Case Summary Hypertension In Pregnancy Health And Social Care Essay

Mdm. SM is a 30-year-old Malay female of gravida 5 parity 3+1 who is at 37 weeks and 5 days of gestation. She was diagnosed to have hypertension in pregnancy during antenatal routine follow-up in Klinik Kesihatan Simpang Renggam at 36 weeks and preeclampsia (blood pressure 160/100mmHg, urine dipstick albumin 1+) 3 days before admission. She was admitted to Hospital Kluang and started on Tab. Methyldopa 250mg TDS. She was advised for induction of labour in view of preeclampsia at term and she requested to be transferred to Hospital Batu Pahat (HBP). She did not have any signs and symptoms suggestive of severe preeclampsia or labour. During admission to HBP, tablet prostin 1.5mg was inserted into the posterior fornix twice to induce labour but there was no change in cervical os and symptoms of labour. Decision was made to try artifical rupture of membranes. However, following the procedure, internal monitoring detected fetal distress and as spontaneous delivery was not imminent, Mdm. SM was agreeable for emergency lower section caesarean section under general anaesthesia. A healthy infant boy was delivered (weight 2.9kg, Apgar score 91105) and there were no intra or post-operative complications. Following the surgery, both mother and infant were well in the ward. Mdm. SM was ambulating and tolerating orally and by the 2nd post-op day, both had passed urine and motion. Wound inspection on day 2 showed clean, non-gaping wound. As she was well, decision was made to discharge her and she was given appointment to review her blood pressure and operative wound at the postnatal clinic at KKSR. On discharge, her blood pressure was 140/70mmHg (without medication) and urine dipstick albumin was trace. Analgesia given on discharge were mefenemic acid and paracetamol.

STUDENT NAME: Paul Kong Fu-Xiang ID NO: M0508129

NAME OF SUPERVISOR: Dr. Sharifah Sulaiha ROTATION: Obstetrics & Gynaecology

PATIENT’S DETAILS

I/C NUMBER: 800318015794 AGE: 30

SEX: Female DATE OF ADMISSION: 20/6/2010

R/N: 1358593

2) CLINICAL HISTORY

Chief Complaint

Elevated blood pressure detected in pregnancy at 36 weeks of gestation.

History of Present Illness

Mdm. SM is a 30-year-old Malay female of gravida 5 parity 3+1 who is currently at 37 weeks and 5 days of gestation. She was referred to Hospital Kluang from Klinik Kesihatan Simpang Renggam (KKSR) for elevated blood pressure detected on routine antenatal follow-up and subsequently transferred to Hospital Batu Pahat (HBP) for induction of labour in view of her development of high blood pressure in pregnancy. Her elevated blood pressure was first detected during her routine antenatal follow-up at Klinik Kesihatan Simpang Renggam 10 days before admission to HBP. During this visit, her blood pressure was recorded as 150/90mmHg and she also complained of slight bilateral swelling of her feet but otherwise had no other complaints. The feet swelling resolved after 3 days. Throughout the next 7 days, she went to KKSR every alternate day for monitoring and 3 days before admission to HBP, her blood pressure was noted to be 160/100mmHg with presence of albumin 1+ on urine dipstick that was previously not present. She was immediately given tablet labetolol 100mg and admitted to Hospital Kluang where she was subsequently started on tablet methyldopa 250mg 8-hourly. Three days after admission to Hospital Kluang, she was advised by the doctor to undergo induction of labour and she thus requested to be transferred to HBP so her family members in Batu Pahat could take care of her. During the course of these events, she did not experience shortness of breath, headache, blurring of vision, epigastric pain, seizures, abdominal pain, vaginal bleeding, nausea, vomiting, palpitations, or recurrence of the foot swelling. At time of admission, she did not experience contraction pain, show, leaking of liquor. Fetal movements were good.

Systemic Review

Mdm. SM did not have fever. Her appetite was good and her urinary and bowel habits were normal. Her sleep was unaffected.

Antenatal History

This was an unplanned but wanted pregnancy. Mdm. SM realized she was pregnant when she missed her period, of which the last was 28/12/09. She bought a pregnancy test kit and it tested positive. She subsequently did her booking at KKSR at 7 weeks of period of amenorrhoea. At booking, her blood pressure was 120/80mmHg, hemoglobin 13.4g/dL, sugar undetected, and urine albumin negative. Infective screening was negative and blood type O positive. Her expected due date was given as 14/8/10. During follow-up 1 month later, she had her first ultrasound scan which found her uterus to be larger than dates. Her due date was revised to 6/7/10. Modified glucose tolerance test done twice during pregnancy were negative. She experienced morning sickness and vomiting during the first 3 months of pregnancy but it was not severe and she could cope without medication. Throughout the pregnancy, she was diagnosed to have urinary tract infection twice and was treated with antibiotics. A further 3 ultrasound scans were done and all were normal. She was also compliant to the supplements given throughout pregnancy. There were no other problems during the antenatal follow-up until the detection of elevated blood pressure 10 days before admission to HBP.

