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HypertensiveIn PregnancyDisorders

Case Scenario

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Patient Profile

Rahayu binti AmanName:

Age:Occupation:

Period of Gestation:

Parity Index: LMP:

EDD:Date of

Admission:Clerk on:

Rahayu binti Aman32 y/oHousewife34 weeks 5 daysG3 P1+128th October 20154th August 201628th June 201629th June 2016

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Chief Complaint

1

Giddiness for 1 day (2-3 hours)

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History of Presenting IllnessThe patient was apparently well until one day ago when she experienced

giddiness sensation after she awoke for ‘sahur’; around 4.30am. It was sudden in onset & worsening in nature. She complaint that she only slept 2-3 hours prior to the onset of the headache & was not associated with head or body position changes.

Both her leg swells up to both ankle & leaves a dent in the skin after she press the area with a finger.

She also complaint of having a mild headache. Frontal headache. Sudden onset and continuous in nature. Not related posturally.

Subsequently she was brought to A&E by her husband for further evaluation. BP was taken and the reading was 169/94mmHg. In here, she was given tablet medication, ECG, CTG, blood & urine sample was done but was uneventful. She was then admitted.

She is not diabetic. Other than that, there’s no previous history of viral illness, no fever, blurry of vision, no syncope, no abdominal pain, no nausea, no vomiting. No decrease in urine output. No bleeding per vaginal, no any other fluid discharge.

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Systemic ReviewRespiratory Symptoms• No cough, • No SOB, • no wheezing, • no hemoptysis

Cardiovascular Symptoms• Bilateral pitting edema• No breathlessness• No PND• No Chest Pain

ENT• No blurring of vision• No ear discharge• No tinnitus• No ear pain

CNS symptoms

• No faints• No history of seizure• No muscle/limbs weakness

Gastrointestinal Symptoms• No loss of appetite• No bowel and bladder symptoms

Genitourinary Symptoms • No frothy urine• Normal urine color

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History of Present Pregnancy

• Quickening felt at 20 weeks• BP monitoring was done twice a week• MGTT was done during 4th and 7th months• Her Hb level was normal• Tetanus injection has been given at 20+ weeks

1st Trimester

2nd Trimester

• This is unplanned pregnancy. She noticed it when she missed her period for one cycle and proceed with urine pregnancy test. The pregnancy then was confirmed at Klinik Peringgit.

• Booking visit was also done at Peringgit. Routine urine and USG was done and was uneventful.

• No fever, No excessive vomiting, no discharge PV.• Was told that her EDD will be in 4th of August 2016

3rd Trimester• She never misses her antenatal check-ups• Growth scans appears to be normal. No any other active

complaints• Fetal movements was satisfactory according to mother.• She only starts her Obimin supplement at 31 weeks (Hb:

10.5)

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Past Obstetric HistoryFirst Pregnancy

Second Pregnancy

• 1st pregnancy 2010• Term delivery, SVD• ♀• 2.5kg• Breastfed lasted only for one month. No milk produced from

mother. Switched to formulated milk.• Now 5y/o, asthmatic, otherwise normal.

• 2nd pregnancy 2013• 8 weeks of gestation missed abortion• No active symptoms, no pain, no bleeding PV.• D&C was done in Hospital Melaka.• Admitted because of Dengue Fever.

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Menstrual History• She attained her menarche at 11 years old• Menstrual cycle

• 30 days duration with 7 days of bleeding• Regular• Normal amount of flow• No blood clot

• No dysmenorrhea• No history of contraceptive usage• PAP smear: done once after her first pregnancy

(2012)• Result was normal

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Past Medical and Surgical History

During first pregnancy, she was admitted for one day due to high BP. Other than that, she is not diabetic, no heart disease, thyroid problems, epilepsy, TB

Diagnosed as hypertensive since 2011• On T. Methyldopa 250mg TDS. Compliance to her

medication.• On T. Aspirin 25mg OD

No previous surgery done (e.g: C-sec. appendicectomy, ovariotomy, etc)

No history of allergy to drugs and foods

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Family HistoryHer husband is a 33y/o guy, works as a clerk in a national sewerage company. Their first child, suffered from bronchial asthma but under medications. Her late father (‘98) got DM and her late mother (‘15) got HPT, died from stroke.

Other than that, there is no history of premature menopause, menorrhagia, dysmenorrhea, thyroid disorder or ovarian cancer.

No consanguinity. Twins: Cousin

Personal History• Married for 9 years. She is a

housewife. Currently staying with her husband and child.

• She ate balanced diet. No decrease in appetite. No significant weight loss.

