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MRCOG PART 2 SBAs and EMQs

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Essay 344

Essay 344 Posted by PAUL A.

A healthy 32 year old woman has been referred by her community midwife because her BP is 168/99 mmHg and there is 2+ proteinuria at 32 weeks gestation. (a) Discuss your assessment of this woman [6 marks]. (b) Discuss your subsequent antenatal care given that hypertension and proteinuria are confirmed [9 marks]. (c) Discuss her post-natal care given that she eventually has a normal vaginal delivery [5 marks].

Posted by Jamil Ahmad A.

A healthy 32 year old woman has been referred by her community midwife because her BP is 168/99 mmHg and there is 2+ proteinuria at 32 weeks gestation. (a) Discuss your assessment of this woman [6 marks]. (b) Discuss your subsequent antenatal care given that hypertension and proteinuria are confirmed [9 marks]. (c) Discuss her post-natal care given that she eventually has a normal vaginal delivery [5 marks]. 

Ans-- First i would repeat BP of this patient . I will take history of increased risk factors for PIH, i.e. previous pregnancy PIH, previous preeclampsia, history of  SLE, renal diseases, diabetes mellitus, chronic hypertension. Also if her BMI>35, she is at risk. I would enquire about symptoms of headache, epigastric pain, blurring of vision, abdominal pain etc as all these in this patient indicate high risk for pre eclamsia. Repeat BP if again high with an appropriate cuff and preferably manually taken necessitates admission . Send FBC, renal function test, coagulation, bilirubin, platelets,transaminases, spot urine protein/creatinine ratio and start 24 hr urine protein collection.  Inform the woman about the high risk of eclampsia and that she might need urgent delivery.

b) I will admit this patient  and check all her results. Meantime after informing her that she may need an urgent delivery , i will adminster a course of steriods for lung maturity. Also i would send request for  neonatologist and paediatricians to come and counsel her about the risks and outcome for preterm delivery.  I will start antihypertensives for her. If the repeat BP was > 160/110, IV hydralazine can be given slow IV over 20 minutes ( to prevent a sudden fall in BP), if < 140/100 , oral labetolol can be given and repeated every 1 hour. Aim to keep BP < 140/90. USG and doppler to evaluate the foetus - growth, liq, placental insufficiency. CTG also to be done at admission. Evaluate her results, if all normal and prot/creat ratio is normal, patient can be managed as outpatient once her BP is controlled.

              If BP still high, or protein more than 3 gm/litre, she will need urgent delivery. Till delivery her BP should be checked >4 times/day, investigations checked atleast 3 times / week. Check for HELLP- hemolysis, elevated transaminases, low platelets. Document a care plan inconsultation with multidisciplinary team. Involve hematologist early if hellp is suspected as patient has chances of going into DIC. Anaesthesia consultant should be notified .

                  If high BP, proteinuria and unwell or epigastric pain etc, magnesium sulphate should be started prophylactically 4 gm IV stat and 1 gm/hrly. Bp should be checked hrly. If she is multi and favourable os, induction after explaination and consent should be done, but if primi, more chances of failed induction at 32 weeks , so LSCS is better.

                 In case patient was sent home to follow as an outpatient, a documented care plan should be informed to her, written in all her case notes, her GP should be informed. Also her subsequent visits( weekly preferably), who will see her, the antihypertensive drugs and their effects on baby should all be informed.  In this case USG and doppler to be done every 2 weeks if normal. Consider thromboprophylaxis in all cases depending upon risk factors.

c) BP might fall in the first 24 hours followed by a rise again so BP check every 4 hours. To be vigilant  about  eclampsia as the risk is high. Encourage the patient for breastfeeding and help her if she is having any problems. To consider thromboprophylaxis if any other risk factor like BMI>30, any other medical disorders, if she received thromboprophylaxis antenataly etc.  If she was on methyl dopa, this should be stopped and other antihypertensive like labetolol can be given( as methyl dopa can cause depression). The risk for eclampsia is highest in 1st four days so frequent monitoring in this time. SOme patients may need antihypertensives even upto 3 months.  If BP still high at 6 wks visit, review with physicians should be done. If  proteinuria persistent at 6 wks visit, referral to nephologist should be done.

      The mother should be counseled about  diet modifications, lifestyle before she is discharged. The role of exercise is to be emphasized. This is a part of healthy lifestyle but more stress should be given in those with BMI>30. Importance of breastfeeding and reassurance about the drugs prescribed should be done. Documented plan of care is essential part of any follow up and should be done before the patient is discharged. It should include information about her further visits, with whom, drugs prescribed. All this information should be sent to her GP also.

Posted by miss T.

(a)

This woman most likely is suffering from pre-eclampsia but further assessment is needed to confirm or refute the diagnosis.

I will take detailed history from her the parity, LMP, personal or family h/o pre-eclampsia, pregnancy interval if she is multip, inquiry about any symptom like head ache, visual disturbance, pain just below ribs, lower abdominal pain etc. and I will review her antenatal follow up how her Bp use to be and if she is already on any hypertensive treatment.

I need to check her blood pressure. Pre-eclampsia is diagnosed if there are 2 readings of diastolic >90 mmHg or single reading >110mmHg. I will take her height and weight for body mass index, reflexes, abdominal palpation for epigastric tenderness, fundal level. Pelvic assessment is not needed unless she has associated complaint of labour pains or vaginal losses. Fundoscopic and neurological examination may be needed.

I will request investigations full blood count for Hb and platelets, biochemistry for liver and renal function tests, uric acid. Coagulation screen only if platelets come <100. Quantification of proteinuria by 24 hour urine collection for proteins. A CTG trace for fetal well being and USS for growth and liquor and umbilical artery Doppler.

(b)

When confirmed pre-eclampsia this woman is at risks of eclampsia, multi-organ failure, cerebral hemorrhage, and her fetus is at risk of IUGR, prematurity, pre-term delivery, placental abruption.

Aim of management is to stabilize maternal condition and deliver the baby at appropriate time balancing the risk of fetal prematurity with deterioration in maternal condition.

She need to be admitted in hospital and given multidisciplinary care involving senior obstetrician, neonatologist, senior midwife, and may need physician and anesthetist assessment later.

Antihypertensive therapy need to be started. Labetolol is first line if patient not asthmatic. Methyldopa and Nifedipine may also be used. Aim should be to keep blood pressure at <150/80-100 mmHg.

I will give her corticosteroids (2 doses of betamethaose, 12 hours apart) as her condition may prompt immediate delivery. There is evidence that it promotes fetal lung maturity and reduces respiratory distress syndrome, interventricular hemorrhage, NICU admission and stay.

Fluid intake will be restricted to 80ml/hr. Monitoring include Bp every 4 hours, input output charting. Blood tests three times a week. Weekly CTG unless there is an indication like abdominal pain or vaginal bleeding. USS for growth every 2 weeks and liquor and Doppler every week.

Seizure prophylaxis is not needed in all cases of pre-eclampsia and it will be considered if delivery of fetus is considered. Magnesium sulphate is effective in preventing seizures (Magpie) and if started need HDU care with hourly monitoring of respiratory rate, urine output, reflexes.