Past Obstetric History

This is her fifth pregnancy and her last childbirth was in 2008. She has 3 children, 2 boys and a girl, of whom all were born via vaginal delivery at postdate after induction of labour. Birth weights ranged from 2.7 to 3.0kg, all are healthy with no complications and were breastfed. However, during her 3rd pregnancy, she suffered a miscarriage during the 12th week and dilatation and curettage was performed during that admission.

Gynae & Menstrual History

Mdm. SM achieved menarche at the age of 12. Her menstrual cycles have always been regular with 28 days per cycle and 5 to 7 days of flow. She does not experience menorrhagia or dysmenorrhoea. She has never had a cervical smear done and has never used oral contraceptive pills. She has not required medical attention for any gynaecological problem.

Past Medical History

Mdm. SM has never been diagnosed with any chronic disease such as diabetes, hypertension, and asthma before. She has also never been admitted for non-pregnancy related reasons. She also does not have any known food or drug allergies.

Family History

Mdm. SM is the eldest of three siblings. Her youngest sister also had gestational hypertension. Her father has hypertension and her mother had diabetes, but passed away 2 years ago due to tuberculosis. All family members have been screened and all tested negative for tuberculosis.

Social History

Mdm. SM is now a housewife. She formerly worked in a factory but decided against returning to work following her last pregnancy in 2008 for her children’s benefit. She is a non-smoker and does not consume alcohol. Her husband is a short-haul lorry driver and smokes, but only outside their home. They live slightly off Kluang, and it takes them slightly over an hour to reach HBP, and 15 minutes to reach KKSR.

STUDENT NAME: Paul Kong Fu-Xiang ID NO: M0508129

NAME OF SUPERVISOR: Dr. Sharifah Sulaiha ROTATION: Obstetrics & Gynaecology

3) FINDINGS ON CLINICAL EXAMINATION

(Mdm. SM was examined by me on the 2nd day of admission)

Mdm. SM was alert, conscious and cooperative. She was not in any pain or distress. She was sitting comfortably on her bed. On examination, there was no pallor, jaundice or pedal edema. Her reflexes were not brisk. Her clinical parameters are:

Blood Pressure : 124/80 mmHg

Heart Rate : 95 beats per minute. Regular rhythm

Respiratory Rate : 20 breaths per minute

Temperature : 37°C

Examination of the cardiovascular system, respiratory system, fundus, thyroid and breasts were normal.

On examination of the abdomen, it was distended with gravid uterus as evidenced by linea nigra, and striae albicans. There was no striae gravidarum, scars, or pulsations noted. On palpations, the abdomen was soft and non-tender, uterus non-irritable, and fetal parts felt. The symphysio-fundal height was 36cm, which corresponds to dates. On examination, this is a singleton fetus at longitudinal lie with cephalic presentation, with the fetal back on the maternal left. The fetal head was four fifths palpable. Estimated fetal weight is 2.8 to 3.0kg. Liquor is adequate. Fetal heart was heard and the rate was 142 beats per minute.

Vaginal examination (by medical officer on admission) revealed no perineal, vulval or vaginal abnormalities. Cervical os was 1 cm with cervix tubular, soft and axial, station high and membrane intact. Bishops score was 3/10.

STUDENT NAME: Paul Kong Fu-Xiang ID NO: M0508129

NAME OF SUPERVISOR: Dr. Sharifah Sulaiha ROTATION: Obstetrics & Gynaecology

4) PROVISIONAL AND DIFFERENTIAL DIAGNOSES WITH REASONING

Provisional Diagnosis

Preeclampsia in pregnancy

Mdm. SM developed new onset elevated blood pressure of 160/100mmHg at 36 weeks of gestation and urine dipstick albumin of 1+ (300mg/L). This fits the minimum requirement of preeclampsia among the hypertensive diseases in pregnancy. However, Mdm. SM did not experience any symptoms to suggest a severe preeclampsia or impending eclampsia such as headache, visual disturbances, epigastric pain, vomiting, liver tenderness. The urine dipstick for albumin is not the best way to detect proteinuria required for the diagnosis of preeclampsia 3 and is usually only used for screening, but as the blood pressure and urine albumin were persistently elevated, it is better to err on the side of caution and treat Mdm. SM as such since patients with relatively mild preeclampsia can rapidly progress into severe disease 1. Following the repeated positive detection of urine albumin of only 1+, more definitive tests should be performed to better quantify her proteinuria 2,3.

