INTRODUCTION

Pregnancy is the state of carrying a developing embryo or fetus within

the female body. This condition can be indicated by positive results on an over-the-
counter urine test, and confirmed through a blood test, ultrasound, detection of fetal
heartbeat, or an X-ray. Pregnancy lasts for about nine months, measured from the date of
the woman's last menstrual period (LMP). It is conventionally divided into
three trimesters, each roughly three months long.

The most important tasks of basic fetal cell differentiation occur during the first

trimester, so any harm done to the fetus during this period is most likely to
result in miscarriage or serious disability. There is little to no chance that a first-
trimester fetus can survive outside the womb, even with the best hospital care. Its systems
are simply too undeveloped. This stage truly ends with the phenomenon of quickening:
the mother's first perception of fetal movement. It is in the first trimester that some
women experience "morning sickness," a form of nausea on awaking that usually passes
within an hour. The breasts also begin to prepare for nursing, and painful soreness from
hardening milk glands may result. As the pregnancy progresses, the mother may
experience many physical and emotional changes, ranging from increased moodiness to
darkening of the skin in various areas. During the second trimester, the fetus undergoes a
remarkable series of developments. Its physical parts become fully distinct and at least
somewhat operational. With the best medical care, a second-trimester fetus born
prematurely has at least some chance of survival, although developmental delays and
other handicaps may emerge later. As the fetus grows in size, the mother's pregnant state
will begin to be obvious. In the third trimester, the fetus enters the final stage of
preparation for birth. It increases rapidly in weight, as does the mother. As the end of the
pregnancy nears, there may be discomfort as the fetus moves into position in the woman's
lower abdomen. Edema (swelling of the ankles), back pain, and balance problems are
sometimes experienced during this time period. Most women are able to go about their
usual activities until the very last days or weeks of pregnancy, including non-
impact exercise and work. During the final days, some feel too much discomfort to
continue at a full pace, although others report greatly increased energy just before the
birth. Pregnancy ends when the birth process begins.

Pregnancy-induced hypertension (PIH) is a condition in which vasospasm occurs

during pregnancy in both small and large arteries. Signs of hypertension, proteinuria, and
edema develop. It is unique to pregnancy and occurs in 5% to 7% of pregnancies (Bailes
& Witter, 2007). Despite years of research, the cause of the disorder is still unknown
although it is highly correlated with the antiphospholipid syndrome or the presence of
antiphospholipid antibodies (Clark, Silver, & Branch, 2007). Originally it was called
toxemia because researchers pictured a toxin of some kind being produced by a woman
in response to the foreign protein of the growing fetus, the toxin leading to the typical
symptoms.

3
 PIH tends to occur most frequently in women of color or with a multiple
pregnancy, primiparas younger than 20 years or older than 40 years, women from low
socioeconomic backgrounds perhaps of poor nutrition), those who have had five or more
pregnancies, those who have hydramnios (overproduction of amniotic fluid; refer to
discussion later), or those who have an underlying disease such as heart disease, diabetes
with vessel or renal involvement, and essential hypertension.

Preeclampsia is the most common serious medical disorder of human pregnancy.

Pre-eclampsia is a process of pregnancy-related illness manifested by high blood pressure
and proteinuria. The old term for preeclampsia was toxemia. This is because researchers
have imagined that women produce a type of toxin in response to the growth of foreign
proteins in the fetus, causing symptoms. This condition occurs in 5-7% of pregnancies
(Silbert-Flagg & Pilliteri, 2018). The risk factors of preeclampsia are the following:
multiple pregnancy (twins or more), low maternal socioeconomic status, history of
preeclampsia, a mother or sister who had preeclampsia, history of obesity, high blood
pressure before pregnancy, history of lupus, diabetes, kidney disease, or rheumatoid
arthritis, having in vitro fertilization, being younger than 20 or older than 35 (Esplin,
2018).

According to Singh & Trivedi (2017), compared to singleton pregnancies,

multiple pregnancies are reported to carry higher maternal as well as perinatal morbidity
and mortality. The various complications encountered in mothers are anemia,
hyperemesis, preterm labor, hypertensive disorders of pregnancy, antepartum
hemorrhage, polyhydramnios, increased pressure symptoms, varicose veins and
gestational diabetes. Low birth weight, contributed by both prematurity and IUGR, is the
main factor responsible for higher perinatal mortality in twins.

