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OBSTETRICS AND GYNECOLOGY

CASE MANAGEMENT
CONFERENCE
GATDULA A., GATDULA E., GAUTANI,
GONZALES, MUTIA
OBJECTIVES
General: To be able to diagnose and initially manage patients
presenting with hypertension during pregnancy.

Specific:
1. Extract a concise clinical history
2. Perform relevant physical examination
3. Assess and come up with differential diagnosis
4. Know the initial management and treatment options
for this case
GENERAL DATA
● M.D., 40 y/o G5P3 (3013)
● Married
● Filipino
● Born and currently living in Silang, Cavite
● Admitted for the first time on April 2, 2019
CHIEF COMPLAINT

Headache
PAST MEDICAL HISTORY
● Hypertensive – 5 years
○ maintained on AMLODIPINE 5mg OD taken regularly
FAMILY MEDICAL HISTORY
● Hypertension - maternal side
PERSONAL AND SOCIAL HISTORY
● Patient:
○ College graduate and a housewife
○ Non-smoker, non-alcoholic beverage drinker, no
illicit drug use
● Husband:
○ College graduate
○ Non-smoker and occasional alcoholic beverage
drinker
● Lives with children on their own house
MENSTRUAL HISTORY
● M: 13 years of age
● I: Monthly
● D: 3-4 days
● A: 3 moderately soaked napkins per day
● S: (-) dysmenorrhea
OBSTETRICAL HISTORY: G5P3 (3013)
MANNER OF PLACE OF BIRTH COMPLI-
PREGNANCY DATE AOG SEX
DELIVERY DELIVERY WEIGHT CATIONS

HOSPITAL
G1 2003 TERM VSD MALE 3.0 kg NONE
/ DOCTOR

HOSPITAL
G2 2006 TERM VSD MALE 3.1 kg NONE
/ DOCTOR

HOSPITAL
G3 2008 TERM VSD FEMALE 3.1 kg NONE
/ DOCTOR

ABORTION HOSPITAL
G4 2014 2 MOS. - - NONE
S/P D&C / DOCTOR

G5 PRESENT PREGNANCY
GYNECOLOGICAL HISTORY
● No history of breast diseases nor any gynecologic
diseases or surgeries
CONTRACEPTIVE HISTORY
● No history of contraceptive use of any forms
SEXUAL HISTORY
● First sexual contact at 22 years of age
● 1 lifetime sexual partner
● 3-4x a week
● Last sexual contact: August 2018
● (-) post coital bleeding
● (-) dyspareunia
HISTORY OF PRESENT PREGNANCY
● LNMP: JULY 15, 2018
● EDC: APRIL 21, 2019
● AOG BY LNMP: 37 2/7 WEEKS AOG
● QUICKENING: 2ND WEEK OF NOVEMBER, 2018
HISTORY OF PRESENT PREGNANCY
● 7 months PTA (9 2/7 weeks AOG)
○ Amenorrhea
○ (+) pregnancy test
HISTORY OF PRESENT PREGNANCY
● 5 months PTA (17 weeks AOG)
● Consulted at DLSUMC for 1st prenatal check-up
● Early UTZ: Single live intrauterine pregnancy
compatible with the AOG
● Referred to IM for Hypertension
● BP 160/100
● Methyldopa 250 mg TID
HISTORY OF PRESENT PREGNANCY
● 4 days PTA
● Nape pain and headache
● Continued Methyldopa 250mg TID

