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Case

Presentation
PRE ECLAMSIA
Objectives
• To discuss a case of preeclampsia
• To know the etiology and risk factors of preeclampsia
• To discuss the management plan for preeclampsia
General data

• J.P
• 30 years old
• Gravida 2 Para 1(1001)
• Date of admitted : June 29, 2018
• Date of discharged :July 2 , 2018
Chief Complaint

 Labor Pains
History of Present Pregnancy
• LMP: October 5, 2017
• AOG: 38 1/7 weeks AOG by LMP
• PMP: September 7, 2017
• EDC: July 12, 2018
History of Present
Pregnancy
1st Trimester:
(+) Missed of menses on November 8, 2017
(+) Pregnancy test done on November 8, 2017 (4 6/7 weeks
AOG)
(+) Prenatal check up in health center on Nov 23 2017 (7
weeks AOG by LMP)
Labs: CBC, Urinalysis – no official results
(+) Chronic hypertension
(+) Methyldopa 250 mg BID, Folic acid and multivitamin and
Calcium
(-) Exposure to teratogens and radiation.
TVS November 23, 2017
(approximately 7 weeks AOG)

Intrauterine pregnancy compatible with 6 4/7 weeks


with good cardiac activity, adnexae unremarkable,
cervix is closed
2nd Trimester:
(+) Quickening on 2nd week of February 2018 (approx 18 weeks AOG )
(+) continue PNCU at health center
(-) UTZ, Labs
 (+) Continue Methyldopa BID, Ferrous sulfate and multivitamin, Calcium
once a day
 (-) exposure to teratogens and radiation
3rd Trimester:
(+) 1st PNCU in our institution (35 weeks AOG)
Labs- CBC, UA, HbsAg, VDRL, 75 g OGTT were within normal limits
(+) Placental doppler UTZ
(+)Continue Methyldopa BID, Ferrous sulfate and multivitamin,
calcium once a day
(-) exposure to teratogens and radiation
Complete Blood Count (June 11, 2018)

Level
Normal levels
10.1
WBC 5.00 – 10.00 10^9/L
0.72
Neutrophil 0.40 – 0.60
0.16
Lymphocytes 0.20 – 0.40
102
Hemoglobin 123.00 – 152.00 g/L
0.33
Hematocrit 0.37 – 0.42
3.8
RBC 4.50 – 5.50 10^12/L
151
Platelet 150.00 – 450.00 10^9/L
Urinalysis (June 11, 2018)
RBC 0-2/hpf

PUS CELLS 0-2/hpf

BACTERIA Few

EPITHELIAL CELLS +1

PROTEIN Negative

GLUCOSE Negative
Labs (June 11, 2018)

VDRL HbsAg
Nonreactive Negative
Placental doppler UTZ (June 14, 2018, approximately 36 weeks)

• Pregnancy uterine 33 weeks and 1 day by fetal biometry


• Live singleton in cephalic presentation
• Adequate amniotic fluid volume
• Placenta anterofundal, grade II, high lying
• Placental doppler revealed no sonological finding of
placenta accreta
History of Present
illness
• Few hours PTA, patient had labor pains every 30
minutes, with pain scale of 8/10.
• (-) Headache, blurring of vision, nausea,
vomiting, hypogastric pain, watery vaginal
discharge, vaginal bleeding
Past Medical History
(+) Hypertension since 2015, maintained on Amlodipine 5 mg
OD
(-) Diabetes Mellitus, Asthma
(-) Allergic to food or drugs
(-) History of blood transfusion
(+) Previous hospitalization - Previous LTCS I at Fabella
hospital (2015) for pre eclampsia with severe features
Personal Social
history
• Non-Smoker
• Non-alcoholic beverage drinker
• No illegal drug use
• Patient is college graduate
• Currently unemployed
• Married to a 30 y/o salesman
Family Medical
History
(+) Diabetes :maternal side
(+)Hypertension, liver disease:
paternal side
(-)Asthma
(-) Heart disease
OB GYNE History

