What should the nurse evaluate before continuing the administration of IV magnesium sulfate therapy to a client with preeclampsia?

This peer reviewed course is applicable for the following professions:

Advanced Practice Registered Nurse (APRN), Certified Nurse Midwife, Certified Nurse Practitioner, Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Nursing Student, Registered Nurse (RN), Registered Nurse Practitioner

This course will be updated or discontinued on or before Saturday, December 16, 2023

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.

≥90% of participants will understand what care patients with preeclampsia need.

After completing this continuing education course, the participant will be able to complete the following objectives:

1. Define preeclampsia.
2. List risk factors for preeclampsia.
3. Generate a plan of care, including nursing assessments for patients with preeclampsia.
4. Identify the medications used to treat preeclampsia.
5. Identify the risks of preeclampsia to the woman and the fetus.
6. Discuss the long-term consequences of preeclampsia.
7. Describe what follow up care women with preeclampsia need.

CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Last Updated: 7/22/2022

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Overview of Preeclampsia

Not all hospitals have standardized protocols for caring for women with preeclampsia (ACOG, 2019). Recent reports from the World Health Organization (WHO) estimate that preeclampsia is responsible for 70,000 maternal deaths annually in the world (Risk factors, 2019). Preeclampsia and elevated blood pressures are serious problems that must be treated appropriately and quickly. When caring for pregnant women with blood pressure issues, it is important to review the different types of hypertension in pregnancy. Chronic hypertension is diagnosed when a woman has systolic blood pressure (SBP) ≥ 140 or diastolic blood pressure (DBP) ≥ 90, and this occurs pre-pregnancy or <20 weeks gestation. Gestational hypertension is diagnosed with SBP ≥ 140 or DBP ≥ 90; the patient is > 20 weeks, and there is an absence of proteinuria or systemic signs/symptoms.

Preeclampsia is defined as SBP ≥ 140 or DBP ≥ 90 and proteinuria with or without signs/symptoms OR presentation of signs/symptoms/lab abnormalities but no proteinuria. Preeclampsia with severe features is defined as systolic BP of 160 mm Hg or higher or diastolic BP of 110 mm Hg or higher on 2 occasions at least 4 hours apart while the patient is on bed rest (unless antihypertensive therapy is initiated before this time), thrombocytopenia (platelet count less than 100,000/microliter), impaired liver function as indicated by abnormally elevated blood concentrations of liver enzymes (to twice normal concentration), severe persistent right upper quadrant or epigastric pain unresponsive to medication and not accounted for by alternative diagnoses, progressive renal insufficiency (serum creatinine concentration greater than 1.1 mg/dL or a doubling of the serum creatinine concentration in the absence of other renal diseases), pulmonary edema, OR new-onset cerebral or visual disturbances. Eclampsia is diagnosed if the woman has seizures.

HELLP syndrome is considered to be a variant of preeclampsia. Sometimes the presence of HELLP syndrome is due to an underlying disease such as antiphospholipid syndrome. HELLP develops in 10% to 20% of pregnancies in women with preeclampsia or eclampsia. HELLP is characterized by hemolysis (the breakdown of red blood cells), elevated liver enzymes, and low platelets (HELLP, 2019).

However, the cause of hypertension is not important with severely elevated blood pressures. Acute onset, persistent (lasting 15 min or more), severe systolic (≥160 mm Hg) or severe diastolic hypertension (≥ 110 mm Hg) or both in pregnant or postpartum women with preeclampsia/eclampsia constitutes a hypertensive emergency, and it is inadvisable to wait 4 hours for treatment function (Preeclampsia Toolkit, 2019). Controlling blood pressure is the optimal intervention to prevent deaths due to stroke in women with preeclampsia (Wisner, 2019). Prompt treatment to lower BP can decrease maternal morbidity and mortality.

Risk Factors

There are known risk factors for preeclampsia. Not all women with these risk factors will develop preeclampsia. And not all women with preeclampsia had these risk factors. The risk factors may be useful in the early identification and treatment of women (see table 1) (Risk factors, 2019).

Table 1: Summary of Principal Risk Factors for Preeclampsia

Abbreviations: CI = confidence interval; RR = relative risk

Plan of Care

Patients with preeclampsia require close monitoring. A thorough initial assessment of the woman with possible preeclampsia should include a complete history a complete physical exam with close attention to preeclampsia symptoms, including unremitting headaches, edema, visual changes, and epigastric pain, fetal activity, and vaginal bleeding. The RN should review baseline BPs and medications or drugs throughout pregnancy (illicit & OTC). The patient should have current vital signs, including O2 saturation. The RN should also review current and past fetal assessments: FHR monitoring results estimated fetal weight and recent biophysical profile. Labs that should be drawn are CBC, platelets, LDH, liver function tests, electrolytes, BUN and creatinine, and a urine sample sent for a protein/creatinine ratio.

