Main Complaint
My patient Madam Siti a 31 year old Indonesian maid Gravida 3 para 2 at 38 weeks and 1day of Period of Amenorrhoea (POA) was admitted to the ward for blood pressure stabilization and induction of labour (IOL).
History of Presenting Illness
She was referred from antenatal clinic during follow up in PPUKM on 29/11/2010. During the check up at the follow up, her vital sign showed she was afebrile, pulse rate of 90beats per minute and blood pressure was noted to be 160/100mmHg and no abnormality was found in the urine.
During booking her blood pressure was noted to be 100/70mmHg and she was normotensive throughout the pregnancy up until at 38weeks and 1day of POA.
She complained to have frontal headache and nausea 2 days prior to admission. She denied symptoms of impending eclampsia such as blurring of vision, epigastric pain and vomiting. There was also no dizziness, shortness of breath, chest pain, reduced urine frequency and leg swelling. She also had per vaginal discharge which was whitish and creamy in nature, no foul smelling and no pruritus vulvae. There was no urinary tract infection symptoms such as urgency and dysuria.
Fetal movement was good.
She was admitted to the ward for further management.
Antenatal History
This is an unplanned but wanted pregnancy. Her urine pregnancy test (UPT) was positive at 6weeks of POA. Dating scan done at 15weeks of POA which correspond to date. Booking was done at 15weeks of POA at private clinic at Medviron.
Antenatal screening done showed that:
Blood Pressure : 110/70mmHg
Haemoglobin level : 12.8g/dL
Height : 158cm
Weight : Pre : 62kg Current : 69kg
Blood Group : O Positive
VDRL/HIV/HEP B : Non Reactive
Urine Albumin/Sugar : Nil
No MGTT was done. Despite having a family history of diabetes mellitus.
Latest scan done at 38 weeks and 1day POA and all parameters are correspond to date. It was a singleton fetus on longitudinal lie and cephalic presentation. Fetal heart and fetal movement are seen. Amniotic Fluid Index are 11. Estimated fetal weight was 3.3kg and placenta was on anterior upper segment.
Otherwise, antenatal visits are uneventful.
Past Obstetric History
On 1999, she had a full term normal pregnancy and delivered a baby girl by Spontaneous Vaginal Delivery (SVD) at a hospital in Indonesia and weight of the baby was 2.6kg and is alive and well.
On 2007, she also had a full term normal pregnancy and delivered a baby boy by spontaneous vaginal delivery also at Indonesia. The baby weight 2.3kg and currently is alive and well.
Both of her children stays with her mother at Indonesia.
Past Gynaecology History
She attained her menarche at the age of 13year old with 28 to 30days regular cycle with 7days of menses. She denied dysmenorrhoea, menorrhagia, intermenstrual bleeding, dyspareunia and postcoital bleeding.
As for contraception, she uses Implanon for 4years from 2002 to 2006 between the first and the second pregnancy. She was then on Oral Contraceptive Pills for 2months and had stop taking them afterward until today. After this pregnancy, she is keen to take Intrauterine Contraceptive Device (IUCD).
She had never had pap smear done before.
Past Medical History
Nil.
Past Surgical History
Nil.
Allergy and Drug History
No known drug allergy or food allergy.
Family History
Her mother is alive and was diagnosed to have diabetes mellitus and hypertension and currently on medication. Her father died on 2007 due to renal failure.
She had 3siblings and currently all of them are alive and well.
Social History
She has been married for 12years and came to Malaysia on 2006 which was 4years ago.
She lives in a terrace house at Cheras and worked as a maid.
Her husband came to Malaysia 5years ago but had recently go back to Indonesia 2months ago. He previously worked as a contractor for the same employer. He planned to return to Malaysia after his permit is renewed.
Both of them does not smoke or consumed alcohol.
Both of their children were in Indonesia and are taken care by her mother.
Relevant Clinical Examination
General
On examination, she was alert, conscious and she was not pale or jaundiced. Her Blood Pressure was 142/92mmHg lying and 152/104mmHg standing. Her pulse rate was 90beats per minute and respiratory rate was 20breath per minute. She was afebrile. Her current weight was 69kg. There was no pedal oedema noted.
Thyroid Gland
There was no scar, lump or dilated veins noted around the area of the neck. There was no lymphadenopathy noted.
Breast
On inspection, both breast were symmetrical and bilaterally in size. Both her nipple were not hyperpigmented or retracted. There was no nipple discharge. Her breast were non tender and no mass was palpable.
Cardiovascular System
On inspection of the hand, there was no clubbing and peripheral cyanosis. Inspection of the mouth showed that there was no central cyanosis and hydration status was good. There was no surgical scar and no notable abnormalities detected on the praecordium. Jugular Venous Pressure was not raised. Peripheral pulses were present with normal rhythm and good volume. There was no radio-radial delay or radio femoral delay. There was no collapsing pulse.