Differential Diagnosis

Pregnancy-induced hypertension, late onset

As Mdm. SM has been compliant to her antenatal follow-ups and did not have elevated blood pressure detected at any time before 36 weeks of gestation, it is likely that she has developed the onset of a hypertensive disease in pregnancy and it appears to be of late onset as it developed only after 32 weeks gestation. However, as subsequent visits showed urine dipstick albumin of 1+, indicating the onset of proteinuria (although poor predictive value and not as significant as 2+) 3, it might prove wiser to be more vigilant and assume that Mdm. SM does indeed have preeclampsia as it would be foolish to dismiss these warning features despite the fact that she does not demonstrate any suggestive symptoms because it is possible that even patients with no prodromal signs may suddenly progress into eclampsia 1,3.

Essential hypertension in pregnancy with superimposed preeclampsia

Another possibility that we may entertain is that Mdm. SM has had previously undiagnosed essential hypertension with currently superimposed preeclampsia. However, this seems rather unlikely. Firstly, Mdm. SM is young at the age of 30 and unlikely to suffer from essential hypertension as this disease common presents after the age of 40. Secondly, at no time throughout antenatal follow-up did she have elevated blood pressure recorded before that particular visit at 36 weeks of gestation. However, following delivery of her infant, she should have her blood pressure rechecked during postnatal follow-up care at 6 to 12 weeks post-delivery. If her blood pressure if still elevated at that time, then it will be more likely that she has essential hypertension.

STUDENT NAME: Paul Kong Fu-Xiang ID NO: M0508129

NAME OF SUPERVISOR: Dr. Sharifah Sulaiha ROTATION: Obstetrics & Gynaecology

5) IDENTIFY AND PRIORITISE THE PROBLEMS

1. Elevated blood pressure and its implications in pregnancy

Mdm. SM has newly discovered elevated blood pressure at 36 weeks of gestation. This is considered late onset but is not uncommon, and gives rise to a spectrum of hypertensive disorders in pregnancy. While it seems that at first she has gestational hypertension, the mildest of the disease spectrum, she demonstrated proteinuria on her subsequent antenatal visit, therefore concluding that she has preeclampsia. Hypertensive disorders in pregnancy have the potential to put both mother and infant at increased risk of mortality. Its complications are elaborated below. During admission, Mdm. SM should be monitored for any change in her condition as she may quickly progress into severe disease states and this would require urgent intervention, the most definitive being the delivery of the infant. Ward management includes close observation of both mother and infant, and medication to control the elevated blood pressure.

2. Induction of labour in view of preeclampsia at term

Termination of the pregnancy is the only definitive sure for preeclampsia. On presentation, Mdm. SM has features categorized as mild preeclampsia. Normally, severe preeclampsia would dictate the need for antihypertensive and anticonvulsive therapy followed by subsequent delivery and symptoms such as headache, epigastric pain, and visual disturbances may indicate this. The fetal age is usually an important deciding factor when it comes to inducing labour as the treatment goals seek the best outcome for both mother and infant. As Mdm. SM is already at term and there have been no issues previously detected regarding the health of her fetus, it should be safe to proceed with induction of labour. There is also no reason to prolong the pregnancy as the risk of eclampsia increases. If for any reason an obstetric reason arises e.g. fetal distress, delivery should proceed via caesaren section.

3. Impending eclampsia and other potential complications

Warning signs and symptoms of impending eclampsia or severe preeclampsia include headache, visual disturbances, epigastric pain, reduced urine output, edema and ultimately, convulsions. These symptoms should be recognized early so the necessary intervention can take place. Seizures increase the risk of maternal and perinatal morbidity and mortality rates. Some maternal complications are placenta abruption, neurological deficits, aspiration pneumonia, pulmonary edema, cardiopulmonary arrest, and acute renal failure. Other major complications that may occur as a result of severe preeclampsia are HELLP syndrome, pulmonary embolism and stroke. Fetal complications include growth restriction, fetal distress, and death.

4. Risk of post-partum eclampsia

It is possible for eclampsia to occur in the postpartum period especially when the patient has reached term. In such cases, up to 44% of eclampsia occurs postpartum 3. As the risk is quite high, Mdm. SM should continue to be monitored in the ward for the development of any signs and symptoms. As she is comfortable and relatively symptom free while in the ward, it appears unlikely that she may worsen into an eclamptic state but the risk should not be afforded. As there are no guidelines to suggest an optimum postpartum inward observation period, it would depend on her clinical situation during the subsequent days following her delivery.