• OB Score: G2 P1 (1-0-0-1)
Type of Place of Gender of Condition of Present Age
Gravida Year Delivery Attendee Delivery Baby Baby Complication and
Condition
CS Fabella Alive,
G1 2015 secondary OB Female Term, live None
Hospital 3 y/o
to PES

G2 2018 Current pregnancy


OB GYNE History
• Coitarche: 24
• M – 11 y.o.
• No. of sexual partners: 1
• I – Regular (28-30
• No Hx of STI
days)
• No Hx of contraceptive use
• D – 5 days
• Last sexual contact:
• A – 3-4 napkins/ day, November 2017
moderately soaked
• S – (-) dysmenorrhea
ROS
• General: (-) fever (-) weight loss (-) fatigue
• HEENT: (-) headache (-) migraine (-) vertigo (-) syncope (-) blurring of vision (-) tinnitus (-) sore
throat
• Respiratory: (-) chest pain (-) SOB (-) wheezing (-) dyspnea, (-) cough (-) hemoptysis (-)
orthopnea
• Cardiovascular: (-) chest pain (-) palpitations (-) tachycardia (-) PND (-) cyanosis
• GIT: (-) dysphagia (-) nausea (-) vomiting (-) jaundice (-) hematemesis (-) melena
• GUT: (-) polyuria (-) urgency (-) frequency (-) hematuria (-) oliguria (-) anuria
• Musculoskeletal: (-) muscle pain (-) joint stiffness (-) swelling (-) bone deformity (-) weakness (-)
atrophy
• Endocrine: (-) weight change (-) heat or cold intolerance (-) polyuria (-) polydipsia (-) polyphagia
• Hematologic: (-) easy bruisability (-) easy fatigability (-) pallor
Physical Examination
• General Survey: conscious, coherent, ambulatory, not in Cardiopulmonary
distress
• BP: 170/110 mmHg HR: 88 bpm RR: 19cpm T: 36.5°C
• Ht: 153cm Pre-pregnancy Wt: 78 kg BMI:33.3 kg/m2 (Obese)
• Skin: warm, with good skin turgor of less than 2 sec, no active dermatoses
• HEENT: Pink palpebral conjunctiva, Anicteric sclera, No nasoaural discharge, No
cervical lymphadenopathy
• Chest & Lungs: Symmetrical chest expansion, No retractions, Vesicular breath
sounds
• Cardiovascular: Adynamic precordium, Normal rate, regular rhythm, No
murmur
Physical Examination

• Abdomen : Globular
FH – 32cmFHT – 140 bpm EFW – 3100 grams
• L1 – large nodular mass, breech
• L2 – Maternal right – fetal back;
Maternal left -fetal extremities
• L3 – Hard, round, ballotable cephalic
• Pelvic exam: normal looking external female genitalia, no mass, no lesion
• Speculum exam: Not done
• Internal exam: Not done
• Extremities: Grossly normal extremities, no edema, no cyanosis, no pallor,
with full equal pulses
Admitting Diagnosis

• Gravida 2 Para 1 (1001) PU 38 1/7 weeks AOG,


Chronic Hypertension with superimposed
preeclampsia with severe features, Previous CS 1x
for Preeclamsia with severe features uncontrolled,
2015
PLAN
• For control of BP
• For Repeat Cesarean Section
Upon Admission
• NPO
• IVF with D5LR 1L to run for 12 hrs
• SD: D5W 1 L + Magnesium sulfate 10 g to run for 100 cc/hr for 10 hrs
• Meds: Hydralazine 5mg TIV, Magnesium sulfate 4 g SIVP
• Diagnostics: CBC, UA, blood typing, LDH, BUN, Creatinine, and
SGPT/SGOT, 24H urine protein
• Foley catheter inserted
• Oxygen inhalation 2-3 lpm
• Electronic fetal monitoring
• Monitoring for VS, FHT, and progress of labor
Complete Blood Count (June 29, 2018)
Level Normal levels

