Week 1 Portfolio

Student name: Tharsika Dasnamurthy Reddiar

Student ID:18100759

MW, 22 years old, currently at 33+4, presented to Maternity Day Assessment Unit for
continuous blood pressure monitoring. During her clinic appointment 3 days before, she was
noted to have a blood pressure of 147/91 mmHg. She said it was a first for her as her blood
pressure readings during the clinics have always been normal.

In the unit, her blood pressure readings were:

1 2 3 4 5
135/80 137/88 139/85 139/86 138/87

Her urine was checked via dipstick, which contained traces of protein. She also reported
feeling a headache as she was lying down. She described the headache as a tight band around
her head. She denied any nausea and vomiting. There were no changes in vision. She does
have swelling of hands and feet but feels its due to the pregnancy. She said she felt a little
faint, but it could be due to the fact she had not eaten yet.

Other than the recent hypertensive readings, she previously had hyperemesis with dizziness
when she was 14 weeks for which she had to be hospitalized to receive IV fluids. At 23
weeks, she reported an increased frequency of urination, but she did not have an infection.

She had received anti-D at 26 weeks as she has an O- blood type.

Past medical history: Nil

Drugs and allergies: NKDA and not on any medication.

Family history: Both parents have high blood pressure, and her father had a heart attack a few
years ago.
Social history: Currently not working and lives at home with her partner and his family.

Physical Examination

Respiratory rate (bpm) 17

O2 saturation rate 98%
Temperature 36.3
Maternal Heart rate 85
Pain X

BMI=39kg/m2

She was lying down comfortably, not in respiratory distress, and was alert. Upon inspection,
the abdomen was distended with an everted umbilicus. There was linea nigra and pale striae
noted on the abdomen. There were no scars in the suprapubic area and around the rest of the
abdomen. There were some fetal movements noted.

Symphysial Fundal height was 32cm, and palpation of the abdomen showed that the fetus
was in a longitudinal lie and cephalic presentation. The fetus was not engaged in the pelvis.
Auscultation of fetal heart rate was done using the doppler and was at 136bpm, which is
normal.

Learning points

1. Gestational Hypertension
2. Pre-Eclampsia
3. Hyperemesis Gravidarum

What aspects of the case increased your knowledge on this topic?

Gestational HTN and Pre-Eclampsia

Gestational hypertension often happens in the third semester, usually after 32 weeks(NICE
defines it as presenting after 20 weeks of pregnancy without significant proteinuria), and
patients are at risk of pre-eclampsia if diagnosed with pregnancy-induced hypertension.
According to the HSE, about 2-5 in 100 women will be diagnosed with pre-eclampsia. Their
blood pressure rises, and they also have protein in their urine. In MW's case, the risk factors
identified are nulliparity and BMI>35kg/m2. She was commenced on 200mg Labetalol PO
OD.

According to NICE Guideline [NG133],

1. An ultrasound for fetal growth, amniotic fluid volume assessment and umbilical artery
doppler velocimetry should be carried out at diagnosis and if normal, repeat every 2 to
4 weeks (If clinically indicated)
2. CTG is only done if clinically indicated (at diagnosis of pre-eclampsia or severe
gestational hypertension).
3. There is no need to offer planned early birth before 37 weeks for women with
gestational hypertension if blood pressure below 160/110mmHg unless there are other
medical indications. (Timing of birth, maternal and fetal indications should be agreed
between the women and the obstetrician)
4. If planned early birth necessary, antenatal corticosteroids and magnesium sulfate
should be offered.
5. During labour, blood pressure measured hourly OR every 15-30 minutes until blood
pressure below 16/110mmHg in women with severe HTN. Continue use of antenatal
antihypertensive treatment during labour. Do not routinely limit the duration of the
second stage of labour in women with controlled hypertension. Consider operative or
assisted birth in the second stage of labour for women with severe hypertension
whose hypertension has not responded to initial treatment.
6. In terms of postnatal care, measure BP daily for the first 2 days, at least once between
day 3-5 and as indicated if antihypertensive treatment changes after birth. Reduce
treatment if blood pressure falls below 130/80mmHg, and if methyldopa was taken,
stop within 2 days after birth and change to an alternative treatment. For women who
were not on treatment, but blood pressure is >150/100mmHg, consider treatment.
7. For breastfeeding, treatment can be adjusted. Antihypertensives can pass into breast
milk but only very low levels. Women are advised to monitor babies for signs of
drowsiness, lethargy, pallor, cold peripheries, and poor feeding.
8. Medications that are offered during the postnatal period are:
-Enalapril (monitor maternal renal function and serum potassium)
 -Nifedipine/Amlodipine (Black African/Carribean family origin)
-Combination of Nifedipine(Or amlodipine) and enalapril OR adding
atenolol/labetalol.
-Avoid diuretics or ARBs with women who are breastfeeding.
9. For postnatal review, if they are still on treatment review in 2 weeks, but if they are
not a 6-8 weeks postnatal review is sufficient.

Symptoms of pre-eclampsia are:

 severe headache
 problems with vision, such as blurring or flashing before the eyes
 severe pain just below the ribs
 vomiting
 sudden swelling of the face, hands, or feet.

