CASE PRESENTATION

1
CASE PRESENTATION

• PREPARED BY
• SONIA SEBASTIAN
• LR/DR DEPARTMENT

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DEMOGRAPHIC DATA

• CASE NO 123.
• NAME MS. G.X AGE 36 Y/O SEX FEMALE
• DIAGNOSIS
• HEMOLYSIS ELEVATED LIVER ENZYMES LOW PLATELET
  SYNDROME (HELLP SYNDROME)

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GENERAL

• The patient is 36 years of age, FEMALE, weighs 87
  kgs.
• She is conscious, coherent, with the following
  Vital Signs
• BP 170/100mmHg
• PR96 bpm
• RR 22 cpm
• Temp37 C
• SPO² 98

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SKIN

• Fair complexion
• No palpable masses or lesions, moist, with good
  turgor

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HEAD

• Maxillary, frontal, and ethmoid sinuses are not
  tender.
• No palpable masses and lesions
• No areas of deformity
• Always complaining of mild headache (score of 4
  in pain scale)

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LEVEL OF CONSCIOUSNESS AND ORIENTATION

• Awake and alert
• Oriented to
• Persons
• Place
• Time

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EYES

• Pink conjunctivae and no dryness
• Pupils equally round and reactive to light
• But according to patient sometimes she
  experienced changes in vision including blurring
  of vision or light sensitivity

8
EARS

• No unusual discharges noted

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NOSE

• Pink nasal mucosa
• No unusual nasal discharges
• No tenderness in sinuses

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MOUTH

• Pink and moist oral mucosa and free of swelling
  and lesions

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NECK AND THROAT

• No palpable lymph nodes
• No masses and lesions seen

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CHEST AND LUNGS

• Equal chest expansion
• No retraction
• Clear breath sounds

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HEART

• Regular rhythm

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ABDOMEN

• Globular abdomen
• The patient always complained of epigastric pain
  (score of 6 in pain scale)
• Leopolds Maneuver done fetus in cephalic
  presentation

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ABDOMEN

• USG report
• Pregnancy Uterine 20 weeks
• Mild hepatomegaly with generalized gall bladder
  wall edema
• Singleton in cephalic presentation
• Moderate to severe oligohydramnios
• Umbilical Artery Doppler indices revealed
  reversal of diastolic flow in the umbilical
  artery
• FETUS Reflex preferential blood flow to the
  brain in response to fetal hypoxemia.

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GENITALS

• No unusual bleeding, no leaking per vagina

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EXREMITIES

• Presence of edema on both legs
• Pulse full and equal
• No lesions noted

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PATIENT HISTORY

• PAST MEDICAL HISTORY
• NO PAST MEDICAL HISTORY
• PAST SURGICAL HISTORY
• LSCS, 4 years back due to pre eclampsia diagnosed
  at 35 weeks of gestation with baby girl A/S 8/9,
  1.8 kg

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PRESENT MEDICAL HISTORY

• C/O EPIGASTRIC PAIN,HEADACHEVOMITING
• OBSTETRICAL-HISTORY G2P1,LMP17/9/2012
  EDD29/7/2013 Pregnancy Uterine 20 weeks
• ON EXAMINATION BP 170/100 mmHg, PR 96 bpm,
  RR24 cpm, Temp. 37 C. SPO²- 98,
• INVESTIGATION
• Hgb 10.6 g/dL, PLT 77u/L, Creatinine- 31.71,
  SGOT 97u/L , SGPT125.5 u/L, Blood Group A
  positive
•  

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PRESENT MEDICAL HISTORY

• USG report
• Mild hepatomegaly with generalized gall bladder
  wall edema
• Pregnancy Uterine 20 weeks ,singleton Fetus
• Moderate to severe Oligohydramnios
• Umbilical Artery Doppler indices revealed
  reversal of diastolic flow in the umbilical
  artery
• FETUS Reflex preferential blood flow to the
  brain in response to fetal hypoxemia.

