o&g_case_pih, pp
DESCRIPTION
Case PresentationBy: Siti Nurulismah Bt Che HaronChief complaint• Madam N, 41 years old Malay housewife gravida 8 para 7 currently at 38 weeks of gestation presented with high blood pressure and low lying placenta on the day of admission.• REDD: 11/5/2011 • Menstrual history: menarche at 14 years old, regular, 4 – 7 days in 29 days cycle • OCP: for 1 years (1995-1996)History of chief complaint• She has high BP since 16 weeks of gestation. Currently on T. Methyldopa 500 mg tds. BP ranTRANSCRIPT
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Case Presentation
By: Siti Nurulismah Bt Che Haron
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Chief complaint
• Madam N, 41 years old Malay housewife gravida 8 para 7 currently at 38 weeks of gestation presented with high blood pressure and low lying placenta on the day of admission.
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• REDD: 11/5/2011• Menstrual history: menarche at 14 years old,
regular, 4 – 7 days in 29 days cycle • OCP: for 1 years (1995-1996)
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History of chief complaint
• She has high BP since 16 weeks of gestation. Currently on T. Methyldopa 500 mg tds. BP range from 130-140/90 mmHg.
• Her latest BP is 170/100 mmHg. • There is no features of impending eclampsia.
No per vaginal bleeding and no abdominal pain. • Fetal movement is normal. • Systemic review is normal.
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History of presenting pregnancy
• Booking: 23/12/2011 at Kuala Selangor health clinic.
• BMI: 33.3 kg/m2 (Obese)• 16 weeks of gestation, she is diagnosed with
PIH and ultrasound scan shows low lying placenta.
• Quekening: 20 weeks gestation.• No anemia, no GDM, no other problems
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Past O&G and sexual history
• Last pregnancy is 4 years ago. Not having PIH or other problems during past pregnancies.
• No past gynaecological history.• Married at 18 years old until now.
No. of children
Year Mode of delivery
Birth weight (kg)
Venue Note
• 6 boys • 1 girl
1994 - 2008 SVD 2.5 – 3.1 Tanjung Karang and Klang Hospital
2nd: breech and neonatal death
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• No known long term medical illness including hypertension and diabetes mellitus
• Never undergoes any surgery• Not taking any long term medication• No allergy
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Family history
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Social history
• Housewife, living in village house at Kuala Selangor.
• Never smoking and not consume alcohol. Not take ilicit drug.
• Husband working as civil contractor and smoke 20 cigarettes per day.
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Vital signs
• Pulse: 83 bpm, regular rhythm and good volume
• BP: 113/80 mmHg• Temperature: 37C• RR: 16 breaths per minute
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Physical examinations
• Abdomen is distended, umbilicus centrally located and inverted. There is linea nigra and striae gravidarum. There is no scar.
• Uterus is at 38 weeks, measures 36 cm• Single fetus, longitudinal lie, cephalic
presentation, head is 5/5th palpable, liquor is adequate and estimates fetal weight is 3.0 kg
• Fetal heart rate is 148 bpm• Systemic examinations: normal
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Summary
• Madam N, 41 years old Malay housewife gravida 8 para 7 currently at 38 weeks of gestation presented with high blood pressure and low lying placenta on the day of admission.
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Diagnosis
• Provisional – Madam N 41 years old gravida 8 para 7 currently at 38 weeks of gestation having asymptomatic pregnancy induced hypertension and placenta praevia.
• Differential diagnosis – pre eclampsia, eclampsia and chronic hypertension
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Investigations• FBC• Urine albumin• Urine protein 24 hours• Uric acid• Renal profile• Liver function test• Coagulation profile• Transabdominal scan: shows placenta praevia
type 2
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Management
• Monitor BP 2 hourly• T. Methyldopa 500mg tds• Plan for elective LCSC• Check for features of impending eclampsia• Daily urine albumin• Monitor pad chart and time contraction• FBC weekly• CTG once daily
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DiscussionPIH Pre
eclampsiaImpending eclampsia
Eclampsia Chronic HPT
Onset ≥ 2nd trimester
> 20 weeks of gestation Prior to pregnancy
BP (mmHg) ≥ 140/90 > 120/80
Urine protein (mg/24 hrs)
- ≥ 300
Risk factors and causes
· primigravida · previous history· family history · diabetes· pre existing hpt· multiple gestation
· older age· family history· diabetes· obesity· 2 causes
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PIH, PE, IE,
eclampsia &
chronic HPT
Features
Ix
Cx
Rx
• headache, nausea, vomiting• clonus, hyperreflexia• tonic clonic seizure
• HELLP syndrome• seizure• post partum • oligohydramnios• placenta insufficeincy• fetal distress
• bed rest• antihypertensive medications • Mg SO4
• dexamethasone• SVD, C sec
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Placenta praevia
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Definition
Type
Risk factorComplication
Management
• previous c sec• uterine anomaly• assisted conception • multiple gestation
• APH & PPH • pre term labor• caesarean section
• symptomatic mx• conservative mx• dexamethasone• Mcafee regimen