11
Introduction (Change of shift 1800)
Maggie Richmond is a 35 year old woman, G2P1, who is 33 weeks pregnant and is being admitted onto the labor and delivery unit. She presented to an OB appointment this morning with complaints of abdominal pains, which she believes to be contractions. Maggie also reports experiencing flu like symptoms including fatigue, headache, nausea and vomiting this past week. Maggie has a history of hypertension and preeclampsia.
Admitting Assessment
Maggie is admitted alone and reports that her husband is at home taking care of their two year old son. The family does not have any close family members and therefore they need to rely on the help from a babysitter. Maggie also explains that she previously worked as a manager of a restaurant but has quit her job, in order to focus on care of her son. She expresses concerns about financial stability and explains that this has caused some stress on her and her husband.
Maggie reports feeling abdominal pain that feels like contractions upon further assessment it is noted that this pain is confined to the right upper quadrant only. An ultrasound is performed and the baby seems to be doing well. Maggie is placed on an tocotrandsducer and ultrasound transducer in order to monitor and be alerted if Maggie begins experiencing contractions and monitor the fetus’s well-being. Monitor demonstrated fetal heart rate was within the 150s, with moderate variability, presence of accelerations, and no decelerations. Additionally, it is discovered that Maggie has 2+ pitting edema in her dependent extremities. Upon assessment it is discovered that Maggie’s blood pressure is 162/101 and these findings are reported to the physician.
Pathophysiology
To understand Maggie’s current physical presentation and further treatment, we need to look at the complex pathogenesis of HELLP syndrome. In a normal pregnancy, the spiral arteries are remodeled in such a way that they can proficiently supply the placenta and fetus with enough nutrients and blood supply to sustain life. However, the spiral arteries do not adapt properly in a woman with preeclampsia, while according to Perry et. al. (2014) is the cause of placental hypoxia that prompts the placenta to release toxins as placental cells become ischemic. Perry et al. (2014) go on to explain that these toxins cause direct damage to endothelial cells which translates to generalize vasospasm. In addition to the vasospasm, the activated endothelial cells release von Willebrand factor that results in platelet aggregation and fibrin deposits to vessels walls (Abildgaard & Heimdal, 2013). Hemolysis begins to occur as vessels vasoconstrict from vasospasm and fibrin deposits which decreases the amount of circulating red blood cells and platelets; the breakdown of RBCs causes hyperbilirubinemia (Perry et al., 2014).
Lab Workup
As a result of Maggie’s history of preeclampsia and other risk factors, a CBC, liver function tests, and urinalysis are ordered to determine if Maggie is experiencing HELLP syndrome. The results indicate that Maggie is meeting the criteria for a diagnosis of HELLP. Hemolysis is indicated through an abnormal peripheral blood smear, a serum bilirubin level of 2.0, and hemoglobin of 9.9. AST of 84, ALT 90 indicate the elevated liver enzymes and her platelets are at 75,000. Other lab results are as follows:
HCT 30%
HGB 9.9
PLT 75,000
AST 84
ALT 90
LDH 750 (IU/L)
Serum Bilirubin 1.9
Abnormal peripheral blood smear: presence of schistocytes
Urinalysis: 4+ proteinuria on dipstick analysis
Include full labs panel & tidbit about fetus and fetal distress.
Protein in urinalysis & bilirubin will be high
2 Hours After Admission-Reassessment
Maggie Richmond reports feeling a different type of abdominal pressure, which she thinks may be contractions. Concurrently, the monitor indicates that the FHR soon begins trending in the 170s for duration of 15 minutes and there is now minimal variability. A quick assessment reveals that Maggie is now experiencing vaginal bleeding and the physician is paged immediately.
3 Hours After Admission
Placental abruption led to fetal distress, a complication of HELLP. The doctor performed an emergency C-section because delivery was the definitive treatment for HELLP syndrome. Otherwise, the placenta would continue to produce damaging toxins. Mr. and Mrs. Richmond were evaluated for understanding of the situation and consent was obtained.
