GROUP 2

 VAIBHAV JAIN
 KALIYANNAN KAYALVIZHI
 KRISHNAMOORTHY SRINATH
 KUMAR ESWARI
 CASE
 36 year old, 38 6/7 weeks of gestation presented with
bloody discharge.
GENERAL DATA:
 Name : J.P
 Age: 36 years old
 Religion: Roman catholic
 Marital status: married
 Occupation: House wife
 Address: Davao city
 Informant : patient
 Reliability : 90%
 Date and Time of admission: February 10, 2019; 3am
CHIEF COMPLIANT:

VAGINAL DISCHARGE
ABDOMINAL PAIN
HISTORY OF PRESENT ILLNESS:
4 hours prior to admission JP noticed sticky blackish
vaginal spotting quantified as 1+1/2 teaspoon associated
with intermittent progressive crampy, hypogastric abdominal
pain every 30 minutes with pain scale rating of 6/10 . Before
the onset of symptoms, she was walking around and reading.
JP also felt palpitations at the onset of her symptoms along
with increased urine frequency for every 15 mins. No other
associated symptoms like fever ,vomiting, chest pain, cough,
were reported. No medications were taken to relieve the pain.
Since the pain was progressively increasing, this made her
seek medical attention.
Menstrual HIstory
 Menarche: 14 years old
 Interval: regular monthly
 Duration: 3-4 days
 Amount: 6 pads/day, changes every 3 hour
 Dysmenorrhea on 2nd day
OB HISTORY:
 G1P1(1001)
 AGE : 36 years
 LMP: May 14,2018
 AOG: 38 6/7 weeks
 EDC: Feb 21,2019
 MODE OF DELIVERY: C- section
 Complications: Preeclampsia with severity.
ANTENATAL HISTORY:
 Antenatal visits: every 4 weeks till 28months at private
ob clinic, every 2 weeks till delivery at SPMC.
 Immunization: tetanus toxoid 3 doses
 Medications: calcium supplements, ferrous sulfate,
vitamin B complex, folic acid.
 Contraceptives: none
 Complications : UTI at 8 months AOG treated with
cefuroxime.
SEXUAL HISTORY:
 JP had her coitarche at 27 years old. She had 2 sexual
partners in her lifetime. She is married for the past 1
year 6months. Her last sexual intercourse during
midtrimester.
 No pain, no discharge was experienced by JP.
PAST MEDICAL HISTORY:
 JP was diagnosed with allergic rhinitis in her 20’s.
 At 34 years of age,JP was admitted at dmsf for
pneumonia for 7 days and was given antibiotics and
Budesonide .
 At 8 months AOG the patient had asthmatic attack and
was treated with a nebulizer by her pulmonologist. She
was adviced to take monteleukast and salbutamol when
her symptoms exacerbates
 History of UTI at 17 years old, treated with antibiotics.
 No allergies to foods and medications.
 No surgeries were done
FAMILY HISTORY:
 Father side : Diabetes
 Mother side: Hypertension
 No other illness like stroke,heart disease,
TB,obesity,allergy,asthma.
DIET AND NUTRITIONAL
HISTORY:
The patients has 3 meals per day composed
of rice,fruits and vegetables and sometimes junk foods.
PERSONAL AND SOCIAL HISTORY
She has good relationship with her husband
who is a driver. She lives in extended family of 10
members. She doesn’t smoke or drinks alcohol but her
husband drinks.
ENVIRONMENTAL HISTORY
JP reports that her neighbourhood is clean,
and their water supply is from the water district, she
reports that there is increase in cases of dengue In her
locality. They have 2 pet dogs, but no rodents or cats
around the house.
REVIEW OF SYSTEMS
 General:
(+)weight change,(+)fever,(+)weakness
(-)anorexia (+)sweats
 Endocrine System:
(+) Heat cold intolerance (-) Thyroid problems,
surgeries
(-) Diabetes/ diabetes indicators (-) Others.
 Eye:
(-) Visual Dysfunction,(-) Itching (-)Pain
(-)Redness, (-) Lacrimation
• Ear:
(-) Deafness (-) Tinnitus (-) Discharge (-) Others

• Nose:
(-) Epistaxis (-) Discharge (-) Obstruction
(-) Postnasal drip (-) Sinusitis

• Mouth:
(-) Bleeding gums (-) Sores (-) Fissures
(-) Dental Caries (-) Others

• Throat:
(-) Soreness (-) Tonsilitis (-) Others
• Neck:
(-) Stiffness (-) Limited motion (-) Others
• Gastro-intestinal:
(-)Nausea (+) Vomiting ,(-)Dysphagia
( -)Distention (-)Diarrhea
(-)Constipation
(-) GI surgery (-)Hemorrhoids .

• Pulmonary system:
(+) Dyspnea (-)Breathlessness ,
(-)Cough (+) asthma (-) Sputum production
(+)wheezing (+) Chest X-ray (-) Pain (-)Others.

• Cardiac:
(-) Pain
(-)Orthopnea (-) Nocturnal dyspnea (+)Palpitations
(-)Syncope (-)Edema (-) Previous heart disease
Neurological System:
(+)Headaches (-)Seizures (-)Head trauma
(-)Pain
(-)Episodic neurologic symptoms (-)others.