On palpation, apex beat was not displaced it was palpable at the 5th intercostals space and left midclavicular line. There was no parasternal heave and thrills detected.
On auscultation, the first and second heart sounds were heard with no murmur or added sound heard.
Respiratory System
On inspection, the chest moved bilateral symmetrically with inspiration. There was no scars and deformities noted. She did not use accessory muscles on breathing.
On palpation, her trachea was not deviated. Chest expansion was equal bilaterally. Air entry was good and equal bilaterally as evidenced by normal vocal fremitus and vocal resonance.
Percussion of both lungs were resonant.
There were vesical breath sounds equal on both sides with no added sounds on auscultation.
Neurological System
She was orientated to time, place, and person. All cranial nerves were intact. Both her upper and lower limbs were normal. Muscle tones, power, and reflexes were all good and normal.
Abdominal Examination
On inspection, the abdomen was distended by gravid uterus as evidenced by cutaneous signs of pregnancy such as linea nigra and striae gravidarum. The umbilicus is centrally located and flat. No scars noted and no dilated veins seen.
On palpation, her abdomen was soft and non tender and uterus was not irritable. Clinical fundal height revealed that the uterus was 38weeks in size and was correspond to date. Symphysiofundal height was 37cm.
Palpation of the fetus showed that it was a singleton in longitudinal lie with cephalic presentation. The head was 3/5 palpable and not engaged. The fetal back was on the maternal left side. The liquor was adequate and estimated fetal weight was 3.2 to 3.4kg.
Pelvic Examination
Vaginal examination was not done.
Per Rectal Examination
Per rectal examination was not done.
Summary of Case
31year old maid gravida3 para2 at 38weeks and 1day POA admitted for blood pressure stabilization and induction of labour (IOL) due to gestational hypertention.
Diagnosis and Differential Diagnosis
Provisional Diagnosis
Gestational Hypertension:
She develop hypertension which is a blood pressure of 140/90mmHg aand above recorded on 2 separate occasions at least 4hours apart.
Hypertension occur in second half of pregnancy which is after 20weeks of gestation.
She is previously normotensive.
There is absence of proteinuria
She had risk factor; family history of hypertension.
Differential Diagnosis
Pre-eclampsia:
Points for:
Hypertension at least 140/90mmHg recorded on 2 separate occasions at least 4hours apart.
Hypertension occur at second half of pregnancy, after 20weeks gestation.
She is previously normotensive.
She had risk factor; family history of hypertension.
Points against:
There was absence of proteinuria of at least 300mg Protein in a 24hour collection of urine.
She had no risk factor such as pre-existing hypertension or pre-eclampsia.
Chronic Hypertension:
Points for:
She has a family history of hypertension.
Points against:
She is normotensive prior to pregnancy.
She had no other disease such as renal or connective tissue disorders that can lead to hypertension.
Relevant Investigations with Reasons
Full Blood Count
To check whether patient is anaemic or not (Hb).
To confirm patient is not on any infection such as urinary tract infection (WBC).
White Cell Count + 14.2 x 109/L
Red Cell Count 4.18 x 1012/L
Haemoglobin 12.3 g/dL
MCV 37.1%
MCH 88.7 Fl
MCHC 29.3 Pg
RDW 33.0 g/dL
Mean Platelet Volume 8.0 Fl
Platelet 302 x 109 /L
Neutrophils ++ 10.3 x 109 /L
Eosinophils 0.4 x 109 /L
Basophils 0.0 x 109 /L
Lymphocytes 2.6 x 109 /L
Monocytes 0.9 x 109 /L
Nucleated RBC 0 x 109 /L
Comment:
There is a reduction of Red Cell count. This is due to pregnancy, as there is haemodilutional effect due to an increase in plasma volume. Patient is not anaemic as haemoglobin is on the normal range. However, there is leukocytosis mainly the neutrophils. This suggest an infection most likely bacterial in origin such as urinary tract infection.
Renal profle
To exclude secondary cause of hypertension due to renal damage.
To detect abnormality in the level of serum urea and creatinine that will indicate renal damage or failure.
Sodium 139 mmol/L
Potassium 4.0 mmol/L
Urea 2.3 mmol/L
Creatinine 54 umol/L
Comment:
There is hypouremia. This is normal in pregnancy, as there will be an increase in Glomerular Filtration Rate (GFR), therefore there will an increase in clearence of urea in the body. Besides that, a reduction in deamination process in the maternal body will also cause blood urea to be reduce.
Liver Function Test
To see whether patient had any liver damage
Albumin 33 g/L
Total Protein 68g/L
Bilirubin toral 6 umol/L
ALT 19 u/L
ALP + 141 u/L
Comment:
There is hypoalbuminaemia. There is increase level of Alkaline Phosphatase (ALP) due to placenta production. Thus, making it a normal physiological reaction.
Serum Uric Acid
Serum uric acid is a sensitive indicator of renal damage in pre-eclampsia.