Expectant management is an option with close monitoring of maternal and fetal condition aiming to prolong pregnancy till 34 weeks and avoiding prematurity as much as possible.

Consider delivery if there is evidence of maternal or fetal compromise, uncontrolled blood pressure, and abnormal lab results, eclampsia. Decision and mode of delivery will be made by senior obstetrician involving women and taking her wishes into consideration. SCBU need to be notified. Induction of labour is an option but cesarean delivery is needed as rapidly deteriorating maternal condition may not permit time consumption in induction.

When in labour, hourly Bp monitoring is needed. Ergometrine will be avoided for third stage management.

(c)

After delivery she is still at risk of eclampsia as 44% of cases occur postpartum.

Her blood pressure will be monitored and treated accordingly. Anti hypertensives may need to be continued for up to 3 months. If she was on methyldopa it need to be changed to either labetolol or nifedipine in 2 working days, as there is risk pf post partum depression. ACE inhibitors are safe but diuretics and ARB should be avoided.

Her Bp will be checked daily for first 2 days and once between day 3 & 5. On discharge a letter will be given to GP detailing her care and treatment. If she is still in anti hypertensive a follow up at 6 weeks is arranged.

She will be given counseling detailing events of her delivery. And recurrence risk in further pregnancy that is up to 16%. No contraindication to breast feeding and it will be encouraged. Contraception will be discussed with her.

ANSWER TO ESSAY 344 Posted by DHARSHITHA J.

(a)The initial assessment include assessing the mother and the foetus using detailed history , proper examination, and investigations.

Mother is assessed regarding symptoms of severe PET including severe headache, vomiting,visual disturbances, epigastric pain and good foetal movements are assessed to confirm the foetal well being.

Examination includes measurement of BMI and  weight to assess weight gain, BP measurement using WHO standards with accurate positioning(either sitting or left lateral ) and appropriate sized cuff. Also funduscopy to exclude retinal haemorrhages and papiloedema, neurological examination including assessment of reflexes and clonus carried out.

Assessment of level of oedema (swelling of face hands , feet), and measurement of urine out put also important.

Abdominal palpation to assess the fundal height, foetal heart auscultation and clinical assessment of liquor volume are important to assess foetal well being.

Investigations include-24hour urine protein collection, and serum urate  levels to confirm the diagnosis of PET. Also  FBC to assess haemoglobin level and platelet count to exclude HELLP syndrome. LIver function tests to assess rising ALT AST levels-(a sign of PET and HELLP syndrome).

In addition serum electrolytes and blood urea, serum creatinine to assess renal function. Clotting profile is advocated only if platelet count is below 100 000.

Foetal well being is assessed by u/s scan for growth and liquor volume and umblical artery doppler and CTG  to exclude acute foetal distress.

(b)This is a case of severe to moderate PET, and she needs admission to the ward for close monitoring and investigation.

Involvement of an senior experienced midwife, senior obstetrician, anaesthetist is important to plan the care -multi desciplinary involvement. Ideally she should be managed in HDU setting in her initial period.

Mother is first assessed as above and monitored closely , using MEOWS chart. BP is checked 4 hourly, fluid balance chart is maintained to assess input / output to prevent fluid overload. Urinalysis carried out daily to assess deterioration.IV access and bloods for group and save should be done if any signs of severe PET.

Anti hypertensives are used to control the BP. The aim is to bring the BP down to 150/100mmhg or below.

Anti hypertensive of first choice is labetalol either oral or IV. Also hydralazine can be used in acute settings, to bring the BP down. Methyl dopa can also used  during the pregnancy.

Steroids are considered due to possibility of iatrogenic preterm delivery (Betamethazone IM 12mg bd). Also should discuss and inform to the neonatalogist and the SCBU. If no facilities available in scbu, consider transfer of the baby after delivery (ex-utero transfer)

Urgent delivery/ termination of pregnancy is considered if signs of severe PET/ HELLP syndrome or foetal compromise. Delivery either by LSCS or induction of labour if cervix is favourable.Intrapartum continues BP monitoring  and continues CTG monitoring are considered during the labour.

Magnesium sulphate is considered if signs of severe PET  and decision to terminate the pregnancy is taken to prevent eclampsia. It is given as initial bolus dose 5g iv and continued as an infusion for 24hours after delivery. However close monitoring with respiratory rate , reflexes and urine out put are necessary.

If the patient become stable , she is debriefed regarding the events and the outcome and clear plan of management is documented in her notes including foetal indications to delver, when to involve neonatalogists, regarding foetal monitoring and assessment in the rest of the pregnancy.

She will be reviewed three time a week to assess the BP, urinalysis and blood tests including FBC, liver function tests to assess any deterioration.No more 24 hour urine protein collections necessary once diagnosis of PET is established.

CTG can be performed, but not more than once a week  and u/sscan for growth and liquor and umblical artery doppler not more than once in two weeks to assess foetal well being and growth.

Mother is advised to  review ,if symptoms-(swelling of hands , feet face, vomiting severe headache,epigastric pain) presents.

Urgent delivery indicated if any deterioration, signs of severe PET, or fetal compromise during the follow up.

Delivery depend on the favourability of the cervix- if favourable for induction of labour if not for emergency LSCS. Continues BP monitoring and continues CTG monitoring recommended during the labour

(c)The risk of eclampsia is still high even after the delivery and she needs close postpartum observation  of BP, urine output, and signs of severe PET , in first two days.

BP should be checked at least once daily in first 2 days and then once in 3 to 5 days. The aim is to maintain the BP at or below 140/90mmhg.

If she is on methyl dopa convert it to another anti hypertensive. eg; Labetalol, atenelol, as methyl dopa assosciate with mood changes and high profile of side effects.

Debrief regarding events and counsel regarding risk of PET in next pregnancy and explained the importance of follow up.

Consider tailing off of medications if BP normal in next 2 weeks.

Follow up review by GP at 6-8weeks postpartum to make sure BP has come to normal.

