CASE • Pregnancy Induced HTN, to consider Gestational HTN

• Lucia, 19 y/o, G1P0, 37 weeks AOG, came in at the vs Pre-eclampsia (Dra. Luzon’s group)
st
  ER due to watery vaginal discharge. Physical exam
THERAPEUTICS  (DOC  LUZON  +  DOC  GARDUNO  GROUP)   1  Semester  AY  2018-­2019      
revealed normal vital signs. Internal exam: 7 PATHOPHYSIOLOGY AUG  8,2018  
SGD  3  
centimeters cervical dilatation, 50% effaced, station 0,
ruptured bag of water. You RDU  CASE  ON  CARDIOVASCULAR  DISEASE  (HYPERTENSION  
admitted the patient for trial  
ON  PREGNANT  WOMEN)   Risk Factors
of labor. At the labor room, patient’s vital signs were
  monitored hourly. The junior intern informed you that THERAPEUTIC  OBJECTIVES  
the patient’s CASE FORnoted
BP  was  DISCUSSION  
to be 160/100 mmHg. You OBJECTIVES   First NON-­PHARMA   PHARMA  
pregnancy
advised the intern to repeat the BP after a uterine
Jamella,  19  year  old,  G1PO  on  her  28  weeks  AOG,  came  in  at   Lower  down  BP   N/A   Anti-­  
the   OPD   for   her   but
contraction regular  
the BP prenatal  
remainedcheck-­up.  
the same. Upon   physical   hypertensive  
examinations,   her   BP   was   noted   to   be   persistently   170/11   drugs:    
mmHg   which   was   repeated   15   minutes   after   being   placed   on   Fertilization
PERTINENT DATA Vasodilators-­  
the   left   lateral   recumbent   position.   She   denies   any   untoward   hydralazine,  Ca  
• Lucia, 19 y/o
signs  and  symptoms  felt  at  this  time.  Other  pertinent  history  was   channel  blockers  
• G1P0
unremarkable   except   that   her   sister   had   history   of   seizure   Implantation  
• pregnancy  
during   37 weeks AOG – term pregnancy
and   immediately   operated   on   for   a   cesarean   Sympathoplegics
• Internal exam:
section  for  the  delivery  of  the  baby.  You  decide  to  admit  her  for   -­  methyldopa,  
o 7 centimeters cervical dilatation
further  evaluation  and  management.    
o 50% effaced, station 0
Active Trophoblast invasion of spiral arteriesclonidine  
IDENTIFY  THE  PROBLEM   Labor  
o Rupture bag of water Diuretics  
o   19  years  old  
• BP: 160/100 mmHg ARBS  
o   G1PO   Release of EGF Proinflammatory
• o   CC: Watery vaginal
28  weeks  AOG   discharge Prevent   o   Bed  rest    
and SFLT mediator released
• o   Vital signs: Normal
170/100  mmHg  (persistently)  repeated  15  mins  on  left   complications   o   Left  lateral  
lateral  recumbent  position     recumbent  
T
o   denies  untoward  signs  and  symptoms  
ERMS Maternal:   o   Avoid  stress  
Endothelial Release of EGF
other  hx:  unremarkable  
• o   Effacement – thinning of the cervix in preparation for eclampsia,   o   Monitor  by  
damage and SFLT
family  history  of  seizure  during  pregnancy  immediately  
o   delivery stroke,  general   hospitalizati
operated  on  CS  for  delivery.       vasoconstrictio on  
• Ruptured bag of water – tearing of amniotic sac
DIAGNOSIS   n  (Renal  failure)   o   Diet  low  in  
• Cervical dilatation – widening of the cervical opening Fibrous Conversion of
PREGNANCY     sodium  and  
• Station 0 UTERINE  
– the lower 28  mostWEEKS  
portion ofAOG,   PIH   PRE-­
the presenting predominates over phospholipid to
ECLAMPSIA  VS  GESTATIONAL  HYPERTENSION   Fetal:     low  in  fat  
part of the fetus is at the level of the ischial spine elastic arachidonic acid
o   Pregnancy   induced-­   pre-­eclampsia   (>20   weeks),   IUGR,  fetal  
• G1P0 – First pregnancy; Primigravid distress  
eclampsia,  gestational  HPN  
o   Pregnancy   aggravated-­   chronic   hypertension   (<20   Push  pregnancy   o   Monitor      
WHAT IS YOUR DIAGNOSIS? Rigid BV Production of
weeks),  with  eclampsia,  with  pre-­eclampsia   as  far  as   o   Prenatal  
prostaglandin and
possible  to  term   checkup  thromboxane
Gestational Pre- Eclampsia Determine   Gold  standard:    
eclampsia etiology   Urinary  CHON  
Onset >20 weeks >20 weeks >20 weeks determination  (24  
Vasoconstriction Platelet
Proteinuria (-) (+) (+) hour  collection)  
aggregation
Seizure (-) (-) (+)  
Hypertension (+) (+) (+) DRUG  INVENTORY  
Increased peripheral vascular resistance
  o   Vasodilators-­   hydralazine,   Ca   channel   blockers  
Monitor  treatment  after  20  minutes  
Diagnosis: (Nifedipine)  
If  BP  is  still  elevated:  
• G1P0, Pregnancy uterine, 37 weeks AOG, Cephalic, o   Sympathoplegics-­  methyldopa,  clonidine  
o   add  increments  of  5mg  until  20mg   Increased BP
in labor, to consider Gestational HTN vs Pre-  
o   add  combination  drug  (vasodilator)  
eclampsia (Complete diagnosis according to Doc TITLE:    ANTI-­HYPERTENSION  
If  BP  normalizes,  give  maintainance  and  monitor    
Garduño) Drugs     Efficacy   Safety   Suitability   Cost   Total  
DEFINITION  OF  TERMS    
3MD2019 st B OLLENBACH 1OF2
G1PO-­  G#  of  pregnancies,  P#  of  deliveries,  1  pregnancy  
Vasodilators   ++++   ++   +++   ++++   13  
(current),  OB  score  
Left  lateral  recumbent-­  side  lying  position  facing  left  
Sympathoplegics   ++   +   ++   ++   7  
Caesarian  section-­  alternative  way  of  childbirth  by  way  of  
surgery.   P  treatment:  Vasodilators    
   