The nursing assessments needed vary depending on the diagnosis. Women with preeclampsia without severe features need vital signs, pulse ox, and lung sounds every 4 hours. Level of consciousness, edema and assessment for headache, visual disturbances, and epigastric pain should occur every 8 hours. Intake and output should be monitored hourly. Fetal monitoring should be done as ordered.

Women with preeclampsia with severe features OR women on magnesium sulfate need vital signs, including pulse ox every 30 minutes (should be done every 5 minutes during loading dose of magnesium sulfate). These women need lung sounds assessed every 2 hours. Level of consciousness, edema and assessment for headache, visual disturbances, and epigastric pain should occur every 8 hours. Strict (hourly) intake and output should be monitored, and intake should be ≤ 125 mL/hour. Fetal monitoring should be continuous as an ordered function (Preeclampsia Toolkit, 2019). Once the woman is stable without severe features and not on magnesium sulfate, she may be monitored as a patient with preeclampsia without severe features.

Treatment

Medication

Persistent, severe hypertension can occur antepartum, intrapartum, or postpartum. Two severe BP values (≥ 160/110) taken 15-60 minutes apart require treatment within 60 minutes of the 2nd elevated BP. The acceptable treatments for severe BP are intravenous (IV) labetalol, intravenous hydralazine, or oral nifedipine. One medication should be chosen and initiated (see table 2) (ACOG, 2019).

Table 2: Antihypertensive Medications

Intravenous hydralazine may increase the risk of maternal hypotension. Intravenous labetalol may cause neonatal bradycardia and should be avoided in women with asthma, heart disease, or congestive heart failure. Nifedipine has been associated with increased maternal heart rate and less risk of overshoot hypotension. No significant changes in umbilical blood flow have been observed using either labetalol or hydralazine, and outcomes are similar for both drugs. No significant changes in the uteroplacental blood flow or the fetal heart have been noted with the use of immediate-release oral nifedipine to treat severe pregnancy-induced hypertension. However, immediate-release oral nifedipine should not be given sublingually because of the risk of hypotension (ACOG, 2019).

Using an algorithm like the one in table 3 can improve treatment times and patient outcomes (ACOG, 2019).

Table 3

Magnesium sulfate may also be administered as a central nervous system depressant to decrease the risk of seizures. While magnesium may decrease BP, it is not used as an antihypertensive. Myasthenia gravis is a contraindication to giving Mag sulfate.

Magnesium is usually given as a 4 to 6gm loading dose followed by 2 gm/hr IV. This dose may be started antepartum or intrapartum and continue for 24 hours after delivery. The therapeutic range: is 4.8-8.4. Serum levels are not indicated unless signs and symptoms of toxicity or renal insufficiency. Before starting mag sulfate, a BUN and creatinine should be drawn to assess renal function (Preeclampsia Toolkit, 2019). Magnesium toxicity is dangerous and can cause severe complications, such as renal failure or death. The RN must perform proper assessments, including checking for headaches, visual changes, and altered levels of consciousness. Vital signs, reflex status, and intake and output need to be monitored. The provider should be notified of the following signs of magnesium toxicity: depressed or absent reflexes, respirations less than 12 per minute, or urinary output of less than 30 mL per hour or less than 120 mL in four hours of function (Preeclampsia Toolkit, 2019). Early signs of magnesium toxicity are warm/hot “all over,” flushing, increased thirst, diaphoresis, depressed reflexes, hypotension, or flaccidity. Late signs are CNS depression, increased drowsiness, lethargy, slurring of speech, respiratory paralysis, or circulatory collapse. The antidote for magnesium sulfate toxicity is 10% Calcium Gluconate 1-gram IV push over 3 minutes.

An eclamptic seizure would include antihypertensives, magnesium sulfate, and anticonvulsants.

Risks to Mom and Baby

Preeclampsia and eclampsia are dangerous diseases that can cause complications to both the woman and the fetus. Women with preeclampsia are at increased risk for kidney damage, liver, brain, and other organs and blood systems. Central nervous system disturbances are possible (seizure, unremitting headache, visual disturbance). A woman with preeclampsia is at an increased risk of pulmonary edema, thrombocytopenia, hemolysis, coagulopathy, and oliguria. These women are also at an increased risk of stroke (Kennedy, 2019).

Preeclampsia may affect the placenta. This condition could lead to placental abruption, preterm delivery, intrauterine growth restriction, or stillbirth (Kennedy, 2019).

Long Term Effects

Women with preeclampsia are still at risk for problems after discharge. Women who had preeclampsia are four times more likely to develop hypertension and are twice as likely to develop later ischemic heart disease, a blood clot in a vein, and stroke than those who did not. Mothers who have preeclampsia can also experience permanent damage to their organs, such as their kidneys and liver. These women can experience fluid in the lungs and remain at increased risk for developing eclampsia and seizures (Kennedy, 2019). Studies show that many women do not know their risks when being discharged ( Education is a vital part of preeclampsia.

