CASE PRESENTATION

PREPARED BY: SONIA SEBASTIAN

LR/DR DEPARTMENT

• CASE NO: 123….• NAME: MS. G.X AGE: 36 Y/O

SEX: FEMALE• DIAGNOSIS:

HEMOLYSIS ELEVATED LIVER ENZYMES LOW PLATELET SYNDROME (HELLP SYNDROME)

DEMOGRAPHIC DATA

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%

SKIN

• Fair complexion• No palpable masses or

lesions, moist, with good turgor

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)

LEVEL OF CONSCIOUSNESS AND ORIENTATION

• Awake and alert• Oriented to:

–Persons–Place–Time

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

EARS

• No unusual discharges noted

NOSE• Pink nasal mucosa• No unusual nasal

discharges• No tenderness in sinuses

MOUTH

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

NECK AND THROAT

• No palpable lymph nodes• No masses and lesions

seen

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

HEART•Regular rhythm

ABDOMEN

• Globular abdomen• The patient always complained

of epigastric pain (score of 6 in pain scale)

• Leopold’s Maneuver done: fetus in cephalic presentation

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.

GENITALS

•No unusual bleeding, no leaking per vagina

EXREMITIES• Presence of edema on both

legs• Pulse full and equal• No lesions noted

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

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

•

PRESENT MEDICAL HISTORYUSG 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.

PRESENT MEDICAL HISTORYTREATMENT

– 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

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.

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.

ANATOMY AND PHYSIOLOGY

ANATOMY AND PHYSIOLOGY

Fibrin forms crosslinked networks in the small blood vessels

Fibrin forms crosslinked networks in the small blood vessels

a microangiopathic hemolytic anemiaa microangiopathic hemolytic anemia

The mesh causes destruction of red blood cells (HEMOLYSIS)

The mesh causes destruction of red blood cells (HEMOLYSIS)

liver cells suffer ischemia(ELEVATED LIVER ENZYMES)

liver cells suffer ischemia(ELEVATED LIVER ENZYMES)

platelets are consumed(LOW PLATELET COUNT)platelets are consumed(LOW PLATELET COUNT)

RISK FACTOR:Previous pregnancy with history of hypertension

Women have severe

pre-eclampsia

General activation of the

coagulation cascade

ADDITIONAL

ETIOLOGY

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.

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.

VIII. NURSING INTERVENTION

1) Assess maternal VS and fetal heart rate.2) Monitor maternal well being3) Monitor fetal well being 4) Promote bed rest in calm and quiet environment darken the

room if possible.5) Encourage elevation of edematous arms and legs6) Obtain daily hematocrit levels as ordered(reference ranges 34.1-

44.9%)7) Obtain blood studies (CBC, platelets count, liver function, BUN

and creatinine, and fibrin degregation).8) Obtain daily weights at the same time each day9) Support nutritious diet of low salt low fat.10) Provide emotional support11) Encourage compliance with bed rest in a lateral recumbent

position

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.

TREATMENTHELLP MANAGEMENT

MEDICAL TREATMENTNAME OF DRUG

ACTION DOSAGE ROUTE TIME DURATION FREQUENCY

1. Labetalol Tablet

Anti hypertensive

200mg PO 0400H-1000H-1600H-

2200H

1 DAY q6°

1. Calcium Tablet

Replaces and maintains calcium

600mg PO 1800H 1 DAY OD

1. FeSO4 Tablet

Replaces and maintains iron

100mg PO 0600H 1 DAY OD

1. Magnesium Sulfate (Pregnancy risk category B)

Anti hypertensive/

prevent siezure

4mg+ 100mL NSS

IV 1030H 1 DAY STAT

1. Magnesium Sulfate Infusion

10mg+ 500mL NSS

IV 1130H 24°

1. Misoprestol tab

Prostaglandin&abortifacient

200mcg SL/PV 0600H-1200H-1800H-

2400H

1 DAY q6°

Goal: Establish baseline levels early in pregnancy and monitor for progression to HELLP

LABORATORY TEST:TEST RESULT REFERENCE

RANGE19/02/13 20/02/13 21/02/1

322/02/13 23/02/1

3

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

TEST RESULT REFERENCE RANGE19/02/13 20/02/13 21/02/

1322/02/13

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

12.133.749

11.030.536

8.925.145

10.630.277

11.2-15.7 g/dL34.1-44.9%182-369/UL

Urinalysis Total Protein Pus cells

2+ 15-20/HPF

Negative0-2/

HPFPTAPTT

14.046.1

14.331.4

10.1-17.0 seconds26.1-36.3 seconds

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

PRIORITIZATION OF NURSING PROBLEMS

1. Ineffective Tissue Perfusion: Cardiac and Cerebral related to altered placental blood flow caused by vasospasm and thrombosis

2. Excess Fluid Volume related to pathophysiologic changes of hypertensive disorders and increased risk of fluid overload.

3. Fatigue related to increased stress on body functioning secondary to hemolysis

4. Anxiety related to diagnosis and concern for self and fetus

5. Deficient Diversional Activity related to prolonged bed rest

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

ASSESSMENT PLANNING IMPLEMENTATION EVALUATIONCUES/

EVIDENCENURSING

DIAGNOSISGOALS & DESIRED

OUTCOMENURSING

ORDER/ACTIONRATIONALE FOR ACTION EVALUATION

SUBJECTIVE:“ I feel mild headache”OBJECTIVE:Rising BP or widening pulse pressure RestlessnessPedal edemaV/S taken as follows:BP: 170/100 mmHgPR: 92 bpmRR: 24 cpmTemp.: 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

1. Maintained input and output chart hourly and kept I V fluid intake to minimum.

2. Nursed in side-lying position.

3. Placed patient in upright position, head shoulders up, feet & legs hanging down.

4. 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

1. To observe a decrease in urine output that may indicate a decrease in renal bold flow.

2. To promote placental perfusion

3. To favor pooling of body by gravitational forces & to decrease venous return

4. To decreased the pressure in the blood stream

5. To reduce BP gradually and wide pressure variations avoided because lowered BP may not be adequate to perfuse vital organs

6. 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 mmHgPR: 90 bpmRR: 24 cpmTemp.: 37◦C

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.

CONCLUSIONPresented 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

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.

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/

Thank you!!

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