Rami Posted by Rami  M.
A)The likely diagnosis is pre eclampsia which is associated with risk of maternal  and perinatal mortality and morbidity. She should be asked about head ache, vomiting, disturbances of vision and epigastric pain or pain below the ribs which indicate severe pre eclampsia. Enquiry is made if she noticed sudden swelling of face and hands.  Examination is done to record blood pressure in sitting position with appropriate cuff for the arm placed at the level of the heart. BMI is assessed along with the assessment of other risk factors for VTE. Abdomen is examined for uterine height and epigastric tenderness. Fundoscopy is arranged to detect papilloedema. Reflexes are tested to identify clonus.  Investigations include estimation of FBC, Renal, liver function tests and clotting screen. The platelet count, transaminases, and serum creatinine are useful indicators for progression of severe pre eclampsia. Although it doesn't have any additional value, raising serum uric acid is associated with severe pre eclampsia and is a weak predictor of eclampsia, severe hypertension and low birth weight. Urine is tested for protein : creatinine ratio and 24h urine protein quantification but there is a weak association between proteinuria > 5 g/24 hours and stillbirth, admission to the neonatal unit and low birth weight Fetal well being is assessed initially by CTG and later by ultrasound measurement of fetal parameters, amniotic fluid depth, umbilical artery Doppler studies. B)  The aim of the treatment is to control BP to prevent morbidity and to prolong pregnancy to improve the perinatal outcome. Management should follow the local unit protocol. She should admitted to achieve control of BP , for maternal and fetal monitoring.Labetalol appears to be as effective and safe as other antihypertensives and is licensed for use in pregnancy used as first-line treatment. It is aimed to keep systolic BP 100 x 109/L. It is not required to repeat proteinuria quantification. If the results of all fetal monitoring are normal, there is no need to  repeat cardiotocography more than weekly.  Ultrasound fetal growth + amniotic fluid volume assessment + umbilical artery Doppler are repeated every 2 weeks.  Appropriate counselling is undertaken by consultant obstetrician, neonatologist, anaesthetist and midwife. Regarding timing of birth,Consultant obstetric staff should document in the woman's notes  the maternal (biochemical, haematological and clinical) and fetal  thresholds for elective birth before 34 weeks. The reasons for delivery include severe hypertension refractory to treatment, deteriorating renal function as evidenced by biochemical results or fetal compromise. It is essential to maintain good communication between obstetrician and SCBU. Corticosteroids are administered to the mother  for fetal lung maturity. If BP is well controlled with normal biochemical results and  in the absence of fetal compromise, delivery can be induced after 37 weeks. C)  BP should be measured at least four times a day while the woman is an inpatient. Antenatal antihypertensive treatment  is continued which is reduced  if their blood pressure falls below 130/80 mmHg. Methyldopa is avoided because of the risk of depression. Appropriate thromboprophylaxis is administered according to the risk profile. She should be transferred to the community care once there are no symptoms of pre-eclampsia, blood pressure, with or without treatment, is 149/99 mmHg or lower  and blood test results are stable or improving.  While transferring her to community care, care plan for women should be written in detail regarding who will provide follow-up care, including medical review if needed,  frequency of blood pressure monitoring ( every 1–2 days for up to 2 weeks until the woman is off treatment and has no hypertension), thresholds for reducing or stopping treatment,  indications for referral to primary care for blood pressure and review self-monitoring for symptoms. Platelet count, transaminases and serum creatinine are measured 48–72 hours after birth and repeated as clinically indicated and at the postnatal review (6–8 weeks after the birth). In case of proteinuria (1+ or more)  at the post natal review, she should be offered assessment of kidney function and referral to renal physician. Appropriate contraception is offered at the post natal visit.
Mistake while pasting. Please read this bit at systolic BP Posted by Rami  M.
systolic BP < 150 mmHg and diastolic BP between 80 – 100 mmHg. BP is monitored at least 6 hourly or more frequently depending on clinical circumstances. Biochemical parameters like  FBC, renal function tests, LFT are repeated 2-3 times per week depending on results. Tests of coagulation are not helpful where the platelet count is
Posted by BHAWANA  P.

A) My initiall assessment would be to confirm raised B.P. and proteinuria by measuring B.P with appropiate size cuff and urine dipstick.I would assess severity of symptoms by taking history including headache, visual disturbances, epigastric pain, facial, hand and paedal oedema especially recent increase in oedema,felling unwell in  herself. I will also ask about abdominal pain, PV bleed ( to rule out abruption),and will enquire about signs of labour and fetal movements.I will look into growth chart to assess foetal growth.

I will perform abdominal examination to assess SFH (  to assess for Small for gestational age baby),any uterine tenderness,( abruption) and lie and presentation of baby.I will examine patient for exaggerated knee reflexes and look for any clonus.( neurological irritability)

Cardiotocography to assess foetal well-being.Investigations will include Full blood count ( haematocrit, platelets), renal and liver function tests ( deranged in severe PET, HELLP) and uric acid. Protein creatinine ratio/ 24hr urine protein collection to quantify proteinuria.

B) I will admit the patient preferably in HDU setting. This will be a case of multidisciplinary involvement involving anaesthesist, senior midwife, consultant obstetrician and neonatologist.Assuming that airway and breathing is fine , I will acheive IV access. Stabilisation of B.P by giving oral/Iv labetalol, oral nifedipine or IV hydralazine can be done.Continuous B.P monitoring either by arterial /central venous line should be done( By anaesthesist)Input/output should be measured and urinary catheter should be inserted. Fluid restriction to 80ml/hr because of risk of pulmonary oedema should be done.Magnesium sulphate should be considered as it reduces risk of eclapmsia in severe PET.Appropiate thromboprophylaxis will be considered.

Continuous monitoring of Foetal heart is indicated till B.P is stable .Steroids should be given as delivery might be considered early.Neonatologist should be involved and preferably talk to the mother regarding effects of premature delivery.Bloods should be reviewed and decision for delivery should be ideally discussed or made by consultant obstetrician with entire clinical picture.

If decision for delivery is made, cervical assessment and Induction of labour should be done, emergency caesarean will be considered in cases of foetal distress/failed induction.There is little place for conservative management in this case ( may be done till steroids have their effect).If however, conservative mangement is planned, there should be clear documentation by consulatnt obstetrician regarding close follow up(as inpatient),B.p and protein monitoring, repeat bloods thrice weekly, USG for growth, EDF, Liquor volume .

C)Post-partum period is very crucial as most cases of eclampsia happen in post-partum period. B.P monitoring daily for first 2 days and then alternate days for next 3-5 days and then according to clinical pictureshould be done. PET bloods should be repeated if any clinical signs or raised B.p. Consider reducing medication if B.P.<140/90 and stopping the anti-hypertensives if B.P <130/80. If on methyldopa , change it to other antihypertensive as soon as possible /at least within 2 days.Consider appropiate thrombophylaxis, early mobilisation and thrombo-embolic dettrent stockings.

Communication to midwife in community and G.P and arrange follow up with midwife for B.P monitoring as mentioned above.and in 2weeks with G.P for review of medication.Advise about contraception will be given. She should be reassured that labetalol, atenolol,nifedipine has no proven side-effect in breastfeeding.
Also she should be counselled about increase recurrence rate in next pregnancy- the risk of both Pregnancy induced hypertention and pre-eclampsia are increased.

 

Answer 344 By Hbadran Posted by HAnaa B.

A

After referral from the community midwife with hypertension and protinuria .the patient should go through assessment of her condition by making sure that her blood pressure is high so repeated blood pressure reading on 2 occasions 4hrs apart should take place with the appropriate cuff. BP systolic more than 160 mmgh is considered moderate to severe type in relation to the diastolic less than 100 it is considered moderate type of preeclampsia]

Her urine is also measured for protinuria using either protein /creatinine ration or collection of her 24hrs urine, condition with protinuria more than 300mg with hypertension is diagnosed as preeclampsia.

Detailed history taking about her age , parity, BMI on booking, multiple pregnancy ,previous preeclampsia, hypertensive conditions , renal disease, diabetes , SLE , vasculitis  should be clear.