5. Hypertension in pregnancy and its long term implications

As Mdm. SM has developed preeclampsia during this pregnancy, she is at increased risk to develop hypertensive or metabolic complications in future pregnancies. The risk of recurrence is generally higher in earlier onset preeclampsia. At the same time, she should be evaluated in the postpartum period for the possibility of essential hypertension at the 6 week postnatal review. Also, women with preeclampsia are at an increased risk for developing hypertension, diabetes, hyperlipidemia, chronic renal disease, stroke and ischemic heart disease. Mdm. SM should be made aware of all these implications and should be educated on how she can prevent these via the modification of her lifestyle. She should also be advised to attend preconceptual counseling in the event of a future pregnancy and to come early for booking.

STUDENT NAME: Paul Kong Fu-Xiang ID NO: M0508129

NAME OF SUPERVISOR: Dr. Sharifah Sulaiha ROTATION: Obstetrics & Gynaecology

6) PLAN OF INVESTIGATION, JUSTIFICATIONS FOR THE SELECTION OF TESTS OR PROCEDURES, AND INTERPRETATION OF RESULTS

1. Urine Dipstick for Albumin

To look for the presence of albumin in the urine firstly, to confirm proteinuria, and secondly, to evaluate the severity of the preeclampsia. Urine dipstick for albumin should be repeated daily in the ward. Also, if in doubt, further investigation to quantify proteinuria can be done e.g. urine protein/creatinine spot test 2,3.

Results: Urine dipstick albumin on admission was trace. Results at KKSR showed 1+.

Interpretation: This result could be due to the fact that the blood pressure has lowered as Mdm. SM has been started on methyldopa and her blood pressure is under control. This does not mean that she no longer has preeclampsia. She should be checked daily for any changes in both blood pressure and proteinuria.

2. Full Blood Count

To look for anemia which may require correction, haemoconcentration which may indicate severe preeclampsia 1, and platelet levels as HELLP syndrome is a complication that may arise in preeclampsia. This may also serve as baseline in case operative procedures are required.

Result: TWBC – 12.0 x109/L ↑ (neutrophils – 8.20, lymphocytes – 2.70)

Hemoglobin – 10.7 g/dL ↓

Hematocrit – 32.3% ↓

Platelets – 354 x 109/L

Interpretation: The total white cell count is slightly raised, but this is to be expected in pregnancy. The hemoglobin is slightly low but this is also expected in pregnancy and should be monitored especially if the patient requires surgery or experiences anemic symptoms. There is no haemoconcentration and the platelets are normal.

3. Prothrombin Time, INR, Activated Partial Thromboplastin Time (PT/INR/APTT)

To obtain a baseline of the coagulation profile in case operative procedures are required and also to look for potential coagulopathy as it is a possible complication of preeclampsia.

Result: PT – 12.3s INR – 1.05 APTT – 39.6s

Interpretation: PT/INR/APTT is within normal range. Coagulopathy appears unlikely in Mdm. SM given that her platelets are also normal and her preeclampsia is not severe.

4. Renal Profile

To assess renal functions to look for elevation of creatinine as that would indicate severe preeclampsia and also to detect acute renal failure which is associated with increased risk of HELLP syndrome, placenta abruption and postpartum hemorrhage 1.

Result: Urea – 1.3mmol/L Sodium – 140mmol/L

Potassium – 3.7mmol/L Creatinine – 51µmol/L

Interpretation: Mdm. SM renal profile is normal and creatinine is not elevated, adding to the indicators that her preeclampsia is of the mild category. Low urea levels and good urine output also rules out acute renal failure.

5. Liver Functions Test

To assess liver functions and its components such as liver enzymes and bilirubin which would be raised in severe preeclampsia or HELLP syndrome in which there is hemolytic anemia and elevated liver enzymes.

Result: Total protein – 73g/L Albumin – 33g/L Globulin – 40g/L

Total bilirubin – 0.5mg/ml Direct bilirubin – 0.2mg/ml Indirect bilirubin – 0.3mg/ml

ALP – 121U/L ↑ ALT – 7 U/L GGT – 7 U/L

Interpretation: Liver enzymes (ALT) and bilirubin levels are not elevated, indicating a mild preeclampsia and no biochemical evidence of HELLP syndrome. The ALP is slightly elevated, but this could be due to compression of the gravid uterus on the hepatobiliary tree.

6. Serum Uric Acid

Elevated serum uric acid is an early biochemical sign of preeclampsia 1 and may help to predict maternal complications in preeclampsia 4.

Results: Serum uric acid – 103µmol/L ↓

Interpretation: Serum uric acid levels are not elevated and are in fact, slightly lowered. This result indicates low likelihood of severe preeclampsia or maternal complications.

