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OB Case Presentation

OB Case Presentation. Mishell Kris Sorongon. Objectives. To diagnose hypertension in pregnancy To differentiate the classification of hypertension in pregnancy To discuss the pathophysiology of hypertension in pregnancy To apply appropriate management for the case. General Data.

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OB Case Presentation

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  1. OB Case Presentation Mishell Kris Sorongon

  2. Objectives • To diagnose hypertension in pregnancy • To differentiate the classification of hypertension in pregnancy • To discuss the pathophysiology of hypertension in pregnancy • To apply appropriate management for the case

  3. General Data • M. M. G. • 37 y/o • Married • G2P1 (1001) • Filipino • Fairview Quezon City • SSS Specialist

  4. 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

  5. Family History • (+) Diabetes Mellitus - mother • (+) Hypertension – Grandmother • (+) Asthma – aunt • (-) Heart disease • (-) Cancer

  6. Personal and Social History • Non-smoker • Non-drinker of alcoholic beverages • Works in SSS

  7. Menstrual History • Menarche at 14 years of age • Regular monthly intervals • Duration of 5 days • 3-4 pads per day • Dysmenorrhea on D1 • LMP: January 17, 2010 • PMP: December 2009

  8. Obstetric History • G2P1 (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

  9. Gyne History • (-) OCP use • (+) Papsmear (March, 2009) normal results • (+) sexually active • (-) vaginal bleeding • (-) vaginal discharge

  10. Reason for Admission • Epigastric pain

  11. LMP: January 17, 2010 • EDC by LMP: October 24, 2010 • G2P1 (1001) 30 1/7 weeks AOG

  12. History of Present Illness Few 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+

  13. 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

  14. Physical Examination • Conscious, coherent, not in cardiorespiratory distress, VAS 9/10 • BP 140/100 mmHg • Cardiac rate 76 bpm • Respiratory rate 16 cpm • Temp: 37.2 C • Weight 66 kg • Height 155 cm • BMI: 27.5

  15. Physical Examination • Moist skin, no active dermatosis, (+) lineanigra , (+) striaegravidarum • No facial involuntary movement, edema, masses • Pink palpebral conjunctivae, anictericsclerae, 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 • Adynamicprecordium, normal rate, regular rhythm, S1>S2 apex, S2>S1 base, PMI at 5th LICS, no murmurs

  16. Globular abdomen • Fundic Height: 29 cm EFW 2635 gm • L1 breech • L2 maternal right • L3 not engaged • FHT 140s, RLQ • Pelvic exam: normal looking external genitalia • Internal exam: admits 2 fingers with ease, Cervix closed, uterus enlarged to age of gestation • SE: not done

  17. Rectovaginal exam: not done • (+) Grade 2 bipedal edema, pulses full and equal • Conscious, coherent, oriented to 3 spheres • No sensorimotor deficits • Deep tendon reflexes of upper and lower extremities: ++

  18. Admitting Diagnosis • 37 year old G2P1 (1001) Pregnancy uterine 30 1/7 weeks AOG • chronic hypertensive vascular disease with superimposed preeclampsia, mild

  19. Problem List • Epigastric pain • Bipedal edema • BP: 140/100 mmHg • Hypertension • Pregnancy at 30 1/7 weeks AOG

  20. Salient Features

  21. Laboratory Work-ups CBC 13.2/38.5/4.12/10 700/N81L14E1M4/160 000 MCV 94 MCH 32 MCHC 34

  22. Urinalysis • Light 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

  23. Hypertension in Pregnancy • the most common medical problem encountered in pregnancy • WHO (2006) – 16% of maternal deaths in developed countries • remains an important cause of morbidity and mortality

  24. Risk Factors • Young age and nulliparity • multiple pregnancy • BMI > 35 • African American ethnicity • Maternal age > 35 years old • History of chronic hypertension • Family history

  25. Definition • systolic BP (SBP) ≥ 140mmHg • and/or • diastolic BP (DBP) ≥ 90mmHg • confirmed by readings over several hours apart

  26. Categories of Hypertensive Diseases • Gestational Hypertension • Preeclampsia • Eclampsia • Preeclampsia superimposed on Chronic Hypertension • Chronic Hypertension

  27. Gestational Hypertension • Describes any form of new-onset pregnancy-related hypertension – Transient Hypertension • BP ≥ 140/90 mm Hg for first time during pregnancy • No proteinuria • BP returns to normal < 12 weeks postpartum • Final diagnosis is made only postpartum • May have other signs or symptoms of preeclampsia (e.g. Epigastric discomfort, thrombocytopenia)

  28. Preeclampsia • gestational HPN with proteinuria Minimum Criteria: • BP ≥ 140/90 mm Hg after 20 weeks gestation • Proteinuria ≥ 300 mg/24 hours or ≥ 1+ dipstick * edema is abandoned as a marker because it occurs in normal pregnant woman