Uric Acid 371 umol/L
Comment:
Serum uric acid level is normal. Suggesting there is no renal damage.
PE/ Pre-eclampsia Chart
To monitor her blood pressure on lying and standing
To monitor her urine whether there is albuminuria or not.
To detect pre-eclampsia.
Result:
Other than the increase in blood pressure prior to delivery, there is no albuminuria noted. Therefore, patient did not have pre-eclampsia.
Fetal Kick Chart
To monitor the fetal well being. If there is decreased fetal activity, it may indicate some degree of fetal compromise.
Cardiotocography (CTG)
To monitor the heart rate and contraction of the uterus to detect abnormalities in the pregnancy.
Ultrasound.
To assess the fetal growth.
Identify The Problem in Terms of Priority
Gestational Hypertension.
Induction of labour in gestational hypertension.
Immediate and Subsequent Management
Admit to ward for BP monitoring and stabilization.
Monitor for any signs and symptoms of impending eclampsia.
Bed rest.
BP monitoring 2hourly for 24hours. If blood pressure reduce or return to normal patient can be discharge and to come again for antenatal follow up. Bed rest continued if persistent.
Antihypertensive medication given if BP consistently noted to be 150/100mmHg. Preferred agent are alpha and beta blockers agent such as labetolol or methyldopa.
Pre-eclampsia chart to exclude pre-eclampsia.
CTG and fetal kick chart monitoring.
Gestational hypertension not resolve, induction of labour is recommended.
If induction of labour fails or spontaneous delivery is not possible, prepare for lower segment caesarean section (LSCS).
Final Conclusion/ Plan for Further Management/ Patient Progress
On admission on 29 November 2010, her blood pressure (BP) was high which was 142/92mmHg lying and 152/104mmHg standing. She was then given 200mg labetolol TDS. Pre-eclampsia chart done to monitor albumin in the urine. She is also monitored on signs and symptoms of impending eclampsia. Her BP was monitored half hourly for 2hour and induction of labour (IOL) is done soon after BP is stabilize.
On the next day , 7.15am, Bishops Score was done and result was 2/13. Therefore cervix was not favourable. First 3mg of Prostin tablet was inserted into the posterior fornix. CTG was then done after 1hour to monitor for uterine hyperstimulation of fetal distress. The abdomen and cervix will be reassess in 6hours time. Tablet labetolol was continued and signs and symptoms of impending eclampsia (IE) was monitored.
Six hour later, patient had contraction (irregular) but no leaking liquor noted. There was no signs and symptoms of IE, per vaginal discharge and fetal movement was good. Her BP was 129/92mmHg which had decreased slightly. On palpation, her abdomen was soft and non tender. Uterus was 38weeks, presenting part was 3/5 palpable. Bishops Score was done again and cervix is still unfavourable at 3/13. Second prostin was inserted at the posterior fornix. CTG was done 1hour post prostin for monitoring.
Six hour later, she had 2 contraction in 10 minutes and it was moderate. There was no leaking, no per vaginal bleeding and the fetal movement was good. Her BP on lying was 112/86mmHg and 122/90mmHg on standing, well controlled BP. Vaginal examination revealed normal vulvovaginal, cervix dilated to 1cm, os was 3cm membrane intact and station was -2.
2hour later, the contraction was 3 in 10minutes and no leaking liquor. Vaginal examination showed 1cm cervix, 4cm os. Artificial Rupture of Membrane (ARM) was done. Clear liquor was noted. Patient was in active phase of labour and was sent to the labour room for delivery.
Entonox was given for pain management in the labour room. Contraction was 3 in 10 minutes with moderate intensity and os was 4cm. one and a half hour later, patient complained of having strong contraction and felt the urge to bear down. Vaginal examination done and os was fully dilated at 10cm.
She delivered a baby boy weighing 2.53kg with apgar score of 8 in 1minute and 9 in 5minutes. The patient developed first degree tear, placenta was complete weighing 590gm. Estimated blood loss is 250cc. Cord pH was 7.312.
In the ward, day 1 post SVD she was alert, conscious, comfortable and was not pale. Her BP was 118/83mmHg which was normal and her pulse rate was 96beats per minute. She was afebrile. Abdominal examination showed that her abdomen soft and non tender. The uterus was well contracted at 18weeks in size. The lochia was normal. Breastfeeding was established and she was ambulating well. The patient can tolerate orally and had pass urine and bowel movement.
She had completed her family size and plans to use intrauterine contraceptive device (IUCD) for contraception.
Prescription of labetolol was stopped as her BP has been stable and she had delivered her baby. She was then allowed for discharge and to come again 2weeks later to review her BP. She was given hematinics to increase haemoglobin level.
Discharge Summary
Name : Siti Arifah Age : 31
MRN : N285492 Race : Indonesian
Gender : Female Discharge Date: 01/12/2010
Case Summary
Date of admission : 29/11/2010
Date of delivery : 30/11.2010 at 22:35
Date of Discharge ; 01/12/2010
