A Study to Assess the Effectiveness of Structured Teaching Programme on Knowledge Regarding

A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING PRE-ECLAMPSIA AMONG THE STAFF NURSES WORKING IN GOVERNMENT DISTRICT HOSPITAL, TUMKUR.

PROFORMA FOR REGISTRATION OF

SUBJECT FOR DISSERTATION

MRS. SHARANJEET KAUR

AKSHAYA COLLEGE OF NURSING

S.I.T. Main Road, Tumkur.

December 2009

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION:

Pregnancy is a special event. The family and the community should treat a pregnant woman with particular care. They must know the danger signs which may arise during pregnancy, labour, delivery and puerperium, so that help for the mother and child can be sought early. Pregnancy can be a thrilling and wonderful part of a woman’s life. Some women have problem free pregnancies, but some women are at risk of developing life threatening complication during pregnancy or childbirth. (Healthy pregnancy .com)

Safe motherhood has been neglected as an important requisite for national development. Ensuring safe and high quality delivery of maternal and child health care services, particularly within easy access to the poor is one of the biggest challenge facing the health care system today.1

In developing countries the great majority of deaths are due to eclampsia and higher when antenatal coverage is lower. This is taken as evidence of higher probability of progression from pre-eclampsia in the absence of antenatal care.2

According to Sample registration system estimates 90% of the maternal deaths were due to eclampsia. Stillbirth, lower birth weight and asphyxia are associated problems of pre-eclampsia and eclampsia, leading to high perinatal mortality rates. Women with severe pre-eclampsia require specialist care. The early detection, treatment and regular monitoring of the condition can literally make a difference of life and death to woman and her child.3

A study on obstetric complications in Primigravida in year 2001 at Sri Devraj Urs Medical College Kolar in Karnataka showed an incidence of 21% pre-eclampsia among 1124 patients.4

According to World Health Organization estimates about 510,000 maternal deaths occurred globally during the year 2002. The statistical data on causes of maternal deaths worldwide as per the world health report revealed 12% of maternal deaths are due to hypertensive disorders of pregnancy.5

In India, the maternal mortality rate as per the annual report (2002) is 407 per 100,000 live births; in Karnataka it is 195 per 100,000 live births. The maternal mortality rate in India due to direct obstetric causes is 70% of which pregnancy induced hypertension (PIH) is one among them.6

Pre-eclampsia is the most common hypertensive disorder during pregnancy, affecting an estimated 5.8% of pregnant women annually in the United States and has greatest effect on maternal and infant outcome. Over past decade, the rate of pre-eclampsia has increased by nearly one-third. This increase is due to a rise in the number of older mothers and of multiple births, where pre-eclampsia occurs more frequently. High blood pressure problems occur in 6% - 8% of all pregnancies in United States and about 70% of which are first time pregnancies. In 2002 more than 146,320 cases of pre-eclampsia alone were diagnosed. Incidence is significantly higher in low socio-economic group. About 5% of females with pre-eclampsia develop eclampsia and from these about 15% die from PIH it self or its complications. Fetal mortality is high due to the increased incidence of premature delivery and utero-placental insufficiency.7

Women who have had two pregnancies complicated by pre-eclampsia are at a higher risk of hypertension after pregnancy, it has been reported. Researchers at the University of Copenhagen in Denmark based their findings on a retrospective study of over 11 million women who gave birth in the country United Kingdom from 1978 to 2007.They found that the only reliable treatment for pre-eclampsia is delivery of the baby. But while delivery may 'cure' pre-eclampsia in the moment, these mothers are at high risk of chronic hypertension; type two diabetes mellitus and blood clots for the rest of their lives. Pregnancy acts like a natural stress test for women."Physicians and other healthcare professionals should be encouraged to include the history of a woman's pregnancy outcomes when estimating the risk of cardiovascular disease, Pre-eclampsia, which causes high blood pressure, protein leaks from the kidneys into the urine, and other conditions, can affect any pregnant woman.8

The effectiveness of health education to improve recognition of the importance and gravity of symptoms like high blood pressure, oedema as well as headache, abdominal pain and visual disturbances in late pregnancy and particularly in conjunction with signs of pre-eclampsia need to be evaluated.9