• No previous sleep disturbances

• Family wage is enough to support whole family

• Economically stable

• Not a smoker, non-alcoholic

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SummaryPuan Rahayu, 32 years old, G3P1+1, currently 34 weeks and 5 days was admitted on 28th June 2016 due to giddiness for 1 days, also comes with headache and bilateral leg swelling. Other than that, no other impending eclampsia symptoms History of miscarriage on 2nd pregnancy in 2014. diagnosed with Pregnancy Induced Hypertansion (PIH). She is admitted for further investigation and monitoring. She is now under evaluation for appropriate management plan. Her blood pressure currently normalize.

Provisional Diagnosis

• Pregnancy Induced Hypertension

Examinations

General Examinations

• Patient is conscious, coherent and lying comfortably in supine position. She is cooperative. Moderately built and moderately nourished. Her weight currently is 83.3kg and height is 153.3 (BMI : 36.87 kg/m2)

• No pallor over the nail bed. • No pallor over lower palpebral

conjunctiva• Good oral hygiene, tongue is moist

and pink• No obvious thyroid or cervical lymph

node swelling• Not consented for breast examination

to look for cracked nipples, discharge or mass.

• There is slight pitting edema up to ankle of both legs.

General Examinations

VITAL SIGNS

• Pulse : 92bpm regular rhythm, normal volume, no vessel wall thickening.

• Blood pressure : 116/76 mmHg over right arm on lying position.

• Respiratory rate: 20 breaths per minute.

• Temperature: 37°C

Obstetric Examinations INSPECTION

• The abdomen is uniformly distended. The flanks are full. Linea gravidarum and linea nigra are not seen. The umbilicus is inverted and centrally located. There is no scar or dilated veins. Fetal movement is visible. Hernia orifices is intact.

PALPATION• The clinical fundal height is 34 weeks and SFH is

36cm. The fundal grip is soft, broad and non-ballotable suggestive of buttocks. Right maternal grip, small-knob like structures suggestive of foetal limbs. Left maternal grip, smooth curve structure suggestive of foetal back. The pelvic grip was foetal head. The head is 5/5th palpable.

AUSCULTATION• Fetal heart sound was not auscultable.

CONCLUSION: It is a singleton live pregnancy with longitudinal lie, incephalic presentation, with head 5/5th palpable.

Systemic Examinations

CARDIOVASCULAR SYSTEM S1 and S2 heard. Soft systolic murmur audible. Best

heard at mitral area.

RESPIRATORY SYSTEM Bilateral vesicular breath sounds heard equally on

both lungs. No adventitious sounds.

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InvestigationsCoagulation Profile (28.6.2016)PT (ACL TOP 500)

• PT Test 10.7sec (9.3 – 11.5) • PT Control 11.2sec• P.R. 1.03• I.N.R 1.03

APTT (ALC TOP 500)• APTT Test 27.5sec – Low (26.5 – 35.9)• APTT Control 31.5sec• APTT Ratio 0.88

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InvestigationsFull Blood Count (28.6.2016)• Haemoglobin 113 g/L (120 - 150)• RBC 3.92 x10 12/L• HCT 34.7% (36 – 46) • MCV 75 fL• MCH 28.8 pg• MCHC 32.6 g/dL• RDW-ED 42.3 fL• RDW-CV 13.2 %• Platelets 398 x109/L• WBC 13.2 x109/L (4 –

10)• Lymphocytes# 1.5 x103/L • Neutrophils # 10.7 x103/uL (2 –

7)• Monocytes # 0.7 x103/L • Eosinophils # 0.3 x103/L

• Basophils # 0.0 x103/uL (0 – 1)

• Lymphocytes%11.5% (20 – 40)• Neutrophils % 80.7% (40 – 80) • Monocytes % 5.6%• Eosinophils % 1.9%• Basophils % 0.3%

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Investigations

CTGDate: 28/06/16Time: 0743h

• All parameters are normal

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InvestigationsIron/TIBC (28.6.2016)• Iron (serum) 10.3 µmol/L (6.6 – 26µmol/L)• TIBC 70.2 µmol/L (41 – 77 µmol/L)

• ECG: Sinus rhythm. No ischemic changes• Blood Grouping and Cross Matching : Blood Group B+• Pending for Urine Investigation, LFT and RFT.

Management Plan1) Admit patient for BP monitoring ½ hourly for an hour2) If turns out normal repeat 2 hourly for 2 times 4

hourly if still normal3) Full blood count and recheck haemoglobin level.4) Continue T. Methyldopa 250mg TDS & T. Aspirin 75mg

OD till 36 weeks5) Daptone (fetal heart monitoring) 4 hourly.

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