Toxemia

of
Pregnancy

Prepared by:
MA. CONCEPCION F. COLUMBRES, RN,RM, MN
Toxemia of Pregnancy
 Pre-eclampsia
 Eclampsia
Introduction:
 Synonyms:
Toxemia of pregnancy, pre-eclampsia, EPH gestosis,
pregnancy induced hypertension.
 Pre-eclampsia commonly manifests after the 20th week
of pregnancy.
 Prevalence of pre-eclampsia: varies from one place to
another
 Severe pre-eclampsia and eclampsia
 Are serious and potentially fatal
 Third commonest cause of maternal mortality
 Occurs prior to, during or after delivery
 Pre-eclampsia
 Preeclampsia -- development of
hypertension with proteinuria, edema,
or both due to pregnancy between 20
weeks of pregnancy and first
postpartum day
Incidence:
 5% of all pregnancies
 Increased in primapara
 Increased in women with hypertension
or other vascular disorders.
 Eclampsia
 Eclampsia--occurrence of one or more
convulsions not attributed to other
cerebral conditions in a patient with
preeclampsia.
Incidence:
 Perinatal mortality with eclampsia = 15%
 Eclampsia develops in 1/200 pre-
eclamptic patients and usually total if
untreated.
 PREECLAMPSIA- SEVERE PREECLAMPSIA –
ECLAMPSIA
PREECLAMPSIA- hypertension with
proteinuria but no convulsion
SEVERE PREECLAMPSIA- a woman has passed
from mild to severe preeclampsia when her
blood pressure has risen to 160 mmHg systolic
and 110 mmHg diastolic or above on atleast 2
occasions 6 hours apart
a. Marked proteinuria
b. Extensive edema
 ECLAMPSIA- means convulsion. This is
the more severe classification of
hypertension of pregnancy, A women has
passed into this stage when cerebral edema
occurs as a result of sever edema.
DIAGNOSIS:
 When SBP > 140 mm Hg, DBP > 90 mm Hg in a
woman known to be normotensive prior to
pregnancy.

 The diagnosis requires 2 such abnormal BP

measurements recorded at least 6 hours apart.
Diagnostic Test:
 Because there are no diagnostic tests
available that can predict which woman will
develop preeclampsia, EARLY DETECTION
thru PRENATAL CARE reduces morbidity
and mortality.
RISK FACTORS
 Young maternal age
 Nulliparity: 85% of pre-eclampsia occur in
primigravida
 Increased placental tissue for gestational age:
Hydatiform moles, twin pregnancies
 Family history of pre -eclampsia
 Diabetes mellitus
 Renal diseases
 Chromosomal abnormality in the fetus (eg,
trisomy)
RISK FACTORS: cont.

Worrisome signs for pre-eclapmsia

development
 Rapid increase of weight during the latter ½ of
pregnancy
 An upward trend in diastolic BP even while still
within normal range
CLASSIFICATION OF PRE ECLAMPSIA:
ACCORDING TO SEVERITY
1. Mild pre-eclampsia
2. Moderate pre-eclampsia
3. Severe pre-eclampsia

1. Mild to Moderate Pre eclampsia

Diagnostic Features
 Systolic BP is 140 -160 mmHg
 Diastolic BP is 90 – 100 mmHg
 Proteinuria up to ++
2. Severe pre-eclampsia
Also called – Imminent eclampsia
Symptoms
 Severe & persistent occipital or frontal headaches
 Visual disturbance: blurred vision, photophobia
 Epigastric and/or right upper-quadrant pain
Signs
 Diastolic BP > 11ommHg, systolic BP > 160mmHg
 Proteinuria +++ or more
 Altered mental status
 Hyper-reflexia
 Oliguria
HELLP SYNDROME
 Is a severe form of pre-eclampsia
 Affects approx 10% of women with severe
preeclampsia and 30-50% of women with
eclampsia.
 Characterized by:
 Hemolysis,

 Elevated liver enzymes

 Low platelet count.

