CONVERGENCE OF VOGT-KOYANAGI-HARADA AND PRE-ECLAMPSIA SYNDROME

Objective: to discuss the clinical case of pregnant women with Vogt-Koyanagi-Harada syndrome (VKHS) associated with severe pre-eclampsia (PE). Method: this is a qualitative, case-study study with data from the medical records after admission of pregnant women with VKHS and severe pre-eclampsia. Results: primigravid VKHS and PE patients were hospitalized for arterial pressure increase and bilateral amaurosis; sulfate therapy and cesarean section was indicated after laboratory confirmation of partial HELLP syndrome. The ophthalmologic evaluation revealed retinal detachment and mild ocular hemorrhages necessitating pulse therapy and posterior visual recovery. Conclusion: assistance to pregnant women with rare clinical situations, supported by complex thinking, was considered, which enabled the construction of expanded care, with targeted interventions and positive results, resulting in improved quality of life during and after hospitalization. Descriptors: Uveomeningoencephalic syndrome; Preeclampsia; Eclampsia; Nursing care; Epistemology, Philosophy, Nursing. RESUMO Objetivo: discutir caso clínico de gestante com síndrome de Vogt-Koyanagi-Harada (SVKH) associada com préeclâmpsia (PE) grave. Método: trata-se de estudo qualitativo, do tipo estudo de caso, com dados de prontuário após internação de gestante com SVKH e pré-eclâmpsia grave. Resultados: identificou-se primigesta portadora de SVKH e PE internada por aumento pressórico arterial e amaurose bilateral; instalada a sulfatoterapia e indicada a cesariana após a confirmação laboratorial de síndrome HELLP parcial. A avaliação oftalmológica constatou descolamento de retina e hemorragias oculares leves necessitando de pulsoterapia e com recuperação visual posterior. Conclusão: considerou-se a assistência a gestantes com situações clínicas raras, respaldada no pensamento complexo, que possibilitou a construção de cuidados ampliados, com intervenções direcionadas e resultados positivos, obtendo-se a melhoria da qualidade de vida durante e após o internamento. Descritores: Síndrome Uveomeningoencefálica; Pré-eclâmpsia; Eclâmpsia; Cuidados de Enfermagem; Epistemologia, Filosofia em Enfermagem. RESUMEN Objetivo: discutir caso clínico de gestante con síndrome de Vogt-Koyanagi-Harada (SVKH) asociada con pre eclampsia (PE) grave. Método: se trata de un estudio cualitativo, del tipo estudio de caso, con datos de prontuario después de la internación de gestante con SVKH y pre eclampsia grave. Resultados: se identificó primigesta portadora de SVKH y PE internada por aumento presórico arterial y amaurosis bilateral; instalada la sulfatoterapia e indicada la cesárea después de la confirmación de laboratorio de síndrome HELLP parcial. La evaluación oftalmológica constató desprendimiento de retina y hemorragias oculares leves necesitando de pulsoterapia y con recuperación visual posterior. Conclusión: se consideró la asistencia a gestantes con situaciones clínicas raras, respaldada en el pensamiento complejo, que posibilitó la construcción de cuidados ampliados, con intervenciones directas y resultados positivos, obteniéndose la mejora de la calidad de vida durante y después del internamiento. Descriptores: Síndrome Uveomeningoencefálico; La preeclampsia; Cuidados de Enfermería; Epistemología; Filosofía en Enfermería. Specialist, Sobral (CE), Brazil. E-mail: adrian_belarmino@hotmail.com ORCID iD: http://orcid.org/0000-0003-4401-9478; Master, Higher Institute of Applied Theology / INTA. Sobral (CE), Brazil. E-mail: larissacalves@hotmail.com ORCID iD: http://orcid.org/0000-0001-61737549; Doctor, State University of Ceará / UECE. Fortaleza, Brazil. E-mail: arodrigues.junior@uece.br Orcid iD: http://orcid.org/00000002-9483-8090 ORIGINAL ARTICLE Belarmino AC, Holanda LCA de, Ferreira Junior AR. Convergence of vogt-koyanagi-harada...