7. Serum Lactate Dehydrogenase

To check for elevated levels which should indicate hemolytic anemia, a component of HELLP syndrome.

Results: Not done during this admission.

8. Cardiotocograph (CTG)

Done on admission as a baseline for fetal monitoring.

Results: Baseline fetal heart rate was 130 beats per minute, baseline variability was 5 – 10, accelerations present with no decelerations.

Interpretation: CTG is reactive with no signs of any fetal compromise. CTG should be repeated following each procedure e.g. prostin insertion, AROM or if fetal compromise is suspected.

9. Transabdominal Ultrasonography

This should be done to confirm fetal age, as confirmation of fetal age is important when it comes to deciding whether or not to induce labour in preeclampsia. Also to check for fetal well-being and growth restriction, but these requires repeated scans and plotting of growth chart over a period of time.

Result: No ultrasonography was done during this admission. The last scan was done in Hospital Kluang before patient was transferred to HBP. The last scan reports fetal age corresponding to dates, AFI of 9, and no abnormalities detected with no mention of other findings.

Interpretaion: As fetal age is corresponding to dates and there is no suggestion of fetal compromise or restriction, it is safe to proceed with induction of labour.

10. Urinalysis (UFEME)

To check the levels of proteinuria which may be more quantitative than urine dipstick.

Results: Leukocytes, nitrite, protein, glucose, ketone, urobilinogen, and bilirubin were not detected.

Interpretation: No proteinuria was detected. This could mean that the patient does not have preeclampsia but rather gestational hypertension, or it could be undetected as the blood pressure has also become well controlled with medication. However, no risks should be taken and Mdm. SM should be closely observed in the ward. Either way, induction of labour and delivery would still be ideal for her as she has already reached term.

STUDENT NAME: Paul Kong Fu-Xiang ID NO: M0508129

NAME OF SUPERVISOR: Dr. Sharifah Sulaiha ROTATION: Obstetrics & Gynaecology

7) WORKING DIAGNOSIS AND PLAN OF MANAGEMENT ON ADMISSION

Working Diagnosis

Induction of labour at term in view of mild preeclampsia in pregnancy

Comment: As Mdm. SM has elevated blood pressure and urine dipstick albumin 1+ but has no physical or biochemical features suggestive of severe preeclampsia, the working diagnosis is mild preeclampsia. However, she should be monitored closely in the ward for any symptoms indicative of disease progression. As she has reach term, it would also be wise to induce labour in her, especially given her history of postdates as delivery would be the only definitive management in such cases.

Plan of management on admission

Continue T. Methyldopa 250mg 8-hourly

Daily urine albumin dipstick

Vital signs monitoring 4-hourly

Baseline cardiotocograph on admission

Fetal kick charting and

Labour progress charting

To notify immediately if spontaneous rupture of membranes

To notify immediately if strong contractions commence

Encourage orally

For induction of labour with T. Prostin 1.5mg as Bishops score unfavourable

To notify immediately if any symptoms occur

STUDENT NAME: Paul Kong Fu-Xiang ID NO: M0508129

NAME OF SUPERVISOR: Dr. Sharifah Sulaiha ROTATION: Obstetrics & Gynaecology

8) SUMMARY OF INPATIENT PROGRESS (INCLUDING MAJOR EVENTS, CHANGE OF DIAGNOSIS OR MANAGEMENT AND OUTCOMES)

Throughout the first two days of admission, Mdm. SM was comfortable in the ward with no development of any symptoms of severe preeclampsia, eclampsia, or labour. Her vital signs were stable with blood pressure ranging 122-138/70-84. On the morning of the 2nd day, tablet prostin 1.5mg was inserted into her posterior fornix under aseptic technique. Cardiotocograph was reactive and vaginal examination 6 hours post-insertion showed cervical os 3cm, cervix 2cm, soft and axial, and high station. Therefore, a 2nd tablet of prostin was inserted on the morning of the 3rd day. Once again, post-insertion cardiotocograph was reactive and vaginal examination 6 hours later showed no changes to before. Mdm. SM still did not experience any signs and symptoms of labour. She also did not have any symptoms indicating progression of her preeclampsia. On the morning of the 4th day, it was decided that Mdm. SM should undergo artifical rupture of membranes (AROM) rather than have a 3rd prostin tablet inserted. Cardiotocograph monitoring had been difficult so decision was made to insert fetal scalp electrode at the same time for internal monitoring. Following the AROM, internal monitoring revealed a drop of fetal heart rate from 130 to 100 beats per minute with no accelerations. Cervical os was still 3cm with no symptoms of labour. Decision was made to proceed with emergency lower section caesarean section (ELSCS) under general anaesthesia and Mdm. SM gave her consent. Via ELSCS, a healthy baby boy was delivered weighing 2.9kg with Apgar score of 91105. There were no intra or post-operative complications. Post-operative medications given include IV ampicillin 500mg QID, subcutaneous heparin 5000 units BD, IV pitocin 40 units QID, IM pethidine 50mg PRN, Tab. paracetamol 1g QID and Tab. Mefenemic acid 500mg TDS. Throughout the next 2 days, Mdm. SM was comfortable in the ward and had mild operative site pain with no other symptoms and vital signs were stable. All medications except analgesia were stopped. She was ambulating well, tolerating orally and had passed urine and motion by the 5th day. As for the baby, breastfeeding had commenced and he had also passed urine and motion. The uterus was well contracted at 22 weeks size and dressing was not soaked. Inspection of the wound on the 6th day revealed a clean and non-gaping wound. She was counseled on contraception and indicated a preference for intrauterine contraceptive device. As she was well, she was discharged with appointment to return to postnatal clinic at KKSR to review her blood pressure and operative wound in 1 week’s time. On discharge, her blood pressure was 140/70mmHg and urine dipstick albumin was trace.

