Complications of

Pregnancy
By Jonathan Tellier
Objectives
➢ Gain a better understanding of preeclampsia and HELLP syndrome.

➢ Identify lab values associated with the different conditions.

➢ Understand the possible etiologies of these diagnosis.

➢ Understand the treatment course for this patient.

 Conditions Overview
Preeclampsia- characterized by high blood pressure and presence of protein in the urine,
occurring only during pregnancy and the postpartum period, affecting 5-8% of all
pregnancies. Eclampsia- Refers to occurrence of new-onset, generalized, tonic-clonic
seizures in woman with preeclampsia.

HELLP Syndrome- Is characterized by H-Hemolysis, EL- elevated liver enzymes, LP- low
platelets, occuring in 0.2-0.6 percent of all pregnancies and in 10-20% of cases with
severe preeclampsia.

Intraventricular hemorrhage- Bleeding inside or around the ventricles in the brain.

Bleeding in the brain can build up and put pressure on nerve cells and damage them.

Haram et al (2009)
Fairhall et al (2009
 Preeclampsia/Eclampsia
❏ Etiology- result of a placenta that doesn’t function properly
❏ Prognosis- 2% mortality rate.
❏ S/S- Proteinuria, edema in feet, legs, and hands
❏ Pertinent lab values- Protein/creat. Ratio >0.3, Serum creatinine >1.2 mg/dL, Low
platelets/coagulopathy, platelet count < 100,000/mm
❏ Treatment- Depends on due date and complications. If the baby is viable and gestation is 34 weeks
the doctor will likely recommend delivery.
❏ Medications- Antihypertensive
❏ Risk- First-time mom, Obesity

Abildgaard U & Heimdal (2013)

American Pregnancy Organization
Haram et al. (2009)
 HELLP Syndrome

❏ Etiology- Is unclear to many doctors but immunological maladaptations is a probable trigger.

❏ Prognosis- 1.1% maternal mortality rate and 10-60% infant mortality rate
❏ Diagnosis- Indirect bilirubin > 1.2 mg/dL, LDH >600 U/L, Elevated AST > 70 U/L, Low Platelets count
<100,000/mm.
❏ S/S- Headaches, N/V, Abdominal pain, Fatigue, High blood pressure, Proteinuria, Edema, Bleeding
❏ Pertinent lab values- LFT, Blood tests (thrombocytopenia), Urine tests
❏ Treatment- Depending on the gestation of pregnancy, delivery of the baby is the best way to stop
this condition.
❏ Other treatment- Blood transfusion
❏ Medications- Corticosteroid, Magnesium Sulfate, Anti-hypertensive

Abildgaard U & Heimdal (2013)

American Pregnancy Organization
Haram et al. (2009)
 Mechanisms Involved
● Immune response at the placental-maternal interface
○ Embryo expresses paternal antigens foreign to the mother.
○ Causing an immune response.
● Placentation and angiogenesis
○ Arterial wall remodeling causes arterial dilation.
○ Angiogenic factors released are linked to preeclampsia.
● Oxidative stress and inflammation
○ Impaired arterial remodeling, causes O2 concentration to
fluctuate.
○ Causes apoptosis and necrosis of the trophoblast cells.
○ Increased cell death increases inflammation (IL6 and
cytokines).

Jebbink et al (2012)
 B12 deficiency can mimic HELLP
❏ B12 deficiency occurs in 38% of all pregnant women upon delivery.
❏ Manifestations of microangiopathic hemolytic anemia and
thrombocytopenia, hemolysis, elevated liver enzymes, and low
platelet count, neural tube defects, preterm birth, low neonatal birth
weight.
❏ Risks include obesity, prior bariatric surgery, inflammatory bowel
disease, Heli-cobacter pylori infection, use of metformin or proton
pump inhibitors, and certain vegan diets

Govindappagari et al. (2019)

 Preeclampsia/HELLP Syndrome Nutrition
● Nutrition care should focus on managing blood pressure and preventing complications:
○ Optimizing protein intake
○ Lowering fat intake
○ Adding fruits and vegetables
○ Consume less salt
○ Drink at least 8 glasses of water
● Foods to avoid:
○ Beverages: Alcohol, caffeine, herbal teas
○ Raw or uncooked meats and foods high in mercury
○ Dairy products: Unpasteurized milk, soft-serve yogurt, brie, blue cheese, gorgonzola
○ Fruits vegetables: Raw sprouts, unpasteurized juice
American Pregnancy Organization
Nutrition Care Manual
 Intraventricular Hemorrhage in Pregnancy
Etiology- Severe hypertension in conjunction with increased
cerebrovascular resistance and loss of autoregulation.
Prognosis- Fourth leading cause of death
S/S- Sudden numbness, weakness in arms and legs, confusion,
trouble seeing in one or both eyes, trouble walking dizziness,
loss of balance, loss of coordination.
Pertinent lab values- Prothrombin time, Partial
thromboplastin time, Blood glucose, HDL, LDL, Electrolytes.
Treatment- Lifestyle changes and medication to lower
cholesterol and blood pressure.
Medications- Aspirin, Warfarin, and other anticoagulant or
antiplatelet medications to reduce risk of stroke.

