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Thrombotic Thrombocytopenic Purpura and Hemolytic-Uremic Syndrome in the Postpartum Period
CASE STUDIES Proceedings of the 2016 AWHONN Convention
A Patient’s Rights and the Nurse’s Responsibility to Provide Nonjudgmental Care Background s the Internet has become an increasing source of information and education for the public, health care professionals are experiencing a challenge: how to care for patients who may distrust standard medical care.
A
Case A woman presented to a tertiary care center triage unit at 40 weeks and 6 days gestation complaining of contractions and leaking fluid. Her history and physical revealed that she had two previous cesarean births, a failed attempt at a trial of labor after cesarean, and a rupture of the right lateral segment of the uterus after 8 cm dilation during the previous pregnancy. After many unsuccessful attempts to find a provider who would care for her and honor her request for
trial of labor after cesarean, the woman waited until the onset of labor to seek medical care. Despite multiple conversations with the medical team, she continued to withhold consent for cesarean. On admission, the nursing staff became “uncomfortable” and initially refused to care for the woman because they were not willing to assume the risk associated with her decision. During a multidisciplinary huddle, staff discussed nursing practice, ethics, and current issues on litigation; the emphasis was on nursing roles and the provision of nonjudgmental care. Conclusion The woman had a successful vaginal birth after cesarean within 6 hours of admission with Apgar scores of 9/9 and normal cord gases; she was discharged in 24 hours.
Kendra L. Folh, BSN, RN, Children’s Memorial Hermann Hospital, Houston, TX Keywords multidisciplinary care nurse practice trial of labor after uterine rupture uterine rupture safety rounds
Obstetric Poster Presentation
Thrombotic Thrombocytopenic Purpura and Hemolytic-Uremic Syndrome in the Postpartum Period Background hrombotic thrombocytopenic purpura and hemolytic-uremic syndrome are rare complications that may develop in pregnancy and that mimic common obstetric complications, including severe preeclampsia, eclampsia, and HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome. Delay in diagnosis and treatment can lead to increased mortality.
T
Case A 25-year-old primigravida presented at term with contractions and decreased fetal movement. Her prenatal care and medical history were unremarkable. A prolonged fetal bradycardia prompted an emergency cesarean birth of a healthy male newborn. The woman’s postpartum recovery was unremarkable. On postoperative day 3, her blood pressure increased to 146/99 mmHg, and she developed a nose bleed with small clots, increased vaginal bleeding, and low urine output with hematuria. During the next few days, her
S56
hematocrit decreased while her blood urea nitrogen increased. She remained alert and normotensive. She was transfused with packed red blood cells, platelets, and fresh frozen plasma. Differential diagnosis indicated a ureteral injury or HELLP syndrome. On postoperative day 4, her hematocrit was 9.2, platelets were 48 with giant platelets observed, and lactate dehydrogenase was 3,258 (91 to 180). There was a lack of improvement on postpartum day 5: hematocrit was 6.9, platelets were 42, and blood urea nitrogen was 89. This prompted transfer of care to a regional tertiary center at which she received aggressive plasma exchange therapy.
Connie von Kohler, MSN, RNC-OB, C-EFM, CPHQ, Miller Children’s & Women’s Hospital, Long Beach, CA Mary Favre, BSN, RNC, St. Francis Medical Center, Los Alamitos, CA Rosemarie Cervantes, BSN, RN, St. Francis Medical Center, Lynwood, CA Allyson Harris, MSN(c), University of California, Los Angeles, Simi Valley, CA Keywords
Conclusion thrombotic thrombocytopenic Knowledge of unusual syndromes should prompt purpura-hemolytic uremic nurses to advocate for women by recommending syndrome differentiating tests and transfer to higher level of HELLP care. Follow-up case study presentations will in- preeclampsia crease knowledge in staff at community facilities to reduce maternal morbidity and mortality.