English/Portuguese J Nurs UFPE online., Recife, 12 (10):2775-83, Oct., 2018  2776  It is known that Vogt-Koyanagi-Harada syndrome or uveomeningoencephalic syndrome is characterized as an idiopathic multisystemic disease, with probable autoimmune etiology, involving inflammatory process and destruction of tissues with melanocytes, causing neurological, auditory and cutaneous impairment. 1 The syndrome is considered, in summary, as a rare disease affecting, mostly, women and certain ethnic groups, mainly Asians, Indians, Native Americans, Hispanics and individuals of the Middle East.Its incidence is diversified, with values of 7% in Japan and 3% in Brazil. 2 It is explained that, at the same time, pre-eclampsia (PE) is a multifactorial and systemic syndrome involving several body organs and is defined by arterial pressure increase and proteinuria after 20 weeks of gestation. 3It is seen that the etiology and pathophysiology are not well-defined and evidence suggests the link between placental ischemia, endothelial inflammatory response and oxidative stress, with the release of catecholamines. 4pidemiologically, it is noted that hypertensive syndromes have an incidence around 2% to 7% of pregnancies depending on the population and diagnostic criteria used.It is considered that they are linked to multifactorial conditions, such as nulliparity, obesity, multiple gestations, previous gestation with preeclampsia, preexisting conditions such as chronic hypertension and diabetes, among others. 5 It is an urgent problem and one of the main causes of hospitalization in maternity hospitals, being a precursor of complications during pregnancy, childbirth and puerperium and even several years after childbirth. 8It is also linked to neonatal complications such as prematurity, intrauterine growth restriction (CIUR), low birth weight and fetal death. 9t is exposed that, thus associated with Vogt-Koyanagi-Harada syndrome, SHEG potentiates effects for the individual, which makes the accompaniment of autoimmune disease and hypertensive syndrome complex, concomitantly representing a higher maternal-fetal risk with high morbidity and psychological attrition and physiological exacerbation.
It is understood that, in this context, the nurse, as a professional intrinsically linked to the care of pregnant women, appears as a preponderant factor in maintaining the quality of care and in the planning of integral actions of health and life improvement of these patients with the guarantee of their rights, individuality and subjectivity, including participation in decision-making of great relevance to their own well-being and their baby. 10his theme was preferred due to the scarcity of material on the subject and the relevance that care directed to pregnant women with rare diseases and difficult to treat, such as VKHS, have in Obstetric Nursing, and may reduce negative implications arising from the diseases described in the future of the patentient and their newborn.
• To discuss clinical case of pregnant woman with Vogt-Koyanagi-Harada Syndrome (VKHS) associated with severe pre-eclampsia (PE).This is a qualitative, exploratory and descriptive study, like a case study 11  The medical record of the patient with the syndromes after permission was selected and analyzed in the second methodological moment for the elaboration of a case study, after consent by means of the Free and Informed Consent Term (FICT) and Faithful Depositary Term (FDT).Information about the case and construction of the study, such as medical and nursing admissions, evolutions, prescriptions and requested exams and behaviors carried out by the teams were collected in the medical record.
The Content Analysis technique was used to explore the data collected, which enabled the interpretation of the information presented by the health team professionals, contained in the medical record fields, allowing the description of the content in the communications through systematic procedures and objectives for the construction of the case study. 12t is reported that this stage consisted of three phases: pre-exploration of the content of the evolutions contained in the medical record, with notes of the care process; selection of units of analysis and categorization of the evolution of care teams. 12e case of the pregnant woman and the SAE were quickly contextualized in the discussion section of the event, dialoguing with the theoretical framework of diseases and Edgar Morin's Theory of Complexity, making it possible to understand the line of phenomenological data and unpredictable events that constitute the basis of human life contained in the case discussed.13 The research project was approved by the Research Ethics Committee (REC) of the State University of Vale do Acaraú-UVA under opinion No. 1,937,137 / 2017, according to CAAE 62456016.8.0000.5053.Accordingly, it meets the requirements of Resolution 466/2012 of the National Health Council, which covers norms on research involving human beings, considering respect for human dignity and ethics/bioethics in scientific and technological development.14 The primigravida TKJN, with a gestational age of 33 weeks and six days, 28 years, a stable union, born in Sobral-CE, with Vogt-Koyanagi-Harada syndrome, was admitted on the 7th of April, 2015, in the obstetric emergency of reference hospital, with a diagnostic hypothesis of severe preeclampsia presenting 150x110 mmHg blood pressure, bilateral amaurosis, difficulty in ambulation and in the execution of daily life activities.An 8 ml of MgSO4 + 100 ml of 5% SG sulfatherapy atack dose and maintenance dose in a continuous infusion pump of 12 ml of MGSO4 + 500 ml of 5% SG were prescribed and installed, as well as symptomatic for nausea and vomiting, corticoid (betametasone) for the fetal pulmonary maturement, hidralazine (HDZ) for pressure control, if necessary (s / n), and requested routine exams for the hypertensive syndrome, which consisted of: blood count, urea, creatinine, transaminases, dosage of bilirubins, uric acid, 24-hour proteinuria.To measure urine output, the patient was probed with probe # 14 in a closed collection system, two doses of HDZ were administered to contain the blood pressure increases and she was referred to the obstetric clinic ward.