6.1. NEED FOR THE STUDY

It is a tragic fact that in the very act of giving births of achieving motherhood nearly half a million women die every year world over. Many more who escape death; survive with serious ill health and a host of pregnancy and child birth related complication. It is the women in the developing countries, who face the gravest risks. These women die of neglect, ignorance and in accessibility of required services. 25% of all the deaths in the child bearing age, women die in developing countries due to complication of pregnancy and child birth in comparison with 1% in the United States.10

The worldwide prevalence of pre-eclampsia range from 3-15% of pregnancies. Yearly, more than 8500,000 cases are reported worldwide of which 5000 in Sweden. Pre-eclampsia is responsible for 25% of deaths for both children and mother during pregnancy and is responsible for 15% of premature births worldwide.11

Pre-eclampsia is a condition that typically starts after the 20th week of pregnancy and is related to increased blood pressure and protein in the mother’s urine (as a result of kidney problem). Pre-eclampsia affects the placenta and it can affect the mother’s kidney, liver and brain. When pre-eclampsia causes seizures, the condition is known as eclampsia, the second leading cause of maternal death. Pre-eclampsia is also a leading cause of fetal complications, which include low birth weight, premature birth and stillbirths. There is no proven way to prevent pre-eclampsia. Most women, who develop the signs of pre-eclampsia, however are closely monitored to lesson or avoid related problem. The only way to ‘cure’ pre-eclampsia is to deliver the baby. The exact nature of the primary event causing pregnancy-induced hypertension is not known but following are thought to be the possibilities.

1.  There is a relative or absolute deficiency of vasodilator prostaglandin (PGI2), synthesized in vascular endothelium and increased synthesis of thromboxane (TXA2), a potent vasoconstrictor in platelets.

2.  There is increased vascular sensitivity to the pressor agent angiotension-II.

3.  Nitric oxide, which normally relaxes vascular smooth muscle, inhibits platelets aggregation and prevents intervillous thrombosis, is found deficient in pre-eclamptic clients.

4.  In pre-eclampsia, trophoblastic invasion of the spiral arteries is thought to be inhibited by some immunological mechanism.12

Who are more likely to develop pre-eclampsia; -

1.  Women with chronic hypertension (high blood pressure before becoming pregnant).

2.  Women who developed high blood pressure or pre-eclampsia during a previous pregnancy, especially if these condition occurred early in the pregnancy.

3.  Women who are obese prior to pregnancy.

4.  Pregnant women under the age of 20 or over the age of 40.

5.  Women who are pregnant with more than one baby.

6.  Women with diabetes, kidney disease, rheumatoid arthritis, etc.13

Clinical features and complication:

Clinical classification of Pre-eclampsia:-

The clinical classification of pre-eclampsia is principally dependent on the level of blood pressure for management purpose.

·  Mild pre-eclampsia is diagnosed when there is sustained rise of blood pressure of more than 140/90 mm Hg but less than 160 systolic or 110 diastolic without significant Proteinuria on two occasions six hours apart.

·  Severe pre-eclampsia is diagnosed when the blood pressure exceeds 160/100 mm Hg, when there is an increase in the Proteinuria (75gm per day) and edema is marked. The woman may complain of frontal headaches, visual disturbances and upper abdominal pain with or without vomiting, reduced platelets count, elevated liver enzymes, retinal hemorrhages, pulmonary edema and intra uterine growth retardation of the fetus are also seen.

Clinical features: -

§  Pre -eclampsia frequently occurs in primigravida (70%).

§  It is often associated with obstetrical-medical complications, such as multiple pregnancy, polyhydramnios, preexisting hypertension, diabetes, etc.

§  The clinical manifestations usually appear after the 20th week.

§  The onset is usually insidious and the symptoms run slow course. Sometimes may be acute and follows a rapid course.

§  Edema is seen in approximately 80% of women with pre-eclampsia. It may appear rather sudden and be associated with a rapid weight gain. The edema pits on pressure and may be found in the face, hands, lower abdomen, vulva, sacral area, pretibial region, ankles and feet.

§  Elevated blood pressure: more than 140/90 mm Hg in mild cases and above 160/110 mm Hg in severe pre-eclampsia.

Effects on the fetus: -

§  Reduced placental function can result in low birth weight.

§  There is an increased incidence of hypoxia in both the antenatal and intrapartum period.

§  Placental abruption, if minor, will contribute to fetal hypoxia, if major, intrauterine deaths will occur.