Chronic hypertension (occurring before 20 weeks' gestation or lasting longer than

12 weeks after delivery), gestational hypertension (occurring after 20 weeks' gestation),
preeclampsia, or preeclampsia superimposed on chronic hypertension are all possible
causes of elevated blood pressure in pregnancy. Hypertension with proteinuria or
thrombocytopenia, renal failure, poor liver function, pulmonary edema, or cerebral or
visual problems are all signs of preeclampsia. Severe preeclampsia is new onset
hypertension in pregnancy after 20 weeks’ gestation with proteinuria. Severe features of
preeclampsia include a systolic blood pressure of at least 160 mm Hg or a diastolic blood
pressure of at least 110 mm Hg, platelet count less than 100 × 103 per μL, liver
transaminase levels two times the upper limit of normal, a doubling of the serum
creatinine level or level greater than 1.1 mg per dL, severe persistent right upper-quadrant
pain, pulmonary edema, or new-onset cerebral or visual disturbances (Silbert-Flagg &
Pilliteri, 2018). In normal pregnancy, urinary protein excretion substantially increases and
total protein excretion is considered abnormal in pregnant women when it exceeds 300
mg in a 24 h urine collection. Proteinuria can be one of the cardinal features of
preeclampsia (Dong, 2017). Preeclampsia swelling is the outcome of leakage of fluid
from your capillaries into your tissues. This may even lead to the leakage of tiny blood

4
vessels in your kidneys, which will release protein from your bloodstream into your
urine.

TABLE 1.1 SYMPTOMS OF GESTATIONAL HYPERTENSION

Gestational Mild Pre- Severe Pre- Eclampsia

HTN eclampsia eclampsia
Blood Pressure 120/80 ≤ 140/90 160/110mmHg ≥
mmHg mmHg 160/110mmHg
Returns
normal after
birth
Proteinuria Absent 1+ to 2+ 3+ to 4+ 3+ to 4+
Thrombocytopeni Absent ≥ 100,000- < ≥ 100,000- < < 100,000
a 150,000 150,000
Jaundice Skin and/or Present Present Present
eyes (HELPP (HELPP (HELLP
Syndrome) Syndrome) Syndrome)
Edema Absent Mild Pitting Edema Pitting Edema
(upper
extremities or
face)
Dizziness Dizzy spells Present if Present if Present if
cerebral cerebral edema cerebral edema
edema is is present is present
present
Visual Absent Flashing Present if Present
disturbances lights, auras, cerebral edema
light is present
sensitivity,
blurry
vision/spots
Seizure Absent Absent Absent Present
Abdominal Pain Absent Upper-right Severe Upper-right
abdomen or epigastric pain abdomen
in with nausea
Epigastrium and vomiting
Headache Dull Dull and Migraine- like Migraine-like
throbbing headache headache
headache
Creatinine 0.40 – 0.4-1.10mg/ More than 1.2 mg/dl
0.80mg/dl dl 1.2mg/dl
Oliguria Transient ≤ 500ml 500ml or less 500ml less
in 24 hrs. than 24 hrs.
5
 Severe pre-eclampsia/eclampsia has serious complications for maternal and
neonatal health, killing 50,000-100,000 people worldwide each year and is associated
with severe fetal and neonatal morbidity and mortality (Oyston, 2015). Although
maternal mortality is much lower in high-income countries than in developing countries,
16% of maternal deaths can be attributed to hypertensive disorders. In the United States,
the rate of preeclampsia increased by 25% between 1987 and 2004. Moreover, in
comparison with women giving birth in 1980, those giving birth in 2003 were at 6.7-fold
increased risk of severe preeclampsia (Wisner, 2019). Multiple interrelated pathways
contribute to the pathogenesis of preeclampsia, and variants in susceptibility genes may
play a role among Filipinos, an ethnically distinct group with high prevalence of the
disease (Amosco, & etc., 2019). In the Philippines, preeclampsia and eclampsia were the
cause of up to 30% of maternal deaths according to the Department of Health Philippine
Health Statistics of 2017.