Hematopoietic:
(-)Abnormal bleeding (-)Bruising (-)Anemia
(-)Pica (-)Adenopathy (-)Others

Genito-urinary:
(+)Urinary frequency (-)Urgency (-)Dysuria
(-)Flank pain (-)Nocturia (-) Discharge
(-) Urine stream flow abnormality
(-) genital lesions (-) pains
Skin:
(-)Itching (-)Colour (-) Rash. (-)Pigmentation
(-)Vasomotor changes (-)hair (-)Nails
(-)Photosensitivity (-)Other.

Musculoskeletal:
(-)Joint stiffness (+) Back Pain (-)Swelling
(-)Cramps (-)Wasting (-)Trauma
(-)Kyphosis (-)Scoliosis ( )Others.

Psychiatric:
(-)Previous problems (-) Hospitalization
(-) Interpersonal relationship difficulties
PHYSICAL EXAMINATION:
GENERAL STATUS: Conscious, coherent and cooperative.
VITAL SIGNS:
 Temperature: 36.5 degree celsius
 Blood pressure: 140/80 mm hg
 Respiratory rate: 16 breaths per minute
 Heart rate: 59 beats per minute
 Weight: 52 kg
 Height:4’11
 BMI : 23
PHYSICAL EXAMINATION:
 HEENT:
 Atraumatic with equal hair distribution, no
lesions or scars.
 White sclera with pinkish conjuctiva no redness,
no discharge, follows objects in all directions with
no lag
 Good acuity with whispered voice test.
 Patent non deviated septum with no discharge
and respiratory distress
 moist pinkish buccal mucosa, No dental caries.
CHEST:
 LUNGS:
 Inspection : no lesions ,no chest wall
deformities,no retractions.
 Palpation: mild vocal fremitus equal on both
sides
 Percussion: not assessed.
 Auscultaion: Vesicular breath sounds equal
across the breath fields on both sides,no
adventitious sounds.
HEART:
Inspection: adynamic precordium, No cyanosis,
Non pitting Bipedal Edema
Palpation: No thrills or heaves, Point of Maximal
Impulse- 5th ICS mid-clavicular
Percussion: not assessed.
Auscultation: distinct s1 and s2, no murmurs heard.
BREAST:
no masses,retractions and discharges.
The patient is actively breastfeeding.
 ABDOMEN:
 Distended abdomen with a binder. Non tender .
 PELVIC EXAM: not assessed.
 Neurologic :
 Awake , alert, responsive
 No exaggeration of reflexes, flexion , extension against gravity
and resistance
 No sensory deficits
 Cranial nerves:
Cranial nerves:
 Cn 1: not assessed
 CN 2: no visual field defects, bilateral symmentric pupillary light reflex
 CN 3,4, 6: Follows object in 6 directions, no lag while closing eyelids
 CN 5- Protrude and Retracts Jaw, + Fine and Coarse sensations on the
face
 CN7- Bilaterally symmetric facial expressions and frowning of
eyebrows
 CN8-Correctly identifies words and numbers on whisper test
 CN9,10- No difficulty Swallowing, Uvula could not be visualized due to
large tongue size
 CN11- Can shrug shoulders symmetrically even against resistance.
 CN12- Could not protrude her tongue outside.
SALIENT FEATURES:
 Age 36y/o, G1P1 (1-0-0-1)
 No history of Hypertension or Diabetes
 New onset Blood pressure >150/90mmHg
 lower abdominal Pain ( Crampy;6/10)
 Black Sticky Bloody Discharge
 Non pitting bipedal edema

Impression: preeclampsia with

severity
IMPRESSION:
JP,36 year old, G1P1(1-0-0-1) elderly primigravid,
uterine pregnancy , cephalic presentation,
preeclampsia severe, c- section delivery at 38 6/7
weeks AOG,
DIFFERENTIAL DIAGNOSIS:
Chronic Hypertension/ Chronic Hypertension
Superimposed with Preeclampsia
RULE IN
 High Blood Pressure- 150/90 mm Hg
 Older women are at greater risk for chronic hypertension
with superimposed preeclampsia.

RULE OUT
 No history of Maternal Hypertension or Diabetes before
preganancy or before 20 weeks of gestation as seen in
Chronic Hypertension
 Chronic Hypertension with Preeclampsia develops early in
the course of Pregnancy
Gestational Hypertension

RULE IN:
 Rise in Blood pressure (150/90mmHg) first time after
midpregnancy
 Abdominal Pain

RULE OUT:
 (If symptoms of Preeclampsia do not develop and the
Blood Pressure returns to normal within 12 weeks
postpartum)
Ecclampsia

 Rule In
High Blood Pressure(150/90 mmHg)
Abdominal Pain
 Rule Out
No Seizures or other Cerebral Symptoms
Discussion- Pathophysiology
PATHOPHYSIOLOGY:
 Placental implantation with abnormal trophoblastic
invasion of uterine vessels

 Immunological maladaptive tolerance between

maternal, paternal (placental), and fetal tissues.

 Maternal maladaptation to cardiovascular

or inflammatory changes of normal pregnancy

 Diet, Nutrition and Genetic factors including inherited

predisposing genes and epigenetic influences.
Diseased placenta releases pro-inflammatory proteins TNF-A and IL-1 that cause-
Hypertension
Vasoconstriction
Endothelial cell dysfunction
Formation of thrombi
End-organ damage
Management and Treatment
 Only definitive treatment is Termination of pregnancy
 Magnesium Sulfate to prevent progression to
Eclampsia and reduce blood pressure
 Anti-Hypertensives
 Low dose Aspirin to reduce the risk of thrombosis
 Diuretics should not be given
Thank you…..