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PREGNANCY

INDUCED
HYPERTENSION
(PIH)
Case History and Topic Presentation

Furqan Shakeel Roll#250


Umiar Haider
Roll# 295
Batch C-1

Case History

Profile of patient

Name: Mamona
Occupation: Housewife
Age: 25yr old
Wife of: Mr. Mohd Ashraf
Married for: 3yrs
Resident of: shadbagh Lahore
Gravida: 2
Para: 1
LMD: 10th June 2015
EDD: 17th March 2016
DOP: 33 weeks and 1day
MOA: Opd
DOA: 29th Jan 2016

Presenting complaints

Gestational amenorrhea for 33 weeks and 1 day with pregnancy confirmed by


urine dipstick and USG
Headache for last 8 weeks

History of present pregnancy

My patient was having regular menstrual cycle of 6 / 28 until when she missed her last period on
10th July 2015 since then she has developed gestational amenorrhea for 33 weeks + 1 day and she
confirmed her pregnancy by urine dipstick test at home on 15th July 2015 and later went to doctor
who confirmed this pregnancy again by USG on 27th July 2015

1st Trimester

nausea and vomiting (normal in frequency and amount)


Increased urinary frequency with no incontinence and UTIs
No fever and flu-like symptoms

No history of headache
No visit to doctor on 7th week for dating USG
No history of spotting, PV discharge
History of intake of Folic acid

2ND Trimester

1.

Fetal movements appreciated at 13th week of pregnancy


Visit to doctor on 20th week for anomaly USG (preterm baby)
Symptom of headache started at 24th week of pregnancy. Doctor told her its
HTN(160/100mmHg)
No history of spotting or PV discharge

2.
3.
4.

History of present pregnancy (contd.)

3rd Trimester

1.
2.
3.

Continuation of normal fetal movements (1 kick every hour)


Headache (moderate in severity)
Aldomet tab. (1+1+1)

Management and follow up

Clinical investigations done are

Lab investigations done are

.
.

GPE, PA and follow-up every 4 hours

CBC (WBCs 6820, Polymorph 72%, Lymphocyte 21%, Monocytes 5%, Eosinophils 2%,
platelets 25300, Hb 10.8mg/dl)
Blood grouping (A+)
APTT (35 sec)
PT
(15 sec)
HbSAg ve
HCV -ve
Urine analysis (Proteins 0.08 g/dl)
RFT (Serum creatinine, Serum BUN, GFR____________Normal)
LFT (SGOT, SGOPT__________Normal)
Fasting glucose
Drugs given for management of HTN (Aldomet 1+1+1)
Transfusion of 1pint blood on 29 th of january

Obstetrics History

No.

AGE

SEX

Pre-natal History

MOD

TERM

Weight

Post-op

Post-natal

1yr
6mon

Jaundice at 6th
month of pregnancy,
HTN at 6th month of
pregnancy

NVG

PRETERM

2.8 kg

N/S

Fetal low
vision

Gynecological History

Menarche at 14yrs of age


Regular menstrual cycle of 6/28 with normal quantity, color and flow
of blood associated with mild pain
No history of dysmenorrhea, menorrhagia, postcoital bleeding or
intermestrual PV Bleeding
No history of use of contraceptives

Past Medical and Surgical History

1.

8.

H/O Hepatitis B 2yrs ago


Diabetes ve
Thyroid disease ve
HTN ve
TB ve
Transfusions ve
Allergy -ve
Surgery ve

Family History

History of chronic HTN in grandfather, father and sister

Socioeconomic History

2.
3.
4.
5.
6.
7.

Education of mother : Matric (10th)


Family members : 3
Earning member : 1
Occupation of husband : Khateeb & Teacher at a madrassa

Systemic Review

CNS: No seizures and dizziness


GIT: Nausea and vomiting of pregnancy
Respiratory: No cough, wheezing and breathlessness
CVS: No chest pain, palpitations. HTN for last 3 months
Urinary: increased frequency of urination

Examination of Patient

General Physical Examination

My patient, a lady of young age, with average height and weight, was sitting comfortably in bed,
oriented in time place and person.

Pulse: 86/min
BP: 160/100mmHg
Respiratory Rate: 17/min
Temperature: 98.2*F
No signs of

Pallor
Koilonychia
Excessive sweating
Peripheral/central cyanosis
Jaundice
Palpable lymph nodes
Thyroid swelling
Increased JVP
Periorbital, Sacral, pretibial or ankle edema

Systemic examination
CNS: Grossly intact
CVS: HTN (160/100mmHg), Normal S1 S2 with no added sounds
Respiratory: Normal vesicular breathing with no added sounds

Abdominal Examination

Inspection:

Abdomen was protuberant in shape, having regular symmetry, with stria gravidum
present.
Umbilicus was central in position, moving equally with respiration
No visible scar marks or visible veins present

Palpation:
Fundal height of 31 weeks with longitudinal lie and cephalic presentation. No engagement
(5/5)

Auscultation:
Fetal Heart Rate: 130-140/min

Case Summary

A 25yr pregnant lady G2P1 having gestational amenorrhea for 33


weeks and one day came with presenting complaint of headache. She
is being kept under observation and all investigations were done. She is
being given aldomet tab (1+1) for the management of HTN.

