interesting case 24/11/2011

1. Interesting case
11/24/2011
Warawut suttison , GP

2. • A pregnant woman , 19 yrs
• History taking from patient and her husband
• CC : seizure 30 min PTA

3. • OB-GYN Hx :
– G1P0 GA 35 wks by U/S
– ANC x 8 at private clinic : normal
• PH :
– No underlying disease
– No drug allergy
• FH :
– No history of seizure

4. • PE :
– General appearance : confusion
– Vital sign : BP 140/100 mmHg , RR 22 /min ,
BT 38.1 c , PR 120 /min
– HEENT : pink conjunctiva , anicteric sclera
– Heart and lungs : equal breath sound , normal S1S2
, no murmur
– Abdomen : HF - , position : ROA , FHS : 160 , uterine
contraction : can’t evaluate , EFW : 2500 gram
– PV : not done

5. Provisional diagnosis

6. Hypertensive Disorders of
Pregnancy

7. I. Introduction
• Hypertensive disorders complicate 5 to 10
percent of all pregnancies, and together they
form one member of the deadly triad
• In developed countries, 16 percent of
maternal deaths were due to hypertensive
disorders
Ref : William obstetric 23rd edition,2009

8. II. Diagnosis
• Hypertension is diagnosed empirically when
appropriately taken blood pressure exceeds
140 mm Hg systolic or 90 mm Hg diastolic
• women who have a rise in pressure of 30 mm
Hg systolic or 15 mm Hg diastolic should be
seen more frequently
Ref : William obstetric 23rd edition,2009

9. III. Classification and Definitions
Ref : William obstetric 23rd edition,2009

10. Ref : William obstetric 23rd edition,2009

11. III. Classification and Definitions
• Gestational Hypertension
• Preeclampsia and eclampsia syndrome
• superimposed Preeclampsia on chronic
hypertension
• Chronic hypertension
Ref : William obstetric 23rd edition,2009

12. II. Classification and Definitions
• 1. Gestational Hypertension:
– Systolic BP 140 or diastolic BP 90 mm Hg for first
time during pregnancy
– No proteinuria
– BP returns to normal before 12 weeks postpartum
– Final diagnosis made only postpartum
– May have other signs or symptoms of
preeclampsia, for example, epigastric discomfort
or thrombocytopenia
Ref : William obstetric 23rd edition,2009

13. • 2. Preeclampsia and eclampsia syndrome
• Preeclampsia:
Minimum criteria:
– BP 140/90 mm Hg after 20 weeks' gestation
– Proteinuria 300 mg/24 hours or 1+ dipstick
Ref : William obstetric 23rd edition,2009

14. Increased certainty of preeclampsia :
– BP 160/110 mm Hg
– Proteinuria 2.0 g/24 hours or 2+ dipstick
– Serum creatinine >1.2 mg/dL unless known to be
previously elevated
– Platelets < 100,000/L
– Microangiopathic hemolysis—increased LDH
– Elevated serum transaminase levels—ALT or AST
– Persistent headache or other cerebral or visual disturbance
– Persistent epigastric pain
Ref : William obstetric 23rd edition,2009

15. • Eclampsia:
– Seizures that cannot be attributed to other causes
in a woman with preeclampsia
Ref : William obstetric 23rd edition,2009

16. Ref : William obstetric 23rd edition,2009

17. • 3. Superimposed Preeclampsia On Chronic
Hypertension:
– New-onset proteinuria 300 mg/24 hours in
hypertensive women but no proteinuria before 20
weeks' gestation
– A sudden increase in proteinuria or blood
pressure or platelet count < 100,000/L in women
with hypertension and proteinuria before 20
weeks' gestation
Ref : William obstetric 23rd edition,2009

18. • 4. Chronic Hypertension:
– BP 140/90 mm Hg before pregnancy or diagnosed
before 20 weeks' gestation not attributable to
gestational trophoblastic disease
or
– Hypertension first diagnosed after 20 weeks'
gestation and persistent after 12 weeks
postpartum
Ref : William obstetric 23rd edition,2009

19. Investigation

20. • UA (15/11)
– Color : yellow
– Appearance : clear
– glu ,ketone
– alb : neg
– RBC : 2-3
– WBC : 5-10
– Epi : 5-10

21. • CBC
Hb 12.4 Hct 38.2 WBC 23000
Plt 430000 PMN 66 Lymph 26
MCV 78
• Coagulogram
PT 9(11.2) PTT 28.1(29.2)
INR 0.83

22. • Blood chemistry
BUN 5 , Cr 0.9
Electrolyte : Na 136 K 2.8
HCO3 22.3 Cl 104
LFT : pro 7.9 alb 3.8 glob 4.1
DB 0.06 TB 0.47 SGOT 19
SGPT 10 ALP 136

23. Diagnosis

24. • Management
– Non-severe preeclampsia
– severe preeclampsia
– eclampsia

25. Non severe preeclampsia
• Admit
• Bed rest
• Monitoring for symptoms of pre-eclampsia ; daily kick counts
• Body weight once a day
• Blood pressure check every 6 hours , no antihypertensive
drug not shown to improve perinatal outcome
• Laboratory testing: baseline 24-hour urine protein collection
at least 3 days
• Non-stress test/biophysical profile
• Termination
term
clinical worsing (severe PIH)
Ref : Johns Hopkins Manual of Gynecology and Obstetrics, The, 3rd Edition

26. Severe preeclampsia
• Principle
1. Seizure prophylaxis
2. Antihypertensive therapy
3. Delivery
Ref : William obstetric 23rd edition,2009

27. Severe preeclampsia
• 1. Seizure prophylaxis
Ref : William obstetric 23rd edition,2009

28. Severe preeclampsia
• Seizure prophylaxis
• LD : Give 4 g of magnesium sulfate diluted in 100 mL of IV
fluid administered over 15–20 min
• MD :Begin 2 g/hr in 100 mL of IV maintenance infusion.
• Monitor for magnesium toxicity:
The patellar reflex is present,
Respirations are not depressed, and
Urine output the previous 4 hr exceeded 100 mL
• Magnesium sulfate is discontinued 24 hr after delivery
Ref : William obstetric 23rd edition,2009

29. Severe preeclampsia
• Antihypertensive therapy
• The three most commonly employed in North
America and Europe are
hydralazine, labetalol, and nifedipine
• 1. nifedipine
Dosage :
– (soft capsule) 10 mg sublingual
– (film-coat tablet) 10 mg oral
Ref : William obstetric 23rd edition,2009

30. Severe preeclampsia
• 2. hydralazine
Dosage : 5 mg IV
Ref : William obstetric 23rd edition,2009

31. Severe preeclampsia
• Delivery
– 1. induction
– 2.route of delivery
Ref : William obstetric 23rd edition,2009

32. Ecclampsia
• Management
– Control of convulsions
– Intermittent administration of an antihypertensive
medication
– Avoidance of diuretics unless there is obvious
pulmonary edema
– Delivery of the fetus to achieve a "cure."
Ref : William obstetric 23rd edition,2009

33. Thank you