Another complication during pregnancy that is also said to be a variant of

preeclampsia and may occur in the later stages of pregnancy or after childbirth is the
HELLP syndrome. The syndrome is a progressive condition and serious complications
are frequent. It has been known for a long time that preeclampsia may be associated with
hemolysis, elevated liver enzymes and thrombocytopenia. Weinstein regarded signs and
symptoms to constitute an entity separated from severe preeclampsia and in 1982 named
the condition HELLP (H = Hemolysis, EL = Elevated Liver enzymes, LP = Low
Platelets) syndrome. The HELLP syndrome is a serious complication in pregnancy
characterized by hemolysis, elevated liver enzymes and low platelet count occurring in
0.5 to 0.9% of all pregnancies and in 10–20% of cases with severe preeclampsia. About
70% of the cases develop before delivery, the majority between the 27th and 37th
gestational weeks; the remainder within 48 hours after delivery (Haram, Svendsen, &
Abildgaard, 2009).

6
CHAPTER 2
ASSESSMENT
A. HEALTH HISTORY
Vital Information:
Name: Athena Sun Marital Status: Married
Address: Bayabason, Maramag Home Phone: 09531771555
Contact Person: Zeus Sun Work Phone:
Religion: Iglesia sa Diyos Espiritu Santo Education: HS Level (Grade 7)
Sex: Female Occupation:
Age: 24 years old Health Insurance: Point of Service
Birth Date: March 07, 1998 Source & Reliability:
Place of Birth: Maramag Referral: BPH - Maramag
Ethnicity: Cebuano Advance Directives:
Nationality: Filipino Room #: Room 13. Bed 07, OB Ward
Race: Asian Attending Physician: Dr. Janeth
Date of Admission: 04/21/2022 Admitting/Final Diagnosis: G2P2 (3003)
Pregnancy Uterine term delivered Twin A
Apgar score 8,9, bb girl BW 3.0 grams cephalic,
twin B, Apgar Score 8,9 bb girl, B.W 1.8 grams
complete breech, with preeclampsia with severe
features multiple pregnancy under spinal
anesthesia
(SA) monochorionic diamnotic monozygotic twin.
Reason for Seeking Health Care:
Elevated BP at 180/90 mmHG
Current Health Status:
The patient had her prenatal check up at BPH- Maramag last April 21, 2022 when
noted to have elevated BP at 180/90 mmHG and pitting bipedal edema +2, she was then
given Magnesium Sulfate via intramuscular through her gluteus maximus. She was also
given antihypertensive drugs such as Methyldopa (April 23, 2022 with 200mg fr 3 times
a day), Clonodine(April 25, 2022 with 75mg 1 tab 5L stat) and Hydralazine ( April 21,

7
 2022 with 5mg IVTT). Drugs like vasodilators are used also like Metropolol(April 24
and 26, 2022 50mg Stat). She was scheduled for emergency cesarean section thus, she
was referred to BPMC–Malaybalay because the operating room of BPH-Maramag was
not available as of that moment. The patient was brought to BPMC per ambulance.

Present Obstetric Status:

The patient has been pregnant twice and she has given birth to live, full term
neonates with gestational age of 37 weeks for the first pregnancy and 38 weeks for the
second pregnancy. Three (3) full term deliveries and three (3) living children with one (1)
multiple gestation (G2P2 (30031). The patient’s last menstrual period was on July 28,
2021 and the expected date of confinement was on April 25, 2022 but she was brought to
the hospital on April 21, 2022. On November, the patient verbalized that she has dizzy
which spells started on September the 2nd month of her pregnancy where she took
Alaxan Forte and Bioflu without prescription. The patient experienced nocturia,
chloasma in face and arms, enlargement of gravid uterus, and fetal movement which
started during her 2nd trimester. She has experienced edema, difficulty of breathing, breast
tenderness on the third week of January during her 6th month. She was given tetanus
toxoid on the third week of January. Her first prenatal was on the third week of January
during her 6th month and her second prenatal was on the third week of March during her
8th month of pregnancy. Her first ultrasound was on March 7, 2022 and the second was
on April 9, 2022.