The sulphate therapy was suspended in the ward at night by oliguria.The following morning, with the results of exams, the partial HELLP syndrome (93,000 mm3 and 370 U / L platelets) was diagnosed and, due to the decompensated condition, a cesarean section was indicated, and the patient was referred immediately to the patient.Obstetric Surgical Center -OSC.At the site, the sulphate therapy was restarted and the cesarean section occurred without intercurrences, and the newborn was referred to the Conventional Neonatal Intermediate Care Unit (NICU).On the same day, electrolyte exams were requested and a new routine of exams for SHEG.
It is revealed that, on April 9th, the patient remained on HDZ 8 / 8h, Captopril s / n and an ophthalmologic evaluation was requested.The results of the tests show an improvement in thrombocytopenia (111 thousand per mm3) and a change in magnesium 5.70 mg / dl.It was considered that, due to the lack of a specific device for retinal and vitreous analysis, the patient was transferred externally to another

RESULTS
English/Portuguese J Nurs UFPE online., Recife, 12 ( -Control of fluids administered through daily water balance; -Improvement of edema, especially in the region of lower limbs.
To orient the patient and her companion the pathological process and the need for periods of rest in left lateral decubitus; -Monitor vital signs every hour, according to medical prescription.
-Maintenance of stable vital patterns and fetal well-being.
Alteration of cardiac, cerebral and fetal tissue perfusion related to altered placental blood flow.
-Identification of changes in fetal heart rate patterns due to maternal instability.
-Fetal monitoring; -Monitoring of vital signs.
-Maintenance of stable vital patterns and fetal well-being; -Maintenance of pressure levels under control.Risk of injury from seizures and / or amaurosis.
-Performance of daily activities with the assistance of the Nursing technician and the companion; -Preventing the falls.
-Keep the atmosphere quiet; -Offer of orientation; -Keep high side rails to prevent injury in case of seizure.
-Patient evolves without seizures and lesions.
Deficit of knowledge related to Diagnosis.
-Comprehension and clarification of doubts about the disease, its course and probable symptoms associated with pre-eclampsia and treatment for the syndromes.
-Allow time for patient or companion questions.
-Patient understands and participates in the treatment.
Risk of intolerance to the activity related to presence of circulatory problems (increased of pressure; pre eclampsia).
-Realization of pressure control of 4 / 4h; -Offered rest and stimulated sleep.
-High-risk pregnancy care; -Identification of the level of knowledge of the patient; -Offer of orientation.
-Maintains activities of daily living.
Risk of disturbed mother / fetus dyad related to complication of pregnancy (preeclampsia) and decreased oxygen transport (hypertension and HELLP syndrome).
-Verification of vital signs according to the routine of the sector and necessity of the case; -Pre-and post-operative cesarean care; -Observation of locks and surgical wound; -Administration of analgesics, anti-inflammatories and corticosteroids.
-Monitoring ssvv and fetal; -Preparation for delivery indication; -Care during childbirth and postpartum; -Passing information on babies; -Treatment of pain; -Monitoring of lochia and uterine contraction; -Guidance on breastfeeding.