PATHOPHYSIOLOGY    
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3MD2020 BONGCO , BAYUDAN

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b Sympathoplegics ++++ ++ ++ ++++ 12
t be Vasodilators ++++ ++ ++ +++ 11
ACEI & ARBs ++++ +++ +++ ++ 12
Therapeutics    
 
TITLE:  T
VASODILATORS
ITLE: DIURETICS     PATHOPHYSIOLOGY  
Vasodilators   Efficacy   Safety   Suitability   Cost   Total    
Drugs Efficacy Safety Suitability Cost T
Hydrochlorothiazide
Hydralazine   ++++   ++++++   +++ +++   +++++++   ++++
13   14
(Thiazide)
Spironolactone ++++ ++ ++ +++ 11
(K-sparer)
Ca+  channel   ++++   ++   -­   -­   6  
Furosemide
blockers   ++++ + + ++ 8
(Loop diuretic)
(Nifedipine)    
P  drug:  hydralazine    
PRESCRIPTION
 
  MCU FDTMF Hospital
PRESCRIPTION
EDSA, Caloocan    City
MCU  FDTMF  HOSPITAL  
EDSA,  CALOOCAN  CITY   August 01, 2017
Jamella  Rivera,  19    y/o,  female                                                                Aug  8,2018  
Danny Boy, 50 y/o, male
Caloocan  City  
Caloocan City
 
c Rx
Hydralazine  20mg/ml  ampule  
Hydrochlorothiazide 12.5 mg/tablet
dispense:  1  ampule  
label:  inject  5mg  IV  bolus  now  for  hypertension      
Dispense fourteen (14) tablets
                         No  refill   Label: Take one tablet once a day for two weeks for
                                                                                                               
hypertension.
 
 
  No refill.  
 
ney  
  (signature)
   
n Karen Tehani F. San Pedro
  Lic # _____
 
  PTR # _____  
                                                                                                               (signature)    
s)                                                                                                              Natalie  Gail  T.  Bongco,  MD  
MONITORING AND ADVICE  
- What drug is for
                                                                                                             Lic  #    
- How to take the drug
                                                                                                             PTR#    
  - Possible side effects, expected side effects ( increased urine
 
  output, weakness)
 
  - Monitor and record BP everyday
 
   
   
SAN PEDRO 1OF5
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   

3MD 2020 BONGCO , BAYUDAN

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Therapeutics    
 
*ADDITIONAL  INFO    FROM  DOC  GARDUNO’S  GROUP    
   
OBJECTIVES   NON-­PHARMA   PHARMA    
Lower   down   o   Bed  rest   Anti-­  hypertensive    
BP   o   Left  lateral   drugs:      
decubitus   Vasodilators-­    
position.   hydralazine,  Ca  
 
Avoid   channel  blockers  
 
compressio  
n  of  the   Sympathoplegics-­    
IVC  for   methyldopa,  clonidine    
good  blood      
flow  and   Diuretics    
perfusion   ARBS    
o   Still    
perform    
normal  
 
ADLs  
 
 
Manage  and   o   Give   Monitor  BP  every  hour  
 
control   magnesium   especially  at  the  ER    
BPuntil   sulfate  (if   while  waiting  for  lab    
postpartum     pre-­ results  45  minutes  to    
eclampsia)     hour  then  admit  if    
there  is  proteinuria    
Prevent   o   Monitor  the   o   Maternal:    
complication baby  for   eclampsia    
s  both  for   fetal  HR,   with  oxygen  
maternal  and   stress  test,   therapy.  
fetal     non-­stress   Monitor  for  
test  via   HELLP  
cardiotoco-­ (hypertension
graphy   ,  elevated  
liver  
enzymes,  low  
platelet)  
o   Fetal:  oxygen  
therapy  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

3MD 2020 BONGCO , BAYUDAN

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