Previous family history of preeclampsia or autoimmune disease in her family should be also known.

 She should be asked about sudden arise of symptoms like headache, swelling of her face ,feet or hands, diplopia of vision or epigastria pain.

Examination includes BMI, abdominal for fundal height and epigastric  pain, fundoscopy , reflexes and neurological examination

Investigation should be done to exclude HELLP syndrome and to assess the severity of the condition, FBC, LFT, uric acid  and clotting factors.

B

Subsequant antenatl care after making sure of her BP and protinuria should include admission for treatement of her Bp,  by using either labetalol or alpha methely dopa with regards to the side effect of each one  depression for methyl dopa and thrompocytopenia .

Labetalol is much preferred  as it decrease the risk of sever hypertension.

Blood pressure should be monitored  4 times a day.

Fetal monitoring by CTG, US fetal growth , AFI and UA dopplar studies

IF all investigation came to be normal  then CTG 2 times a week, and other US , AFI , Doppler is repeated every 2 weeks.

More frequent if deterioration of maternal conditions, decreased fetal movement, vaginal bleeding

or pain  arise.

iN case of adjustement of BP she can go home and follow up on outpatient basis, after teaching her worning symptoms.

Delivery plan should be written in her chart including time of her delivery, mode of delivery, it is not necessary by cs , vaginal delivery is allowed after 39 weeks .

If investigation came to be abnormal, consultant alert should take place, more intense monitoring of her blood work and chemistry.

Steroid should be discussed with the patient especially she is below 34 weeks.

Discussion with the neonatologist and risk of prematurity is explained to the parents.

Delivery plane should be written clearly in patient chart. Its timing and mode of delivery also at the best place ,and best time and in the best environment.

Discussion of delivery should be assessed according to the mother situation and severity of the condition in relation to gestational age.

Condition warrant delivery includes deterioration of maternal condition, signs of eminent eclampsia, reversed of absent Doppler flow in the UA and DA.

During labor, BP , CTG and blood chemistry is monitored well, with the use of antihypertensive , IV labetallol can be used in severe cases better than hydrazine .

Magnisum sulphate  in labour is having a statistically  results in prevention of seizures in labour than placebo. its use is accompanied by better neonatal outcome  high apgar scores more than 7 in 1,5 minutes and less neonatal stay in the NICU than 7 days . 4grms as initial dose followed by 1-2 grm iv for 24 hrs post natal,  monitored by clinical signs of decreased urine output, maternal confusion, depressed respiratory rate and lost reflexes .antidote Ca gluconate  given as iv bolus if signs of toxicity appears after stopping of the Magnesium sulphate.

Cs is for obstetric causes and fetal distress.

C

Post partum care, should include BP monitoring, for 3 days  in the hospital, antihypertensives can be used till 3 month post partum. Breast feeding is encouraged and it is not affected by the medication.labetalol, nifidipine , metheldopa can be used.

Follow up of her investigation till normal if it was abnormal.

Risk of eclampsia is increased in the post natal period 30%.

Recurrence in the next pregnancy can occur.1-4 if sever preeclampsia had occurred.

Contraception offered POP is suitable for breast feeding moms and can be started as early as 3 weeks post partum.

  

essay 344 sofia Posted by sofia  S.

 

 

Ans a;  assessment of patient will include taking history of any symptoms suggestive of imminent ecclampsia such as headach,blurring vision, epigastric discomfort nausea and vomiting. review of patients record to  determine  other high risk factors  like  high BMI  and multiple pregnancy. Examination include measurement of BP initially every  half hourly till patient is stable followed by 4 hourly if asymptomatic and conservative management is planned. Single measurement of diastolic BP >110mm of Hg  Or two records of diastolic BP>90 mm of Hg 4hrs apart with significant protienuria (1+ on automated reagent strip reading) is suggestive of pre-eclampsia.p/a examination for fundal height and fetal heart rate for fetal wellbeing. Presence of ankle clonus(>3 beats)  would indicate  risk of imminent eclampsia. Investigations would include, quantification  of protienuria (24 hr urinary protein or protein creatinine ratio). Blood test are kidney function,electrolytes ,FBC transaminase and bilirubin. Ctg and  ultrasound for biometry,fluid volume and umbilical artery Doppler.

Ans b: I will admit the women to hospital . Multideciplinary care involving consultant  obstetrician,neonatalogist,anesthetist,intensivist and specialist midwife. aim is to balance risk of prematurity with risk of preclampsia and try to prolong pregnancy.treat hypertension with oral labetalol  as first line (other options are nifedipine and hydralizine)with aim to keep BP< 150/80-100 mmHg. Corticosteroids for fetal lung maturity as preterm delivery may be required.magnesium sulphate would be required if symptoms and signs suggestive of imminent ecclapsia or  in case of eclampsia. Fluid restriction to 80ml/hr to avoid pulmonary edema. Monitoring would include 4 hourly BP measurement pulse temp,saturation ,input output charting using early obstretics warning chart. Blood investigations to be repeated 3 times a week  or earlier in case of abnormality. Ultrasound should not be repeated more than every 2 weeks and ctg every week if results are normal.plan  of care should be documented  in notes that would include maternal (uncontrolled BP,Imminent ecclampsia,HELLP syndrome)and fetal indications (abnormal ctg, severe iugr with abnormal doppler)of elective birth before 34 wks and plan for antenatal fetal monitoring..     timing for delivery will depend on response to antihypertensive treatment,hematological and biochemical parameters and result of fetal monitoring. Earlier delivery may be required if severe refractory hypertension or maternal or fetal indication develop as defined in plan. If her BP  is controlled she should be offered delivery between 34 to 36+6 wks. Aim for vaginal delivery but mode of delivery will depend on bishop score and blood pressure control and fetal factors.level 2 critical care would be required if patient  requires iv antihypertensive treatment, or develops HELLP syndrome,eclampsia,severe oliguria, coagulopathy, neurological symptoms or signs of pulmonary edema.clear communication between the team would improve perinatal and maternal out come.

Ans c: postnatally measure BP every 4 hourly till inpatient. continue antenatal anti hypertensive treatment(if methyldopa used stop within 2 days). consider reducing dose if BP falls to <140/90 or reduce if< 130/80mmHg.ask patient about  severe headach and epigastric pain each time BP is measured.thromboprophylasxis after assessment of risk factors. Measure platlet count, transaminase and creatinine 48-72 hrs after birth. Transfer to community care if BP <150/100 mmHg , blood test stable and improving and no symptoms of preeclampsia. Write care plan to include frequency of BP monitoring and indications for referral and communicate with GP and community midwife.. BP  monitoring 1-2 days for 2 weeks or till antihypertensive treatment given.  Support and advice to maintain breasfeeding and information about safety of drugs. Contraceptive advice should be given. medical review after 2 week. Postnatal review a 6-8 weeks including medical review.specialist advice is sought if anti hypertensive still needed or protienuria >1+. Repeat platlet  tranaminase and creatine if treatment still   required. inform regarding risk of recurrence in subsequent pregnancy and  role of asprin .advice regarding healthy lifestyle and weight reduction if obese. Written information should be provided.