In the OR
Symptomatic treatment of HELLP included: 2 units of PRBCs, hydralazine, corticosteroids and magnesium sulfate. A study conducted by the University of Mississippi Medical Center showed that the early implementation of the Mississippi Protocol MP prevented HELLP syndrome progression and reduced severity (magnesium sulfate, blood pressure and dexamethasone) (Martin, 2012). However, there is still not enough evidence to support the routine use of corticosteroids (Dusse, 2015). Maggie was admitted to the ICU and monitored for 96 hours.
Baby- outcomes/NICU
We educated Mrs. Richmond about her prescriptions (anti-hypertensive or betablocker), informed her of her increased risk for recurrence of preeclampsia and HELLP and that early detection is important in preventing complications (HELLP, 2017). We recommended ways to control HTN, a healthy diet and exercise and collaborated with a nutritionist (L., 2015). Furthermore, we educated her about complications after delivery (DIC, pulmonary edema, kidney failure, and liver failure). We referred the Richmonds to Case Management and Social Services who did an assessment on how the Richmonds were coping with baby Julia being in the NICU. The family received help and resources in finding a support group and child care (Office, 2017). Government Benefit Programs in California were explored and alternative job placement was considered for Maggie (Administration, 2017; Department, 2017). The Richmonds also received referrals to standard postpartum services (lactation) and follow-up visits and well-baby appointments were scheduled.
Discussion Questions
- As an ICU nurse, it is not common to interact with pregnant patients and post-partum patients. As an ICU nurse caring for Maggie Richmond, what are some resources or additional preparation that may be necessitated?
- Maggie Richmond’s baby was admitted into the NICU and this caused distress for her and her husband. What are some interventions that can be implemented in order to help her cope with her own recovery and the absence of her baby?
- HELLP syndrome can cause an array of issues within the body. What organ systems can you expect to be affected and what would that damage entail?
References
Abildgaard, U., & Heimdal, K. (2013). Pathogenesis of the syndrome of hemolysis, elevated liver enzymes, and low platelet count (HELLP): a review. European Journal of Obstetrics & Gynecology and Reproductive Biology, 166(2), 117-123.
Administration for Children and Families, U. (2017). Administration for Children and Families. Retrieved May 5, 2017, from https://www.acf.hhs.gov/
Deglin, J., & Vallerand, A. (2009). Davis’s drug guide for nurses (11th ed.). Philadelphia, Penn.: F.A. Davis.
Department, E. D. (2017). Employment Development Department Home. Retrieved May 05, 2017, from http://www.edd.ca.gov/
Dusse, L. M., Alpoim, P. N., Silva, J. T., Rios, D. R., Brandao, A. H., & Cabral, A. C. (2015). Revisiting HELLP syndrome. Clinica Chimica Acta, 451, 117-120. doi:10.1016/j.cca.2015.10.024
Government Benefits of California. (2017). Retrieved April 28, 2017, from https://www.benefits.gov/benefits/browse-by-state/state/146
Hagle-Fenton, D. (2008). Beyond preeclampsia: Hellp syndrome. RN, 71(3), 22.
Haram, K., Mortensen, J. H., & Nagy, B. (2014). Genetic aspects of preeclampsia and the HELLP syndrome. Journal of Pregnancy, 2014.
HELLP syndrome. (2017, March). Retrieved March 23, 2017, from https://medlineplus.gov/ency/article/000890.htm
L. (2015, March 24). About HELLP Syndrome. Retrieved March 23, 2017, from https://www/preeclampsia.org/health-informantion/hellp-syndrome
Martin, J. N., Owens, M. Y., Keiser, S. D., Parrish, M. R., Tam Tam, K. B., Brewer, J. M., & … May, W. L. (2012). Standardized Mississippi Protocol Treatment of 190 patients with HELLP Syndrome: Slowing Disease Progression and Preventing New Major Maternal Morbidity. Hypertension in Pregnancy, 31(1), 79-90. doi:10.3109/10641955.2010.525277
Office of Child Care, U. (2017). Homepage. Retrieved May 05, 2017, from http://www.childcareaware.org/
Padden, Maureen. (September 1, 1999). HELLP Syndrome: Recognition and Perinatal Management. Retrieved from http://www.aafp.org/afp/1999/0901/p829.html
Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2014). Maternal Child Nursing Care (5th ed.). St. Louis, MI: Elsevier Mosby