● 3 hours PTA
● Severe headache and nape pain
● Prompted consult at DLSUMC ER
REVIEW OF SYSTEMS
● (-) blurring of vision
● (-) abdominal pain
● (-) convulsion
PHYSICAL EXAMINATION
GENERAL SURVEY
● Well-developed, well-nourished, awake, conscious,
coherent, oriented to time, place and person
● Appears her chronological age of 40
VITAL SIGNS
● BP: 200/120 mmHg, supine, right arm
● HR: 78 bpm
● PR: 78 bpm
● RR: 21 cpm
● Temperature: 36.4 C
SKIN
● (-) pallor (-) erythema (-) jaundice
(-) hyper/hypopigmentation
● (-) lesions
● Normal hair texture and distribution
● Normal nails
● Good skin turgor
HEENT
● Hair: normal texture
● Head is symmetrical, (-) mass (-) tenderness
● (-) facial asymmetry
● Eyes: pink palpebral conjunctiva, 2-3 mm EBTRL
● Ears: (-) mobile pinna (-) masses (-) discharge (-)
swelling (-) tenderness
● Mouth: (-) oral lesions (-) masses
CHEST AND LUNGS
● Symmetrical chest expansion
● (-) use of accessory muscles
● Clear breath sounds
● (-) rales (-) wheezes (-) stridor
HEART
● Regular rate, regular rhythm
● S1>S2 on the apex, S2>S1 on the base
● (-) extra heart sounds
● (-) murmurs
ABDOMEN
● Globular, soft
● (-) masses
● Normoactive bowel sounds
● (-) uterine contractions
ABDOMEN
● FH: 33 cm
● FHT: 158 bpm at the LLQ
● Leopold maneuvers
○ LM1: Soft, nodular mass
○ LM2: Hard, resistant at the maternal left and small
nodular mass at the maternal right
○ LM3: Hard ballotable mass
GENITALIA
● External: (-) lesions (-) discharge
● Internal Exam: cervix posterior, closed,
uneffaced, (+) BOW, cephalic, station -1
EXTREMITIES
● (+) Grade 2 bipedal pitting edema
● (-) varicosities
● (-) masses
● (-) deformities
● (+) Full and equal peripheral pulses
NEUROLOGIC
● GCS 15
● MSE: Awake, cooperative towards examiner, normal
stream of talk, conscious, oriented to time, place and
person, good immediate, recent and remote memory,
good judgement, concentration, and attention span,
appropriate mood and thought content
● Intact Cranial Nerves
● No sensory nor motor deficits
SALIENT FEATURES
● 40 years old
● G5P3 (3013)
● Chief complaint of headache
● No blurring of vision, abdominal pain and convulsion
● Hypertensive for 5 years
● BP 0f 160/100 on initial prenatal consult
● Maintained on Amlodipine 5mg OD
● Methyldopa 250 mg TID
● BP of 200/120 mmHg, supine, right arm
ADMITTING IMPRESSION:

40 G5P3 (3013) PU 37 2/7 weeks AOG


cephalic not in labor; Chronic Hypertension
with superimposed Preeclampsia with severe
features; Elderly Multigravid
DIFFERENTIAL DIAGNOSIS
RULE IN RULE OUT
Chronic
Hypertension,
uncontrolled
Preeclampsia ● BP of 200/120 mmHg ● Cannot be ruled out
upon consult
● (+) Headache
CASE DISCUSSION
HYPERTENSIVE DISORDERS OF PREGNANCY
● One of the leading causes of maternal and perinatal
mortality worldwide

● In Africa and Asia: 9% of maternal deaths


HYPERTENSIVE DISORDERS OF PREGNANCY
● Gestational Hypertension
● Chronic Hypertension
● Preeclampsia
● Chronic Hypertension with superimposed
Preeclampsia
● Eclampsia
● HELLP Syndrome
GESTATIONAL HYPERTENSION
● BP ≥ 140/90 mmHg after 20 weeks gestation
● No proteinuria
● No other signs/ symptoms
● No preeclampsia features
● BP returns to normal 12 weeks postpartum
CHRONIC HYPERTENSION
● BP ≥ 140/90 mmHg before 20 weeks gestation or
pre-pregnancy
● With or without proteinuria
● Persistent BP ≥ 140/90 mmHg 12 weeks postpartum
in women with gestational hypertension
PREECLAMPSIA
● BP ≥ 140/90 mmHg after 20 weeks gestation
● With or without proteinuria, thrombocytopenia
CHRONIC HYPERTENSION WITH SUPERIMPOSED
PREECLAMPSIA
● Development of proteinuria after 20 weeks
● Worsening proteinuria
● Sudden worsening of hypertension
● Elevation of liver enzymes to abnormal levels
● Platelet levels below 100,000 / μL
CHRONIC HYPERTENSION WITH SUPERIMPOSED
PREECLAMPSIA
● Development of right upper quadrant pain and
severe headache
● Development of pulmonary congestion or edema
● Doubling of creatinine level or ≥ 1.1 mg/dL
ECLAMPSIA
● Generalized tonic-clonic seizures that can’t be
attributed to other causes
● Usually preceded by headache, visual disturbance,
epigastric or RUQ pain, altered mental status
HELLP SYNDROME
● Hemolysis
● Elevated Liver enzymes
● Low Platelet

