Obstetri cs

SGD

4/30/12

August 12, 2011

BLOCK W Bacena. Lavilla. Lupisan. Click to edit Master subtitle Si-Cavero. Sierra. style Simbulan. Sinda. So. Sobrio. Suarez. Suguitan. Sumalapao. Villamil.

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General Data
M.I. 34 years old Married G3P2 (2002) Date of admission: July 7, 2011

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Chief Complaint
Elevated blood pressure

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Past Medical History

(+)

Hypertension : 1 yr PTC

BP range of 130-150/90 No consult, no medications Asymptomatic

(-)

Diabetes mellitus (-) Bronchial asthma (-) Pulmonary tuberculosis (-) Goiter/ Thyroid disorder (-) Allergy to food & medications (-) Previous surgery or hospitalization

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Family Medical History

(+)

Hypertension & bronchial asthma: Father (+) DM: Mother

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Personal/ Social/ Sexual History

College

graduate Employee @ a private company Coitarche at 28 years old with 1 nonpromiscuous sexual partner (-) OCP/ IUD/ DMPA use (-) vices non smoker, non alcoholic beverage drinker, denies illicit drug use

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Menstrual History
Menarche:

14 years old Interval: RMI Duration: 3-5 days Amount: 3-4 pads/ day Symptoms: (-) Dysmenorrhea
LNMP:

4th week of December 2011

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Obstetric History
Date G1 2004 G2 2008 G3 2011 AOG FT FT Manner SVD SVD Present pregnancy Place Sex CGH CGH M M Birth Wt
Unrecalled Unrecalled
Complic ations

(-) (-)

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History of Present Illness

1 week PTC

28 5/7 wks AOG by LUTZ

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History of Present Illness

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What

medication given in private clinic Review of systems? DOB?

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Antenatal Visits
PNCU:

4x w/ a private physician First: Feb 2, 2011 Last: July 6, 2011 Meds: FeSo4+FA 1 tab OD, MV 1 cap OD, anti hpn meds? Normal CBC and U/A

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PHYSICAL EXAMINAT ION

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PE on Admission

Awake, coherent, ambulatory not in cardiorespiratory distress VS: BP=140/90 CR=76bpm RR=18 T=37 C Pink palpebral conjunctivae, anicteric sclerae, (-) cervical LA, (-) tonsillopharyngeal congestion, (-) anterior neck mass Equal chest expansion, no retractions, clear breath sounds, no crackles/ wheezes/ rales Adynamic precordium, distinct heart sounds, normal rate, regular rhythm, no murmurs Globular abdomen, FH=20cm, EFW=0.8-1kg, FHT=140s LLQ IE: normal external genitalia, parous smooth vagina, cervix closed, corpus enlarged to AOG, no adnexal mass/ tenderness, intact BOW

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Pregnancy uterine 30 3/7 weeks AOG, transverse lie not in labor Chronic Hypertension with Superimposed Click to edit Master subtitle Preeclampsia style G3P2 (2002)

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Plan
DIAGNOSTIC:

Stat urine albumin- negative CBC, UA, PT/PTT, BT, Na, K, Cl, BUN, Crea, AST, ALT, LDH For BPP/Biom with CAS

24hr

urine collection for TV, TP and crea HbsAg and RPR FBS and 1 hour pp Refer to Neonatology, Genetics, Pedia Surgery

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Plan
THERAPEUTIC:
MgSO4

4 doses Methyldopa 250mg/tab 2 tab q8. defer if bp <110/70 Hydralazine 5mg SIVP prn for BP> 160/110 mHg Aspirin 80mg 1 tab OD until 35 weeks Ferrous fumarate 1 tab OD Calcium carbonate 1 tab q8 Dexamethasone 6mg IM q12 for 4 doses

4g SIVP, 5g IM each buttock q6 for

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Course in the Ward

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Day 2
Genetics A> PU 30 weeks AOG by LUTZ Prenatal G3P2 (2002) Notes P> Prenatal genetic counseling- done Explained incidence of neural tube defects: 1 in 500 to 1 in 1000 live births and importance of folic acid intake prior to next pregnancy Will get to examine baby once born to see if patient has dysmorphic features that can be explained by a known syndrome Refer back once delivered

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Day 3
(+) yellowish, greenish, frothy vaginal discharge was noted P> For TMG of vaginal discharge: Negative For fernings test: Negative

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Day 6
Perinatology For control of BP Notes Seizure prophylaxis Work up of CH and pre eclampsia Steroid administration for lung maturity

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The

rest of the hospital stay was unremarkable. Patient has stable VS since admission BP range of 90-110/60-70.