STUDENT NAME: Paul Kong Fu-Xiang ID NO: M0508129

NAME OF SUPERVISOR: Dr. Sharifah Sulaiha ROTATION: Obstetrics & Gynaecology

9) DISCHARGE PLAN, COUNSELLING AND MOCK PRESCRIPTION

Discharge Plan

Tab. Mefenemic acid 500mg TDS PRN

Tab. Paracetamol 1g QID PRN

Follow-up appointment at Klinik Kesihatan Simpang Renggam (KKSR) Postnatal clinic in 1 week to review blood pressure and operative wound.

Follow-up appointment at KKSR in 6 weeks for review, cervical smear, and contraception.

Counseling

Advised to return immediately to the hospital if Mdm. SM has problems with the caesarean wound e.g. pain, discharge or if she develops any new or worrying symptoms.

Advised on the need to be compliant to postnatal follow-up to review Mdm. SM’s condition.

Advised for cervical smear during postnatal follow-up as previously never done.

Counseling regarding breastfeeding and contraception.

Explain about the nature of pregnancy-related hypertensive disorders and its long term implications.

Advised to attend antenatal clinic for preconceptual counseling if future pregnancy is desired, or to come for booking immediately once discovered to be pregnant.

Advised to observe a healthy lifestyle in order to prevent development of conditions such as hypertension and diabetes.

Mock Prescription

Tab. Paracetamol 1g QID PRN x 1/52

Tab. Mefenemic acid 500mg TDS x 1/52

STUDENT NAME: Paul Kong Fu-Xiang ID NO: M0508129

NAME OF SUPERVISOR: Dr. Sharifah Sulaiha ROTATION: Obstetrics & Gynaecology

10) REFERRAL LETTER (IF APPLICABLE)

Medical Officer,

Postnatal Clinic,

Klinik Kesihatan Simpang Renggam,

86200, Simpang Renggam. 20th June 2010

Mdm. SM (IC.800318015794)

Date of admission: 20th June 2010, Date of discharge: 25th June 2010

Problem: Late onset hypertensive disease in pregnancy

Dear medical officer,

Mdm. SM is a 30-year-old Malay lady of parity 4+1 who was diagnosed to have preeclampsia at 36 weeks of gestation during routine antenatal follow-up at your centre. During admission to our ward, she underwent induction of labour with tablet prostin and artificial rupture of membranes. However, fetal distress developed, picked up on internal monitoring and Mdm. SM underwent emergency lower section caesarean section under general anaesthesia. She delivered a healthy baby boy (2.9kg, Apgar 91105) with no complications intra- and post-operatively. We are discharging her into your care. Please review her blood pressure as scheduled and also offer contraception and cervical smear as previously never done. She has indicated preference for intrauterine contraceptive device. Do not hesitate to contact us immediately should the need arise. Thank you very much for your attention.

Yours sincerely,

Paul Kong Fu-Xiang (Final year medical student, IMU),

Department of Obstetrics & Gynaecology, Hospital Batu Pahat.

STUDENT NAME: Paul Kong Fu-Xiang ID NO: M0508129

NAME OF SUPERVISOR: Dr. Sharifah Sulaiha ROTATION: Obstetrics & Gynaecology

11) LEARNING ISSUES IN THE 8 IMU OUTCOMES

1. Disease prevention and health promotion

Hypertensive disorders in pregnancy are one of the most common antenatal problems and eclampsia is a major source of maternal mortality. What are the ways in which some element of prevention can be instituted or to decrease the severity of preeclampsia?