● Sudden deterioration in maternal and fetal condition


● Higher rates of maternal morbidity and mortality
CLASSIFICATION
OF
HELLP SYNDROME
RISK FACTORS
● Nulliparity
● Multifetal gestations
● Preeclampsia in a previous pregnancy
● Chronic hypertension
● Pregestational diabetes
● Gestational diabetes
● Thrombophilia
RISK FACTORS
● Systemic lupus erythematosus
● Prepregnancy body mass index of greater than 30
● Antiphospholipid antibody syndrome
● Maternal age 35 years or older
● Kidney disease
● Assisted reproductive technology
● Obstructive sleep apnea
PATHOPHYSIOLOGY
● Several mechanisms have been proposed in
preeclampsia including the ff:
○ Chronic uteroplacental ischemia
○ Immune maladaptation
○ Very low-density lipoprotein toxicity
PATHOPHYSIOLOGY
○ Genetic imprinting
○ Increased trophoblast apoptosis or necrosis
○ Exaggerated maternal inflammatory response to
deported trophoblasts
○ Imbalances of angiogenic factors
ETIOLOGY
1. Placental implantation with abnormal trophoblastic
invasion of uterine vessels
2. Immunological maladaptive tolerance between
maternal, placental and fetal tissue
3. Maternal maladaptation to cardiovascular or
inflammatory changes of normal pregnancy
4. Genetic factor including inherited predisposing genes
and epigenetic influences
Abnormal trophoblastic invasion
IMMUNOLOGICAL FACTORS
● Loss of maternal immune tolerance to paternally
derived placental and fetal antigen
● Increased risk with 2 sets of paternal chromosomes
(molar pregnancy)
● Women with Trisomy 13 has 30-40% risk of
preeclampsia
● Exposure to paternal antigens “immunizes” against
preeclampsia
ENDOTHELIAL CELL ACTIVATION

Extreme Lipid peroxides Toxic radicals


activated state
of leukocytes

Cytokines, Toxic radicals


reactive 02 and
free radicals
NUTRITIONAL FACTORS
● Diet high in fruits and vegetables, lower BP
● Increase preeclampsia with low vitamin C intake
● Calcium supplementation in those with low calcium
intake lowers perinatal mortality rates
GENETIC FACTORS
● Risk for preeclampsia of 20-40% for daughters of
preeclamptic mothers
● 11-37% risk for sisters of preeclamptic women
● 60% concordance in monozygotic female twin pairs
PATHOPHYSIOLOGY OF ECLAMPSIA
● Vasospasm
● Endothelial activation → vascular constriction
● Endothelial cell damage → interstitial leakage
VASCULAR CHANGES
● Hemoconcentration
● Interaction of vasoactive agents: intense vasospasm
HEMATOLOGIC CHANGES
● Thrombocytopenia: marker for disease severity
○ Platelet count < 150,000
● Hemolysis
○ High serum concentrations of LDH may be a sign
of hemolysis
INITIAL WORK-UP
Maternal Side Fetal Side
● CBC with platelet ● Biometry
count ● Biophysical profile
● Serum creatinine ● Amniotic fluid index
● AST, ALT, LDH ● Non Stress Test
● 24-h urine protein ● Doppler velocimetry
of umbilical artery if
growth-restricted
MANAGEMENT
PREECLAMPSIA WITHOUT SEVERE FEATURES
● Weekly monitoring of CBC with platelet count, AST,
ALT, LDH, Serum creatinine, Amniotic fluid index, NST
● Every 3 weeks monitoring of Biometry, Doppler
velocimetry
● Delivery at 37 weeks
● Before 37 weeks, expectant management unless
there are fetal or maternal indications for immediate
delivery
PREECLAMPSIA WITH SEVERE FEATURES
● Delivery at 34 weeks gestation
● Unstable maternal or fetal status
● After maternal stabilization
CHRONIC HYPERTENSION
● Early prenatal care
● Ideally during pre-pregnancy to rule out end-organ
damage – usually present in chronic hypertension
● Basic workup: Serum creatinine, Electrolytes, Uric
acid, Platelet count, Urine protein
CHRONIC HYPERTENSION
● Anti-hypertensive not started unless SBP ≥ 160
mmHg or DBP ≥ 105 mmHg
● May opt to discontinue antihypertensives if with
well-controlled BP prior to pregnancy
● Maintain BP to 120-160/80-105 mmHg
CHRONIC HYPERTENSION WITH SUPERIMPOSED
PREECLAMPSIA
● For stable patient without severe features, delivery at 37 weeks
gestation
● Delivery for women with the following:
○ Uncontrolled severe hypertension
○ Eclampsia
○ Pulmonary edema
○ Placental abruption
○ DIC
○ Non-reassuring fetal status
HELLP SYNDROME
● Prompt delivery of 34 weeks and beyond
● Before 34 weeks, delivery may be delayed for 24-48
hours for corticosteroid administration if stable
maternal-fetal status
ANTI-HYPERTENSIVE MEDICATIONS
ANTI-HYPERTENSIVE MEDICATIONS
SEIZURE PROPHYLAXIS
● Magnesium sulfate proven to halve the risk of
eclampsia and reduce risk of maternal death
JOURNAL
DIAGNOSTIC
I. APPRAISING DIRECTNESS
CLINICAL QUESTION RESEARCH QUESTION
(RESEARCHER) (ARTICLE APPRAISED)