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NST/ BPP/ Biometry

Laborator y Examinati ons Click Ancillary & to edit Master subtitle style Procedure s

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CBC
07/07/11 WBC RBC Hgb Hct PC Diff Count Neutrophils Lymphocytes Monocytes Eosinophils 0.787 0.136 0.063 0.011 0.714 0.912 0.073 0.017 10.70 4.11 126 0.374 271 07/18/11 9.2 4.11 125 0.378 252

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Urinalysis
Result (07/07/11) Color Yellow RBC WBC (-) 0-1 Transparency Sl Hazy SG pH Sugar Protein 1.015 6.5 (-) 1+ Result (07/07/11)

Epith Cells 1+ Bacteria Mucus Thread Cast Crystals Few 1+ Hyaline 0-1/ lpf (-)

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PT/ aPTT
PT Reference Value Patients Value % activity INR 0.83 13.9 sec 12.7 >1.0 0.83 aPTT 34.7 sec 25.4

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Blood Chemistry
07/07/11 FBS BUN 7.75 mmol/L H 1.10 mmol/L H 2.10 mmol/L L 49 umol/L 07/18/11 LDH 07/07/11 354 IU/L Calciu 2.16 m mmol/L Na K 24 IU/L 20 IU/L Cl 139 mmol/L 3.3 mmol/L 3.4 mmol/L LL 109 mmol/L 07/18/11 420 IU/L

Creati 43 umol/L nine AST ALT 23 IU/L 18 IU/L

Album 30 g/L L in

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Urine Chemistry
07/18/11 Creatinine Total Protein 13.15 mmol/24 hours 277 mg/24hrs H

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Cervicovaginal Smear
No

growth after 2 days of incubation

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GUIDE QUESTION S
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Question 1

What are the pertinent points in the history and physical examination that would guide us in the management of this patient?

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Pertinent Points in the History

34 y.o. G3P2(2002)

LMP: Last week of December (unsure of date) AOG: 30 3/7 weeks by LUTZ

Chief Complaint: elevated BP and proteinuria Family Hx: of (+) DM in mother and HPN in father Menstrual Hx: HPI:

1 week PTC: elevated BP (150/100mmHg) 24 hour urine protein: 374.90 mg/24 hr vaginal spotting, (-) contractions (+) good fetal movement

PNCU : 4x c/o private OB

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Pertinent Points in the PE

Not

in cardiorespiratory distress BP: 140/90 CR: 76 RR: 18 T: 37 C Essentially normal systemic PE findings Abdomen: globular, FH: 20cm, EFW 0.81kg, FHT 140s LLQ IE: NEG, smooth parous vagina, cervix closed, uterus enlarged to AOG, (-) AMT, intact BOW

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Question 2

What other questions in the history would you have asked?

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c/o

Orlyn

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Question 3

What are the risk factors for hypertension in pregnancy for this patient?

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Risk factors for HPN in pregnancy

Age

>40 yrs OB/personal/sexual Hx:

Nulliparity Twin

gestation Change of partner for second or subsequent pregnancy

Family

Hx:
hypertension

Pregnancy-induced

Ref: Clinical Practice Guidelines on Hypertensive Complications in Pregnancy. 2nd ed. 2010. Philippine Obstetric and Gynecological Society.

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Risk factors for HPN in pregnancy

Past

medical Hx:

Hypertension

in previous pregnancy Diabetes mellitus Chronic renal disease Anti-phospholipid antibody syndrome
Risk

factors present in the patient is gestational DM and family Hx of DM

Ref: Clinical Practice Guidelines on Hypertensive Complications in Pregnancy. 2nd ed. 2010. Philippine Obstetric and Gynecological Society.