WBC 9.7 5.00 – 10.00 10^9/L


Neutrophil 0.72 0.40 – 0.60
Lymphocytes 0.18 0.20 – 0.40
Hemoglobin 120 123.00 – 152.00 g/L
Hematocrit 0.34 0.37 – 0.42
RBC 4.0 4.50 – 5.50 10^12/L

Platelet 178 150.00 – 450.00 10^9/L


Urinalysis
RBC 0-2/hpf
PUS CELLS 0-2/hpf
BACTERIA Few
EPITHELIAL CELLS +1
PROTEIN Negative
GLUCOSE Negative
Blood chemistry
System International
Result Normal Values
Creatinine (C) 45.60 45.00-84.00 umol/L

Blood Urea Nitrogen 2.50 2.14-7.14 mmol/L

SGPT (ALT) 10.50 0.00-33.00 U/L


SGOT (AST) 20.80 0.00-32.00 U/L
Lactate Dehydrogenase 207.20 135.00-214.00 U/L
INTRAOPERATIVE FINDINGS
• Gravid uterus
• Transverse curvilinear uterine incision done on a well-formed lower
uterine segment
• Clear amniotic fluid noted
• Live girl delivered in occiput left transverse position with outcome:
• AS 9,9 BW 2500g AGA BL=46 cm BS 38 weeks
• Placenta delivered completely via manual extraction from it
anterofundal implantation, weighing 400 g
• Umbilical cord with 2 arteries and 1 vein centrically inserted
• Estimated blood loss of 600 ml
COURSE IN WARD Post-Op Day 1
• NPO
BP: 130/90 (120-130/80-90)
• IVF was D5LR 1L with 10 ‘u’ oxytocin
PR: 89 run for 8 hours
RR: 19 • SD: D5W 1 L + Magnesium sulfate 10 g
to run for 100 cc/hr continue until 24
T: 36.9 C
hrs
Soft abdomen, normoactive bowel• Ketorolac 30mg TIV every 6 hours,
sounds, minimal vaginal bleeding, Tramadol 50mg every 8 hours for 3
adequate urine output, no flatus doses and PRN for severe pain, not
exceeding 400mg in 24 hours,
Ranitidine 50mg TIV every 8 hours
COURSE IN WARD Post-Op Day 2
• Low Salt Low Fat diet
BP: 120/80 (110-120/70-80)
• IVF to consume
PR: 89 • Oral meds started:
RR: 19
1. Cefuroxime 500 mg 1 tab BID x 7
T: 36.9 C days
Soft abdomen, normoactive bowel2. Paracetamol + Tramadol 1 tab Q8
sounds, minimal vaginal bleeding, • IFC removed after completion 24h
adequate urine output, (+) flatus, (+)urine protein
BM
• Urine protein: 150 g/dl
• Urine total volume: 2530 ml
COURSE IN WARD Post-Op Day 2
• Advised for May Go Home
BP: 110/70 • Home Oral meds:
PR: 78 1. Cefuroxime 500 mg 1 tab BID x 7
days
RR: 17
2. 2.Tramadol and paracetamol (TDL
T: 36.7 C
Plus) x PRN
Soft abdomen, normoactive
3. 3.FeSO4 1tab x OD x 1 month
bowel sounds, minimal vaginal
bleeding, adequate urine 4. 4. Ascorbic acid x 1tab x OD x 2
output, (+) flatus, (+) BM weeks
• Follow up after 1 week at OPD
FINAL DIAGNOSIS

• G2P2 (2002) Pregnancy Uterine delivered


term cephalic baby girl BW 2500 g, AGA, AS
9,9, Chronic Hypertension with superimposed
Preeclampsia via LTCS II for repeat under
spinal anesthesia, previous LTCSI for
preeclampsia with severe features
uncontrolled (2015)
Case Presentation
PRE ECLAMSIA
Objectives