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PRESENT MEDICAL HISTORY

• TREATMENT
• On tablet Labetalol 200mg TID, Iron tablet OD,
  inj.cefuroxime 750 mg ivBD ,tablet cytotec 200
  mcg per vagina,Inj.Oxytocin 10 i.u in 500 ml
  Ringer Lactate,Inj.Magnesium Sulphate 10 mg in
  500 ml Normal Saline solution,2 unit Platelet
  transfusion

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INTRODUCTION

• HELLP syndrome is a life-threatening liver
  disorder thought to be a type of severe
  preeclampsia. It is characterized by Hemolysis
  (destruction of red blood cells), Elevated Liver
  enzymes (which indicate liver damage), and Low
  Platelet count.
• HELLP is usually related to preeclampsia. About
  10 to 20 of women who have severe preeclampsia
  develop HELLP. In most cases, this happens before
  35 weeks of pregnancy, though it can also develop
  right after childbirth.

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INTRODUCTION

• HELLP syndrome often occurs without warning and
  can be difficult to recognize. It can occur
  without the signs of preeclampsia (which are
  usually a large increase in blood pressure,pedal
  oedema and protein in the urine).
• HELLP syndrome can be life-threatening for both
  the mother and her fetus. (Most fetal deaths that
  follow HELLP syndrome are actually caused by
  complications of premature birth before 28 weeks
  of pregnancy. A woman with symptoms of HELLP
  syndrome requires emergency medical treatment.

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ANATOMY AND PHYSIOLOGY
25
ANATOMY AND PHYSIOLOGY
26

• ETIOLOGY

RISK FACTOR Previous pregnancy with history of
hypertension
Women have severe pre-eclampsia
General activation of the coagulation cascade
Fibrin forms crosslinked networks in the small
blood vessels
a microangiopathic hemolytic anemia
The mesh causes destruction of red blood cells
(HEMOLYSIS)
ADDITIONAL
liver cells suffer ischemia (ELEVATED LIVER
ENZYMES)
platelets are consumed (LOW PLATELET COUNT)
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VII. SIGNS AND SYMPTOMS

• Women with HELLP syndrome often "do not look very
  sick."
• Early symptoms can include
• In 90 of cases, either epigastric pain described
  as "heartburn" or right upper quadrant pain.
• In 90 of cases, malaise.
• In 50 of cases, nausea or vomiting.
• There can be gradual but marked onset of
• headaches (30)
• blurred vision
• and paresthesia (tingling in the extremities).
• Edema may occur but its absence does not exclude
  HELLP syndrome. Arterial hypertension is a
  diagnostic requirement, but may be mild.
• Rupture of the liver capsule and a resultant
  hematoma may occur.
• If the patient has a seizure or coma, the
  condition has progressed into full-blown
  eclampsia.

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VII. SIGNS AND SYMPTOMS

• 20 of all women with HELLP syndrome has
  Disseminated intravascular coagulation
• 84 when HELLP is complicated by acute renal
  failure.
• 6 of all women with HELLP syndrome has found
  with Pulmonary edema
• Patients who present with symptoms of HELLP can
  be misdiagnosed in the early stages, increasing
  the risk of liver failure and morbidity. Rarely,
  post caesarean patients may present in shock
  condition mimicking either pulmonary embolism or
  reactionary hemorrhage.

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VIII. NURSING INTERVENTION

• Assess maternal VS and fetal heart rate.
• Monitor maternal well being
• Monitor fetal well being
• Promote bed rest in calm and quiet environment
  darken the room if possible.
• Encourage elevation of edematous arms and legs
• Obtain daily hematocrit levels as
  ordered(reference ranges 34.1-44.9)
• Obtain blood studies (CBC, platelets count, liver
  function, BUN and creatinine, and fibrin
  degregation).
• Obtain daily weights at the same time each day
• Support nutritious diet of low salt low fat.
• Provide emotional support
• Encourage compliance with bed rest in a lateral
  recumbent position

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TREATMENT

• Stabilize maternal condition should include
  correction of coagulopathy and correction of
  thrombocytopenia
• Antiseizure prophylaxis with magnesium sulphate,
  treatment of severe hypertension with
  antihypertensive medications like labetalol.
• If the syndrome develops at or beyond 34 weeks'
  gestation, or if there is evidence of fetal lung
  maturity or fetal or maternal risk then delivery
  is the definitive therapy.
• Without laboratory evidence of disseminated
  intravascular coagulopathy and absent fetal lung
  maturity, the patient can be administered the
  doses of steroids to accelerate fetal lung
  maturity and then be delivered 48 hours later.
• However, maternal and fetal conditions should be
  assessed continuously during this period.
• If the syndrome develops before 23 weeks after
  stabilizing maternal condition medical
  termination of pregnancy is the most preferable
  management.

