HYPERTENSION COMPLICATING

PREGNANCY OR PIH CASE

• SANGEETH.S
 DEMOGRAPHIC DETAILS

• 21 YEARS OLD MRS. K. KEERTHIKA, FROM BESANT NAGAR, HOME MAKER, BELONGING TO SOCIO-
ECONOMIC CLASS IV( INCIDENCE:HIGH >LOW SOCIOECONOMIC CLASS ,BUT PROGNOSIS GOOD IN
HIGH SOCIOECONOMIC CLASS)

• OBSTETRIC CODE : PRIMI GRAVIDA(MORE COMMON IN ELDERLY PRIMI)

• BOOKED AND IMMUNIZED WITH 2 DOSES OF TT( CAN IDENTIFY AND ASSESS THE RISK FACTORS
AND GIVE ADVICE TO OVERCOME PIH AND COMPLICATIONS)

• LMP : 20/06/2019

• EDD : 27/03/2020

• GESTATIONAL AGE : 35 WEEKS(COMPLICATIONS ARE MORE IN THIRD TRIMESTER)

 PRESENTING COMPLAINTS

• THE PATIENT WAS REFERRED FROM ADAYAR HOSPITAL FOR SWELLING IN BOTH LEGS (COMPLAINTS
OF EDEMA IN THE DEPENDENT PARTS)FROM THE 5TH MONTH AND FOR SAFE CONFINEMENT OF
PREGNANCY

• THE SWELLING WAS PRESENT IN THE ANKLE AND FEET OF BOTH LEGS, FROM 5TH MONTH AND IT
DISAPPEARS ON REST(RULE OUT THE OTHER CAUSES LIKE ANEMIA, HEART DISEASE, LIVER
DISEASE,RENAL DISEASE, DVT AND CHRONIC HTN WITH CCF)

• NO H/O HEADACHE, VISUAL DISTURBANCES, GIDDINESS, EPIGASTRIC PAIN, VOMITING, DECREASED

URINE OUTPUT(INDICATES SEVERE PRE-ECLAMPSIA, IMMINENT ECLAMPSIA)

• ABLE TO PERCEIVE FETAL MOVEMENTS WELL(DUE TO ABRUPTIO PLACENTA)

 PRESENT OBSTETRIC HISTORY
FIRST TRIMESTER :

• SPONTANEOUS CONCEPTION, CONFIRMED BY UPT

• H/O VOMITING PRESENT(RULE OUT HYPEREMESIS GRAVIDARUM)

• NO H/O LETHARGY, FEVER WITH RASH OR ANY INFECTIONS

• NO H/O BURNING MICTURITION, INCREASED FREQUENCY OF MICTURITION,

BLEEDING PV, VAGINAL DISCHARGE(UTI OR REPRODUCTIVE TRACT INFECTIONS)

• NO H/O DRUG INTAKE, RADIATION EXPOSURE(TERATOGENIC EFFECTS)

• DATING SCAN AND NT SCAN WERE DONE AND FOUND TO BE NORMAL

• USG ABDOMEN CORRESPONDS TO GESTATIONAL AGE OBTAINED FROM LMP

• URINE SUGAR AND ALBUMIN : NEGATIVE

• HB : 10.7 G/DL, BP : 125/83 MM HG, BLOOD GROUP : O+VE, WT : 81 KGS

• HIV, HBSAG, VDRL : NEGATIVE

• REGULAR INTAKE OF FA, TT FIRST DOSE GIVEN AT 3RD MONTH

SECOND TRIMESTER :

• QUICKENING FELT FROM 5TH MONTH(IN PRIMI AROUND 20 WEEKS AND MULTI
AROUND 16-18 WEEKS)

• H/O VOMITING PRESENT

• H/O SWELLING IN ANKLE AND FEET OF BOTH LEGS(MAY BE DUE TO

PHYSIOLOGICAL OR PATHOLOGICAL EDEMA)

• NO H/O HEADACHE, ABDOMINAL PAIN, BLURRING OF VISION, REDUCED URINE

OUTPUT(IMMINENT SYMPTOMS OF PRE-ECLAMPSIA)

• NO HISTORY SUGGESTIVE OF GDM

• NO H/O OF BURNING MICTURITION, BLEEDING PV

• ANOMALY SCAN DONE AND NO ANOMALIES WERE PRESENT

• OGCT DONE AND FOUND TO BE NORMAL

• HB : 11 G/DL, BP : 130/90 MM HG, WT : 87 KGS

• LABETALOL 100MG BD FROM 5TH MONTH(ANTIHYPERTENSIVE MEDICATION)