 To discuss a case of preeclampsia


 To know the etiology and risk factors of preeclampsia
 To discuss the management plan for preeclampsia
General data

J.P
30 years old
Gravida 2 Para 1(1001)
Date of admitted : June 29, 2018
Date of discharged :July 2 , 2018
Chief Complaint

 Labor Pains
History of Present Pregnancy

 LMP: October 5, 2017


 AOG: 38 1/7 weeks AOG by LMP
 PMP: September 7, 2017
 EDC: July 12, 2018
History of Present Pregnancy
1st Trimester:
 (+) Missed of menses on November 8, 2017
 (+) Pregnancy test done on November 8, 2017 (4 6/7
weeks AOG)
 (+) Prenatal check up in health center on Nov 23 2017 (7
weeks AOG by LMP)
 Labs: CBC, Urinalysis – no official results
 (+) Chronic hypertension
 (+) Methyldopa 250 mg BID, Folic acid and multivitamin
and Calcium
 (-) Exposure to teratogens and radiation.
TVS November 23, 2017
(approximately 7 weeks AOG)

 Intrauterine pregnancy compatible


with 6 4/7 weeks with good cardiac
activity, adnexae unremarkable,
cervix is closed
2nd Trimester:
 (+) Quickening on 2nd week of February 2018 (approx 18 weeks
AOG )
 (+) continue PNCU at health center
 (-) UTZ, Labs
 (+) Continue Methyldopa BID, Ferrous sulfate and multivitamin,
Calcium once a day
 (-) exposure to teratogens and radiation
3rd Trimester:
 (+) 1st PNCU in our institution (35 weeks AOG)
 Labs- CBC, UA, HbsAg, VDRL, 75 g OGTT were within normal
limits
 (+) Placental doppler UTZ
 (+)Continue Methyldopa BID, Ferrous sulfate and
multivitamin, calcium once a day
 (-) exposure to teratogens and radiation
Complete Blood Count (June 11, 2018)

Level
Normal levels
10.1
WBC 5.00 – 10.00 10^9/L
0.72
Neutrophil 0.40 – 0.60

Lymphocytes 0.16 0.20 – 0.40

Hemoglobin 102 123.00 – 152.00 g/L

Hematocrit 0.33 0.37 – 0.42

RBC 3.8 4.50 – 5.50 10^12/L


151
Platelet 150.00 – 450.00 10^9/L
Urinalysis (June 11, 2018)

RBC 0-2/hpf

PUS CELLS 0-2/hpf

BACTERIA Few

EPITHELIAL CELLS +1

PROTEIN Negative

GLUCOSE Negative
Labs (June 11, 2018)

VDRL HbsAg
Nonreactive Negative
Placental doppler UTZ (June 14, 2018, approximately 36 weeks)

 Pregnancy uterine 33 weeks and 1 day by fetal


biometry
 Live singleton in cephalic presentation
 Adequate amniotic fluid volume
 Placenta anterofundal, grade II, high lying
 Placental doppler revealed no sonological finding
of placenta accreta
History of Present illness

 Few hours PTA, patient had labor pains


every 30 minutes, with pain scale of 8/10.
 (-)Headache, blurring of vision, nausea,
vomiting, hypogastric pain, watery vaginal
discharge, vaginal bleeding
Past Medical History
(+) Hypertension since 2015, maintained on
Amlodipine 5 mg OD
(-) Diabetes Mellitus, Asthma
(-) Allergic to food or drugs
(-) History of blood transfusion
(+) Previous hospitalization - Previous LTCS I at Fabella
hospital (2015) for pre eclampsia with severe
features
Personal Social history
Non-Smoker
Non-alcoholic beverage drinker
No illegal drug use
Patient is college graduate
Currently unemployed
Married to a 30 y/o salesman
Family Medical History
(+) Diabetes :maternal side
(+)Hypertension, liver disease:
paternal side
(-)Asthma
(-) Heart disease
OB GYNE History