Follow Up Care

These women need to know their risks and signs and symptoms to look for, such as headache, visual changes, shortness of breath, or altered level of consciousness. Women must understand that they must call their provider or go to the emergency department for any of these symptoms. Women treated with medications for elevated BPs should have a visit to their provider 3 days after discharge for a blood pressure check. These women also need to know the long-term consequences of preeclampsia and the importance of seeing their family physician. Women with preeclampsia should see their physician or a visiting nurse within 3-5 days after delivery and 7-10 days after delivery function (Preeclampsia Toolkit, 2019). Some hospitals are beginning to use telemedicine to follow up with these patients. Some of these women may see nephrologists in the outpatient setting. Emergency departments must also be aware of the signs and symptoms of postpartum preeclampsia.

Case Study

Scenario

24-year-old G2, P0-0-1-0 @ 39 wks. Prenatal course unremarkable, blood pressure normal throughout the prenatal period.? Presented to the office with a complaint of regular uterine contractions, BP: 142/95. Urinalysis negative for protein. The patient was admitted for spontaneous labor and gestational hypertension. On admission to labor and delivery: BP 133/74, urinalysis negative, platelet count: 187,000/unit, AST 14, ALT 18. BP remained modestly elevated throughout labor and postpartum stay. The patient had a primary late-term c/section for failure to progress. The postpartum course was unremarkable. No documented complaints of headache, blurred vision or epigastric pain. On day 3 post-op, the patient complained of “acute, crushing headache,” pain rated 8/10. Discharge orders are already written. The patient received hydrocodone 15 mg/acetaminophen 650 mg and was discharged 30 minutes later. Post-op day #4: Patient-reported worsening headache to family. Post-op day #5: Progressively worsening headache and new-onset visual changes.

Interventions

The family called 911. The initial seizure occurred shortly after, and the family witnessed multiple seizures. The patient was intubated in the field and transported to the hospital, where she was started on Magnesium sulfate, Ativan, Keppra, and labetalol. The patient was extubated shortly after admission, and BP’s remained elevated with max 148/98; SBP mostly 130’s; DBP mostly 80’s, platelet count 370,000, AST 30, ALT 33, creatinine 0.9 mg/ dl, urinalysis: negative for protein. Persistent, mild headache with some postural component. MRI: “no evidence of ischemic injury.”

Discussion

Delayed eclampsia >48 hours following delivery, up to 4 weeks postpartum, accounts for approximately 15% of cases of eclampsia. 63% had no antepartum hypertensive diagnosis. The most common presenting symptom was a headache, which occurred in about 70% of patients; other prodromal symptoms included shortness of breath, blurry vision, nausea or vomiting, edema, neurological deficit, and epigastric pain.

Strengths and Weaknesses

Delayed onset prevented the ability to predict this outcome. She did not indicate early follow-up to see the provider. The only indicator was the headache. The patient could have been kept in the hospital longer to evaluate the headache, especially with her history of gestational hypertension. She also may have called her doctor or gone to ED sooner if she had the proper education.

Conclusion

Preeclampsia is a complicated disease. It can have devastating consequences to the mother or fetus if not treated promptly and correctly. Nurses and providers need to know the facts about preeclampsia. It is also important for nurses to educate the woman so that she can advocate for her care.

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References

• ACOG Committee Opinion No. 767. Obstetrics & Gynecology. 2019;133(2). doi:10.1097/aog.0000000000003075.
• Risk factors and effective management of preeclampsia. Accessed November 22, 2019. Visit Source.
• HELLP syndrome: MedlinePlus Medical Encyclopedia. MedlinePlus. Accessed November 22, 2019. Visit Source.
• Preeclampsia Toolkit. Preeclampsia Toolkit | California Maternal Quality Care Collaborative. Accessed November 22, 2019. Visit Source.
• Wisner K. Safety Bundle for Severe Hypertension During Pregnancy and Postpartum. MCN, The American Journal of Maternal/Child Nursing. 2018;43(3):171. doi:10.1097/nmc.0000000000000420.
• Kennedy, E. What are the risks of preeclampsia & eclampsia to the mother? Shriver National Institute of Child Health and Human Development. Accessed November 23, 2019. Visit Source.
• Burgess A, Feliu K. Women’s Knowledge of Cardiovascular Risk After Preeclampsia. Nursing for Womens Health. 2019;23(5):424-432. doi:10.1016/j.nwh.2019.07.001.

Which would the nurse implement before administering magnesium sulfate to a client with preeclampsia?

What should you check before administering magnesium sulfate?

What assessments are most important for a patient receiving magnesium sulfate?

What will the nurse monitor during magnesium sulfate therapy?