Mishell Kris Sorongon
OB Case Presentation
ObjectivesTo diagnose hypertension in pregnancyTo differentiate the classification of hypertension in
pregnancyTo discuss the pathophysiology of hypertension in
pregnancyTo apply appropriate management for the case
General DataM. M. G.37 y/oMarriedG2P1 (1001) FilipinoFairview Quezon CitySSS Specialist
Past Medical History(-) Diabetes Mellitus(+) Hypertension (2008) – was started on Atenolol 20
mg once a day but stopped when she became pregnant. UBP 120/80 mmHg HBP 140/100 mmHg
(+) Bronchial asthma – last attack on July 2010 was given Prednisone 5 mg twice a day for 5 days
(-) Thyroid disorders(-) known allergies to food and drugs
Family History(+) Diabetes Mellitus - mother(+) Hypertension – Grandmother(+) Asthma – aunt (-) Heart disease (-) Cancer
Personal and Social HistoryNon-smokerNon-drinker of alcoholic beveragesWorks in SSS
Menstrual HistoryMenarche at 14 years of ageRegular monthly intervalsDuration of 5 days3-4 pads per dayDysmenorrhea on D1LMP: January 17, 2010PMP: December 2009
Obstetric HistoryG2P1 (1001)G1 (1999) 39 weeks AOG delivered 6.6 lbs male via
LTCS due to breech in SLMC. No lengthened hospital stay
G2 Present pregnancy
Gyne History(-) OCP use(+) Papsmear (March, 2009) normal results(+) sexually active(-) vaginal bleeding(-) vaginal discharge
Reason for AdmissionEpigastric pain
LMP: January 17, 2010EDC by LMP: October 24, 2010G2P1 (1001) 30 1/7 weeks AOG
First Trimester Second Trimester Third Trimester
• First prenatal check-up at 8 weeks AOG• Started taking multivitamins, iron, and calcium once a day• No maternal illness
•URTI - given Cefalexin 500 mg three times a day for 7 days• Episode of vaginal spotting - given Duvadillan once a day for 20 days then as needed• OGCT showed normal results
•UTI – Amoxicillin three times a day for 7 days. •Proteinuria +2•Repeat urinalysis not done
History of Present IllnessFew hours prior to
admission
Epigastric pain, severe, burning in
character, no radiation. No changes in
bowel habits.
Sought consult with attending physician
Blood pressure :160/100 mmHg.
(-) watery or bloody vaginal discharge (+)
good fetal movement
(+) bipedal edema
(-) headache or blurring of vision.
Patient claimed that urinalysis done last
week showed proteinuria 2+
Review of Systems General: no weigbt loss, anorexia, fever Skin: no skin changes Eyes: no blurring of vision, redness, itchiness, discharge, pain Nose: No discharge, epistaxis, anosmia Mouth & Throat: No bleeding, circumoral cyanosis, hoarseness, soreness,
difficulty of swallowing Pulmonary: no difficulty of breathing, cough, hemoptysis, chest wall
abnormalities Heart: No palpitations, chest pain, chest heaviness Abdomen: (+) epigastric pain, no constipation, diarrhea, hematochezia,
melena, hearburn, belching Genitourinary: no hematuria, frequency, urgency, flank pain Vascular: no excessive bleeding, easy bruisability Neurologic: no headache, seizure episode, one-sided weakness or numbness
Physical ExaminationConscious, coherent, not in cardiorespiratory distress,
VAS 9/10BP 140/100 mmHgCardiac rate 76 bpmRespiratory rate 16 cpmTemp: 37.2 CWeight 66 kgHeight 155 cmBMI: 27.5
Physical ExaminationMoist skin, no active dermatosis, (+) linea nigra , (+)
striae gravidarumNo facial involuntary movement, edema, massesPink palpebral conjunctivae, anicteric sclerae, patent
external auditory canal, non-congested turbinates, no nasal discharge, supple neck, no lymphadenopathies, no palpable anterior neck mass
Symmetrical chest expansions, clear breath sounds in all lung fields, no retractions
Adynamic precordium, normal rate, regular rhythm, S1>S2 apex, S2>S1 base, PMI at 5th LICS, no murmurs
Globular abdomenFundic Height: 29 cm EFW 2635 gmL1 breechL2 maternal rightL3 not engagedFHT 140s, RLQPelvic exam: normal looking external genitaliaInternal exam: admits 2 fingers with ease, Cervix
closed, uterus enlarged to age of gestationSE: not done
Rectovaginal exam: not done(+) Grade 2 bipedal edema, pulses full and equalConscious, coherent, oriented to 3 spheresNo sensorimotor deficitsDeep tendon reflexes of upper and lower extremities:
++
Admitting Diagnosis37 year old G2P1 (1001) Pregnancy uterine 30 1/7
weeks AOGchronic hypertensive vascular disease with
superimposed preeclampsia, mild
Problem ListEpigastric painBipedal edemaBP: 140/100 mmHgHypertensionPregnancy at 30 1/7 weeks AOG
