Identification:

Gandi Memorial Hospitall

Name:

Kulye Humessa

Age: 22
Sex: F
Marital status: Married
Address: Burayu, Oromia
Occupation : High school teacher
Religion: Christian Protestant
Date of clerking: 30/12/04EC
Date of admission: 28/0912/04 EC
Ward: Obstetrics maternity
Hospital no 25/4

Previous admission
No history of previous admission

Chief complaint:
Referred from St Paul hospital in assessment of severe preeclampsia

HPP:
This is a 22 year old primigravida lady whose LNMP was on 19/05/04EC(Tir 19)
making the EDD 24/02/05(reliable) and the gestational age 31 weeks +4 day. The
menstrual cycle was regular and she had not used any contraceptives.
She knew she was pregnant after she missed two consecutive menses. She went to
a health center for her first ANC on the 14 th week of gestation. Diagnosis of
pregnancy was confirmed by urine test at the first ANC. General physical
examination, blood tests, ultrasound and urinalysis were done. She was told that
the pregnancy is smooth and she is in a good state then she went again for checkup
at 24th week she was given TT vaccination and appointed to come after a month and
was told she was fine. After a month she went to the health center for the second
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vaccination and was told her Bp has risen dangerously and referred to St paul
hospital for further investigation and treatment. She was given TT vaccination.
At St paul, general physical examination and ultrasound were done. BP was
170/110 mmHg. Lab was requested and the results were Hgb 12 g/dl. Blood group
and Rh (B+), FBS (108 mg/dl), VDRL (non-reactive), HBsAg (-ve), PICT (NR), U/A
(380mg/day protein in urine). She was told she should have follow up because of
the raised blood pressure but there were no other complications. At this, she
referred to Gandi memorial hospital for further treatment. She is on magnesium
sulphate, methyldopa and dexamethasone.
Quickening first occurred on 25/09/04. It was kicking in type. Fetal kicking
movements have not decreased during the rest of the pregnancy. She had no loss in
appetite. She had 5 meals per day consisting of injera, meat, vegetables and fruit.
She claims weight gain but could not tell specifically by number.
Apart from the elevated blood pressure there were no significant events in the 1 st,
2nd, 3rd trimester.
She had a swelling on the both feet, on legs and on her face
She has no history vaginal bleeding, discharge or fever.
She has no history of headache, vision disturbances, Leakage of liquor
She has no history of epigastric pain, Pushing down pain or yellowish discoloration
of skin and eye.
She has no history of abnormal body movement or loss of consciousness.
She has no history of decreased urine output
She has no history of cough, shortness of breath or bluish discoloration of skin.
She has no history of diabetes mellitus.
She has no history of hypertension before the pregnancy

The pregnancy was planned, wanted and supported.

Past Obstetric history

No obstetrics performance

Gynecologic History:
The lady never took contraceptives. She has no history of sexually transmitted
diseases. She is sexually active, 3 times per week and she is monogamous. The lady
has had no abortions. She has no history of gynecologic operations. She has no
history of circumcision.

Menstrual history:
She had menarche at 14th year. Her menses were regular and spaced 4 weeks
apart . The duration of flow is 4 to 5 days. She uses 2 pads per day. The flow is dark
and non-clotting. She feels mild discomfort associated with her menstrual flow.

Past medical and Surgical history:

She has no history of medical disorders like DM, or hypertension before the
pregnancy. She has had no previous transfusions. She has not experienced
hypersensitivity to drugs. She has no history of infection with STD during
pregnancy.

Family/Personal history:
She was born in Burayu and was raised in there until she joined college . She has 4
older brothers and they are all healthy. She has 3 sister all of them are healthy and
active; 2 of her sisters gave birth to a child their course of pregnancy was safe there
was no complication . Her mother and father are alive and currently healthy. She is
educated up to the level of 12th grade plus college (BSc on language and
communication) . She has no habit of smoking, alcohol intake or illicit drug use. She
is a high school teacher her monthly income is 1600br. Her husband also is a high
school teacher his monthly income is 1800br. She lives with her husband in a four
room house. There is a separate kitchen and toilet and clean water supply. They
have no car. There is no family history of hypertension, diabetes mellitus,
tuberculosis, allergies or mental disorders.no history of twinning.