  29. Eclampsia • Preeclampsia complicated by generalized tonic clonicconvulsions – cannot be attributed to other causes • One of the most dangerous conditions in pregnancy • Most common in the last trimester and becomes increasingly more frequent as term approaches • Prognosis is always serious

  30. Superimposed Preeclampsia on Chronic Hypertension • New 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)

  31. Chronic Hypertension • detection prior to 20 weeks AOG and persistence beyond 12 weeks postpartum

  32. Preeclampsia

  33. Increased Certainty • BP ≥ 160/110 mm Hg • Proteinuria • Serum creatinine > 1.2mg/dl unless known to be previously elevated • Platelets < 100,000/mm3 • increased LDH (Microangiopathichemolysis) • Elevated ALT or AST • Persistent headache or other cerebral or visual disturbance • Persistent epigastric pain

  34. Indications on Severity of Preeclampsia

  35. Abnormal Placentation in Preeclampsia • Pseudovasculogenesis • Cytotrophoblasts fail to adopt an invasive endothelial phenotype • Invasion of the spiral arteries is shallow – remains small caliber, resistance vessels • Placental Ischemia

  36. Pathophysiology

  37. Normotensivegravidas • Decreased pressor responsiveness to several vasoactive peptides and amines, espAngiotensin II • Preeclampsia • Hyperresponsiveness to angiotensin II and endothelin

  38. Basic Management Guidelines • Termination of pregnancywith least possible trauma to the mother and the fetus • Birth of an infant who subsequently thrives • Complete restoration of the health to the • mother

  39. Preeclampsia Management • Goal 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 status • BP monitoring q4 • creatinine, hematocrit, platelet count, Liver transaminases • Urinalysis every 2 days • Fetal BPS, dopplervelocimetry

  40. Termination of Pregnancy • Headache, 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 oxytocin • Cesarian delivery is indicated for cases of failed induction

  41. Some Indications for Delivery in Early-Onset Severe Preeclampsia Maternal • Persistent severe headache or visual changes; eclampsia • Shortness of breath; chest tightness with rales and/or SaO2 < 94 percent breathing room air; pulmonary edema • Uncontrolled severe hypertension despite treatment • Oliguria < 500 mL/24 hr or serum creatinine 1.5 mg/dL • Persistent platelet counts < 100,000/L • Suspected abruption, progressive labor, and/or ruptured membranes

  42. Fetal • Severe growth restriction—< 5th percentile for EGA • Persistent severe oligohydramnios—AFI < 5 cm • Biophysical profile 4 done 6 hr apart • Reversed end-diastolic umbilical artery flow • Fetal death

  43. Effects of Expectant Management for Severe preeclampsia • Maternal: placental abruption (20%), HELLP syndrome, pulmonary edema (4%), renal failure, and eclampsia • Perinatalmortality rates averaged from 39 to 133 per 1000 - Fetal-growth restriction and perinatal mortality • Risks for eclampsia, cerebrovascularhemorrhage, and maternal death.

  44. Intrapartum Management • Magnesium SO4 - used to arrest and prevent convulsions w/o producing generalized CNS depression • Loading dose: 4 gms IV, 10 gms IM • Maintenance dose: 5 gms q 4 hrs • Therapeutic level: 4-7 mEq/L • Loss of patellar reflex: 8-10mEq/L • Respiratory depression: 10mEq/L • Respiratory arrest: 12 mEq/L • Treatment MgSO4 toxicity: • calcium gluconate, 1 gm IV, Oxygenation

  45. MOA: Anti-convulsant • Acts by: 1. Neuronal calcium-channel blockade through N methyl- d-aspartate receptors 2. Reversal of cerebral arterial vasoconstriction distal to the middle cerebral arteries 3. Release of endothelial prostacyclin and inhibition of platelet clumping

  46. Intermittent intramural injections • Every 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 that a. the patellar reflex is present b. respirations are not depressed c. urine output the previous 4 hours exceeded 100ml • Magnesium sulfate is discontinued 24 hours after delivery

  47. Anti-hypertensive Therapy Hydralazine- Causes direct relaxation of arteriolar vascular smooth muscle • Drug of choice for rapid control of acute hypertension • 5 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

  48. Labetalol • a1- and nonselective -blocker. • fewer side effects (maternal hypotension and bradycardia) • Initial: 10 mg IVq10 – 20 mg, then 40 mg, 40 mg, 80 mg • maximum dose of 220 mg per treatment cycle Nifedipine - 10 mg PO q30 min. • third line drug that acts by limiting calcium channel causing relaxation of smooth muscle

  49. Prophylaxis • Aspirin, 60-80 mg OD • suppression of thromboxane synthesis by platelets and promoting prostacyclin production • Antioxidants • significantly reduces endothelical cell activation

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