Case of Preeclampsia Severe Final3

8/3/2019 Case of Preeclampsia Severe Final3

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CASE OF GESTATIONAL

HYPERTENSIONJunior Intern Fairoz Macud Adap

200870003


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General Data

J. B.

40 years old

Married, Filipino, Catholic

Housewife

Cembo, Makati

G4P3 (3003)


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ChiefComplaint

BP Elevation


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Historyof Present Illness

1st

TrimesterAmenorrhea

Pregnancy Test not done

No bloody show

No nausea and vomiting

With increase in appetite

No medication taken

No maternal illnesses noted

No UTZ

No consult done


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2nd Trimester

Patient had nausea

With quickening noted on the 6th month

No mucoid/watery/bloody vaginal discharge

Experienced irregular contractions

First consult done at St. Andrew Lying-In Center

and was prescribed with multivitamins OD,

ferrous sulfate OD and calcium tablet OD Isoxsuprine tablet given at 32 weeks for 1 week

No laboratory work up done


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3rd

Trimester Presence of good fetal movement

With irregular contractions

No mucoid/watery/bloody discharge

With intake of multivitamins and ferrous sulfate

UTZ, CBC with PC, UA, BT, VDRL/RPR, HbSAg

were done


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Laboratory Results

Patient

VDRL Nonreactive

RPR Nonreactive

HBsAg Nonreactive

Blood Type B positive


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CBC withPC September20,2011

WBC

10Neutrophils 78.6

Lymphocytes 14.3

Monocytes 7.1

Eosinophils

Basophils

RBC 3.85

HGB 10.9

HCT 32

MCV

79MCH 24.2

MCHC 30.6

RDW 16.3

Platelet 340


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URINALYSIS September20,2011

Color Yellow

Transparency Hazy

Epithelial Cell Few

MucusThread Rare

AmorphousUrates Rare

Pus Cells 4-8

Erythrocytes 0-2

Albumin Negative

Sugar Negative

S

pecificG

ravity 1.010pH 6.0

Bacteria


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BPS withBiometry

(November 11, 2011)Single, alive, intrauterine pregnancy, cephalic presentation,

33 4/7 weeks AOG by BPD and 344/7 weeks AOG by FL.

Placenta posterior, high-lying, grade 2-3.

Adequate amniotic fluid.

Sonographic estimated fetal weight is appropriate for

gestational age.

Biophysical profile score is 8/8.


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FewHours

PT

A

4th PNCU at OMMC OB-OPD

With good fetal movement

No bloody show

No watery discharge

No headache

No dizziness

BP was 160/90 and patient was brought to ER for

further management


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Past MedicalHistory

(-) previous hospitalization

(-) BA

(-) HPN

(-) DM


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Family MedicalHistory

Hypertension father

(-) BA

(-) DM

(-) allergy to food and medications


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Personal and SocialHistory

Nonsmoker

Non-alcoholic beverage drinker


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Reviewof Systems General: No fever, weight loss and loss of appetite

Skin: No jaundice, no pallor, no cyanosis

HEENT: No headache, no blurring of vision, no pain and

redness of the eyes, no tinnitus, no lymphadenopathies

Respiratory: No colds, cough and dyspnea

CardiovascularCardiovascular:: NoNo palpitations,palpitations, nono paroxysmalparoxysmal

nocturnalnocturnal dyspneadyspnea andand nono chestchest painpain


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Reviewof Systems GastrointestinalGastrointestinal:: NoNo abdominalabdominal pain,pain, nono changechange inin

bowelbowel movement,movement, nono nausea,nausea, nono vomiting,vomiting, nono

melenamelena..