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Question 4

What are the complications of hypertension in Pregnancy?

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Gestational Hypertension
BP

> 140/90 mm Hg for the first time in pregnancy No proteinuria BP returns to normal < 12 weeks postpartum Final diagnosis made only post partum May have other signs of pre eclampsia, for example, epigastric discomfort, or thrombocytopenia

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Pre Eclampsia
Minimum criteria
BP

> 140/90 mm Hg after 20 weeks age of gestation Proteinuria >300mg/24 h or >1+ dipstick

Increased certainty of preeclampsia

BP >160/110 mm Hg Proteinuria 2.0g/24hr or >+2 dipstick Serum creatinine >1.2mg/dl unless known to be previously elevated Platelets

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Eclampsia
Seizures

that cannot be attributed to other causes in a woman with pre eclampsia

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Chronic Hypertension
BP

> 140/90 mm Hg before pregnancy or diagnosed before 20 weeks age of gestation OR

Hypertension

first diagnosed after 20 weeks age of gestation and persistent after 12 weeks postpartum

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Chronic Hypertension with Superimposed Pre Eclampsia

New

onset proteinuria >300mg/24 h in a hypertensive woman but no proteinuria before 20 weeks age of gestation sudden increase in proteinuria or blood pressure or platelet count <100,000/mm3 in women with hypertension and proteinuria before 20 weeks age of gestation

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Question 5

How was the diagnosis of Chronic Hypertension with Superimposed PreEclampsia arrived at?

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Patient

was hypertensive even before pregnancy. Her BP ranges from mmHg and she is maintained on. There was a new onset proteinuria during admission (374.90 mg/24 hr).

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Question 6

What is the goal of management of the patient in this case?

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Revise

bec too wordy.should be bulletform. c/o anji

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Goal of Management
Management

of women with gestational hypertension/mild preeclampsia in general must always consider maternal safety first and then the delivery of a newborn who will not require intensive and prolonged neonatal care. management of patients with gestational hypertension/mild preeclampsia has been documented to beon Hypertensive Complications of Ref: Clinical Practice Guidelines more costPregnancy.2nd effective than similar in-patient therapy. edition. April 2010. Philippine Obstetrical and Gynecological Society(Foundation) Therefore, outpatient management must

Outpatient

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The

initial management of preeclampsia includes stabilization of the mothers condition, confirmation of gestational age and assessment of fetal well-being. Once the diagnosis of severe preeclampsia is established, traditional management has focused on maternal safety with expedited delivery.

Ref: Clinical Practice Guidelines on Hypertensive Complications of Pregnancy.2nd edition. April 2010. Philippine Obstetrical and Gynecological Society(Foundation)

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Because

these pregnancies are associated with high rates of maternal morbidity and with potential risks for the fetus, there is general agreement that such patients should be delivered if the disease develops > 34 weeks age of gestation. Although delivery is always appropriate for the mother, it may not be optimal for the premature fetus(< 34 weeks). Ref: Clinical Practice Guidelines on Hypertensive Complications of
Pregnancy.2nd edition. April 2010. Philippine Obstetrical and Gynecological Society(Foundation)

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Question 7

Will the patient and her fetus benefit from expectant management?

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Expectant Management
3

circumstances in which expectant management of severe preeclampsia remote from term(<34 weeks) is clearly acceptable 1. severe preeclampsia by proteinuria 2. severe preeclampsia on the basis of intrauterine growth restriction (IUGR) alone with good fetal testing 3. there is precedent in the literature to Ref: Clinical Practice Guidelines management support the expectanton Hypertensive Complications of Pregnancy.2nd edition. of women with severe preeclampsia April 2010. Philippine Obstetrical and Gynecological Society(Foundation) blood pressure (BP) criterion.

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Question 8

How should the fetus be assessed?

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Assessment of Fetal Status

Since

for this case, expectant management is recommended, assessment of the fetus with ultrasound measurements of fetal size every 2 weeks, biophysical screening (BPS) and amniotic fluid index (AFI) measurement at least twice weekly, umbilical artery Doppler once a week and daily nonstress test (NST) should be undertaken. Serial assessment will allow timing of delivery to be optimized.
Ref: Clinical Practice Guidelines on Hypertensive Complications of Pregnancy.2nd edition. April 2010. Philippine Obstetrical and Gynecological Society(Foundation)

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Question 9

What are the things to watch out for in this patient?