Review of systems:
H.E.E.N.T
Head: no headache, no head injury, no dizziness
Ears: no impaired hearing or discharge, no ringing in the ears
Eyes: no discharge, no redness, no blurred vision
Nose: no discharge, no stuffy nose, no runny nose, no sneezing
Mouth: no dental caries, no bleeding gums, no artificial dentures
Throat: no sore throat, no difficulty in swallowing, no hoarseness of voice
L/G: no mass in the neck, axillae, or groins. There is breast enlargement and
tenderness associated with the pregnancy. No discharge from the nipples. No heat
or cold intolerance
Respiratory: no cough, no expectoration, no chest pain, no wheezing, no cyanosis,
no night sweats
Cardiovascular: occasional palpitations, no shortness of breath, PND or orthopnea,
no chest pain, fatigue

Gastrointestinal: one episode of nausea and vomiting in 1 st trimester, no diarrhea,

no constipation, no abdominal pain or heart burn, no change in stool color.
Genitourinary: unquantifiable increased frequency, no dysuria, no urgency, no
hesitancy, no dribbling, no reddish discoloration of urine.
Integumentary: no rash, moist skin, no discoloration, no hair changes,
hyperpigmentation on abdomen along the midline from the umbilicus downwards.
Locomotor system: no history of pain, weakness or swelling of the joints,
Central nervous system: no history of numbness, no paralysis, urine incontinence,
seizures or speech defect

Physical examination
General Appearance
She is healthy looking. The abdomen is grossly distended but she is not in cardio-respiratory distress. She
was lying on a bed in a left lateral position. She seems happy about the pregnancy. She was cooperative
during history taking.

Vital Signs:

Blood pressure (BP): 140/90 mm Hg, (right arm, sitting position) => Raised
Pulse (P): 108 beats / min (left radial, regular with full volume). =>Normal (for pregnancy)
Respiratory rate (RR): 24/BPM. => Normal (for pregnancy)
Temperature (T): 35.80C (axillary) on the afternoon. => Normal
Weight: 58Kg
Height: 158 centimeters
BMI: 23.23
H.E.E.N.T

Head: Proportionate size and shape. No scar, Normal hair distribution.

Ears: Normal contour of pinnae. Clear external ear canal. She responds/turns her face towards the source
of loud sound.
Eyes: Normal eyebrows. No per-orbital edema, ptosis, exophthalmoses or strabismus. She has no
excessive lacrimation. The conjunctivae are pink. The sclerae are not icteric. The pupils are equal
in size.
Nose: The nasal septum is not deviated. There is no polyp or unusual discharge.

Mouth and throat The breath has no bad odour (halitosis). The lips show no fissure, ulceration or herpes.
The gums are intact and clean, there is no teeth loss. The tongue and buccal mucosa are wet. The
tonsils are intact.

Lymphatic and glandular system

There are no significantly enlarged lymph nodes in all accessible areas. The thyroid gland is also not
enlarged. There is no tremor or lid lag. There is no palpable lump in both breasts.
Respiratory System:
Inspection: There is no cyanosis or clubbing of the fingers. Breathing is shallow and rapid. There is no
use of respiratory accessory muscles.
Palpation: The trachea is central. The total circumferential chest expansion is not done because the
patient was not comfortable.
Tactile fremitus is symmetrically equal.
Percussion: The chest is resonant. Diaphragmatic excursion is not assessed because the patient was not
comfortable.
Auscultation: Breath sounds are vesicular on most part of the chest. Has good air entry bilaterally. No
added sound is appreciated.
Cardiovascular system:
Arteries: BP and pulse (see under vital signs). The pulse volume is normal, the rhythm is regular and
there was no abnormal character or unusual condition of vessel wall. Pulse volume can be tabulated as
follow:

Right
Left

Carotid
+++
+++

Brachial
++
++

Radial
++
++

Femoral
+++
+++

Popliteal
0
0

DP
+
+

PT
+
+
5

Veins: The jugular venous pressure observed at an inclination of 45 0 is not abnormally raised above the
angle of Louis and there is no hepatojugular reflux. There are no distended veins over the neck, chest
wall, no phlebitis in the legs.