• REGULAR INTAKE OF IRON AND CALCIUM, TT SECOND DOSE GIVEN AT 5TH MONTH
THIRD TRIMESTER :

• H/O PERCEPTION OF FETAL MOVEMENTS(DECREASED IN IUGR AND ABSENT IN

IUD)

• H/O SWELLING IN LEGS

• NO H/O ABDOMINAL PAIN

• NO H/O DISCHARGE, BLEEDING PV OR DRAINING PV(PAINFUL-ABRUPTIO

PLACENTA,PAINLESS BLEEDING-PLACENTA PREVIA)

• HB : 13.2 G/DL, BP : 116/85 MM HG, WT : 90 KGS

• GROWTH SCAN WAS DONE AND FOUND TO BE NORMAL

• CONTINUING LABETALOL 100MG BD

MENSTRUAL HISTORY :

• AGE AT MENARCHE : 11 YEARS

• CYCLE : 4/28 REGULAR, NORMAL FLOW

• NO CLOTS, NO PAIN

MARITAL HISTORY :

• AGE AT MARRIAGE : 20 YEARS

• DURATION : 1 YEAR

• NON-CONSANGUINEOUS(FAMILY H/O HYPERTENSION)

• NO H/O ANY CONTRACEPTIVES

PAST HISTORY :

• NOT A KNOWN CASE OF DIABETES MELLITUS, TUBERCULOSIS, THYROID

DISORDERS, BRONCHIAL ASTHMA, EPILEPSY, HEART DISEASES

• NO H/O OF PREVIOUS SURGERIES

• NO H/O CHRONIC DRUG INTAKE(PAST ANTIHYPERTENSIVE MEDICATIONS)

MEDICAL HISTORY :

• THE PATIENT WAS DIAGNOSED TO HAVE GESTATIONAL HYPERTENSION AT THE

5TH MONTH AND WAS GIVEN LABETALOL 100MG BD, BP UNDER CONTROL
PERSONAL HISTORY :

• CONSUMES MIXED DIET

• NO H/O SMOKING OR ALCOHOL CONSUMPTION(IF YES,INCREASED CHANCES OF HTN AND

COMPLICATIONS)

• NORMAL BOWEL AND BLADDER HABITS

• NORMAL SLEEP PATTERN

FAMILY HISTORY :

• NO RELEVANT FAMILY HISTORY(H/O PRE-ECLAMPSIA IN MOTHER OR SIBLINGS)

GENERAL EXAMINATION :

• COMFORTABLE, CONSCIOUS, ORIENTED(TO RULE OUT ANY COSTS

COMPLICATIONS)

• PATIENT IS OBESE(MORE FOR COMPLICATIONS DUE TO HTN)

• NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, GENERALIZED LYMPHADENOPATHY

• BILATERAL (DUE TO SYSTEMIC CAUSES, NOT LOCAL CAUSES)PITTING PEDAL

EDEMA PRESENT – IN ANKLE AND FEET (GRADE 1){INDICATES MILD EDEMA DUE TO
HTN)

• BREAST, SPINE, THYROID : NORMAL

VITALS :

• PR : 84 BEATS/MIN

• RR : 18 BREATHS/MIN

• BP : 116/85 MM HG MEASURED IN RIGHT ARM IN SITTING POSTURE(ASSESS

SEVERITY)

• TEMP : AFEBRILE
ANTHROPOMETRY :

• HEIGHT : 155 CMS

• PRE-PREGNANCY WEIGHT : 79 KGS

• PRESENT WEIGHT : 90 KGS

• BMI : 32.8 KG/M²

SYSTEMIC EXAMINATION :

• CVS : S1, S2 HEARD, NO MURMURS

• RS : NVBS HEARD, NO ADDED SOUNDS

• CNS : NO FOCAL NEUROLOGICAL DEFICIT

 OBSTETRIC EXAMINATION

INSPECTION :

• AFTER GETTING CONSENT, THE PATIENT IS ASKED TO EMPTY THE BLADDER AND
IS EXPOSED FROM XIPHISTERNUM TO PUBIC SYMPHYSIS

• THE PATIENT IS EXAMINED IN SUPINE POSITION WITH THIGHS SEMI-FLEXED

• LONGITUDINALLY ENLARGED, FLANKS ARE FREE

• STRIA GRAVIDARUM, LINEA NIGRA PRESENT

• UMBILICUS IS INVERTED AND IN MIDLINE

• HERNIAL ORIFICE IS FREE

• NO SCARS, SINUSES OR ENGORGED VEINS

PALPATION :

