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

No. of children 6 boys 1 girl Year 1994 - 2008 Mode of Birth weight delivery (kg) SVD 2.5 3.1 Venue Tanjung Karang and Klang Hospital Note 2nd: breech and neonatal death

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 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

Discussion
PIH Onset BP (mmHg) Urine protein (mg/24 hrs) Risk factors and causes 2nd trimester Pre eclampsia Impending eclampsia Eclampsia Chronic HPT Prior to pregnancy > 120/80 > 20 weeks of gestation 140/90 300

primigravida previous history family history diabetes pre existing hpt multiple gestation

older age family history diabetes obesity 2 causes

 bed rest antihypertensive medications Mg SO4 dexamethasone SVD, C sec

Features

headache, nausea, vomiting clonus, hyperreflexia tonic clonic seizure

Rx

PIH, PE, IE, eclampsia & chronic HPT

Ix

seizure post partum oligohydramnios placenta insufficeincy fetal distress

HELLP syndrome

Cx

Placenta praevia

 symptomatic mx conservative mx dexamethasone Mcafee regimen Management

Definition

Type

APH & PPH pre term labor caesarean section Complication Risk factor

previous c sec uterine anomaly assisted conception multiple gestation