Precordium (heart):
Inspection: There is no abnormality in shape (no precordial bulge). The precordium is Quiet. The apical
impulse is visible in the left sixth inter space, along the left midclavicular line (8.0 cm lateral from midsternum).
Palpation: The point of maximum impulse is felt where it is visible. It is localized. There is a no
parasternal or apical heave. There is also no thrill anywhere.
Auscultation: Both heart sounds are normal in intensity over each valvular area. P2 is not accentuated.
There is an S3 gallop heard over the mitral area, no opening snap, ejection click or pericardial Knock.
There is also no murmur.
Gastrointestinal system
Inspection: The abdomen is grossly distended, centrally bulged but moves with respiration. There are not
flank fullness, dilated veins, scares or masses. Both linea nigra and striagravidarum are present. The
umbilicus is everted. Hernial sites are free.
Auscultation: The bowel sound is normoactive. There is no bruit over renal artery, femoral arteries,
abdominal aorta or liver areas. No friction rub over the liver & spleen areas.
Palpation:
Superficial palpation: There was no muscle spasm, or superficially palpable mass. There was
also no tenderness upon such palpation (no change in facial expression).
Deep palpation: There was no tenderness (no change in facial expression). The liver was not
palpable below the right costal margin. The spleen was also not palpable.
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Percussion: No signs of abdominal fluid collection (shifting dullness or fluid thrill). No flanks or supra
pubic dullness. The total vertical span of the liver along the right midclavicular line was difficult to
assess.

Obstetric Palpation
1st Fundal palpation
A. Fundal height measurement:
a. Finger method: The fundus is 7 fingers above the level of the umbilicus:- 34weeks
b. Tape measurement: The fundus is 35 centimeters above the symphysis pubis:
35weeks
B. Fundal content: A soft bulky irregular non-ballotable mass is palpated:- breech
2nd lateral palpation: The longitudinal axis of the uterus aligns parallel to the longitudinal axis of the
mother. Back is felt on the right side
3rd pelvic palpation: fetal head is palpable with cephalic prominence felt and anterior shoulders, 5
fingers above the symphysis pubis. The attitude was difficult to assess.
Fetal heart rate 130/minute
Genitourinary system:
There is no costo-vertebral angle tenderness (no change on facial expression) or mass. The kidneys are
not palpable.
Pelvic examination Was not done, except inspection of External genitallia:
-shape of pubic hair: Inverted triangle
-Bartholins gland:not visible
-Labia majora and minora: no discharge ulcers, swelling, or mass
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-Urethral Orifice: no inflammation

-Perineum : smooth and unbroken, no scars, swelling or external hemorrhoid
Central Nervous System

Integumentary system:
The skin is dry and warm. There is no rash, scar or ulcer. Normal hair distribution. There is no abnormal
nail change.
Locomotors system:
There is no muscle or bone tenderness (no change on facial expression) or spasm. There is no gibbus or
tenderness on percussion of the spine. The joints are normal and there is no bony deformity. There is mild
pedal,ankle and pretibial edema.
Nervous system:
Mental Status: The patient is conscious and oriented in person, place and time. She has good immediate,
short term and long term memory.
Cranial Nerves:
N-I: Smells alcohol via each nostril.
N-II: Normal Visual acuity, good visual fields and color appreciation.
N-III, IV & VI: The eyes can move in all directions. There is no nystagmus. The pupils are round and
regular in outline. They react to light directly and consensually and accommodate normally.
N-V: Pain, sensation is intact over the face (she responds by withdrawal). She also responds for light
touch, mildly warm and cold temperature. Contraction of the temporal and masseter muscles is forceful
and visible.
N-VII: The face is symmetrical both at rest and during application of painful stimuli. Otherwise, she can
close both eyes equally and forcefully.