POPULATION Pregnant women with Pregnant women who had been


(P) suspected preeclampsia evaluated at second trimester
(gestational age between the 15th to
20th weeks) who are diagnosed with
preeclampsia

EXAMINATION Initial workup: CBC with Maternal serum biomarkers,


(E) platelet count, Serum AFP, uE3, and fβ-hCG levels
creatinine, AST, ALT, LDH
and 24-h urine protein

OUTCOME Diagnosis of preeclampsia Relationship between maternal serum


(O) biomarkers and the risk of
preeclampsia.
II. APPRAISING VALIDITY
2. Was the reference standard an acceptable one?

“The diagnostic and classification for preeclampsia


were based on American College of Obstetricians and
Gynecologists' guidelines.”
(p2, Materials and Methods, Study design and
population)
II. APPRAISING VALIDITY
2. Was the reference standard an acceptable one?

“The maternal serum biomarkers, AFP, uE3, and fβ-hCG levels


were measured by time-resolved fluorescence immunoassay
(PerkinElmer Wallac 1235), and the serum biomarkers values were
referred to smoothed median values to produce adjusted multiple of
the median (MoM) values, which can be used to standardize for
factors such as gestation age, maternal weight, smoking status, and so
on.”
(p2, Materials and Methods, Study design and population)
II. APPRAISING VALIDITY
3. Was the reference standard interpreted independently
from the test in question?

No, the reference standards were not independently


interpreted from the test.
III. INTERPRETING RESULTS
4. What were the likelihood ratios of the various test
results?

No likelihood ratios may be calculated due to


insufficient data provided by the article.
III. INTERPRETING RESULTS
In the present study,
● 198 pregnant women who developed into
preeclampsia
● 1171 controls were involved,
● levels of maternal serum biomarkers were compared
III. INTERPRETING RESULTS
III. INTERPRETING RESULTS
III. INTERPRETING RESULTS
III. INTERPRETING RESULTS
IV. ASSESSING APPLICABILITY
5. Biologic issues affecting applicability

A. Comorbidities
No. Preeclampsia with the following situations were
excluded: multiple pregnancy, gestational diabetes
mellitus, pre-pregnancy hypertension, intrahepatic
cholestasis of pregnancy, hysteromyoma, cystic salpinx,
fetal malformations or aneuploidies, stillbirths.
IV. ASSESSING APPLICABILITY
B. Race
Yes. The study population were all Chinese pregnant
women

C. Age
Yes. The maternal age in the cases who develop into
preeclampsia where significantly higher than the control.
Control= 26.57+/-3.5
Cases= 27.69+/-3.62
IV. ASSESSING APPLICABILITY
D. Pathology
There were no mention of other pathologies
mentioned in the study.
IV. ASSESSING APPLICABILITY
6. Are there socioeconomic issues that may affect the
accuracy of the test?