Watch out for

Progression to severe preeclampsia Vigilance in assessing maternal risks Level of BP Degree of proteinuria Involvement of other organ systems

Watch out for

It is emphasized that only 1 of the listed clinical features in addition to hypertension (> 140/90 mmHg) and proteinuria (> 300 mg/24 hours) is required for the diagnosis of severe disease Ultimately as many clinical criteria are subjective, women should be managed according to a careful clinical assessment rather than relying overly on precise criteria

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Question 10

What is the initial management in a woman with severe preeclampsia?

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Initial Management

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Check the ABCs (Airway, Breathing, Circulation)

Checking

of the patients disposition on entry at the OBAS. Includes:

BP HR RR Quick

assessment of perfusion status

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Admission to the Hospital

After adequate assessment through proper history taking and physical examination, patient may be deemed admissible according to the patients status and need for prompt medical or surgical assessment. Hospitalization is considered in women with severe preeclampsia.

woman is unreliable

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Control of BP

Tight BP control (target of systolic BP<160 or diastolic BP<110)

Hydralazine 5 mg IV 5-to 10-mg doses q15-20 minutes

relative hypotension (e.g. diastolic BP <90), which can compromise perfusion in the placenta.

Labetalol 10 mg IV and given double the previous dose every 10 minutes thereafter if BP is not controlled (max dose of 220mg)

found to be as efficacious as hydralazine but with fewer adverse effects

Nifedipine 10 mg initial dose PO, then

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Discuss

meds c/o orlyn

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Accurate diagnosis backed up by laboratory tests

Diagnostic

Tests

help determine the present status of the patient and know the accurate diagnosis to detect end organ damage to prepare the patient for further management (i.e. possible surgery)
Stat

albumin is initially asked to evaluate for proteinuria

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Hematocrit Hemoconcentration supports the diagnosis of preeclampsia but hemolysis, if present, can decrease the hematocrit. Platelet Count Thrombocytopenia is a criterion of severe disease Quantification of ProteinExcretion of 300 mg or more in 24 hours is necessary for excretion: Urine Albumindiagnosis or at least 1+ protein on dipstick of two urine Dipstick, 24 hour Collection specimens collected at least four hours apart; 3+ or greater or 5 g or more per day is a criterion of severe disease. Serum creatinineAn elevated or rising level suggests severe disease. concentration Serum alanine and aspartateElevated or rising levels suggest hepatic dysfunction aminotransferase indicative of severe disease. concentrations (ALT and AST) Serum lactate dehydrogenaseMicroangiopathic hemolysis is suggested by an elevated (LDH) concentration LDH level and red cell fragmentation (schistocytes or helmet cells) on peripheral blood smear. Microangiopathic hemolysis is present in severe disease or HELLP syndrome (Hemolysis, Elevated Liver function tests, Low Platelets). Serum uric acid concentration Often elevated in preeclampsia, but not diagnostic. Coagulation function tests (eg,Usually normal if there is no thrombocytopenia or liver prothrombin time, activateddysfunction, and therefore do not need to be monitored partial thromboplastin time,routinely. fibrinogen concentration)

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Prevent progression to complications and minimizing maternal and perinatal complications

Magnesium

Sulfate prophylaxis for

eclampsia
loading

dose of 14 mg (4 mg IV, 5 mg IM per buttock), subsequent doses of 5 mg IM injected into a buttock alternately discontinued 24 hours after delivery WOF: decreased urine output, depressed patellar reflexes, respiratory depression

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Fetal Well-Being studies and appropriate management of the preterm fetus.

Delivery

of the fetus is usually the cure for hypertensive disorders during pregnancy, but the fetus must be able to survive in an extrauterine environment. Fetal well-being studies like biophysical profile and nonstress test and biometry provide an accurate estimate of age of gestation, important in temporizing management

need to be done to assess if the fetus needs to be delivered or if the pregnancy may be continued.

