A pregnant woman , 19 yrs

History taking from patient and her husband

CC : seizure 30 min PTA
OB-GYN Hx :
G1P0 GA 35 wks by U/S
ANC x 8 at private clinic : normal
PH :
No underlying disease
No drug allergy
FH :
No history of seizure
PE :
General appearance : confusion
Vital sign : BP 140/100 mmHg , RR 22 /min ,
BT 38.1 c , PR 120 /min
HEENT : pink conjunctiva , anicteric sclera
Heart and lungs : equal breath sound , normal S1S2 ,
no murmur
Abdomen : HF - , position : ROA , FHS : 160 , uterine
contraction : cant evaluate , EFW : 2500 gram
PV : not done
Hypertensive Disorders of
Pregnancy
I. Introduction
Hypertensive disorders complicate 5 to 10
percent of all pregnancies, and together they
form one member of the deadly triad
In developed countries, 16 percent of
maternal deaths were due to hypertensive
disorders


Ref : William obstetric 23
rd
edition,2009
II. Diagnosis
Hypertension is diagnosed empirically when
appropriately taken blood pressure exceeds
140 mm Hg systolic or 90 mm Hg diastolic
women who have a rise in pressure of 30 mm
Hg systolic or 15 mm Hg diastolic should be
seen more frequently
Ref : William obstetric 23
rd
edition,2009
III. Classification and Definitions

Ref : William obstetric 23
rd
edition,2009
Ref : William obstetric 23
rd
edition,2009
III. Classification and Definitions
Gestational Hypertension
Preeclampsia and eclampsia syndrome
superimposed Preeclampsia on chronic
hypertension
Chronic hypertension

Ref : William obstetric 23
rd
edition,2009
II. Classification and Definitions
1. Gestational Hypertension:
Systolic BP 140 or diastolic BP 90 mm Hg for first
time during pregnancy
No proteinuria
BP returns to normal before 12 weeks postpartum
Final diagnosis made only postpartum
May have other signs or symptoms of
preeclampsia, for example, epigastric discomfort
or thrombocytopenia

Ref : William obstetric 23
rd
edition,2009

2. Preeclampsia and eclampsia syndrome

Preeclampsia:

Minimum criteria:

BP 140/90 mm Hg after 20 weeks' gestation

Proteinuria 300 mg/24 hours or 1+ dipstick

Ref : William obstetric 23
rd
edition,2009

Increased certainty of preeclampsia :
BP 160/110 mm Hg
Proteinuria 2.0 g/24 hours or 2+ dipstick
Serum creatinine >1.2 mg/dL unless known to be
previously elevated
Platelets < 100,000/L
Microangiopathic hemolysisincreased LDH
Elevated serum transaminase levelsALT or AST
Persistent headache or other cerebral or visual disturbance
Persistent epigastric pain

Ref : William obstetric 23
rd
edition,2009

Eclampsia:

Seizures that cannot be attributed to other causes

in a woman with preeclampsia

Ref : William obstetric 23
rd
edition,2009
Ref : William obstetric 23
rd
edition,2009
3. Superimposed Preeclampsia On Chronic
Hypertension:
New-onset proteinuria 300 mg/24 hours in
hypertensive women but no proteinuria before 20
weeks' gestation
A sudden increase in proteinuria or blood
pressure or platelet count < 100,000/L in women
with hypertension and proteinuria before 20
weeks' gestation

Ref : William obstetric 23
rd
edition,2009
4. Chronic Hypertension:
BP 140/90 mm Hg before pregnancy or diagnosed
before 20 weeks' gestation not attributable to
gestational trophoblastic disease
or
Hypertension first diagnosed after 20 weeks'
gestation and persistent after 12 weeks
postpartum

Ref : William obstetric 23
rd
edition,2009
Investigation

UA (15/11)
Color : yellow
Appearance : clear
glu ,ketone
alb : neg
RBC : 2-3
WBC : 5-10
Epi : 5-10
CBC
Hb 12.4 Hct 38.2 WBC 23000
Plt 430000 PMN 66 Lymph 26
MCV 78
Coagulogram
PT 9(11.2) PTT 28.1(29.2)
INR 0.83
Blood chemistry
BUN 5 , Cr 0.9
Electrolyte : Na 136 K 2.8
HCO3 22.3 Cl 104
LFT : pro 7.9 alb 3.8 glob 4.1
DB 0.06 TB 0.47 SGOT 19
SGPT 10 ALP 136
Diagnosis

Management
Non-severe preeclampsia
severe preeclampsia
eclampsia

Non severe preeclampsia
Admit
Bed rest
Monitoring for symptoms of pre-eclampsia ; daily kick counts
Body weight once a day
Blood pressure check every 6 hours , no antihypertensive
drug not shown to improve perinatal outcome
Laboratory testing: baseline 24-hour urine protein collection
at least 3 days
Non-stress test/biophysical profile
Termination
term
clinical worsing (severe PIH)

Ref : Johns Hopkins Manual of Gynecology and Obstetrics, The, 3rd Edition
Severe preeclampsia
Principle
1. Seizure prophylaxis
2. Antihypertensive therapy
3. Delivery
Ref : William obstetric 23
rd
edition,2009
Severe preeclampsia
1. Seizure prophylaxis

Ref : William obstetric 23
rd
edition,2009
Severe preeclampsia
Seizure prophylaxis
LD : Give 4 g of magnesium sulfate diluted in 100 mL of IV
fluid administered over 1520 min
MD :Begin 2 g/hr in 100 mL of IV maintenance infusion.
Monitor for magnesium toxicity:
The patellar reflex is present,
Respirations are not depressed, and
Urine output the previous 4 hr exceeded 100 mL
Magnesium sulfate is discontinued 24 hr after delivery

Ref : William obstetric 23
rd
edition,2009
Severe preeclampsia
Antihypertensive therapy
The three most commonly employed in North
America and Europe are hydralazine, labetalol,
and nifedipine
1. nifedipine
Dosage :
(soft capsule) 10 mg sublingual
(film-coat tablet) 10 mg oral
Ref : William obstetric 23
rd
edition,2009
Severe preeclampsia
2. hydralazine
Dosage : 5 mg IV
Ref : William obstetric 23
rd
edition,2009
Severe preeclampsia
Delivery
1. induction
2.route of delivery

Ref : William obstetric 23
rd
edition,2009
Ecclampsia
Management
Control of convulsions
Intermittent administration of an antihypertensive
medication
Avoidance of diuretics unless there is obvious
pulmonary edema
Delivery of the fetus to achieve a "cure."

Ref : William obstetric 23
rd
edition,2009