Salient FeaturesSubjective Objective
37 year old G2P1 (1001) 30 1/7 w AOGPrevious LTCS due to breech (1999)Hypertensive since 2008 maintained on Atenolol OD but stopped since JanuaryEpigastric pain, burning, nonradiating, severeElevated BP: 160/100 mmHgNo blurring of vision, headache, seizure episodeBipedal edema
Conscious, coherent, not in cardio respiratory distressBP: 140/100 mmHg HR: 76 bpmDeep tendon reflexes intactGlobular abdomen, FHT 140s at RLQCervix closedBipedal edema grade 2No sensorimotor deficitsDeep tendon reflexes: ++
Laboratory Work-upsCBC13.2/38.5/4.12/10 700/N81L14E1M4/160 000MCV 94 MCH 32 MCHC 34
UrinalysisLight yellow, hazy, glucose 100 mg/dl (2+), negative
bilirubin, ketone 15 mg/dl (1+), specific gravity 1.015, pH 6.5 protein 100 mg/dl (2+), urobilinogen 0.2, nitrites negative, blood trace – intact, leukocytes moderate (2+)
RBC 3 WBC 29 Epithelial cells 11 casts 2 bacteria 15
Hypertension in Pregnancythe most common medical problem encountered in
pregnancy WHO (2006) – 16% of maternal deaths in developed
countriesremains an important cause of morbidity and
mortality
Risk FactorsYoung age and nulliparitymultiple pregnancyBMI > 35 African American ethnicityMaternal age > 35 years oldHistory of chronic hypertensionFamily history
Definitionsystolic BP (SBP) ≥ 140mmHg
and/or diastolic BP (DBP) ≥ 90mmHg
confirmed by readings over several hours apart
Categories of Hypertensive DiseasesGestational HypertensionPreeclampsiaEclampsiaPreeclampsia superimposed on Chronic HypertensionChronic Hypertension
Gestational HypertensionDescribes any form of new-onset pregnancy-related
hypertension – Transient HypertensionBP ≥ 140/90 mm Hg for first time during pregnancyNo proteinuriaBP returns to normal < 12 weeks postpartumFinal diagnosis is made only postpartumMay have other signs or symptoms of preeclampsia
(e.g. Epigastric discomfort, thrombocytopenia)
Preeclampsiagestational HPN with proteinuria
Minimum Criteria: BP ≥ 140/90 mm Hg after 20 weeks gestationProteinuria ≥ 300 mg/24 hours or ≥ 1+ dipstick* edema is abandoned as a marker because it occurs in
normal pregnant woman
EclampsiaPreeclampsia complicated by generalized tonic clonic
convulsions – cannot be attributed to other causesOne of the most dangerous conditions in pregnancyMost common in the last trimester and becomes
increasingly more frequent as term approachesPrognosis is always serious
Superimposed Preeclampsia on Chronic HypertensionNew onset proteinuria > 300 mg/24 hours in
hypertensive women but no proteinuria before 20 weeks’ gestation
Sudden increase in proteinuria/ Blood Pressure/ platelet count <100,000/mm3 before 20 wks AOG (on a chronic hypertensive patient)
Chronic Hypertensiondetection prior to 20 weeks AOG and persistence
beyond 12 weeks postpartum
Preeclampsia
Increased CertaintyBP ≥ 160/110 mm HgProteinuriaSerum creatinine > 1.2mg/dl unless known to be
previously elevatedPlatelets < 100,000/mm3increased LDH (Microangiopathic hemolysis)Elevated ALT or ASTPersistent headache or other cerebral or visual
disturbancePersistent epigastric pain
Indications on Severity of PreeclampsiaAbnormality Mild Severe
Diastolic BP <100 mmHg > 110 mmHg
Proteinuria Traces to +1 Persistent > +2
Headache Absent Present
Visual disturbance Absent Present
RUQ pain Absent Present
Oliguria Absent Present
Convulsion Absent Present
Serum Creatinine Normal Elevated
Thrombocytopenia <100, 000
Absent Present
Liver enzyme elevation Minimal Marked
Fetal growth restriction Absent Obvious
Pulmonary Edema Absent Present
Abnormal Placentation in PreeclampsiaPseudovasculogenesis• Cytotrophoblasts fail to
adopt an invasive endothelial phenotype
• Invasion of the spiral arteries is shallow – remains small caliber, resistance vessels
• Placental Ischemia
Pathophysiology
Normotensive gravidasDecreased pressor responsiveness to several vasoactive
peptides and amines, esp Angiotensin IIPreeclampsia
Hyperresponsiveness to angiotensin II and endothelin
Basic Management GuidelinesTermination of pregnancy with least possible trauma
to the mother and the fetusBirth of an infant who subsequently thrivesComplete restoration of the health to themother
Preeclampsia ManagementGoal of Management: early identification of worsening
preeclampsia and development of a management scheme that includes a plan for timely delivery
Hospitalization Evaluate:
maternal weight and maternal statusBP monitoring q4creatinine, hematocrit, platelet count, Liver
transaminasesUrinalysis every 2 daysFetal BPS, doppler velocimetry
Termination of PregnancyHeadache, visual disturbances, epigastric pain or
oliguria are indicative that convulsions may be imminent
Delivery is usually advisable for severe preeclampsia that does not improve after hospitalization
Labor should be induced by intravenous oxytocinCesarian delivery is indicated for cases of failed
induction
Some Indications for Delivery in Early-Onset Severe Preeclampsia
MaternalPersistent severe headache or visual changes; eclampsiaShortness of breath; chest tightness with rales and/or SaO2
< 94 percent breathing room air; pulmonary edemaUncontrolled severe hypertension despite treatmentOliguria < 500 mL/24 hr or serum creatinine 1.5 mg/dLPersistent platelet counts < 100,000/LSuspected abruption, progressive labor, and/or ruptured
membranes
FetalSevere growth restriction—< 5th percentile for EGAPersistent severe oligohydramnios—AFI < 5 cmBiophysical profile 4 done 6 hr apartReversed end-diastolic umbilical artery flowFetal death
Effects of Expectant Management for Severe preeclampsiaMaternal: placental abruption (20%), HELLP
syndrome, pulmonary edema (4%), renal failure, and eclampsia
Perinatal mortality rates averaged from 39 to 133 per 1000 - Fetal-growth restriction and perinatal mortality
Risks for eclampsia, cerebrovascular hemorrhage, and maternal death.
Intrapartum ManagementMagnesium SO4 - used to arrest and prevent
convulsions w/o producing generalized CNS depressionLoading dose: 4 gms IV, 10 gms IMMaintenance dose: 5 gms q 4 hrs
Therapeutic level: 4-7 mEq/LLoss of patellar reflex: 8-10mEq/LRespiratory depression: 10mEq/L Respiratory arrest: 12 mEq/L
Treatment MgSO4 toxicity: calcium gluconate, 1 gm IV, Oxygenation
MOA: Anti-convulsant Acts by:1. Neuronal calcium-channel blockade through N
methyl- d-aspartate receptors2. Reversal of cerebral arterial vasoconstriction distal to
the middle cerebral arteries3. Release of endothelial prostacyclin and inhibition of
platelet clumping
Intermittent intramural injectionsEvery 4 hours thereafter, give 5 g of a 50% solution of
magnesium sulfate injected deeply in the upper outer quadrant of alternate buttocks, but only after ensuring thata. the patellar reflex is presentb. respirations are not depressedc. urine output the previous 4 hours exceeded 100ml
Magnesium sulfate is discontinued 24 hours after delivery
Anti-hypertensive TherapyHydralazine - Causes direct relaxation of arteriolarvascular smooth muscle
Drug of choice for rapid control of acute hypertension5 mg initial dose, 5-10 mg q 15-20 m IV until there’s
satisfactory response (DBP 90-100 mmHg)Side-effects: palpitations, tachycardia, headaches,
flushing
Labetalola1- and nonselective -blocker. fewer side effects (maternal hypotension and
bradycardia)Initial: 10 mg IV
q10 – 20 mg, then 40 mg, 40 mg, 80 mg maximum dose of 220 mg per treatment cycleNifedipine - 10 mg PO q30 min.
third line drug that acts by limiting calcium channel causing relaxation of smooth muscle
ProphylaxisAspirin, 60-80 mg OD
suppression of thromboxane synthesis by platelets and promoting prostacyclin production
Antioxidantssignificantly reduces endothelical cell activation
Thank you!
Fetal Monitoring in Gestational Hypertension and PreeclampsiaGestational Hypertension(hypertension only without proteinuria, with normal
laboratory results, and without symptoms)Estimation of fetal growth and amniotic fluid status
should be performed at diagnosis. If results are normal, repeat testing only if there is significant change in maternal condition
Nonstress test (NST) should be performed at diagnosis. If NST is nonreactive, perform biophysical profile (BPP). If BPP value is eight or if NST is reactive, repeat testing only if there is significant change in maternal condition
Anti-hypertensive Therapy1. Methyldopa - First line anti-hypertensive agentMOA: stimulation of central alpha-adrenergic
receptors by a false transmitter that results in a decreased sympathetic outflow to the organ systems.
200-500mg tab Q6Lowers BP by reducing sympathetic outflow from
brainstemSuited for long-term use
Patient admitted to HRPUD5LR 1 liter to run for 8 hoursDemerol 50 mg IV nowHydralazine 4 mg IV statMagnesium sulfate 5 mg IM buttocks
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