OB Score: G2 P1 (1-0-0-1)


Present
Type of Place of Gender Condition of Complicatio
Gravida Year Attendee Age and
Delivery Delivery of Baby Baby n
Condition
CS
Fabella Alive,
G1 2015 secondary OB Female Term, live None
Hospital 3 y/o
to PES
G2 2018 Current pregnancy
OB GYNE History
 Coitarche: 24
M – 11 y.o.
 No. of sexual partners: 1
I– Regular (28-30
 No Hx of STI
days)
 No Hx of contraceptive
D – 5 days
use
A– 3-4 napkins/ day,  Lastsexual contact:
moderately soaked
November 2017
S – (-) dysmenorrhea
ROS
 General: (-) fever (-) weight loss (-) fatigue
 HEENT: (-) headache (-) migraine (-) vertigo (-) syncope (-) blurring of vision (-) tinnitus (-) sore throat
 Respiratory: (-) chest pain (-) SOB (-) wheezing (-) dyspnea, (-) cough (-) hemoptysis (-) orthopnea
 Cardiovascular: (-) chest pain (-) palpitations (-) tachycardia (-) PND (-) cyanosis
 GIT: (-) dysphagia (-) nausea (-) vomiting (-) jaundice (-) hematemesis (-) melena
 GUT: (-) polyuria (-) urgency (-) frequency (-) hematuria (-) oliguria (-) anuria
 Musculoskeletal: (-) muscle pain (-) joint stiffness (-) swelling (-) bone deformity (-) weakness (-) atrophy
 Endocrine: (-) weight change (-) heat or cold intolerance (-) polyuria (-) polydipsia (-) polyphagia
 Hematologic: (-) easy bruisability (-) easy fatigability (-) pallor
Physical Examination
 General Survey: conscious, coherent, ambulatory, not in
Cardiopulmonary distress
 BP: 170/110 mmHg HR: 88 bpm RR: 19cpm T: 36.5°C
 Ht: 153cm Pre-pregnancy Wt: 78 kg BMI:33.3 kg/m2 (Obese)
 Skin: warm, with good skin turgor of less than 2 sec, no active
dermatoses
 HEENT: Pink palpebral conjunctiva, Anicteric sclera, No nasoaural
discharge, No cervical lymphadenopathy
 Chest & Lungs: Symmetrical chest expansion, No retractions, Vesicular
breath sounds
 Cardiovascular: Adynamic precordium, Normal rate, regular rhythm,
No murmur
Physical Examination

 Abdomen : Globular
FH – 32cm FHT – 140 bpm EFW – 3100 grams
 L1 – large nodular mass, breech
 L2 – Maternal right – fetal back;
Maternal left -fetal extremities
 L3 – Hard, round, ballotable cephalic
 Pelvic exam: normal looking external female genitalia, no mass, no
lesion
 Speculum exam: Not done
 Internal exam: Not done
 Extremities: Grossly normal extremities, no edema, no cyanosis, no
pallor, with full equal pulses
Admitting Diagnosis

Gravida 2 Para 1 (1001) PU 38 1/7 weeks AOG,


Chronic Hypertension with superimposed
preeclampsia with severe features, Previous CS 1x
for Preeclamsia with severe features uncontrolled,
2015
PLAN

 For control of BP
 For Repeat Cesarean Section
Upon Admission
• NPO
• IVF with D5LR 1L to run for 12 hrs
• SD: D5W 1 L + Magnesium sulfate 10 g to run for 100 cc/hr for 10
hrs
• Meds: Hydralazine 5mg TIV, Magnesium sulfate 4 g SIVP
• Diagnostics: CBC, UA, blood typing, LDH, BUN, Creatinine, and
SGPT/SGOT, 24H urine protein
• Foley catheter inserted
• Oxygen inhalation 2-3 lpm
• Electronic fetal monitoring
• Monitoring for VS, FHT, and progress of labor
Complete Blood Count (June 29, 2018)
Level Normal levels