There haven been certain strategies touted to prevent or modify the severity of preeclampsia. These are categorized as dietary supplements, antihypertensive medications, antioxidants, and antithrombotic agents 5. As low salt diet is one of the recommended dietary changes for hypertensive patients, De Snoo et al 1 was one of the earliest researchers to study the effects of low salt diet in preventing preeclampsia but this practice was discarded as it yielded no significant change. Knuist et al performed a randomized controlled trial in 1998 and they reported that despite helping control blood pressure in non-pregnant individuals, a sodium-restricted diet was ineffective in 361 women in terms of prevention of preeclampsia 6. The dietary supplementation of calcium of at least 1 gram per day is recommended as class I-A evidence 2. Several studies showed that women with low calcium diets were at significantly increased risk of gestational hypertension 7,8,9. Levine et al performed a large, randomized-controlled trial and they found that there was no significant difference in outcome with calcium supplements versus placebos 10. This suggests that unless a pregnant woman has a low calcium intake, calcium supplements may have no added benefit 5. With regards to fish oil supplements and its cardioprotective fatty acids, randomized trials have not shown any benefit 1.

Concerning diuretics, its use was initially advocated due to its link with salt restriction. However, as above, salt restriction has not shown to be helpful in pregnancy. Churchill et al conducted a meta-analysis in 2007 and found that diuretics were successful in reducing incidences of edema and hypertension, but did not lower incidences of preeclampsia 11. Several randomized trials evaluated the use of antihypertensives in reducing the risk of superimposed preeclampsia in pregnant women with pre-existing chronic hypertension, but analysis of these trials failed to demonstrate any beneficial effect 5. Antioxidants, namely Vitamin C and E, were found to be low in plasma levels of women who developed preeclampsia 12. Raijmakers et al therefore recommended these supplements to reduce the risk for preeclampsia but several randomized trials, including the large trial by Roberts et al 13 failed to show a reduction of preeclampsia in women taking antioxidant supplements when compared to placebos.

Preeclampsia involves vasospasm, endothelial cell dysfunction, activation of platelets and the coagulation-hemostasis system 1, and for these reasons, it seems reasonable that aspirin, an inhibitor of platlet thromboxane A2 biosynthesis, might prove beneficial in reducing its incidence. Caritis et al found no significant benefits in any of their outcomes in their clinical trial 14. However, Askie et al reported in their clinical trial a 10% reduction in relative risk concerning the development of preeclampsia, superimposed preeclampsia, preterm delivery or any adverse outcome 15. However, they also found that no particular group of women would benefit from aspirin over others and that the number-needed-to-treat was high 15.

In conclusion, no particular supplement or medication appears to have an overall beneficial effect on pregnant women and their risks of developing preeclampsia. However, it can be implied that certain therapies, mainly calcium supplements and low-dose aspirin, may be recommended to certain individuals depending on their indications 5. Mdm. SM has indicated that she no longer wishes to add to her family of 4 children, so these considerations will not be applicable to her unless she changes her mind in the near future.

2. Family and community issues in healthcare

Hypertensive disorders in pregnancy are associated with some long term implications. What are some of them and what are the chances to contract them?

One major implication of newly-diagnosed hypertension in a pregnant woman is that she may have previously undiagnosed chronic hypertension. If in cases of gestational hypertension, the high blood pressure should resolve by 12 weeks postpartum and any patient with persistent hypertension beyond this period can be said to be having chronic hypertension that was previously undetected. The Magpie trial reported that 20% of 3375 women with preeclampsia still had hypertension at a period of 26 months postpartum 16. This shows that many women are only found to be hypertensive for the first time during healthcare encounters for their pregnancies and were previously asymptomatic. Also, studies have shown that women were likely to get recurrence of hypertensive disorders in pregnancy in their subsequent pregnancies. Sibai et al 17 reported a recurrence of up to 40% in nulliparous women diagnosed with preeclampsia before 30 weeks gestation in subsequent pregnancies and Hjartardottir et al 18 reported a 70% recurrence. Women with HELLP syndrome are associated with not only recurrence risk of preeclampsia, but also a higher incidence of preterm delivery, intrauterine fetal growth restriction, placenta abruption and caesarean delivery 1. Women with early-onset severe preeclampsia have also been associated with underlying thrombophillia and if present, a twofold increased risk of recurrent preeclampsia 19.