• AFTER CORRECTING DEXTROROTATION

• SYMPHYSIO-FUNDAL HEIGHT : 36 CMS, CORRESPONDS TO GESTATIONAL

AGE(REDUCED IN IUD OR FGR)

• FUNDAL GRIP : SOFT, BROAD, NON-BALLOTABLE PART IS FELT PROBABLY BREECH

• UMBILICAL GRIP : RIGHT SIDE – UNIFORMLY HARD RESISTANCE FELT PROBABLY

SPINE, LEFT SIDE – MULTIPLE SOFT NODULES FELT PROBABLY LIMBS

• FIRST PELVIC GRIP : HARD, ROUND, INDEPENDENTLY BALLOTABLE MASS FELT

PROBABLY HEAD

• SECOND PELVIC GRIP : HEAD NOT ENGAGED

AUSCULTATION :

• FETAL HEART SOUND HEARD BELOW THE UMBILICUS ON RIGHT SPINO

UMBILICAL LINE(TO RULE OUT BREECH AND TRANSVERSE LIE)

• FETAL HEART RATE : 150 BEATS/MIN

SUMMARY :

• MRS. KEERTHIKA, 21 YEAR OLD PRIMI AT 35 WEEKS OF GESTATION

BELONGING TO SOCIO-ECONOMIC CLASS IV, BOOKED AND IMMUNISED,
LMP 20/06/19 AND EDD 27/3/2020 WAS ADMITTED WITH H/O SWELLING
IN ANKLE AND FEET OF BOTH LEGS. ON EXAMINATION : BILATERAL
PITTING PEDAL EDEMA (GRADE 1) PRESENT, BLOOD PRESSURE OF
116/85 MM HG, FUNDAL HEIGHT CORRESPONDS TO THE GESTATIONAL
AGE, WITH FETUS IN LONGITUDINAL LIE WITH CEPHALIC
PRESENTATION AND FETAL HEART RATE OF 150 BEATS/MIN

DIAGNOSIS :

• PRIMI AT 35 WEEKS OF GESTATION WITH EDD 27/03/2020 IS DIAGNOSED

TO HAVE GESTATIONAL HYPERTENSION WITH VIABLE SINGLE FETUS IN
CEPHALIC PRESENTATION WITHOUT ANY COMPLICATIONS
 INVESTIGATIONS
• BLOOD INVESTIGATIONS : HB%, PCV, PLATELET COUNT, PERIPHERAL SMEAR,
BLOOD GROUPING, RH TYPING, BT, CT, BLOOD SUGAR(RULE OUT ANEMIA OR
HELLP SYNDROME)

• URINE : SUGAR, ALBUMIN(TO RULE OUT PROTEINURIA), 24HR PROTEIN, DEPOSITS

& CASTS(RULE OUT UNDERLYING RENAL DISEASE)

• RFT : SERUM UREA, SERUM CREATININE, SERUM URIC ACID (RULE OUT OLIGURIA)

• LFT : SERUM BILIRUBIN, AST, ALT

• SERUM ELECTROLYTES

• COAGULATION PROFILE : SERUM FIBRINOGEN, PT, APTT(ANY LIVER

COMPLICATIONS AND RULE OUT HELLP SYNDROME)

• FUNDUS EXAMINATION(RULE OUT HYPERTENSIVE RETINOPATHY)

• ASSESSMENT OF FETUS : DFMC, SERIAL USG, MODIFIED BIOPHYSICAL PROFILE

(NST+ AFI), DOPPLER-UMBILICAL ARTERY(DIASTOLIC NOTCH PRESENT IN PIH)
 MANAGEMENT

• REST, HIGH PROTEIN DIET

• ANTIHYPERTENSIVES(TO REGULATE DBP BETWEEN 90-100 MM HG AND PREVENT

MATERNAL COMPLICATIONS)

• LOOKOUT FOR IMMINENT SYMPTOMS (PROGNOSIS)

• MONITOR FOR FETAL WELL-BEING

• MONITOR BP, URINE ALBUMIN, URINE OUTPUT(PROGNOSIS AND COMPLICATIONS)

• INDUCTION OF LABOUR AT TERM

THANK YOU