Fairhall et al. (2009)

 Stroke Nutrition
● Acute nutritional problems include chewing,
swallowing, or self-feeding impairment that lead to
inadequate nutritional intake.
● Early enteral nutrition is necessary if an oral diet cannot
meet nutritional needs.
● Dysphagia is common in stroke patients.
● Monitoring and evaluation:
○ Swallow status
○ Adequacy of intake
○ Comorbidities

Nutrition care manual

Assessment
Age- 31 years old
Gender- Female
HT- 70 in
Admit WT- 113 kg (pregnant on admission)
UBW- 95 kg (obtained 4/9)
WT Trend: 113kg(Admit), 119.5 (3/31), 120.2 kg (4/6), 118.5
kg (4/9), 109.5 kg (4/12)
BMI- 35.6 IBW%- 166% IBW: 68.1 KG
Social background- Husband denies any drug, alcohol, or
tobacco use. Reports patient takes prenatal vitamins and iron.
Patient last seen at San Bernardino Community Hospital a few
days prior to admission for right upper quadrant pain and
admitted for blood pressure monitoring.
PMHX- Obesity, Weeks Gestation on admission: 27 2/7
Admit Dx- Intraventricular hemorrhage, Eclampsia, S/P C/S
 Biochemical
Labs Normal Values 3/29/19 3/31/19 4/3/19 4/6/19 4/9/-4/12/19 417/19
A1c 4.3-6.1% < 4.3 x x x x x
LDH 120-230 U/L 219 x x x x x
ALT 5-40 U/L 73/75 x x x x x
AST 5-40 U/L 53/44 x x x x x
Albumin 3.5-4.9 g/dL 3.3/2.7 x 3.0 x x x
Alk Phos. 35-125 U/L 109/95 x x x x x
Total protein 6/8 g/dL 6.7/5.7 x 6.3 x x x
Calcium 8.5-10.5 mg/dL 8.7-7.2 6.8/7.9 5.1/ 8.1 7.9 7.6/8.4 x
Creatinine 0.5-1.5 mg/dL 0.7 0.6 <.2 0.4 0.4 x
Phosphorus 2.4-4.4 mg/dL 4.6 4.2 2.1 2.9 2.9 x
Potassium 3.5-5.5 MEQ/L 4 3.5 2.6 4.1 3.8 x
Sodium 135-148 MEQ/L WNL 149/152 149 138 141 x
Magnesium 1.6-2.3 mg/dL 2.2-5.6 3.2/2.5 1.4 1.8 1.9 x
C-RP <0.50 mg/dL x x 4.99 x 7.8 (4/8) 21.48 (4/14)
Procalcitonin <0.08 ng/mL x x 0.22 x x x
Medical tests and procedures
3/29 CT head- Shows intraventricular hemorrhage 4/18 lumbar drain placed for intrathecal gentamycin
with hydrocephalus and midline shift to the left.

3/29 CT head- S/P ventriculostomy placement

3/29 Intubation for respiratory failure

4/1 CT head- Complete resolution of IVH in 4th Consults:

ventricle
Neurosurgery
4/3 CT head- Redemonstration of right basal ganglia
Maternal Fetal Medicine
hemorrhage. The intraventricular component has
decreased. There is no midline shift. Cardiology

4/3 Very large hiatal hernia. Associated bilateral Pulmonary

consolidation, likely representing atelectasis.