 

 

 

ANS TO 344 Posted by SARO K.

 

Ans to essay344:

(a)I will get a detailed history about parity ,prior gestational hypertension /pre eclampsia,family history of preeclampsia ,singleton /multiple pregnancy,headache,blurring of vision,epigastric pain,vomiting,sudden swelling of hands, legs and face.I will examine her blood pressure with appropriate size cuff in sitting position ,uterine fundal height,tenderness or rigidity,deep tendon reflexes,fundoscopy and respiratory rate .I will do urinary spot protein/creatinine ratio or 24 hrs urinary protein.Blood tests includes FBC,RENAL FUNCTION TESTS,Liver function tests.Fetal assessment includes CTG,Fetal biometry,amniotic fluid volume and umbilical artery Doppler.

(b) I will admit her as she is moderate pre eclampsia   as multi disciplinary team  consisting of obstetrician,anesthetist neonatologist and senior midwife.I will start antihypertensive therapy with labetolol 100 mg .Aim is to reduce severe hypertension and does not have any side effects on the fetus.Other option s includes methyldopa and nifidipine.I will monitor her bp 6th hrly and maintain between SBP less than 150 mmHg and DBP less than 80-100 mmHg .I will follow up the investigations and plan for clotting profile if platelet count is less than 100.If found to be normal plan for conservative management. I will give a course of steroids as she might need need delivery at any time. I wont repeat proteinuria quantification   if more than 3gm /24 hrs as it is not going to influence  future management.I will inform the patient and relatives about  the maternal and fetal  condition  in detail if found to be normal and write a  care plan for conservative management.Disharge her and ask her to continue antihypertensives  with repeat blood investigation three times a week ,fetal montoring –CTG weekly ,  fetal growth scan,amniotic fluid volume  and  umbilical artery Doppler every 15 days.  I will write abt time of delivery, mode of delivery , neonate counselling and anesthesia consult.I will assess her risk of VTE and start prophylxis if more than 2 antenatal risk factors.

If Bp is not under control and investigation are not normal with fetal deteiration I will stop conservative management and plan termination of pregnancy which is the definitive treatment.I will   involve consultant obstetrician and anesthetist ,neonatologist.I will make sure abt the availability of beds in SCBU.

Indication  of termination of pregnancy includes uncontrolled Bp, signs and symptoms of imminent eclampsia,eclampsia, abnormal LFT and RFT ,coagulation abnormalties,  fetal growth restriction with abn umbilical artery Doppler  ,abruptio placenta . I will plan MODE OF DELIVERY   depending on the cervical status,fetal doppler and CTG ,any emergent situation like abruption or eclampsia  that necessitate urgent delivery along  with magnesium sulphate regimen. I will alert for a bed  in LEVEL 2 CRITICAL CARE.

Intrapartum Care:  I will continue antihypertensive therapy  with  BP hrly  and  continuous CTG monitoring. Proper analgesia is mandatory throughout labour  with active management of third stage. Avoid ergometrine .Prophylactic  forceps if Bp is very high .Continue MGso4 if already started with  monitoring urine output ,DTR and respiratory rate.I will inform the condition of mother and baby and progress  of labour periodically to the relatives.

(c)I will check her Bp daily for first 2 days and atleast once between  D3-D5.Frequently as per previous BP /change of drugs.Continue labetolol  but change methyldopa within 2 days  if used antenatally as it increases depression.I will consider reducing drug if less than 140/90 mmHg and stop if less than 130/80 mmHg. I will reassess her risk of VTE  and start /continue prophylaxis  if needed for 6 weeks postnatally. Repeat blood tests to check if everything is normal if raised early.She should be in the hospital till 5 days as chance of poatpartun eclampsia is  44percent and can be transferred  to community Midwife with proper plan .  I will plan postnatal medical review  for all at 6 weeks and  if they needed drug for more than 2 weeks.I will counsel her that  chance of recurrence in  next pregnancy is very high and need to start on Low dose Aspirin  from 12 weeks until delivery.Continous surveillance is needed as chance of hypertension is more later life.I will counsel about contraception.I will document in the notes.

 

Ali Naveed Haq Posted by Ali Naveed Haq H.

 

a). I will the history where I will ask about the present pregnancy, confirm the gestation by comparing the dates with an early ultrasound, go through  record and investigations done previously, history of previous visits and blood pressure record, headache, epigastric pain, visual disturbances, dizziness and confusion. History of urinary tract infection, lower abdominal pain, vaginal discharge . In the past history I will look for chronic renal disease, preexisiting hypertension,  outcome of previous pregnancies , any history of preterm births and still births , IUGR along with the gestation at which it happened. In the family history I will look for hypertention in the first degree relatives, pregnancy induced hypertension in the family, autoimmune disease, renal disease diabetes. I will ask for use of medication in the past and any history of smoking etc. I will recheck her blood pressure , recheck the proteinurea , assess the signs of severe preeclampsia epigastric and right hypochondrial  tenderness, make a fetal assessment by assessing the symphysiofundal height, fetal heart rate. I will admit this lady if her blood pressure and proteinuria are the same or increased . I will recheck her blood pressure every four hours ask for  full blood count to look for platelets, 24 hour urinary proteins, creatinine , liver function tests . Fetal ultrasound and fetal umbilical artery doppler , cardiotocography.

 

 

 

b) This lady needs to be managed by using multidisciplinary approach, with the early involvement of physician, heamatologist and nephrologist. In case of eclapmsia, or development of HELLP syndrome early delivery followed by ICU care will be arranged .  If the blood pressure is persistently raised or increasing upon two readings taken four hours apart or there is persistent protein urea I will start an antihypertensive medication like labetalol , or methyl dopa , continue to monitor blood pressure and if there is deterioration or persistant rise , epigastric pain , with deterioration in liver function tests , reduction in platetlet count  below 100000/mil , raised proteinurea ++ or +++, > 500mg/ 24 hours , I will give corticosteroid cover for fetal lung maturity and for severe progressive disease with uncontrollable blood pressure or eclampsia I will deliver  her on urgent basis.

Now if the blood pressure has been controlled and the tests are also with in normal limits I will discharge her form the hospital on medication and check the blood pressure , proteinurea by dipstick on every visit renal function tests and platelets twice weekly.  Ultrasound and fetal Doppler will be carried out  every week till 37 completed weeks if all is well. I will explain to her that it is important for her and the fetal wellbeing that her blood pressure should be controlled and she should continue to attend the hospital for antenatal care. I will discuss delivery plan with in next 1 to 2 weeks and in the absence of obstetric contraindications. I will plan induction of labour and aim for vaginal delivery .