Past Obstetric History:

The patient has no problems of infertility, no maternal, neonatal and fetal
complication on the past obstetric history. During her first pregnancy, she had three
prenatal. At 3 months for her first prenatal, 5 months for her second, and 7 months for
her third. She was given vitamins via oral like Ascorbic acid with 500mg taken once a
day for 8 months , she was also given ferrous sulfate three times a day during her 8 th
month, she was also given Calcium 1000 mg taken once a day. During her first
pregnancy at the 6th month on the third week of January she was administered with
tetanus toxoid 1 followed by tetanus toxoid 2 during her 8 month.

Date of Duration/ Sex of Weight of Method of Place of Remarks

Delivery Character Baby Baby Delivery Delivery
of Labor
Jan. 19, 2020 20 hours Female 3.6 kg NSVD North Lying-
In, Maramag

Medical History:
The patient has no past medical or surgical history, only experience having
rashes and ear wax problem when she was still in Elementary years. She experiences
fever, cough ,and colds in a year but cannot determine the exact date and numbers on
8
how many times she experienced it, as verbalized. The patient uses oral contraceptive
called Marvelon last 2020 for two months before the first child was born, and has
contraceptive implant for 1 month last September 15, 2021 until the next month which
was terminated last October 15, 2021. The patient’s onset of menstruation and her first
cycle was when she was 13 years old. Her menstruation occurs every month that lasts for
three days, monthly. She experienced irregular menstruation when she was 19 years old.
She can use two menstrual pads during the day and she uses cloth at night when she
menstruates, she does not suffer from dysmenorrhea.

9
MATERNAL PSYCHOSOCIAL PROFILE
1. HEALTH PERCEPTION - HEALTH MAINTENANCE PATTERN

The patient loves to prepare vegetables, usually mung beans, squash, and sweet
potatoes, she also loves to sauté it and she serves fruits for the health of her family but
she claimed that they lack money. She does not have regular dental and eye checkup
however she claimed she brushes her teeth three times per day. She does not smoke and
drink alcoholic drinks, nor does she abuse any drug. Her first baby is formula-fed from
birth and only drinks powdered milk “bear brand”. Patient has less knowledge about
breastfeeding because per assessment, she does not know how to do breast care. She has
prior knowledge with infant care as she performs proper handling of neonates. The
family’s daily fare are instant food, fish, and vegetables, with rice. She eats fruit like
papaya, mango, and banana at least once every day. She drinks instant coffee (3 in 1)
twice a day but stopped it when she knew she was pregnant, but she also drinks Coca-
Cola twice every three weeks even during her pregnancy. She does not do physical
exercise. Her daily activities include doing household chores and planting flowers like
rose, and vegetables like okra and spinach when she does not have something to do and
she does not sit when she plants, she only bends down.

2. NUTRITIONAL-METABOLIC PATTERN

The patient eats instant noodles as at least once a week. She eats fish, and
vegetables paired with 1 and a half cup of rice, as claimed. Eats fruits like banana,
papaya, and mango at least once per day. Her usual liquid and water intake is 1-1.5 liters
every day. Patient does not restrict her food intake but she takes ferrous sulfate and
calcium. For 24-hour recall last April 21, 2022, she ate only 1 and a half cup of rice with
sauteed bottle gourd or upo with sardines. Her weight changed during her 6th month of
pregnancy as she was 59.7 kilograms, for her 8th month she was 62 kilograms, and at 9
months she was 65 kilograms.

3. ELIMINATION PATTERN

During her 6th month of pregnancy, patient was experiencing night awakenings
due to frequent urination but she has no dysuria, but during the 7th month of her
pregnancy, she was diagnosed with Urinary Tract Infection at RHU-Maramag. She was
prescribed with Cefalexin as an antibiotic TID for 2 weeks. She urinates 3 to 4 times per
day and usually 6 times every night. She defecates once to twice per day either in the
morning or in the evening and her stool color is dark brown. Patient does not use any
assistive devices, laxatives, or any suppositories used.