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TREATMENT
HELLP MANAGEMENT
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MEDICAL TREATMENT
Goal Establish baseline levels early in
pregnancy and monitor for progression to HELLP
NAME OF DRUG ACTION DOSAGE ROUTE TIME DURATION FREQUENCY
Labetalol Tablet Anti hypertensive 200mg PO 0400H-1000H-1600H-2200H 1 DAY q6
Calcium Tablet Replaces and maintains calcium 600mg PO 1800H 1 DAY OD
FeSO4 Tablet Replaces and maintains iron 100mg PO 0600H 1 DAY OD
Magnesium Sulfate (Pregnancy risk category B) Anti hypertensive/ prevent siezure 4mg 100mL NSS IV 1030H 1 DAY STAT
Magnesium Sulfate Infusion Anti hypertensive/ prevent siezure 10mg 500mL NSS IV 1130H 24
Misoprestol tab Prostaglandinabortifacient 200mcg SL/PV 0600H-1200H-1800H-2400H 1 DAY q6
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LABORATORY TEST
TEST RESULT RESULT RESULT RESULT RESULT REFERENCE RANGE
19/02/13 20/02/13 21/02/13 22/02/13 23/02/13
Glucose(random) 4.0 3.9-7.8 mmol/L
Urea 4.3 3.7 1.8-8.3 mmol/L
Creatinine 34.8 38.79 36.21 31.71 F 46-92 mmol/L
Sodium 135 135-150 mmol/L
Potassium 4.0 3.5-5.0 mmol/L
Magnesium 0.7 1 0.65-1 mmol/L
Chloride 108 98-111 mmol/L
Calcium 2.16 2.20-2.55 mmol/L
AST(SGOPT) 261.6 231.29 100.57 97.96 10-38 U/L
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TEST RESULT RESULT RESULT RESULT RESULT REFERENCE RANGE
19/02/13 20/02/13 21/02/13 22/02/13 23/02/13
ALT(SGPT) 211.8 205.35 137.5 125.5 10-41 U/L
Albumin 31.6 34-48g/L
Cholesterol 5.01 3.1-5.2 mmol/L
Triglycerides 1.40 0.34-2.30 mmol/L
HDLc 1.12 1.01-2.49 mmol/L
LDLc 3.35 3.9-4.7 mmol/L
LDH 508.58 437.6 399.98 408.24 135-225 U/L
CBC Hbg Hct Plt 12.1 33.7 49 11.0 30.5 36 8.9 25.1 45 10.6 30.2 77 11.2-15.7 g/dL 34.1-44.9 182-369/UL
Urinalysis Total Protein Pus cells 2 15-20/HPF Negative 0-2/HPF
PT APTT 14.0 46.1 14.3 31.4 10.1-17.0 seconds 26.1-36.3 seconds
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COMPLICATIONS OF HELLP

• COMPLICATIONS OF HELLP SYNDROME -----MATERNAL
• Coagulopathy
• Placental Abruption
• Seizure
• Acute renal failure
• Maternal permanent hepatic damage
• Retinal detachment
• COMPLICATIONS OF HELLP SYNDROME -----FETAL
• Stillbirth
• Intrauterine growth restriction (IUGR)
• an abnormally restricted symmetric or asymmetric
  growth of fetus
• Risk of preterm delivery
• delivery before 37 weeks of gestation
•  
•  

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PRIORITIZATION OF NURSING PROBLEMS

• Ineffective Tissue Perfusion Cardiac and
  Cerebral related to altered placental blood flow
  caused by vasospasm and thrombosis
• Excess Fluid Volume related to pathophysiologic
  changes of hypertensive disorders and increased
  risk of fluid overload.
• Fatigue related to increased stress on body
  functioning secondary to hemolysis
• Anxiety related to diagnosis and concern for self
  and fetus
• Deficient Diversional Activity related to
  prolonged bed rest

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PRIORITIZATION OF NURSING PROBLEMS

• 6. Decreased Cardiac Output related to
  antihypertensive therapy
• 7. Knowledge Deficit the management of therapy
  and treatment related to misinterpretation of
  information.
• 8. Excess Fluid Volume related to glomerular
  function impairment secondary to the decrease of
  cardiac output.
• 9. Impaired Urinary Elimination related to
  impaired glomerular filtration anuria and
  oliguria.
• 10. Risk for injury related to seizures or to
  prolonged bed rest or other therapeutic regimens