§  Early delivery, if the disease worsens, or if abruption occurs, which will produce a pre-term baby requiring resuscitation.

Complications: -

Immediate complications

·  During pregnancy

ü  Eclampsia 2% more in acute cases.

ü  Placental abruption and intrauterine fetal death.

ü  Oliguria and anuria.

ü  Dimness of vision and blindness.

ü  Preterm labor.

ü  HELLP syndrome (Hemolytic anemia, Elevated Liver Enzymes, Low Platelets count).

·  During labor

ü  Eclampsia.

ü  Postpartum hemorrhage.

·  During puerperium

ü  Eclampsia usually with in 48 hours.

ü  Shock

ü  Sepsis

Remote complications

ü  Residual hypertension: the hypertension may persist even after 6 months following delivery in about 50% of cases.

ü  Recurrent pre-eclampsia: there is 25% chance of pre-eclampsia to recur in subsequent pregnancies.12

Nearly half of all babies 48%has born to women with pre-eclampsia have a low birth weight, 11.5% die shortly after birth and 8.6% are stillborn because of its mismanagement. Diagnosis of pre-eclampsia is defined as a blood pressure of at least 140/90 mm of Hg and protein urea (> 300mg/day) is complicated by normal changes in cardio-vascular function and volume homeostasis during pregnancy, predictive testes may help recognize the condition before it worsens. All women with suspected pre-eclampsia should be hospitalized. Even though delivery of the baby is the only cure for the condition, measures may be used to delay birth if the fetus is not near term. If the decision is made to delay birth and blood pressure rises to unacceptable levels, several antihypertensive medications are safe to use during pregnancy. The drug of choice is methyldopa 0.5-3.0 g/day in two divided doses is preferred.

Gestation is permitted to continue as long as blood pressure is controlled, no ominous signs of life threatening maternal complications occur. Delivery is indicated at any stage of pregnancy when severe hypertension is uncontrolled for 24 – 48 hours. The women who have had pre-eclampsia are at increased risk for cardiovascular and metabolic diseases. Therefore such women should have more frequent health checkups and should be advised that lifestyle and dietary changes may minimize such problems in the future.13.

Pre-eclampsia and eclampsia continue to be among the leading causes of maternal death. The data was analyzed from the National Hospital Discharge Survey; found that 26 per 1000 births were complicated by eclampsia. Maternal age less than 20 years old was the strongest risk factor for both pre-eclampsia and eclampsia. These data indicate a need for improved prenatal care among teenagers.14

An observational study was designed to determine whether the reduced risk of pre-eclampsia in the second pregnancy is dependent or independent of the first pregnancy outcome, including the gestational age at delivery. Data from 24,500 women with first and second pregnancies between 1986 and 2006 were obtained from the Aderdeen Maternity and Neonatal Databank in Scotland. The treatment group included all women who developed pre-eclampsia in their second pregnancy, whereas the control group included all women with normotensive second pregnancies. A total of 903 (3.7%) of the 24,500 women in study population had pre-eclampsia in the second pregnancy. Of these, 167 had a previous history of pre-eclampsia, for a recurrence rate of 14.2%. The incidence rate of pre-eclampsia was increased in women with interpregnancy intervals of 6 years or more (19.3% vs 14.7%) and those with an increase in body mass index (70.8% vs 63.2%), where as a change of partner appeared to have a protective effect (3.5% vs 5.6%). Compared to women who were normotensive in the first pregnancy, women with a history of pre-eclampsia in the previous pregnancy had an adjusted odd ratio of 5.12 (95% confidence interval of 4.42-6.48) for developing pre-eclampsia in the second pregnancy. The study revealed that, the risk of pre-eclampsia in the second pregnancy appeared to decrease with increasing gestational age at delivery of first pregnancy. The findings suggest that the protective effect of previous pregnancy against pre-eclampsia in the second pregnancy is dependent on the gestational age at delivery of the first pregnancy but not on that pregnancy outcome.15

The investigator observed that many pregnant women were admitted to the hospitals in the terminal stage and they invariably suffered from eclamptic fits, which resulted in high maternal and infant mortality rates. Health education regarding the importance of antenatal care should be provided to the family and the community. The nursing personnel’s who act as the back bone of maternity services should know the signs and symptoms such as high blood pressure, edema and Proteinuria in pregnant women which are the hallmarks of pre-eclampsia.