On diagnosis of pre-eclampsia, NICE diagnostics guidance [DG23], recommends the Triage

PlGF test and the Elecsys immunoassay sFlt-1/PlGF ratio, used with standard clinical
assessment and subsequent clinical follow-up, are recommended to help rule-out pre-
eclampsia in women presenting with suspected pre-eclampsia between 20 weeks and 34
weeks plus 6 days of gestation. For assessment of urine, protein:creatinine ratio is used to
quantify proteinuria. (Don’t use first morning urine and no routine 24 hour urine collection).
30mg/mmol is the threshold for significant proteinuria.
For a risk prediction models for place of care and thresholds for interventions, fullPIERS
(used at any time in pregnancy) and PREP-S (use up to 34 weeks only) should be considered
but they do not predict outcome for the babies.
Labetolol is the treatment of choice, but for women in which labetolol is unsuitable,
nifedipine is offered. If neither is suitable for the patient, methyldopa is offered.
Planned early birth before 37 weeks should be considered if there are the following features:
 inability to control maternal BP despite using 3 or more classes of antihypertensives
in appropriate doses
 maternal pulse oximetry less than 90%

 progressive deterioration in liver function, renal function, haemolysis, or platelet

count
 ongoing neurological features, such as severe intractable headache, repeated visual
scotomata, eclampsia.
 placental abruption

 reversed end-diastolic flow in the umbilical artery doppler velocimetry, a non-

reassuring cardiotocograph, or stillbirth. 

Weeks of
Timing of birth
pregnancy
Continue surveillance unless there are indications (see the
Before 34 recommendation above on thresholds) for planned early birth. Offer
weeks intravenous magnesium sulfate and a course of antenatal corticosteroids in
line with NICE's recommendations on preterm labour and birth. 
Continue surveillance unless there are indications (see the
recommendation above on thresholds) for planned early birth.
When considering the option of planned early birth, take into account the
From 34 to
woman's and baby's condition, risk factors (such as maternal
36+6weeks
comorbidities, multi-fetal pregnancy) and availability of neonatal unit
beds. Consider a course of antenatal corticosteroids in line with NICE's
recommendations on preterm labour and birth. 
37 weeks
Initiate birth within 24–48 hours.
onwards

Posnatally:
1. Blood pressure should be checked for women not on any treatment at least 4 times a
day while an inpatient, once between day 3 and 5 (alternate days if abnormal). Ask
about severe headache and epigastric pain each time.
2. If they did have treatment antenatally, measure BP 4 times a day and every 1-2 days
for up to 2 weeks until OFF treatment and has no HTN.
3. Measure platelet count, transaminases, and serum creatinine 48-72 hours after birth.

For both Gestational HTN and pre-eclampsia, it is important to advice women on future risks,
such as:
1. Long term risk of cardiovascular disease and end stage kidney disease.
 2. Thrombophilia and the risk of pre-eclampsia (Routine screening is NOT performed)
3. 1 in 5 overall risk of recurrence. (Women advised to keep a healthy BMI)
4. Inter-pregnancy interval of more than 10 years increases likelihood of recurrence.

Hyperemesis Gravidarum (Green Top Guideline No.69)

Hyperemesis Gravidarum(HG) diagnosed when there is protracted nausea and vomiting with
more than 5% of prepregnancy weight loss, dehydration and electrolyte imbalance. Inpatient
management should be considered if there is at least one of the following:
 Continued nausea and vomiting and inability to keep down oral antiemetics
 Continued nausea and vomiting associated with ketonuria and/or weight loss (greater
than 5% of body weight), despite oral antiemetics.
 Confirmed or suspected comorbidity (such as urinary tract infection and inability to
tolerate oral antibiotics).
Safe to use in pregnancy are first-line antiemetics such as antihistamines (H1 receptor
antagonists) and phenothiazines. For women with severe HG, a parenteral or rectal route may
be more effective than the oral regime. With the use of phenothiazines and metoclopramide,
there is the risk of extrapyramidal symptoms and oculogyric crises. Therefore,
metoclopramide and ondansetron are generally used as 2nd line therapy. For IV rehydration,
normal potassium with additional KCL is the most appropriate. Some complementary
therapies that were found to be useful are ginger and acustimulations. Urea and serum
electrolyte levels should be checked daily in women requiring IV fluids. Thiamine
supplementation should be given to ALL women admitted with prolonged vomiting,
especially before administration of dextrose or parenteral nutrition. Women admitted with
HG, should be offered thromboprophylaxis with LMWH (due to VTE) unless there are
contraindications, and they should avoid iron-containing preparations as it can cause nausea
and vomiting.

How will I apply this learning to my development as a doctor in a meaningful way?

Through this case, I learned about the diagnosis of gestational hypertension as well as pre-
eclampsia according to guidelines. The guidelines highlighted a flowchart looking into
aspects of antenatal care, fetal monitoring, the timing of birth, intrapartum care, and postnatal
care. It was also essential to differentiate between the care of women with chronic
hypertension and gestational hypertension, especially as management would differ from the
start of the pregnancy. I learned of the importance of pre-eclampsia as it can become
eclampsia if not controlled, so it is essential to explore symptoms and signs in a woman
presenting with sustained high blood pressure. Nausea and vomiting, although common in
pregnancy, can be debilitating for women as it can lead to dehydration and fatigue. It is
crucial to address the concerns of the women and help them in any way, even suggesting
complementary therapies that might help if they do not want to take any medications in fear
of harming the fetus. Starting medication for these women could bring some concerns as they
would be worried about the baby; therefore, it is essential to take time to explain why the
medication is needed and that it would not harm the baby.

References

1. [Internet]. Rcog.org.uk. 2020 [cited 10 January 2020]. Available from:

https://www.rcog.org.uk/globalassets/documents/guidelines/green-top-guidelines/gtg69-
hyperemesis.pdf
2. Hypertension in pregnancy - NICE Pathways [Internet]. Pathways.nice.org.uk. 2020 [cited
10 January 2020]. Available from: https://pathways.nice.org.uk/pathways/hypertension-in-
pregnancy#content=view-index&path=view%3A/pathways/hypertension-in-
pregnancy/hypertension-in-pregnancy-overview.xml