JOGNN, 45, S52–S56; 2016. http://dx.doi.org/10.1016/j.jogn.2016.03.128
Obstetric Poster Presentation
http://jognn.org
A Patient’s Rights and the Nurse’s Responsibility to Provide Nonjudgmental Care Background s the Internet has become an increasing source of information and education for the public, health care professionals are experiencing a challenge: how to care for patients who may distrust standard medical care.
A
Case A woman presented to a tertiary care center triage unit at 40 weeks and 6 days gestation complaining of contractions and leaking fluid. Her history and physical revealed that she had two previous cesarean births, a failed attempt at a trial of labor after cesarean, and a rupture of the right lateral segment of the uterus after 8 cm dilation during the previous pregnancy. After many unsuccessful attempts to find a provider who would care for her and honor her request for
trial of labor after cesarean, the woman waited until the onset of labor to seek medical care. Despite multiple conversations with the medical team, she continued to withhold consent for cesarean. On admission, the nursing staff became “uncomfortable” and initially refused to care for the woman because they were not willing to assume the risk associated with her decision. During a multidisciplinary huddle, staff discussed nursing practice, ethics, and current issues on litigation; the emphasis was on nursing roles and the provision of nonjudgmental care. Conclusion The woman had a successful vaginal birth after cesarean within 6 hours of admission with Apgar scores of 9/9 and normal cord gases; she was discharged in 24 hours.
Kendra L. Folh, BSN, RN, Children’s Memorial Hermann Hospital, Houston, TX Keywords multidisciplinary care nurse practice trial of labor after uterine rupture uterine rupture safety rounds
Obstetric Poster Presentation
Thrombotic Thrombocytopenic Purpura and Hemolytic-Uremic Syndrome in the Postpartum Period Background hrombotic thrombocytopenic purpura and hemolytic-uremic syndrome are rare complications that may develop in pregnancy and that mimic common obstetric complications, including severe preeclampsia, eclampsia, and HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome. Delay in diagnosis and treatment can lead to increased mortality.
T
Case A 25-year-old primigravida presented at term with contractions and decreased fetal movement. Her prenatal care and medical history were unremarkable. A prolonged fetal bradycardia prompted an emergency cesarean birth of a healthy male newborn. The woman’s postpartum recovery was unremarkable. On postoperative day 3, her blood pressure increased to 146/99 mmHg, and she developed a nose bleed with small clots, increased vaginal bleeding, and low urine output with hematuria. During the next few days, her
S56
hematocrit decreased while her blood urea nitrogen increased. She remained alert and normotensive. She was transfused with packed red blood cells, platelets, and fresh frozen plasma. Differential diagnosis indicated a ureteral injury or HELLP syndrome. On postoperative day 4, her hematocrit was 9.2, platelets were 48 with giant platelets observed, and lactate dehydrogenase was 3,258 (91 to 180). There was a lack of improvement on postpartum day 5: hematocrit was 6.9, platelets were 42, and blood urea nitrogen was 89. This prompted transfer of care to a regional tertiary center at which she received aggressive plasma exchange therapy.
Connie von Kohler, MSN, RNC-OB, C-EFM, CPHQ, Miller Children’s & Women’s Hospital, Long Beach, CA Mary Favre, BSN, RNC, St. Francis Medical Center, Los Alamitos, CA Rosemarie Cervantes, BSN, RN, St. Francis Medical Center, Lynwood, CA Allyson Harris, MSN(c), University of California, Los Angeles, Simi Valley, CA Keywords
Conclusion thrombotic thrombocytopenic Knowledge of unusual syndromes should prompt purpura-hemolytic uremic nurses to advocate for women by recommending syndrome differentiating tests and transfer to higher level of HELLP care. Follow-up case study presentations will in- preeclampsia crease knowledge in staff at community facilities to reduce maternal morbidity and mortality.
JOGNN, 45, S52–S56; 2016. http://dx.doi.org/10.1016/j.jogn.2016.03.128
Obstetric Poster Presentation
http://jognn.org