A. Availability on the locality


Yes, based on the research gather by the group maternal
serum Biomarker screening is available in the country but
only in the major urban areas. However, there are no
mention of time-resolved fluorescence immunoassay as a
measuring tool.
IV. ASSESSING APPLICABILITY
B. Affordable and Acceptable
Yes, because based on the research gathered by the
group prices depends on each biomarker. Each
biomarker may range from 600-1000php. Physicians
may tend to request the initial work up for preeclampsia
such as CBC, 24 hour urine protein, serum creatinine,
AST, ALT, LDH because of its availability and less costly.
THERAPEUTIC
I. EVALUATING DIRECTNESS
Clinical Question Journal Article

People Pregnant women with hypertension Pregnant women or ≤ 24 h postpartum


with a systolic blood pressure ≥ 160
mmHg or diastolic blood pressure ≥
110 mmHg at two times over 30 min
and ≥ 1+ proteinuria

Exposure Magnesium sulfate Serial intravenous boluses versus a


continuous intravenous infusion of
Magnesium Sulfate

Outcome Prevention and Treatment of eclamptic Serial IV boluses achieve serum


seizure in pregnancy magnesium concentrations statistically
significantly higher but clinically
comparable to those achieved with a
continuous infusion.
II. APPRAISING VALIDITY
1. Were patients randomly assigned to treatment groups?

Yes, it is stated in page 3, paragraph 4, under methods


that,, “Women were randomized to receive one of two
regimens.”
II. APPRAISING VALIDITY
2. Was allocation concealed?

Yes, it is stated in page 2, paragraph 2, under methods that, “a


sequentially numbered, sealed, opaque envelope containing the
participant’s group assignment was opened by research staff. The
envelopes were generated by Gynuity Health Projects staff using a
randomisation code based on a computerised pseudo-random
number generator. Randomisation was stratified by center. ”
II. APPRAISING VALIDITY
3. Were baseline characteristics similar at the start of the trial?

Yes, it is stated in page 2, paragraph 2, under methods that, “To be


eligible, women were required to have a systolic blood pressure ≥ 160 mmHg
or a diastolic blood pressure ≥ 110 mmHg at two times over 30 min and ≥ 1+
proteinuria. Eligible women were pregnant or ≤ 24 h postpartum and deemed
by the admitting physician to benefit from treatment with MgSO4. Women
were excluded if they had experienced an eclamptic seizure, had received
MgSO4 within 24 h of study enrollment, or had a serum creatinine >106
μmol/L (1.2 mg/dL) at the time of enrollment.”
II. APPRAISING VALIDITY
4. Were patients blinded to treatment assignment?

No, as stated in Methods, “An open-label randomized


trial was performed comparing two regimens of
administering MgS04 to women with severe preeclampsia
who were deemed likely to benefit by the reduction in risk
for eclamptic seizures,”
II. APPRAISING VALIDITY
5. Were caregivers blinded to treatment assignment?

No, as stated in Methods, “An open-label randomized


trial was performed comparing two regimens of
administering MgS04 to women with severe preeclampsia
who were deemed likely to benefit by the reduction in risk
for eclamptic seizures,”
II. APPRAISING VALIDITY
6. Were study personnel blinded to treatment
assignment?

No, as stated in Methods, “An open-label randomized


trial was performed comparing two regimens of
administering MgS04 to women with severe preeclampsia
who were deemed likely to benefit by the reduction in risk
for eclamptic seizures,”
II. APPRAISING VALIDITY
7. Were all patients analyzed under the groups to which
they were originally randomized?

Yes, Women were randomized to receive one of two


regimens. The CONTINUOUS INFUSION ARM was the
community standard at each hospital and the the SERIAL
IV BOLUS ARM using Springfusor® springloaded pump.
II. APPRAISING VALIDITY
8. Was follow-up rate adequate?

Yes, Each subject had a


baseline and 6 strategically timed
blood samples drawn during the
study period for measurement of
magnesium concentrations. A
serum creatinine level was drawn
at baseline and at the conclusion
of the study period as well.
III. INTERPRETING RESULTS
1. How large was the effect of the treatment?
IV. ASSESSING APPLICABILITY
1. Are there biologic issues that may affect applicability of
treatment? (Consider the influence of sex, co-morbidity,
race, age and pathology)

There maybe a biologic issue due to race due to the


participants in this study are egyptians. No other issues
regarding sex, age and pathology were mentioned.
IV. ASSESSING APPLICABILITY
2. Are there socio-economic issues affecting applicability
of treatment?

There are no socio-economic issues affecting


applicability of the study in our patient.
V. INDIVIDUALIZING RESULTS
1. Are the benefits to your patient worth the harm and
costs?

Yes. Based on the study, serial IV boluses achieve


serum magnesium concentrations significantly higher but
clinically equivalent to those achieved with a continuous
infusion.
THANK YOU.