TOPIC PRESENTATION

DEFINITION:

development of new hypertension in a pregnant


woman after 20 weeks gestation without the presence of
protein in the urine is called PIH.

INCIDENCE:

7-10% of all pregnancies


about half of which progress to preeclampsia.

DIFFERENTIAL DIAGNOSIS:
CHRONIC HYPERTENSION:
B.P > 140/90 mmHg/
evident before 20th week.
without proteinuria

P.I.H:
B.P> 140/90 mmHg
occurs after 20th week
without proteinuria

PREECLAMPSIA:
B.P> 140/90 mmHg
occurs after 20th week
with proteinuria & edema.

RISK

FACTORS:

Maternal causes

Obesity
Age 35 years or more.
Past history of D.M, Hypertension and Renal diseases.
Adolescent pregnancy.
New paternity.
Anti-phospholipid syndrome
Having donated a kidney.

Pregnancy

Multiple gestation ( twins or triplets, etc.)


Placental abnormalities:
1. Hyperplecentosis: Excessive exposure to chorionic villi.
2. Placental ischemia.

Family history

Family history of pre-eclampsia.

PATHOPHYSIOLOGY:

The initiating event in PIH is reduced uteroplacental


perfusion as a result of abnormal cytotrophoblast invasion of
spiral arterioles. Placental ischemia is thought to lead to
widespread activation/dysfunction of the maternal vascular
endothelium that results in enhanced formation of endothelin
and thromboxane, increased vascular sensitivity to angiotensin
II, and decreased formation of vasodilators such as nitric oxide
and prostacyclin.

COMPLICATIONS OF PIH

High blood pressure can cause complications in mother and baby.


The effects can be mild to very severe. It may cause no problems

Maternal effects:

HELLP syndrome
Abruptio placentae
Pulmonary edema
Acute renal failure
Cerebral hemorrhage
Visual disturbances
Electrolyte imbalance
Hepatic rupture
Postpartum collapse
Put mother at risk for possible heart disease or high blood pressure
when she becomes older

In severe cases, gestational


hypertension leads to
preeclampsia, also known as
toxemia. It can harm the placenta
as well as brain, liver, and kidneys.
Preeclampsia can lead to
eclampsia, a rare and serious
condition that can cause seizures
and coma -- even death

Fetal Complications
Reduce blood flow to the placenta,
so fetus receives less oxygen and
fewer nutrients.
Causes baby to be born too small
or too soon (preterm)

MANAGEMENT

Objectives of Management:

Cure/prevent progression
Reduce blood pressure to normal
Promote fetal maturity
Prolong pregnancy (36-38 weeks)
Delivery: best day, best way, best place
Prevent/manage complications

MATERNAL MONITORING:

Look for appearance of ominous features


Daily record b.p 4 times
Monitor urine output and test for proteinuria
Alternate day body weight
Weekly measure creatinine
LFT and platelet count

FOETAL MONITORING:

CLINICAL MONITORING:
Fundal height, FHR, Foetal movement count,
liquor, CTG
ULTRASOUND:
at the date of admission and then 3 weekly
for foetal biophysical parameters, placenta and liquor volume.
L/S RATIO for foetal lung maturity

TREATMENT

GENERAL MEASURES:

Hospitalization
Nutritional supplements: iron, vit E, Protein, calcium etc.
Stop smoking and alchohol
Reduce salt intake

DRUGS:

Antihypertensives: methyldopa, nifedipine, oral hydralazine


Diuretics: thiazide or loop diuretics, but should be withdrawn
if preeclampsia develops
Glucocorticoid injection for foetal maturity.
Tocolytics if IUGR detected

DELIVERY:

BEST DAY:

36 weeks in all controlled casas


Before 36 weeks if :
Foetal movements decrease, severe IUGR with
olighydromnios or if life of mother is at risk

BEST WAY:

Induction with oxytocin after 36 weeks if foetal condition and


cervix is favourable
By LSCS if termination before 36 weeks in case of maternal
and foetal jeopardy.

BEST PLACE:

High risk pregnancy unit or well equipped tertiary hospital.

POSTPARTUM:

PPH: Be prepared to face it.


NEONATAL CARE
DRUGS: antihpertensives and I/V fluids.
Follow up for 6 weeks

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