-Fetal status: prepartum (fetal heart rate maintained or with minimal variation); -Variability of fetal electronic monitoring findings.
Comfort impaired by anxiety, lack of control of the situation, fear and report of feeling uncomfortable.
-Guidance on course of diseases, post-operative care and breast milking for the Reserve in Human Milk Bank.
-Patient will demonstrate personal well-being and coping skills.
Anxiety evidenced by worry and increased threat-related stress maternal-fetal status.
-Security and trust in the implemented care; -Calm and patience during hospital stay.
-Preparation for delivery indication; -Guidance to parents (about the baby); -Information and support to facilitate birth.
Figure 1: SAE for pregnant women with VKHS and SHEG (Ceará, Brazil, 2017). 15nglish/Portuguese J Nurs UFPE online., Recife, 12(10):2775-83, Oct., 2018 2780 It should be noted that autoimmune syndromes consist of chronic multisystem diseases, usually of unknown etiology, however, linked to exacerbated actions of the immune-regulatory system associated with histocompatibility complex mechanisms, autoantibodies and genetic, hormonal and environmental mechanisms. 2 It was reported in the clinical case that the patient presented a series of complications arising from both the autoimmune syndrome referred to and the hypertensive syndrome, requiring a series of individualized care.The fragility of linear care in health was evidenced, and new care and care arrangements were necessary in order to understand the complexity of health situations described above. 16n this context, one must think of a new complex perspective based on systemic care based on trans, inter and multidisciplinary knowledge and care methods, interconnecting data and information to understand the intricate interface demanded by the subject. 17It is understood that it is in this theoretical-philosophical line that Complexity Theory acts by interconnecting knowledge and phenomena, separating and uniting data and information, organizing and forming antagonistic and heterogeneous paradigms, uncertainties and ambiguities in the fabric of events. 13hus, the case was analyzed in the light of the principles of Morin's complexity, seeking to understand it with an extended look and to interpret the event described in hospital admission.It was made summarily, at the admission of the pregnant woman, the care was initially focused on the hypertensive syndrome, with pressure control, using antihypertensives like hydralazine, and in the prophylaxis of convulsive crisis with the administration of magnesium sulfate.In the literature, it is reported that the use of magnesium sulfate combined with quality care decreases mortality by 50% in pre-eclampsia and eclampsia. 18t is described that, in the conception of nursing care for pregnant women with SHEG, monitoring of urinary output and respiratory rate, maintenance of pressure curves, and surveillance of fetal vitality through heart rate auscultation consist of positive interventions and valuable for the achievement of quality of care .6,7,10Thus, the quality of care for pregnant women with pre-eclampsia and eclampsia was reduced by 50% with the risk of mortality. 18It is also noted that execution of nursing care based on connected and dynamic actions implies the adoption of a certain technical model based on a scientific method for the solution of problems and needs fulfillment. 19t reflects, at this first moment, from the perspective of the Organizational or Systemic Principle, which emphasizes the vision in which the whole is more than the union of the parts being interconnected and having recent qualitative phenomena denominated emergencias as organizational effects of the parts in the systemic unit.It is considered that it is necessary to observe that by glimpsing the genesis of events in the situation and by listing only one cause of aggravation, in the case of the hypertensive syndrome, we were not addressing the amplitude of being and situation, and expanding our gaze in all directions promotes the development of a quality care system. 17t conjectures, in the face of this line of thought, about the linearity and fragmentation of the cartesian system of knowledge in health and how nurses need to adopt singular non-linear postures with interdisciplinary experiences and knowledge focused on the complexity that currently assumes health in order to unite the objective and subjective knowledge, reason and emotion, science and ethics in the construction of care plans and health care. 16t is also emphasized, through Morin's work, that the human being seeking the equality of the parts of a unit culminates, several times, in erasing its peculiarities, nevertheless, it is emphasized that the characteristics of these parts must be preserved for the comprehension of the whole. 13t is considered, in analyzing the case reported, that the patient in debate has, besides the hypertensive syndrome, a disease considered rare in the class of autoimmune diseases that affects and compromises tissues with melanocytes in their constitution.Corticosteroids were used as therapeutics of choice corroborating the literature about its therapeutic applicability. 1

DISCUSSION
