CASE PRESENTATION

1. CASE PRESENTATION PREPARED BY: SONIA SEBASTIAN LR/DR DEPARTMENT

2. 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)

3. GENERAL • The patient is 36 years of age, FEMALE, weighs 87 kgs. • She is conscious, coherent, with the following Vital Signs: • BP= 170/100mmHg • PR=96 bpm • RR= 22 cpm • Temp=37 ⁰C • SPO²= 98%

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

5. 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)

6. LEVEL OF CONSCIOUSNESS AND ORIENTATION • Awake and alert • Oriented to: • Persons • Place • Time

7. 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

9. NOSE • Pink nasal mucosa • No unusual nasal discharges • No tenderness in sinuses

10. MOUTH • Pink and moist oral mucosa and free of swelling and lesions

11. NECK AND THROAT • No palpable lymph nodes • No masses and lesions seen

12. CHEST AND LUNGS • Equal chest expansion • No retraction • Clear breath sounds

13. HEART • Regular rhythm

14. ABDOMEN • Globular abdomen • The patient always complained of epigastric pain (score of 6 in pain scale) • Leopold’s Maneuver done: fetus in cephalic presentation

15. 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.

16. GENITALS • No unusual bleeding, no leaking per vagina

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

18. 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

19. PRESENT MEDICAL HISTORY • C/O: EPIGASTRIC PAIN,HEADACHE&VOMITING • OBSTETRICAL-HISTORY: G2P1,LMP=17/9/2012 EDD=29/7/2013 Pregnancy Uterine 20 weeks • ON EXAMINATION: BP: 170/100 mmHg, PR: 96 bpm, RR:24 cpm, Temp. 37 °C. SPO²- 98%, • INVESTIGATION: • Hgb= 10.6 g/dL, PLT= 77u/L, Creatinine- 31.71, SGOT= 97u/L , SGPT=125.5 u/L, Blood Group= A positive

20. 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.

21. 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

22. 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.

23. 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,pedaloedema 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.

24. 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 platelets are consumed (LOW PLATELET COUNT) liver cells suffer ischemia (ELEVATED LIVER ENZYMES)

27. 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.

28. 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.

29. 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

30. 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.

31. TREATMENT HELLPMANAGEMENT

32. Goal: Establish baseline levels early in pregnancy and monitor for progression to HELLP MEDICAL TREATMENT

33. LABORATORY TEST:

35. 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

36. 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

37. 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

39. 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.

40. CONCLUSION • Presented a case of a 36 y/o G2P1 with pregnancy 20 wks with HELLP syndrome with BP >170/100 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

41. 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 patient’s 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 @ 1135H, a 200 gram dead fetus via Normal Spontaneous Delivery.

42. XV. BIBLIOGRAPHY • Maternal and Child Health Nursing by Adele Pillitteri 5th edition; volume 1 page 426- 433;page 329-332 • All-in-one care planning resource page 748; by Pamela L. Swearlngen, RN • Maternal Neonatal Nursing;page 30 by Lippincott Williams and Wilkins • Luckman and Sorensen’s 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/

43. Thank you !! *********