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Question 11

Is corticosteroid therapy indicated for fetal lung maturity in this case?

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Corticosteroid Therapy
Yes

between 24-34 weeks AOG corticosteroids should be given to enhance fetal lung maturity Recommended regimens:
Dexamethasone

6 mg IM every 12 hours

for 4 doses Betamethasone 12 mg IM every 24 hours for 2 doses

Ref: Crowley P. 2000. Prophylactic corticosteroids for preterm birth. Cochrane Database of Systematic Reviews (2):CD000065.

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Corticosteroid Therapy
In

pregnancy <34 weeks and pregnancy can be prolonged in excess of 24 hours, steroids aid in reducing fetal respiratory mortality There is benefit from steroid therapy even if delivery occurs <24 hours after administration

Ref: Crowley P. 2000. Prophylactic corticosteroids for preterm birth. Cochrane Database of Systematic Reviews (2):CD000065.

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Question 12

What BP is the aim of anti-hypertensive therapy?

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Target BP
Aim:

Mean Arterial Pressure Avoid hypotension !

the

degree to which placental blood flow is autoregulated is not established aggressive lowering may cause fetal distress

Ref: Clinical Practice Guidelines on Hypertensive Complications of Pregnancy.2nd edition. April 2010. Philippine Obstetrical and Gynecological Society(Foundation)

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Target BP
Consideration

should be given to initiating agents for treatment of acute severe hypertension at lower doses, because these patients may be intravascularly volume depleted and may be at increased risk for hypotension.

Ref: Clinical Practice Guidelines on Hypertensive Complications of Pregnancy.2nd edition. April 2010. Philippine Obstetrical and Gynecological Society(Foundation)

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Question 13

What are the indications for expediting delivery in this case?

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Maternal:

-persistent severe headache or visual changes; eclampsia -shortness of breath or chest tightness with rales and/or pulse oximetry of <94% on room air or pulmonary edema -epigastric/RUQ pain with AST or ALT >2x the upper limits of normal -uncontrolled severe hypertension, despite maximum doses of antihypertensive agents

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Fetal

c/o anji

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Question 14

What is the mode of delivery in this case if delivery is indicated?

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Mode of Delivery
Determined

after considering the presentation of the fetus, fetal condition and likelihood of success of induction of labor after assessment of the cervix Vaginal delivery is generally preferable. <32 weeks AOG, caesarian section is more likely as the success of induction is reduced. >34 weeks with cephalic presentation, vaginal delivery should be considered.

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Anti-hypertensive

treatment should be continued throughout assessment and labor.

Ref: Clinical Practice Guidelines on Hypertensive Complications of Pregnancy.2nd edition. April 2010. Philippine Obstetrical and Gynecological Society(Foundation)

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Question 15

What are some preventive strategies to reduce the incidence of the condition?

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Separate

therapeutic from non therapeutic

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Prevention
Dietary

Manipulation: Low salt diet, calcium supplementation, fish oil supplementation Antioxidants: Ascorbic acid, alpha tocopherol Anti-hypertensive drugs: diuretic therapy Anti-thrombotic drugs: Low dose aspirin, aspirin/dipyridamole, aspirin + heparin, aspirin + ketanserin In general, none of these has been found to be clinically efficacious as evaluated in

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Question 16

How do you follow up the patient?

Follow-up

BP control and treatment of any end organ damage since sequelae extend beyond postpartum. Lifestyle modification (e.g. low-salt, low-fat diet, physical activity. Weight reduction Avoidance of smoking, moderate alcohol consumption). Pharmacologic therapy are cornerstones of BP control.

Follow-up

Ophthalmologic assessment Cardiac monitoring and renal function evaluation Referral to internal medicine and/or its subspecialty clinics Counselling for risk in successive pregnancies Predisposition to similar maternal and fetal complications Sequelae of chronic hypertension (such as congestive heart failure secondary to hypertensive heart disease) greatly increase the risk of a complicated pregnancy Advise the patient regarding contraception or sterilization (the patient already has 4 children, after all) to prevent successive pregnancies is very important.

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Thank you for listening!

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