WBC 9.7 5.00 – 10.00 10^9/L


Neutrophil 0.72 0.40 – 0.60
Lymphocytes 0.18 0.20 – 0.40
Hemoglobin 120 123.00 – 152.00 g/L
Hematocrit 0.34 0.37 – 0.42
RBC 4.0 4.50 – 5.50 10^12/L
150.00 – 450.00
Platelet 178
10^9/L
Urinalysis
RBC 0-2/hpf
PUS CELLS 0-2/hpf
BACTERIA Few
EPITHELIAL +1
CELLS
PROTEIN Negative
GLUCOSE Negative
Blood chemistry
  System International
Result Normal Values
Creatinine (C) 45.60 45.00-84.00 umol/L

Blood Urea Nitrogen 2.50 2.14-7.14 mmol/L

SGPT (ALT) 10.50 0.00-33.00 U/L


SGOT (AST) 20.80 0.00-32.00 U/L
Lactate Dehydrogenase 207.20 135.00-214.00 U/L
INTRAOPERATIVE FINDINGS
 Gravid uterus
 Transverse curvilinear uterine incision done on a well-formed
lower uterine segment
 Clear amniotic fluid noted
 Live girl delivered in occiput left transverse position with
outcome:
 AS 9,9 BW 2500g AGA BL=46 cm BS 38 weeks
 Placenta delivered completely via manual extraction from it
anterofundal implantation, weighing 400 g
 Umbilical cord with 2 arteries and 1 vein centrically inserted
 Estimated blood loss of 600 ml
COURSE IN WARD Post-Op Day 1
 NPO
BP: 130/90 (120-130/80-90)  IVF was D5LR 1L with 10 ‘u’
oxytocin run for 8 hours
PR: 89
 SD: D5W 1 L + Magnesium sulfate
RR: 19 10 g to run for 100 cc/hr continue
T: 36.9 C until 24 hrs
Soft abdomen, normoactive  Ketorolac 30mg TIV every 6 hours,
bowel sounds, minimal Tramadol 50mg every 8 hours for 3
vaginal bleeding, adequate doses and PRN for severe pain, not
urine output, no flatus exceeding 400mg in 24 hours,
Ranitidine 50mg TIV every 8 hours
COURSE IN WARD Post-Op Day 2
 Low Salt Low Fat diet
BP: 120/80 (110-120/70-80)
 IVF to consume
PR: 89
 Oral meds started:
RR: 19 1. Cefuroxime 500 mg 1 tab BID x
7 days
T: 36.9 C
2. Paracetamol + Tramadol 1 tab
Soft abdomen, normoactive Q8
bowel sounds, minimal
vaginal bleeding, adequate
 IFC removed after completion
urine output, (+) flatus, (+) 24h urine protein
BM  Urine protein: 150 g/dl
 Urine total volume: 2530 ml
COURSE IN WARD Post-Op Day 2
 Advised for May Go Home
BP: 110/70  Home Oral meds:
PR: 78 1. Cefuroxime 500 mg 1 tab BID x 7
days
RR: 17
T: 36.7 C 2. 2.Tramadol and paracetamol
(TDL Plus) x PRN
Soft abdomen, normoactive
bowel sounds, minimal 3. 3.FeSO4 1tab x OD x 1 month
vaginal bleeding, adequate 4. 4. Ascorbic acid x 1tab x OD x 2
urine output, (+) flatus, (+) weeks
BM  Follow up after 1 week at OPD
FINAL DIAGNOSIS

G2P2 (2002) Pregnancy Uterine delivered


term cephalic baby girl BW 2500 g, AGA,
AS 9,9, Chronic Hypertension with
superimposed Preeclampsia via LTCS II
for repeat under spinal anesthesia,
previous LTCSI for preeclampsia with
severe features uncontrolled (2015)