by swelling in non-dependent areas like the face and hands and also when it is accompanied by rapid gaining of weight (Drife et al., 2010). The signs of preeclampsia include hand and facial edema, retinal vasospasm, tenderness of the hepatic quadrant and hypertensions. Hypertension is characterized by sustained elevation of blood pressure of more than 140/90. This is a necessary element in preeclampsia manifestation but not all patients experience hypertension. The tenderness of the right upper quadrant is highly complicated (Drife et al., 2010). The tenderness is caused by the stretching of the capsular of the liver because of edema. This calls for the need to examine the liver whenever one suspects the development of preeclampsia. This is because a swollen liver due to preeclampsia effects places a major risk to the patient resulting from hepatic rupture and hemorrhage. From the funduscopic examination, retinal vasospasm can be determined by the narrowing segments between the arterial vessels. Hemorrhages, retinal edema, and detachment of exudative retinal are also seen among preeclampsia women. The irritability of the central nervous system is mainly determined by colonus but should not be diagnosed excessively (Drife et al., 2010). This is because some women have been found to have highly brisk reflexes, therefore, a patient should only be said to have an abnormal deep tendon reflex when there is a demonstration of three beats of colonus. Elevated enzymes in the liver are a vital sign of preeclampsia. Decreased fetal growth is an adverse effect of preeclampsia. This condition is known as the intrauterine growth retardation. The condition causes a decreased level of amniotic fluid and placental abruption. These complications come after the preeclampsia’s clinical manifestations are shown by the mother. Diagnosis Preeclampsia consists of edema, and proteinuria but none of this aspect is the guaranteed element for diagnosis. This is illustrated by the occurrence of ecliptic seizures in both the patients with or without hypertension or in patients without proteinuria. Therefore, preeclampsia diagnosis should consider various elements before clear manifestation can be declared (Shaker & Shehata, 2011, p 539-44). MPV count in predicting the occurrence of preeclampsia is an aspect under debate. This can be seen in the work of Dadeszen who said that the platelet ratio in MPV is more sensitive compared to MPV alone for predicting the adverse maternal outcome related to preeclampsia (Von Dadelszen et al., 2004, p 871-879). Dundar et.al, on the other hand, shows that MPV increases during pregnancy, but is highly prominent during preeclampsia development (Dundar et al., 2008, p 1052-6). As such, MPV provides a good diagnosis tool for the condition. Treatment The pharmacologic treatment of preeclampsia involves the use of magnesium sulphate, which works as an anticonvulsant in the prevention of seizures. The aim is to keep high blood pressure below 110 mm Hg (diastolic) and 180 mm Hg (systolic). The patients should further be advised to minimize the intake of fluids. The physicians and nurses should also closely monitor the patient regularly before her health status can deteriorate rapidly. In other cases, the doctor may prescribe drugs such as beta-blockers to reduce hypertension. Maternal vital signs should be strictly monitored as well as the heart rate of the fetus. The mental status of the mother should also be assessed regularly. Serial laboratory tests should be conducted, including the collection of urine to test proteinuria and creatinine clearance (Drife et al., 2010). Delivery is considered the ultimate solution for preeclampsia. This is due to the need of the mother to deliver safely. After delivery, the preeclampsia manifestations rapidly resolve. The patient is required to rest in bed and take food rich in calcium. This will help in reducing the risks associated with preeclampsia. When the patient’s health becomes unstable, many hospital facilities provide expectancy management such as caesarean section when preeclampsia becomes severe and uncontrollable. The patients with preeclampsia should be advised to take a sodium restricted diet. Additionally, they should be advised to take food, such as, vegetables, cabbage, and bananas. The patient is advised to lie on the left lateral position. The environment has to be favorable and quiet with limited visitors. Education Health practitioners are responsible for ensuring health promotion among pregnant women so as to reduce the pathological risks of preeclampsia. They are responsible for informing expectant mothers on the importance of exercise during pregnancy, which is important in preventing preeclampsia. The women should also be taught about dietary guidelines on management of preeclampsia before and during pregnancy. The obese and overweight women should be advised to reduce their weight to less risky level during pregnancy. This will help reduce gestational diabetes by about 50%. Women at risk should also be taught about the risk factors of preeclampsia, such as lifestyle habits like alcohol intake and smoking, weight issues, advanced age, and lack of prenatal ultrasound check up. When women gain insight on this topic, they often try to avoid the associated risk factors of preeclampsia. For instance, increased sensitization increases the habit of visiting prenatal clinics for check up. The Division of Reproductive health (DHR) by CDC aims at providing sufficient education on issues of health and chronic disease prevention among women at their reproductive age. It has implemented