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ASSESSMENT ASSESSMENT PLANNING IMPLEMENTATION IMPLEMENTATION EVALUATION
CUES/ EVIDENCE NURSING DIAGNOSIS GOALS DESIRED OUTCOME NURSING ORDER/ACTION RATIONALE FOR ACTION EVALUATION
SUBJECTIVE I feel mild headache OBJECTIVE Rising BP or widening pulse pressure Restlessness Pedal edema V/S taken as follows BP 170/100 mmHg PR 92 bpm RR 24 cpm Temp. 37.2?C Ineffective Tissue Perfusion Cardiac and Cerebral related to altered placental blood flow caused by vasospasm and thrombosis Within 12 hours of nursing intervention , patient will have stable Vital Signs Maintained input and output chart hourly and kept I V fluid intake to minimum. Nursed in side-lying position. Placed patient in upright position, head shoulders up, feet legs hanging down. Administerd antihypertensive drugs as ordered by the physician like Labetalol 5.BP monitored 2 hourly and recorded, informed the physician about the alteration, advised medication given 6.Provide quiet environment To observe a decrease in urine output that may indicate a decrease in renal bold flow. To promote placental perfusion To favor pooling of body by gravitational forces to decrease venous return To decreased the pressure in the blood stream To reduce BP gradually and wide pressure variations avoided because lowered BP may not be adequate to perfuse vital organs Reduce stress Provide comfort and to the patient After 12 hours of nursing intervention, the goal was partially met as evidenced by BP and other vital parameters stable V/S taken as follows BP 130/92 mmHg PR 90 bpm RR 24 cpm Temp. 37?C
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NURSING HEALTH TEACHING

• Seek medical attention if the patient experiences
  headache ,visual disturbances, epigastric pain or
  sudden weight gain.
• Monitor weight, Blood pressure and urine protein
  at home.
• Perform daily fetal kick counts to monitor fetal
  well being as well as to increase protein intake
  because proteinurea decrease the amount of
  available protein. Avoid foods rich in oil and
  fats.
• Rest in side lying position as much as possible.
• Decrease environmental stimuli by lowering or put
  off light decreasing number of visitors.
• Limit daily activities, including sexual
  activities.
• Encourage patients on deep breathing exercices.

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CONCLUSION

• Presented a case of a 36 y/o G2P1 with pregnancy
  20 wks with HELLP syndrome with BP gt170/100 mmHg,
  2 protein urine, elevated liver enzymes AST
  261U/L,ALT 211U/L,Platelet Count 36U/L.
• Hypertensive work up CBC,, liver enzymes,
  creatinine, LDH, Cholestrol.
• HELLP syndrome is a life-threatening liver
  disorder thought to be a type of severe
  preeclampsia. It is characterized by Hemolysis
  (destruction of red blood cells), Elevated Liver
  enzymes (which indicate liver damage), and Low
  Platelet count

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CONCLUSION

• Anti hypertensive medications such as Labetalol,
  Magnesium Sulphate Given that effective
  preventative measures and screening tools,
  routine nursing assessments of the signs/symptoms
  indicative of Severe Preeclampsia remains
  critical.
• Nurse-led patient education and the provision of
  a supportive environment are essential to the
  optimal management of HELLP syndrome
• Individually tailored and compassionate nursing
  care of women with HELLP syndrome will serve to
  enhance the wellbeing of mother and baby.
• However, the patients AOG before 23 weeks some
  fetal anomalies detected by ultrasound so after
  stabilizing maternal condition medical
  termination of pregnancy was done on 20/02/2013 _at_
  1135H, a 200 gram dead fetus via Normal
  Spontaneous Delivery.

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XV. BIBLIOGRAPHY

• Maternal and Child Health Nursing by Adele
  Pillitteri 5th edition volume 1 page 426-
  433page 329-332
• All-in-one care planning resource page 748 by
  Pamela L. Swearlngen, RN
• Maternal Neonatal Nursingpage 30 by Lippincott
  Williams and Wilkins
• Luckman and Sorensens Medical-Surgical Nursing a
  Physiologic Approach 4th edition Volume 1 page
  734
• Lippincot Manual of Nursing Practice 9th edition
• http//nursingcrib.com/case-study/pregnancy-induce
  -hypertension-case-study/

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• Thank you
• !!?