RenalRenal:: NoNo dysuriadysuria,, nono hematuriahematuria,, nono frequency,frequency, nonoincontinenceincontinence

MusculoskeletalMusculoskeletal:: NoNo paralysis,paralysis, NoNo numbnessnumbness

NeurologicNeurologic:: NoNo lossloss of of consciousness,consciousness, NoNo

convulsionsconvulsions


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SexualHistory

Age of 1st coitus: 21

Sexual partner/s: 2

(+) OCP used for 6 years - Ergestrol

(-) IUD (-) Dyspareunia

(-) PCB

(-) STI


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PhysicalExamination

General Awake, conscious, not in respiratory

distressVital Signs 150/90 82 23 37.5

HEENT AS, PPC, (-) NAD, (-) TPC, (-) CLAD

Chest and Lungs SCE, (-) retractions, clear breath sounds

Heart AP NRRR (-) murmurs

Abdomen Globular, nontender

FH: 30 cm EFW (2.8-3.0kg)

FHT: 140s

Extremities Grossly normal, (-)edema,

(-) cyanosis

IE 1 cm, BE, cephalic, (+) BOW, floating


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URINE ALBUMIN: TRACE


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Admitting Diagnosis

G4P3 (3003) Pregnancy Uterine 36 - 37

weeks AOG by LMP, Cephalic in Beginning

Labor

Gestational Hypertension


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Course in the ER

NPO

IVF: D5LR x 8 hours

For Assisted Vaginal DeliveryDiagnostics:

CBC with PC

Urinalysis Blood Typing

SGOT, SGPT, BUN, Crea, BUA, LDH


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Course in the ER

Medication:

Hydralazine 5 mg TIV for BPu160/100

W

OF: persistent BP elevation, signs ofeclampsia, difficulty of breathing

Monitor progress of labor

Monitor VS q1 and FHT q1


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CBC withPC

WBC 12.1

Neutrophils 76.9

Lymphocytes 15.3

Monocytes 7.8

Eosinophils

Basophils

RBC 3.91

HGB 10.7

HCT 30.4

MCV 77.9

MCH 24.9MCHC 32

RDW 16.3

Platelet 325


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Urinalysis

Color Yellow

Transparency Slightly turbid

Epithelial Cell Moderate

MucusThread Few

AmorphousUrates Many

PusCells 0-2

Erythrocytes 0-1

Albumin Trace

Sugar

Specific Gravity

pH

Bacteria


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LaboratoryResults

Patient Normal Values

BUN 14.05 7-18

Creatinine 0.8 0.6-1.1

Uric Acid - -

AST 9.3 0-38

ALT 23.56 0-40

LDH 165.2 103-227


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Course in the DR

BP = 140/70, HR = 86, RR = 20, FHT = 156

Maintained on NPO

IVF: D5LR 1 L x 8 hours

Meds: HNBB TIV q4

Hydralazine 5 mg TIV prn BP > 160/100

1 cerviprime gel given

WOF: fetomaternal distress, BP elevation

Monitor Progress of labor Monitor Vital signs q1 and FHT q 15mins


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10th HourofLabor

Patient delivered via normal spontaneous delivery with

perineal support to live baby boy, AS 9,9

Placenta out completed

IVF: D5LR + 30 u oxytocin x 8 hours IVF to follow: D5LR 20 u oxytocin x 8 hours, then to

consume

To start on low salt and low fat diet


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Final Diagnosis

G4P4(4004) Pregnancy Uterine Delivered

Spontaneously to a Term Cephalic Livebirth

Baby Boy with AS 9,9, BW 2.9 kg, BL 50

cm, PA 37 weeks

Gestational Hypertension


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Course in theWards

1st Postpartum Day Vital Signs: BP 130/90 (BP range 120-130/80-90)

HR 89 RR 21 Temp 36.8

Low salt low fat diet

Medications:

Co-Amoxiclav 625 mg/cap TID x 7 days

Multivitamins 1 tab OD

Ferrous sulfate 1 tab OD

Metoprolol 50 mg/tab 1 tab BID Clonidine 75 mcg/tab 1 tab SL prn BPu160/100

Mefenamic Acid 500 mg/tab 1 tab q6 prn pain on full stomach


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SGPT, SGOT, BUN, Crea and LDH done normal results

WOF: BP elevation, signs of eclampsia

May go home once with control BP range


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Course in theWards

On 3rd postpartum day, patient was sent home with

controlled BP range of 120-130/80-90

No subjective complaints


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Documents

Case of Preeclampsia Severe Final3