N-VIII: She hears the ticking of a watch bilaterally

N-IX & X: The soft palate rises in the midline when saying ah! The gag reflex is intact and there is no
dysphonia or dysphagia.
N-XI: The sternocleidomastoid and trapezius muscles contract on turning the head against resistance and
on shrugging the shoulders against resistance, respectively.
N-XII: The tongue protrudes in the midline and shows no tremor or atrophy
Motor Function:
Muscle bulk: There is no muscle bulk difference. There is also no spontaneous as well as induced
fasciculation.
Muscle tone & power:

Right

Tone
Upper
Normotonic

Lower
Normotonic

Left

Normotonic

Normotonic

Muscle power
Upper
Five(she can
levitate arm upon
application of full
resisting force)
Five(she can
levitate arm upon
application of full
resisting force)

Lower
Five(she can
levitate leg upon
application of full
resisting force)
Five(she can
levitate leg upon
application of full
resisting force)

Reflexes:
Superficial reflexes: All the plantar, abdominal, & corneal reflexes are intact.
Deep tendon reflexes:

Right
Left

Biceps
++
++

Triceps
++
++

Supinators
++
++

Patellar
++
++

Ankle
++
++

Clonus: No clonus
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Coordination: Cerebellar Finger- to nose or finger-to finger and hell-to-shin tests, supination &
pronation of the forearms and the presence or absence of cerebellar ataxia are not assessed because she is
aphasic.
Sensory: Light touch, pain and temperature sensations are intact. Deep pressure, position sense, vibration
and passive movements are well appreciated by the patient. There is no ataxic gait or Rombergs sign.
Normal recognition of form, size and shape of coin as well as two-point discrimination.
Meningeal signs: Are negative

Summary
1 subjective This is a 22 years old primigravida lady referred from St paul hospital
with assessment of severe preeclampsia who she has a regular ANC follow up.
Gestational age of 31(7month) duration. No personal or family history of chronic
medical diseases. No past gynecologic surgery
2 objective a 22 years old pregnant lady with Bp of 140/90, RR of 24/min, PR of
108beat/min and BMI of 23.23. 34weeks gravid uterus with a longitudinal lie,
breech occupying the fundus and floating head. FHR:140/Min. Also has mild lower
extremity edema. . Reassuring fetal condition.(was with her while she went for
ultrasound check up)

Investigation
Peripheral blood smear
CBC, Hgb ,Hct
LFT & RFT
Urinalysis
(obstetric)Abdomino pelvic ultrasound
BPP
MRI

Assessment:
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Severe preeclampsia
Primigravida (nulliparity)
Pre Term

Risk Assessment
This is a high risk pregnancy because of Preeclampsia and currently all
pregnancies are at high risk.

Discussion
Hypertension is a sustained blood pressure higher than 140/90mmHg measured on
two consecutive occasions 6hrs or more apart or >160/110mmHg on single
measurement . Hypertensive disorder complicate 5-10%(from protocol) of all
pregnancy. Although its etiology patho-physiology remains unknown its been said
toxins(chemicals) released from placenta is responsible. Preeclampsia occurs only
in pregnancy. Preeclampsia is characterized by the onset of hypertension and
proteinuria that occurs after 20weeks of gestation. Risk factors for preeclampsia
age <20 and >35years old, nulliparity , multiple gestation, Dm, family history of
preeclampsia, chronic hypertension, renal diseases, previous preeclampsia, collagen
vascular disease..

Symptoms
Epigastric and Right upper quadrant pain
Generalized body swelling and sudden unexplainable weight gain >12.5kg
Persistent headache
Blurring of vision
Decreased fetal movement
Decreased in urine out put
If complicated convulsion or loss of consciousness and vaginal bleeding

Sign
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Generalized edema
Raised blood pressure
Proteinuria
Decreased urine out put

Sign of severity of preeclampsia

1 Bp >160/110
2 proteiuria >5gm/24hrs
3 oliguria<500ml/24hr
4 Deranged RFT and LFT
5 Thrombocytopenia
6 Pulmonary edema
7 DIC/HEELP syndrome
8 Eclampsia
9 IUGR: absence of the above severity signs put the pregnant lady in to mild
preeclampsia.

Final impression
The patient has no impressive sign or symptoms except the rise in Bp and
proteinuria.
Mild preeclampsia

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