4. ACTIVITY-EXERCISE PATTERN

The patient is a housewife, so she does the sweeping, laundry, taking care of
their child. She also carries heavy things like boxes and pail with water. She does not
have a usual exercise routine and does not do morning walking because she believes that
10
working inside the house with a lot of chores is already a physical activity. The factors
that could interfere her home activities is when her toddler cries. Her mom helps her in
taking care of her child. She loves planting flowers like roses and vegetables such as
spinach and okra as it helps her sweat and it also helps is coping with stress and
boredom. She does not have motor deficits pre-pregnancy.

5. SLEEP-REST PATTERN

The patient usually sleeps from 8 pm to 6 am, but since her pregnancy, her
sleep is not enough. Though she sleeps early, she has night awakenings due to fetal
movement, discomfort from sleeping position, and pain that will last 1 to 2 hours and her
urinary frequency also disturbs her sleep in her 7 th month in pregnancy, as claimed. She
has difficulty to fall asleep again, and when she does, she just look at the ceiling until
she falls asleep. Her sleep only lasts for 2 hours. There are no sleeping aids or pills
taken.

6. COGNITIVE-PERCEPTUAL PATTERN

The patient’s highest education level is first year high school; thus, she can
read, write, and count. She does not have a regular eye checkup. She has intermittent
dizzy spells when she was 2 months pregnant.

7. SELF-PERCEPTION PATTERN

The patient is more concerned about how she should take care of her toddler
and her twins as they are still very young. She claimed that it is easy for her to discipline
them, but providing care for them would really be a struggle for her and her husband as
their finances is not stable. Despite their situation, she knows that there is happiness and
satisfaction at the end of the day. She has thoughts about how her life changed so much,
and she compared her life and how easy it was when she was still single. Now that she is
already a mother, her priorities changed but she still looks at the mirror and sometimes
she feels sad with how her body changed so much.

8. ROLE-RELATIONSHIP PATTERN

Her husband is her primary supporter, followed by their families. Her husband
finished his elementary years only, and she finished the first year of high school only.
During her pregnancy, her mother helped her with the household chores and in taking
care of the first child. She performed her role as a mother and as a wife when she was
pregnant by still doing household chores but with the help of the mother. They are both
Cebuano, thus, there are no difficulties when it comes culture and traditions. The
decision making depends on both her and her husband’s choices, and their
communication with each other is strong as the patient will really say if she has
problems and her husband also shares his problems to her. Weekly, the husband earns
1,000 pesos to 1,500 pesos to get their needs as the husband works as a laborer and as
freelancer, thus his area of work varies where he is assigned. There are no difficulties
11
with the relatives as they do not depend on them, and their problem inside the family is
being solved by both the patient and her husband only. Her parenting difficulties is that
she has to take care of 3 children while her husband works.

9. SEXUALITY-REPRODUCTIVE PATTERN

The patient’s menarche age is 13 years old; she has regular menstruation that
last 3 days monthly. She took contraceptive pills, Marvelon pills for two months last
year January 2021 that lasted for two months only. She has had a contraceptive implant
last September 15, 2021 but it only lasted for a month and it was stopped last October
25, 2021 when she was already 2 months pregnant. She and her husband are both
sexually active and had their coitus twice a week before she knew she was pregnant.
They had coitus until the fifth month of her pregnancy. There are no vaginal itching,
leukorrhea, post coital bleeding, or cystitis. She is satisfied with their sexual activities
and there is no pain in their intercourse. She still has no expectations in the changes of
their activities for now because she believes that they are fine with their sexual activity.

10. COPING STRESS PATTERN

Her decisions are always interdependent and collaborative with her husband.
There is no recent loss of loved ones or any close relative that made her stress
emotionally a lot, but she became so stressed when her husband met an accident last year
where he carried a pilates connected to a live wire and the electricity burned some of his
body parts that left him bedridden for 4 to 7 months. That time became a burden for the
patient as she carried the whole family on her own including the household chores and
the family affairs. Although her mom is around to help, she is still the one who decides
for the family.

11. VALUE-BELIEF SYSTEM

She finds meaning of life and strength through her children and her husband.
She also believes that she has a Great God Who will always be there for her and for her
family. Her husband leads the family worship and they also pray together with their
child.

12
13