a Behavior Risk Factor Surveillance System to monitor the trends and prevalence of various chronic conditions among the population at risks. One of the health conditions that such surveys seek to identify is preeclampsia. The CDC organization has promoted, evaluated, and developed effective policies and interventions that aim at reducing and preventing preeclampsia prevalence among women in their child bearing age (CDC, 2012). Associated problems related to the Treatment Plan Lifestyle issues Lifestyle is one of the difficult aspects that can be changed in daily living. Though, sometimes, it is necessary to improve on several aspects, which pose harm to our health. This especially applies when one is preparing for pregnancy and during the early stages of pregnancy. Some of the things that a woman should do so as to improve her health include doing physical exercises, losing weight, eating healthy foods, avoiding stress, avoiding alcohol intake, and other harmful substances. Lifestyle changes will help a person reduce future health risks. Such changes are especially important when one has a history of preeclampsia or a family history of this condition. It will also help in the reduction of pregnancy induced hypertension and those with a history of diabetes during the gestation period. Lifestyle changes, such as becoming physically active, stopping smoking, maintaining a healthy diet and healthy body weight will help women in their child bearing ages avoid the complications associated with preeclampsia. Social/Psychological/Cognitive barriers Women with preeclampsia have been found to be mentally disturbed and face high risk of losing concentration. Daily activities, such as quitting from work, and losing touch with reality are experienced. Studies on women who had experienced complicated pregnancies accompanied by eclampsia, have reported impaired cognitive functioning. This mainly occurred in women with multiple cases of eclamptic seizures. The psychological and cognitive effects are characterized by unsocial behavior, memory slips, and other forgetful characteristics that impact negatively on psychomotor functions and attention (Aukes et al., 2007, p 1-6). The mother may also forget to take medication, and this poses a major threat to the treatment process. Therefore, neuro-cognitive testing should be done to determine the cognitive status of the affected. Another physiological barrier is migraine, which is characterized by the brain’s hyperfusion and is associated with the changes of the female sex hormone. However, the actual association between preeclampsia and migraine is not well known. Cultural concerns Cultural underpinnings may compromise the ability of a person to seek health care support during pregnancy (Olusanya & Alicia, 2010, p 341-58). The prevention of maternal mortality and improvement of access to sexual, reproductive, and maternal health care can help in improving technical interventions and making these interventions affordable. The strategies used in encouraging women to seek health care services should be sensitive to their culture, their needs, and rights. Therefore, the health care facilities should be accommodative to the minority groups and the indigenous people. The health facility has to respect the culture of the minorities, individuals and be sensitive to community and people needs. The cultural aspects involve social factors, which have an impact to maternal deaths by 27% (Qiu, Lin & Ma, 2010, p 544-8). Therefore, raising awareness on the need of pregnant women to receive prenatal care without delay is a critical task. This will help in ensuring that cultural and social aspects are addressed so that they do not contribute to maternal and neonatal deaths. Members of the community should be educated to be aware of the dangers and signs associated with preeclampsia. Conclusion Predicting the true cause and occurrence of preeclampsia is not yet well understood. Studies on the importance of MPV in predicting the occurrence of this condition have not been useful in providing reliable information. This means that currently there are no known factors that precisely predict the etiology of preeclampsia. However, this paper has presented the known aspects, such as management, treatment, education, barriers to treatment, signs, and symptoms and diagnosis. Though the actual factors that cause preeclampsia are not well-known, I have managed to highlight the importance of understanding the actual nature of severe preeclampsia because it is a leading cause of maternal mortality and neonatal death. Preeclampsia is a condition that manifests towards the end of pregnancy term, but the process of this disease starts early at the onset of gestation and it becomes a challenge to revert the whole process when it is not checked early enough. Preeclampsia can worsen as shown by post partum studies. This is the reason why it is difficult to explain, but this is not surprising because preeclampsia is a complicated disease to understand, and it is associated with placenta abnormalities. References Aukes, A. M., Wessel, I. Dubois, A. M., Aarnoudes, J. G. & Zeeman G. G (2007). Self-reported cognitive functioning in formerly eclamptic women. American Journal of Obstetrics and Gynecology, 197(4), 365.e1-6 CDC (2012). Behavioral Risk Factor Surveillance System (BRFSS), retrieved from http://www.cdc.gov/brfss/ Copstead, L. & Banasik, J. (2010). Pathophysiology, 4th edition. St. Louis Saunders-Elsevier publishers, p 120 David, M. O., Laresgoiti-Servitje, E. & Gomez-Lopez, N. (2010). 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