Case Presentation

By: Siti Nurulismah Bt Che Haron

Chief complaint

• Madam N, 41 years old Malay housewife gravida 8 para 7 currently at 38 weeks of gestation presented with high blood pressure and low lying placenta on the day of admission.

• REDD: 11/5/2011• Menstrual history: menarche at 14 years old,

regular, 4 – 7 days in 29 days cycle • OCP: for 1 years (1995-1996)

History of chief complaint

• She has high BP since 16 weeks of gestation. Currently on T. Methyldopa 500 mg tds. BP range from 130-140/90 mmHg.

• Her latest BP is 170/100 mmHg. • There is no features of impending eclampsia.

No per vaginal bleeding and no abdominal pain. • Fetal movement is normal. • Systemic review is normal.

History of presenting pregnancy

• Booking: 23/12/2011 at Kuala Selangor health clinic.

• BMI: 33.3 kg/m2 (Obese)• 16 weeks of gestation, she is diagnosed with

PIH and ultrasound scan shows low lying placenta.

• Quekening: 20 weeks gestation.• No anemia, no GDM, no other problems

Past O&G and sexual history

• Last pregnancy is 4 years ago. Not having PIH or other problems during past pregnancies.

• No past gynaecological history.• Married at 18 years old until now.

No. of children

Year Mode of delivery

Birth weight (kg)

Venue Note

• 6 boys • 1 girl

1994 - 2008 SVD 2.5 – 3.1 Tanjung Karang and Klang Hospital

2nd: breech and neonatal death

• No known long term medical illness including hypertension and diabetes mellitus

• Never undergoes any surgery• Not taking any long term medication• No allergy

Family history

Social history

• Housewife, living in village house at Kuala Selangor.

• Never smoking and not consume alcohol. Not take ilicit drug.

• Husband working as civil contractor and smoke 20 cigarettes per day.

Vital signs

• Pulse: 83 bpm, regular rhythm and good volume

• BP: 113/80 mmHg• Temperature: 37C• RR: 16 breaths per minute

Physical examinations

• Abdomen is distended, umbilicus centrally located and inverted. There is linea nigra and striae gravidarum. There is no scar.

• Uterus is at 38 weeks, measures 36 cm• Single fetus, longitudinal lie, cephalic

presentation, head is 5/5th palpable, liquor is adequate and estimates fetal weight is 3.0 kg

• Fetal heart rate is 148 bpm• Systemic examinations: normal

Summary

• Madam N, 41 years old Malay housewife gravida 8 para 7 currently at 38 weeks of gestation presented with high blood pressure and low lying placenta on the day of admission.

Diagnosis

• Provisional – Madam N 41 years old gravida 8 para 7 currently at 38 weeks of gestation having asymptomatic pregnancy induced hypertension and placenta praevia.

• Differential diagnosis – pre eclampsia, eclampsia and chronic hypertension

Investigations• FBC• Urine albumin• Urine protein 24 hours• Uric acid• Renal profile• Liver function test• Coagulation profile• Transabdominal scan: shows placenta praevia

type 2

Management

• Monitor BP 2 hourly• T. Methyldopa 500mg tds• Plan for elective LCSC• Check for features of impending eclampsia• Daily urine albumin• Monitor pad chart and time contraction• FBC weekly• CTG once daily

DiscussionPIH Pre

eclampsiaImpending eclampsia

Eclampsia Chronic HPT

Onset ≥ 2nd trimester

> 20 weeks of gestation Prior to pregnancy

BP (mmHg) ≥ 140/90 > 120/80

Urine protein (mg/24 hrs)

- ≥ 300

Risk factors and causes

· primigravida · previous history· family history · diabetes· pre existing hpt· multiple gestation

· older age· family history· diabetes· obesity· 2 causes

PIH, PE, IE,

eclampsia &

chronic HPT

Features

Ix

Cx

Rx

• headache, nausea, vomiting• clonus, hyperreflexia• tonic clonic seizure

• HELLP syndrome• seizure• post partum • oligohydramnios• placenta insufficeincy• fetal distress

• bed rest• antihypertensive medications • Mg SO4

• dexamethasone• SVD, C sec

Placenta praevia

Definition

Type

Risk factorComplication

Management

• previous c sec• uterine anomaly• assisted conception • multiple gestation

• APH & PPH • pre term labor• caesarean section

• symptomatic mx• conservative mx• dexamethasone• Mcafee regimen