4/13 EVD taken out

4/14 CTH -EVD replaced/ CXR LLL pneumonia

4/17 Duplex b/l LE- partial thrombosis of femoral veins

 Estimated needs/ Diet order
3/29 3/31 4/3-4/6 4/9-4/12-4/17
Estimated needs: Estimated needs: Estimated needs: Estimated needs:
2000 calorie/day (18 2350 calorie/day (35 2350 calorie/day (35 2350 calorie/day (35
Kcal/kg on vent Kcal/kg extubated) Kcal/kg extubated) Kcal/kg extubated)
support) Protein Requirement Protein Requirement Protein Requirement
Protein Requirement 110 grams/day (1.60 136 grams/day (2.0 136 grams/day (2.0
110 grams/day (1.60 grams/Kg) grams/Kg Sepsis) grams/Kg Sepsis)
grams/Kg) Estimated Needs Estimated Needs Estimated Needs
Estimated Needs Comment Comment Comment
Comment Kcals and Pro based Kcals and Pro based on Kcals and Pro based on
Kcals based on admit on IBW of 68.1 Kg. IBW of 68.1 Kg. IBW of 68.1 Kg.
wt. 113 Kg, Pro based Diet order- Jevity 1.2 Diet order- Dysphagia Diet order- Dysphagia 3/
on IBW of 68.1 Kg. @ 65 mL/hr (1872 3, Jevity 1.2 @ 65 Dysphagia 2 (4/17), NTL
Diet order- NPO kcal, 93 g mL/hr(1872 kcal, 93 g w/ ensure BID, Aspiration
protein/day) protein/day) precaution 1:1 feeder
 Nutrition Needs Explanation
According to AND Evidence Analysis work group, Penn Recommended calculations according to AND Evidence
State University equation had the highest accuracy Analysis work group
when compared to measured energy expenditure. ● Mifflin St. Jeor
○ 1920 kcal per day
● 1st Assessment (on vent) ● Penn State Equation 2003
○ 2000 calorie (18 kcal /kg) ABW 113 kg ○ 0.85(1586)+175(37)+33(12.9)-6,433= 1,815
○ 110 grams protein (1.6g / kg) IBW 68.1 kg kcal/day
● 2nd Assessment (off vent) ● 20-30 kcal/kg IBW with a BMI >30
○ 2350 calorie (35 kcal/kg) IBW 68.1 ○ 1702-2043 kcal/day
○ 110 grams protein (1.6g / kg) IBW 68.1 ● Protein BMI of 30-40, use > 2 g/kg IBW
● 3rd-7th Assessment ○ 136 grams/day
○ 2350 calorie (35 kcal/kg) IBW 68.1
○ 136 grams protein (2.0g / kg) IBW 68.1

Maday K. (2013)
Nelms et al. (2016)
Dickerson et al. (2017)
 Medication
Drug Name Purpose Drug Nutrient Interaction
Cefotetan Antibiotic Eosinophilia
Colace Stool Softener Bitter taste, throat irritation nausea
Coreg Antihypertensive Diarrhea, hypotension, bradycardia, dizziness ↑
N/V, constipation, Ataxia, dizziness, confusion, ↓
Dilantin IV Anticonvulsant Folate, ↓ Vit D, ↓ Ca, ↓ Phos
Abdominal pain, GI bleeding, constipation, black
tarry stools, Bleeding, hemorrhage, dizziness,
Heparin Anticoagulant headache, ↓ platelets, ↑ AST, ↑ALT, ↑PT
Anorexia, N/V, Diarrhea, Edema, headache,
Hydralazine Antihypertensive tachycardia, palpitations, angina,
Hypertonic Saline IV Sodium repletion Fever, infection
Lisinopril Ace inhibitor Cough
Diarrhea, confusion, fatigue, dizziness, insomnia,
lopressor Antihypertensive depression
breathing difficulties,poor reflexes, confusion,
Mg IV Anticonvulsant weakness, flushing, lowered blood pressure
Propofol Anesthesia, Sedative Hypotension, increased triglycerides/cholesterol
Protonix Anti Gerd Diarrhea
Senna Laxative Intestinal peristalsis, nausea, cramps
SSI Hyperglycemic Hypoglycemia, ↓glucose, ↓A1c
 All other problems (Assessment and plan)

Heart failure with reduced ejection fraction Acute hypoxemic respiratory failure
(10%)
Sepsis DDx pneumonia vs post-op atelectasis vs
Flash Pulmonary edema linde infections

Cardiomegaly Electrolyte depletion

Hypokinesis on bedside cardiac ultrasound Large hiatal hernia - CT demonstrated impacted

food within the esophagus
Acute encephalopathy
Partial thrombosis of common femoral veins
Achalasia bilaterally
1st Assessment
Dx Swallowing difficulties R/T respiratory failure AEB pt. Intubated on vent and NGT in place.