 

   

c) In the post natal period I will recheck her blood pressure every day for 2 days , and day 3 and 5 , a t least twice weekly assessment of blood preseure in the community . I will give written information and make a care plan for her community transfer of care . if the blood pressure is raised in the postnatal period alongwith proteinurea a medical review , nephrologist visit will be arranged . There is a 40 percent chance of developing eclampsia in the postnatal period all symptoms and signs of eclampsia will be explained to the patient and the partner . If the blood pressure has returned to normal as it usually does I will stop or reduce her antihypertensive medication.  I will encourage her to breastfeed her baby and in case of an adverse outcome like a still birth I will advice her for early booking in the next pregnancy and start of intensive monitoring at least 02 weeks before the onset of symptoms in this pregnancy i.e 30 weeks. Contraception will be discussed in the postnatal period. 

answer to essay 344 by N Posted by Sherif N.

a) assessment of the patient by proper history taking whether she has hypertension, diabetes mellitus, history of DVT, thrombophilia disorders, previous PIH (if she is multi) or previous eclampsia, any medical disorder

if she is taking any medications, antihypertensives, anticoagulants, low dose aspirin, corticposteroids

general examination to recheck her BP in proper position, with proper cuff size if she is obese, measure her BMI, check for lower limb oedema

abdominal examination for fundal level (if corresponding to period of amenorrhea or smaller) , fetal presentation, any uterine activity or contractions

local PV examination for bony pelvis (if primi), cervix and its bishop score

US for the amount of liquor AFI, fetal growth and compare it with previous serial growth assessment to detect any element of IUGR, placenta and whether there is any retroplacental haematoma. Doppler study for umbilical artery flow to detect any resistance

CTG if the patient complains of decreased fetal movement or if there is abdominal pain

investigations: liver and kidney functions, coagulation profile, FBC and platelet count, urine analysis and total protein in urine in 24hrs urine collection

b) antenatal care:

admit the patient to control her BP, aim is to reach a BP of 140/90

give her antihypertensive, labetalol

corticosteroids to promote the fetal lung maturity if there will be a need of premature delivery

do lab test 3 times a week, but no need to repeat ptn quatification in urine

US and Doppler for serial fetal growth, AFI, umbilical artery resistance done every 2weeks

CTG not to be repeated except if there is decreased fetal movement or starting abdominal pains

low dose aspirin if taken by the patient, will be continued till delivery

if her BP is controlled, labs are fine, US and Doppler are good, patient is allowed to continue pregnancy with close follow up of her BP and labs twice weekly, US and Doppler every 2weeks until delivery

if BP isn't controlled or worsen, her labs or US or Doppler are not good, decision of termination of pregnancy will be taken, but this needs involvement of multidisciplinary team including senior obstetrician, senior anaesthetiologist, neonatologist, senior mid-wife, haematologist, and inform NICU about possibility of baby admission

NB: magnesium sulphate may be needed if patient develops imminent eclampsia during induction of labour

c) postnatal care:

post normal delivery, she needs level 2 critical care with close follow up of her BP every 6hours durinf the first 3 days, and at least once between day 3 and day 5 (the peak BP is reached at this time)

continue antihypertensive ttt but consider decreasing the dose if BP falls to 130/80

there is more risk of postpartum haemorrhage, so close observation for her pulse, amount of vaginal bleeding, uterine contraction is needed

follow up visit post discharge after 2 weeks to check her BP, stop antihypertensive ttt if BP returns to normal

explain to the patient what happened, answer her inquiries, counsel her about the risk of recurrence of PIH in subsequent pregnancies, how to prevent or minimise this by intake of low dose aspirin starting from 12th week gestation until delivery

 

 

Posted by Preethi A.

 

History symptoms of severe preeclampsia and previous obsterics history regarding parity ,previous mode of delivery and associated medical disorders to be enquried
Multiple BP recordings to be taken with appropriate size cuff and position taking korotoffs phase  5 sounds for diastole measurements
Headache and abdominal pain are the symptoms of worsening disease indicating involvement of cerebrovascular and hepatic system
Clonus if present may indicate risk of convulsions but maternal tendon hyperreflexia might not be suggestive 
Oxygen saturation measurment cotinously with pulse oximetry may help detecting pulmonary edema early
24hr urine protein or serum protien creatine ration are more accurate and  to be  considered as 2+ urine protenuria is  significant but dipstick is associated with high false positive result 
More than 0.3gm/24hrs or 30 gm/mmoul of protien confirms significant  protenuria
Full blood count to check for platelet count and if more than 100 x106 do not require coagulation screen to be performed
Hepatic and renal function test as a base line to done and if normal to be repeated dialy
Renal failure ie raised creatinine indicate heamorrhage ,HELLP syndrome, sepsis or underlying ranal condition
Raised AST and ALT of above 150iu/l are associated with increased risk of maternal morbidity
HELLP syndrome severe form can be diagnosed by heamylsis evident on blood film or raised LDH levels.deranged hepatic function and low platelets
Fetal assessment with cardiiotocoghraphy in acute situation and by ultrasound for growth liquor volume and umbilical artery Dopplers
 
 
b)
 
Admission to labour ward  for, stabilisation, continued monitoring and delivery at the optimal time for the mother and her baby
 Senior obstetric and anaesthetic staff and experienced midwives should be involved
BP to checked every 15minutes untill stablised and 4hrly in conservative management is opted
Antihypertensives like labetalol intravenously or orally or nifedepine orally or hydralazine intravenously to used as per unit protocol in acute situation
Prophylactic magnesium sulphate to considered  if associated with risk factors like headaches visual distrubances epigastria pain pressence of 3 beats of clonus and moderate to severe BP as MAGPIE trial has shown 58%reduction in convulsions
Steroids 2x doses of betamethasone of 12mg intramuscular injection at 12hrly intervals to enhance fetal lung maturation tto be given if risk to the mother are well balanced 
|As her gestation is 32 weeks delivery to be deferred until 34 weeks and conservative mangement with antihypertensive medication to reduce maternal risk of cerebrovascular accident
Prolonging pregnancy if gestation less than 34 weeks helps steroid to help reduce the fetal respiratory morbidity, neonatal unit to be more organised or to transfer the patient where there is cot available only if mother is stable
Vaginal birth is the aim and IOL  considered if more than 34 weeks , cephalic presention 
Ceasearean section if gestation is less than 34weeks or non cephalic presention
Syntometrin to be avoided for prevention of PPH as it is associated with severe vasoconstrition leading to rapid raise of BP and cerebrovascular accidents
 
3)Women who deliver with severe pre-eclampsia (or eclampsia) should have continued close observation postnatal as eclampsia has been reported up to 4 weeks postnatally,
Inpatient monitoring until the incidence of eclampsia and severepre-eclampsia falls ie after the fourth postpartum day
Magnesium sulphate if commenced to be continued 24hrs post delivery
Antihypertensive to be considered even in postpartum period to reduce the risk
Persistent raised BP for 6 weeks  postpartum may have underlying renal disease and needs further investigation 
Debriefing and explaing the events to patients is importand explaining the risk of chronic or essention hypertension risk
 
 
 
 
 
 
 
 
 
 
 
 
Posted by Preethi A.