Besides recurrence of preeclampsia, it is also linked with future cardiovascular and neurovascular morbidity, helped in part by future implications of traditional risk factors such as hypertension and diabetes which have been associated with hypertensive disorders in pregnancy. Lykke et al reported that chronic hypertension was significantly increased 5.2-fold in gestational hypertension, 3.9-fold in mild preeclampsia, 6.4-fold in severe preeclampsia and that there was also a 3.5-fold increased risk for type 2 diabetes 20. Bellamy et al reported significantly increased risks of hypertension, ischemic heart disease, stroke and all-cause mortality in women who had preeclampsia previously 21. Other than diabetes and hypertension, these end outcomes are also in part due to a number of comorbidities including obesity, dyslipidemia and atherosclerosis.

Regarding renal complications of preeclampsia, Vikse et al found preeclampsia was associated with a 4-fold increased risk of end-stage renal failure, although the absolute risk was small, and that women with recurrent preeclampsia were at an even greater risk 22. These women may be suffering the long term sequelae such as chronic hypertension leading to nephropathy as they would have higher peripheral vascular and renal vascular resistance with decreased renal blood flow. In the case of eclampsia, recent evidence suggests that eclamptic women were at increased risk of impaired cognitive functioning and this could be due to increased aggregate white matter lesions in the brain due from cerebral infarctions suffered during the seizure 1,23. However, these conclusions are as yet limited and more studies will be required.

In terms of long term consequences, Mdm. SM and all other women with hypertensive disorder in pregnancy should be made aware of all the implications of preeclampsia during the pregnancy. The link to chronic hypertension and diabetes is definitely worth a mention and these comorbidities could in part lead on to ischemic heart disease and stroke or other complications. For Mdm. SM’s case, she would benefit from primary prevention as she is still young and otherwise, quite healthy. The opportunity to educate her on all these points should not be lost on her discharge or follow-up at the postnatal clinic.

3. Application of basic science in the practice of medicine

Preeclampsia is a multi-system disease that cause changes to major organs which may lead to complications. This issue addresses some of these changes.

The cause of preeclampsia is unknown, but there is evidence of its manifestations in early pregnancy that progresses throughout gestation and may eventually lead to multi-organ involvement with a clinical spectrum ranging from barely noticeable to cataclysmic deterioration for both mother and fetus 1. These changes are thought of to be the effects of vasospasm, endothelial dysfunction, and ischemia. The multi-organ changes of preeclampsia are often multiple and overlap. Cardiovascular changes depend on several factors, including the severity of hypertension, the level of afterload, presence of underlying chronic disease and instil changes such as endothelial activation with extravasation of intravascular fluid into the extracellular space such as the lungs causing pulmonary edema, increased afterload due to the high blood pressure and decreased cardiac preload 1. It is also noted that the blood volume gained (normally around 1.5L) in pregnancy is reduced or even absent in some women with eclampsia 24. This could be due to the endothelial activation causing vasoconstriction leading to leakage of plasma fluid into the interstitial space. However, women with preeclampsia or gestational hypertension usually have less marked changes or even no change respectively 25. Due to these changes in hematocrit, eclamptic women are more likely to be more sensitive towards fluid therapy as well as amounts of blood loss during delivery.

Regarding haematological changes, preeclampsia affects platelets, erythrocytes and clotting factors. Thrombocytopenia in preeclampsia is common and at times, the level of thrombocytopenia can reach life-threatening levels and low counts are associated with increased maternal and fetal morbidity and mortality. This continues to worsen until delivery, and therefore, regular platelet counts will be required for decisions in management. Preeclampsia also decreases platelet lifespan and increased degranulation on activation. Severe preeclampsia is also associated with microangiopathic hemolysis caused by endothelial disruption with platelet adherence and fibrin deposition, and combined with thrombocytopenia and elevated liver enzymes, constitute the HELLP syndrome that may also involve hepatocellular necrosis. There is also a reduction in clotting factors leading to a hypercoagulable state.

Regarding renal changes, extracellular fluid manifests as edema due to endothelial injury and reduced plasma oncotic pressure which is further worsened by proteinuria. There is also decreased renal perfusion and glomerular filtration which could have result from the reduced plasma volume mentioned earlier. This is associated with elevated sodium, creatinine and uric acid levels. Liver changes include hepatocellular necrosis, infarction or hemorrhage that manifest as abdominal pain and elevated liver enzymes or a hepatic hematoma on CT scan. These liver changes are part of the HELLP syndrome.

In conclusion, the changes of preeclampsia to the body are variable and wide, so close attention should be paid to patients admitted with preeclampsia. A high index of suspicion should alert the doctor to possible life-threatening changes taking place, and several quick investigations should be performed to help establish some of these changes or as baseline. Complications that are recognised early can be treated and decrease the risk of mortality for both mother and child.

4. Critical thinking and research

Mdm. SM was treated with tablet methyldopa for her moderate hypertension while she was warded. Will the use of an anti-hypertensive prevent progression to more severe disease and improve the outcome?

(Worksheet attached behind)