English/Portuguese J Nurs UFPE online., Recife, 12 (10):2775-83, Oct., 2018  2781  It is elucidated in this conception that the Holographic Principle emphasizes that the parts are in the whole and the whole is contained in each of the parts, being impossible to know the parts without knowing the whole and knowing the whole without knowing the parts that compose it.It is considered in this context, in the case under discussion, that multidimensional, multiprofessional and intersectorial articulation was necessary to elucidate the therapeutic line and the necessary care for pregnant women. 20 is explained, through the above statements, that health, in the specific case in obstetrics, assumes new conformities implying the need for various arrangements in care and care, so that horizontality and verticality are not fixed principles selfcompleting, and requiring the adoption of a new perspective to address the multifaceted and complex picture.It is seen with this enlarged and permeated vision of increasingly challenging cases in the gestation that the extended care is developed through this construction using, as a tool, SAE for the expansion of the conducts in obstetrics. 21t is understood that in the context of complexity, the human being is plural, sociopolitico-cultural and dynamic, always seeking the exercise of citizenship and autonomy. 13This introduces the notion of self-ethics emphasizing the urgency of an ethics of understanding, of a humanitarian identity and of a planetary consciousness. 17here is another principle, that of "selfeco-organization", which considers the organizational capacity of systems dependent on information, energy and relation to the environment for this purpose.It is observed that before this, during the care performed, it was necessary to adjust the patient's clinical picture.With the information from the personal history of visual impairment (VKHS carrier), blood pressure changes and the results of clinical exams, a line of care was systematized as a result of the progression of hospitalization, taking into account autonomy and self-care of the patient, their adaptability and the physical and personal resources of the health team to meet their demands. 21n this same complex view, through the Principle of the Retroactive Circle, circular causalities, that is, the retroactive effects on the causes and the feedback are praised in this same complex vision.The idea of cause and effect is dematerialized and the concept of non-linear relations is defended.As an example, in the case, it was the sulfate-therapy on admission, therapeutics of choice as prophylaxis to avoid eclampsia, which had to be suspended due to the evidence of oliguria in the water balance. 13t is immediately suggested that the Dialogic Primordium, which defends the duality present in two united logics, leads to reflection on situations, ideas and antagonistic principles that lead to uncertainty, instability and disorder in diverse actions, scenarios, circumstances and circumstances in health.The need for such occurrences for changes and impact changes in the health services, with proof of organic-functional destabilization due to HELLP syndrome in the pregnant woman and high maternal and fetal risk, which led to the necessary indication of cesarean section, aiming at the improvement of the condition and targeted treatment for VKHS. 21inally, we describe the Principle of Circular Knowledge, which promulgates the idea that all knowledge is reconstructed or translated differently depending on each being, place and time determined.In other words, knowledge assumes and is understood in a different way depending on each specific situation and person, and its interaction and exchange of knowledge defines this reconstruction and retranslation.VKHS is considered a rare disease in obstetrics, since it is little known or unknown by the team of doctors and nurses of maternity hospitals in Brazil.However, due to the great affection in the Middle East and Asia in the present times, it is recognized as one of the main uveomeningoencaites in women in these places, provoking researches developed incessantly seeking to understand its pathophysiological mechanisms. 2,22 is concluded that the analysis of health situations based on complex thinking allows the deconstruction of rigid models with the expansion of the problem, which assumes health situations, especially in the obstetric area.It is possible to visualize the possibilities that the expanded view provides for facing the challenges in the assistance and construction of the Obstetric Nursing area, based on the principles of complexity: systemic or organizational, hologramatic, self-eco-organizational, circle retroactive, dialogic and circular knowledge.
It is also considered that the planning of care specific to the clinical scenarios assists in decision-making in the face of occurrences that assume unknown consequences and results and promotes the professional growth of the nursing in the caring relationship and in the creation of bonds with the pregnant women carriers of these injuries.
It is also worth noting that the shortage of material on VKHS associated with other obstetric diseases such as PE in the Nursing area in the databases researched made it difficult to construct the theoretical reference initially.It is evident in this context, the need to develop new studies on autoimmune syndromes and other rare compliance diseases in the obstetric area and their implications for care planning and nursing care.