 

History symptoms of severe preeclampsia and previous obsterics history regarding parity ,previous mode of delivery and associated medical disorders to be enquried
Multiple BP recordings to be taken with appropriate size cuff and position taking korotoffs phase  5 sounds for diastole measurements
Headache and abdominal pain are the symptoms of worsening disease indicating involvement of cerebrovascular and hepatic system
Clonus if present may indicate risk of convulsions but maternal tendon hyperreflexia might not be suggestive 
Oxygen saturation measurment cotinously with pulse oximetry may help detecting pulmonary edema early
24hr urine protein or serum protien creatine ration are more accurate and  to be  considered as 2+ urine protenuria is  significant but dipstick is associated with high false positive result 
More than 0.3gm/24hrs or 30 gm/mmoul of protien confirms significant  protenuria
Full blood count to check for platelet count and if more than 100 x106 do not require coagulation screen to be performed
Hepatic and renal function test as a base line to done and if normal to be repeated dialy
Renal failure ie raised creatinine indicate heamorrhage ,HELLP syndrome, sepsis or underlying ranal condition
Raised AST and ALT of above 150iu/l are associated with increased risk of maternal morbidity
HELLP syndrome severe form can be diagnosed by heamylsis evident on blood film or raised LDH levels.deranged hepatic function and low platelets
Fetal assessment with cardiiotocoghraphy in acute situation and by ultrasound for growth liquor volume and umbilical artery Dopplers
 
 
b)
 
Admission to labour ward  for, stabilisation, continued monitoring and delivery at the optimal time for the mother and her baby
 Senior obstetric and anaesthetic staff and experienced midwives should be involved
BP to checked every 15minutes untill stablised and 4hrly in conservative management is opted
Antihypertensives like labetalol intravenously or orally or nifedepine orally or hydralazine intravenously to used as per unit protocol in acute situation
Prophylactic magnesium sulphate to considered  if associated with risk factors like headaches visual distrubances epigastria pain pressence of 3 beats of clonus and moderate to severe BP as MAGPIE trial has shown 58%reduction in convulsions
Steroids 2x doses of betamethasone of 12mg intramuscular injection at 12hrly intervals to enhance fetal lung maturation tto be given if risk to the mother are well balanced 
|As her gestation is 32 weeks delivery to be deferred until 34 weeks and conservative mangement with antihypertensive medication to reduce maternal risk of cerebrovascular accident
Prolonging pregnancy if gestation less than 34 weeks helps steroid to help reduce the fetal respiratory morbidity, neonatal unit to be more organised or to transfer the patient where there is cot available only if mother is stable
Vaginal birth is the aim and IOL  considered if more than 34 weeks , cephalic presention 
Ceasearean section if gestation is less than 34weeks or non cephalic presention
Syntometrin to be avoided for prevention of PPH as it is associated with severe vasoconstrition leading to rapid raise of BP and cerebrovascular accidents
 
3)Women who deliver with severe pre-eclampsia (or eclampsia) should have continued close observation postnatal as eclampsia has been reported up to 4 weeks postnatally,
Inpatient monitoring until the incidence of eclampsia and severepre-eclampsia falls ie after the fourth postpartum day
Magnesium sulphate if commenced to be continued 24hrs post delivery
Antihypertensive to be considered even in postpartum period to reduce the risk
Persistent raised BP for 6 weeks  postpartum may have underlying renal disease and needs further investigation 
Debriefing and explaing the events to patients is importand explaining the risk of chronic or essention hypertension risk
 
 
 
 
 
 
 
 
 
 
 
 
Posted by Leila R.

A

Maternal and foetal wellbeing

physical examination

biochemical

assessment of this patient should start with enquiring her general well being and symptoms of impending eclampsia like headache, visual disturbances, nausea or vomiting, upper abdominal pain, malaise, and any ill feeling. Signs of foetal wellbeing including foetal movement should be enquired. Then physical examination to confirm the presence of high blood pressure,  abdominal palpation to check symphisio-fundal height for foetal growth and  to establish any right upper quadrant or epigastric  tenderness  which is associated with severe pre eclampsia . Fundal tenderness associated with placental abruption should be ascertained. Neurologic signs of impending eclampsia should be checked including deep tendon reflex and clonus.  

Laboratory investigation to rule out any multiorgan involvement  including renal function test, full blood count to check for thrombocytopenia, liver function test and urate level. And urine dipstic for proteinuria.

B

Admission,

blood pressure monitoring

PCR or 24 hours urine protein

Antihypertensives

Steroids

CTG

Growth scan

Hospital admission is recommended in patient with BP >160/110, Anti hypertensives medication should be initiated preferably with labetalol or Nifedipine. Methyldopa is slow in onset of action, therefore is not best option in patient with such high blood pressure. NICU should be informed following admission of the mother and Neonatologist should discuss the prognosis of delivery at this gestation with the couple. Seniour obstetrician, Labour ward co ordinator and senior anaesthetist should be informed.

 Following admission blood pressure should be monitored every 15minutes until less than 160/110.  Then 6 hourly blood pressure monitoring is recommended. The blood pressure should maintained below 150mmHg systolic and between 80-100 mmhg diastolic. Urine sample  should be sent for PCR or 24 urine collection for proteinuria. Also MSSU should be sent to rule out any presence of UTI.

If investigation and clinical examination indicates severe pre eclampsia, delivery should be expedited following maternal stabilisation. The patient must be cared in a high dependency level with strict fluid balance chard. Mgso4 for prevention of eclampsia should be started. Corticosteroid administration for prevention of neonatal morbidity is recommended, however this should not delay delivery if maternal condition worsen.  CTG should b e performed for foetal wellbeing.

 In the absence of signs of severe pre eclampsia , with good blood pressure control and normal laboratory investigation, this patient can be managed conservatively. Ultrasound for Foetal growth and amniotic fluid volume should be performed, with or without umbilical artery Doppler studies depending on the foetal growth.  This will be repeated in two weeks time to assess foetal growth. If foetal growth is normal at 34 weeks repeat growth scan is not indicated. Weekly CTG for foetal well being is recommended if there is no new concerns like reduced foetal movement PVB, or change in maternal condition.

If the patient stabilises she can be managed as outpatient with twice weekly blood pressure check, and weekly FBC, LFT, and Urate , and weekly CTG. The aim is delivery after 37 weeks if foetal and maternal condition remains stable. Aiming  to keep systolic BP less than 150mmhg and diastolic BP between 80-100mmhg.

C

Afer delivery this patient is still at risk of eclampsia which occur 44% pos natal,  38% antenatal and 18% intrapartum. Hence the patient must be monitored in a high dependency level, With hourly  vital signs and fluid balance chart. Mgso4 should continued until 24 hours post delivery or last seizure. Deep tendon reflex should be checked hourly. After 24 hours, blood pressure should be monitored every 6 hours for first 2 days, then once between day 3 and 5 post natal , Anti hypertansive should be continued, however if she was taking methyldopa, this should be changed within 2 working days as it increases risk of post natal depression. During discharge a letter should be sent to the GP including her condition and management plan . The patient can the be reviewed by her GP in the community one week post natal. If BP is less than 130/80, anti hypertansives can be stopped by the GP. The patient should be seen  in gynaecology clinic at 6 weeks post natal, To check BP, and laboratory analysis if have returned to normal. Screening for anti phospholipid syndrome is recommended.  Counselling regarding the high risk of recurrence of severe pre eclampsia in the future pregnancy.  Use of low dose aspirin once pregnancy confirmed  in the future pregnancy is recommended.  If the patient require medications after six weeks post natal medical review should be arranged to rule out any essential or secondary hypertension. COCP is not contraindicated if this patient test negative for anti phospholipid syndrome.  