●Recommendation 3/29 - Start TF support with Glucerna 1.2 at 20 ml/hr. Increase rate
as tolerated to goal of 65 ml/hr to provide 1872 Kcal, 93 g protein/day.
○ Give Beneprotein 1 pack tid (18g protein extra) to meet needs. Propofol to
contribute to Kcal intake.
○ Suggest MVI daily
➢ Reasoning
○ Expected inadequate intake >7 days.
○ MVI for wound healing
➔ Monitor: TF tolerance, Propofol infusion, labs, skin status, wt. trend.
➔ GOALS: Pt. starts TF support in next 24-48 hrs & tolerates, stable labs, stable wt. as able.
✓ Potential: recommendations not included
○ Vitamin C & zinc for wound healing
○ Iron to replenish nutrient stores of mother.
Nelms et al. (2016)
 2nd Assessment
Dx Inadequate oral intake R/t swallowing difficulties AEB pt NPO pending ST swallow eval s/p
extubation, requiring nutrition support to meet est kcal/PRO needs.

Dx Inadequate EN infusion rate R/t increased nutrient needs AEB pt in critical care, current rate of
EN only meeting 79% kcal and 77% PRO needs.
● Recommendation 3/31- Increase goal rate of EN to Jevity 1.2 @ 85 mL/hr, provides
2450 kcal, 110 g PRO (meets 104% est kcal and 100% PRO needs). Consider switching
formula to Glucerna 1.2 at same goal rate if pt GLU trends up.
➢ Reasoning:
○ Expected inadequate intake > 7 days
➔ -Monitor: EN adequacy/tolerance, labs, wound, wt
➔ -Goal(s): EN meets at least 100% est kcal/PRO needs with good GI tolerance, labs trend
WNL, wound healing, stable wt

Nelms et al. (2016)

 3rd Assessment
Dx Increased protein and energy needs r/t s/p C/S with severe sepsis AEB current diet does not
meet estimated needs.

Recommendation 4/3: RD to add Mighty Shakes TID to meet increased nutrient needs.
●
May need to resume TF if intake is not adequate (consider keeping NGT in until intake
consistently >50% over 3 days)
➢ Reasoning:
○ Begin weaning when pt. Able to meet >60% of needs PO.

➔ -Monitor: PO intake/tolerance, labs, wt trends, skin healing

➔ -Goal(s): PO 90% or greater + Mighty Shakes 100% TID with tolerance to meet needs, labs
trend WNL, wound healing, stable wt as able

Nelms et al. (2016)

 4th Assessment
Dx Increased protein and energy needs r/t s/p C/S with severe sepsis AEB current diet does not
meet estimated needs and is not being given r/t altered mental status.

● Recommendation 4/6- TF Jevity 1.2 @ goal rate of 80 mls/hr to meet majority of estimated
needs until able to take adequate PO.

➢ Reasoning: Pt has not met >50% of needs x 3 days.

➔ -Monitor: PO intake, TF tolerance, labs, wt trends, skin healing

➔ -Goal(s): TF to meet >95% estimated needs for now with tolerance,able to transition to oral
diet, labs trend WNL, wound healing, stable wt as able

Nelms et al. (2016)

 5th Assessment
Dx Increased protein and energy needs r/t s/p C/S with severe sepsis AEB current diet does not
meet estimated needs.

● Recommendation 4/9: Add Ensure BID to help meet increased nutrient needs, specify
NTL in diet order, per ST recomendation. Consider nanaflakes BID, as pt continues with
loose stool.
➢ Reasoning: Pt recently had TF discontinued and NG tube removed. Per ST concerns of
feeding into large hiatal hernia found by CT on 4/3, increasing aspiration.

➔ -Monitor: PO intake, GI fx, labs, wt trends, skin healing

➔ -Goal(s): maintain PO intake 100% of meals + ONS, normalization of GI fx, labs trend WNL,
wound healing, stable wt as able

Nelms et al. (2016)

 6th/7th Assessment
Dx Inadequate oral intake r/t suboptimal appetite (improving however) AEB PO intake ~65% avg past
4 days.

●
Recommendation 4/12: Encourage PO intake, Notified MD to cont. Current diet as pt. is
tolerating (dependent on ST recs)
➢ Reasoning: Pt. has large hiatal hernia with CT showing impacted food within the esophagus.

➔ -Monitor: PO intake, GI fx, labs, wt trends, skin healing

➔ -Goal(s): maintain PO intake 100% of meals + ensure 1 can/day, labs trend WNL, wound
healing, stable wt as able

Nelms et al. (2016)

 Summary

Prognosis:

● HELLP syndrome
○ Maternal mortality rate is 1.1%
○ Fetal mortality rate is 10%-60%
● Hemorrhagic stroke
○ Mortality rate of 50% within first month of treatment.

Recommendations based on this study

● Assess the nutrient stores that may be depleted during

pregnancy.
● Needs of the patient should be assessed using the latest
literature and considerations of multiple sources should be
considered.

Abildgaard et al. (2013) & Jebbink et al. (2012)

References
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