 Increased mortality rate and DIC

Complications:
Maternal effects:
 seizure activity – bodily injury (tongue),
aspiration, placental abruption, or
cerebral hemorrhage
Complications: cont.
Endothelial damage to pulmonary capillaries --
pulmonary edema
Severely elevated BP and cerebral edema - -
cerebral bleeding and complications associated
with cerebral vascular accident (CVA/ stroke). This
complication is rare.
Edema and reduced blood flow to the liver - -
rupture of the liver
Platelet aggregation and consumption of clotting -
- thrombocytopenia and disseminated
intravascular coagulopathy (DIC)
Complications: cont.
Fetal Effects:
 Reduced blood flow to the placenta -
intrauterine growth restriction (IUGR),
oligohydramnios, and placental
abruption.
 Preterm delivery to save mother or baby
- - respiratory distress syndrome and
other complications of prematurity.
Complications: cont.
The primary problem underlying the dev’t of
preeclampsia is GENERALIZED VASOSPASM,
spasm of the arteries, which affects every organ in
the body.
VASOSPASM causes generalized vasoconstriction,
which leads to HPN.
Elevated BP adversely affects the CNS and
decreases blood flow to the kidneys, liver and
placenta.
Complications: cont.
VASOSPASM also leads to endothelial
damage, which causes ABDOMINAL
CLOTTING. Tiny Clots (microemboli)
cause damage to internal organs,
especially the liver and kidneys.
 EDEMA OF THE TISSUES, body
organs, or both may result from this
process.
ASSESSEMENT:
1. Assess major symptoms of triad of preeclampsia
2. Assess for preeclampsia
a. Elevation of systolic BP (140) of 30 mmhg
and diastolic of 15 mmHg on 2 occasions apart
b. Generalized edema
c. Proteinuria- 300mg/L in 24 hour collection
d. weight gain of 5 lbs. Or greater in a week
ASSESSEMENT: cont.
3. Assess for severe-preeclampsia
a. B/P 160/110 or above or systolic pressure 50mmhg
above normal
b. Massive edema –puffiness in the women’s face,
hands-non pitting
c. Proteinuria-5gms or more in 24 hours
d. Visual disturbances
e. Severe headache
f. Marked hypereflexia
ASSESSEMENT: cont.
4. Assess for eclampsia
a. Check urine output that contain RBC, varied
cast, and proteins
b. Assess B/P elevation of 200/110 mmHg or over
c. Check for visual disturbances or even blindness
caused by cerebral edema that may compress the
retina
d. Observed for severe epigastric pain
e. Observe for convulsions
ASSESSEMENT: cont.
- stage of invasion of the convulsion – client’s
eye roll to one side for few sec and stares fixedly
into space with twitching of the facial muscles
- stage of contraction
- stage of convulsion
g. Assess for signs of labor
h. Assess vital signs
i. Assess level of consciosness
ASSESSMENT/ INTERVENTION:
 BP > 140/90 mm Hg after 20 weeks of
gestation
 Assesses BP in 2 occasions and be
accompanied by protein Urine collection)
 Presence of edema or weight gain is no
longer considered a criterion for Dx
 Preeclampsia is classified as MILD and
SEVERE
 SYMPTOMS:
 MILD - - SLIGHTLY ELEVATED BP,
limited protein in the urine.
 SEVERE - - BP above 160/110 mm Hg,
protein +2 in the urine, symptom
related to edema of body organs and
decreased blood flow.
 CNS - - irritability occurs, resulting in
HYPERACTIVE TENDON REFLEXES
and CLONUS.
ASSESSMENT/ INTERVENTION:
 Severe headache may indicate –
cerebral edema
 Eyes becomes edematous - -
Blurring of vision, double vision
and spots before her eyes.
 Visual changes and severe
headache indicate that a seizure
is likely to occur.
Severe preeclampsia experiences
a convulsion or a coma---
progressed from preeclampsia to
ECLAMPSIA
 Seizures are typically
generalized TONIC-CLONIC in
nature and only rarely progress
to STATUS EPILEPTICUS.
MANAGEMENT:
Fetal and maternal monitoring for
symptoms of the condition.
Monitor BP at least q 4 hours for mild
preeclampsia, more frequent for
severe dse.
Auscultate lungs q 2 hours.
 Adventitious sounds may indicate
developing pulmonary edema.
MANAGEMENT: cont.
Weigh the woman daily. Report sudden increase in
weight.
Teach woman to report headache, visual changes
and epigastric pain – impending signs of seizure.
Keep environment quiet and non=stimulating—
bright lights and loud noises can cause seizure.
Seizure precaution: pad the side rails. Keep suction
equipment, an oral airway, supplemental O2 and
medications at bedside.
MANAGEMENT: cont.
Monitor I&O strictly
Report urinary output of less than
30mL/hr.
Encourage adequate nutrition – to
promote fetal growth and maternal
well-being.
No special diet. SALT does not need
to be restricted but avoid excessive
intake.
MANAGEMENT: cont.
The woman should be on bed rest in the LEFT
LATERAL POSITION.
Assess for deep tendon reflexes- clonus is
determined once per shift.
- rhythmic contraction of muscles in response
of suddenly applied and then sustained stretch
stimulus.
Assess for Fetal Kick Counts – done after meal
TREATMENT:
Primary goal – to deliver a healthy baby and
restore the women healthy state.
Fetus is at term (37 weeks) - physician will
induce labor.
Preterm - depends on the severity of the dose
and determination of fetal lung maturity.
 Benefits and risks of conservative management
(bed rest and observation) are weigh against
benefits and risks of a preterm delivery.
TREATMENT: cont.
Conservative management for mild eclampsia
Assess for deep tendon reflexes – clonus is
determined once per shift.
NSTs done 2x weekly.
Amniocentesis may be done to determine LUNG
MATURITY using LECITHIN/SPHINGOMYELIN
(L/S) RATIO. Ratio of 2:1 indicative of lung
maturity.
TREATMENT: cont.
Prevent seizure: medication to prevent and treat
eclamptic seizures is
MAGNESIUM SULFATE – administered via IV
route. A cathartic. It reduces edema by causing a
shift from extracellular spaces into the intestines. It
is also a CNS depressants action that lessen
possibility of convulsion
Relaxing skeletal muscles and raising the seizure
threshold.
MgSO4 – drug of choice to treat eclamptic seizure
Phenytoin (Dilantin) & diazepam (Valium) are
sometimes ordered.- to depress brain cells and
thereby stop convulsion
TREATMENT: cont.
 - hydrallazine (Apresoline) – reduce hypertension.
Lowers blood pressure by peripheral dilatation and
thus causes no interference with placental
circulation.
 SIDE EFFECTS OF OVERDOSAGE OF MgSO4
1. Sever oliguria (less than 100ml/4 hours)
2. Depression of respiration and deep tendon reflex
ANTEDOTE- calcium gluconate- this high colloid
solution will call fluid into intravascular space by
osmotic pressure
TREATMENT: cont.
 PREVENTIVE INTERVENTIONS:
A. During convulsion
1. Prepare mouth gag and have it accessible
2. Suction secretions as necessary
3. Provide oxygen
4. Provide safety measure
B. 24 hours postpartum:
1. Monitor urinary output to detect anuria
2. Continue monitoring BP as PIH continue 10-14
days after delivery