Posted by Muthu M.

I would like to know whether it is her first pregnancy or any other pregnancies before.  I would like to know the booking blood pressure and booking body mass index.  I will make sure appropriate blood pressure cuff is used and I will try to get more than one readings at 30minutes interval.  From the patient I would like to know, whether she has any pre-eclampsia symptoms like headache, flashing lights, double vision, and epigastric pain.  I would like to know whether they are new symptoms and it is persistent inspite of conventional treatment.  From examination, I will check the signs such as pedal edema, reflexes and clonus level. I will check that if she had pregnancies before whether she had the pre-eclampsia before.  I will do blood tests such as Full blood count, renal function tests, liver function tests and urate levels.  I will also send mid stream urine specimen for culture and sensitivity and also either 24hour urine for protein level or protein / creatinine ratio depends on my unit protocol.  In above results, I specifically look for platelet level, liver enzyme level and urate level. 

As she is just 32 weeks, I will give her steroid injections times two as per our units protocol.   I will check with special care baby unit to make sure there would be a cot for baby in case early delivery required.  If the blood pressure is persistently high around 168/99mm Hg, I will start her on medication, preferably on labetalol after discussing with my consultant.  If she is clinically asymptomatic and does do well with regular blood pressure checks and blood results, I will discharge her from the admission and arrange for her to be seen at day assessment unit and antenatal clinic at regular intervals.   It would be like twice a week or three times a week.  I will also repeat the pre-eclampsia blood tests and urine for protein levels.  I will arrange for her to have growth scan to check growth and liquor volume.  If there is any concern with growth or liquor volume, I will request for dopplers.  During her regular visits to hospital, I will arrange for her to have regular fetal monitoring – cardiotocograph.  I will clearly advise the patient that if she feels unwell with any of the pre-eclampsia symptoms or reduced fetal movements or pervaginal bleeding, she should come to labour-ward immediately for an assessment.

Now, I would like to know whether she had to have either magnesium suphate or antihypertensive infusion for her intrapartum care.  If that case, I will monitor her in the high dependency unit- checking her pulse, blood pressure, O2 saturation, urine output and reflexes hourly.  I will maintain strict input and output chart and she will have urometer.  I will slowly wean her off from the above medication roughly about 24hours provided her observations are good.  If she had an uneventful intrapartum care, then she will still need to have regular blood pressure monitor (4hourly – depends on the value) and strict input and output care.  I will continue the blood pressure medication like labetalol postnatlly and send her home (around day 3 – 4) with same if her blood pressure remains stable with medication.  I will advise her, she needs postnatal review at 6 weeks and the blood pressure medication could be stopped then.  First 2 weeks, I will arrange for a community midwife to her at home to check blood pressure every day.

H H Posted by H H.

This is a case of severe pre eclampsia and should be considered a high risk pregnancy and needs admission. Will take history of headache, visual disturbances, nausea, epigastric or upper abdominal pain and lower limb swelling. Will see her notes to see if had already hypertension being treated and this is a superimposed pre eclampsia or this is a new event. Will take obstetric history for any previous obstetric complications and mode of delivery.

Will perform examination including her BMI, BP,pulse ,temp., chest and heart, reflexes, clonus, a epigastric tenderness, Rt hypochondrial tenderness, fundal height, uterine tenderness

Will take blood for FBC , urea and electrolytes. liver function test. If platelets less than 100,000/ml3 or LFT abnormal will do coagulation studies. Will do urine protein :creatinine ratio to confirm proteinuria( above 30 mg/mmol ).

Will do CTG for fetal wellbeing. Will do fetal growth scan and umblical doppler velocimetry at presentation

 

 

The ultimate treatment of severe pre eclampsia is delivery ,but I will balance between, the risks of delivery of this baby having prematurity problems if delivered at such gestation, and the risk of conserving ,with risk of maternal morbidity( e.g eclampsia, HELP,cerebral hemorrhage) and mortality.Therefore a multidisciplinary approach needed ,with informing the consultant obstetrician,midwife with one to one approach,hematologist , neonatologist and anesthetist. Patient information is a must and she should have the chance of talking to neonatologist should delivery is needed at early gestation.

Will lower her BP using oral propranolol ,with frequent measurement of BP at 4-6 hourly and if no response will give IV propronalol. Should BP be resistant to lowering ,is an indication for deliveryز

Will assess her need for Mgso4 ,should she has symptoms and clonus,but should this be needed ,measures for delivery will be needeed ,monitoring for mgso4 toxicity( loss of patellar reflex,resp depression and urine output ), SCBU informed.

Will chart fluid intake and output and limit fluid intake to 80ml/hr as there is shrinkage of circulation and possibility of pulmonary edema .Putting a central line ,by the anesthetist, to avoid fluid overload is of value

Will give steroids for fetal lung maturity if delivery can be delayed .Will assess her risk of thrombophylaxis and consult with hematologist

Delivery is indicated if there is fetal compromise, unresponse to anti hypertensive treatment, imminent eclampsia with symptoms,eclampsia,HELP,and abnormal hematological and biochemical investigations.

Should conservative management is decided,will measure BP/6hr, do blood tests 2-3 times /wk, CTG daily and fetal growth scan and umblical doppler every two weeks.Aim to delay deivery ,if BP is controlled, for fetal benfit,but the risk of eclampsia is not abolished.

Will doument my plan including monitoring, steroid intake and informing SCBU, but not timing or mode of deivery which are dependant on the situation.

 

There is still risk of eclampsia, so mgso4 should be continued for 24hr after delivery. BP should be measured 6 hrly and the antihypertensive continued. Patient can breast feed. Will continue fluid balance monitoring, Will assess her risk for for thromboprophylaxis and advise early mobilisation and proper hydration. If she had epidural analgesia,will consult with anesthetist for timing of removal. Will discuss with her follow up in antenatal care in 6 wk time and medical consultation and referral if still has high BP. Will discuss contraception.

 

 

Essay 344-Reena Posted by Reena G.

a) The most likely diagnoses is moderate to severe preclampsia which is high risk pregnancy and needs admission.I will quickly take her history in which I will ask about her parity, pregnancy interval(if >10 year), , multiple pregnancy, family history of preeclampsia, her past history of preeclampsia or gestational hypertension, diabetes, chronic hypertension, SLE, Antiphospholipid syndrome, her booking BMi (>35kg/m2) as all are risk factors for preeclampsia & her presentation  at 32 weeks gestation age further increases her risk and fetal morbidity, I would like to know about any associated symtoms like headache, nausea, vomitting, blurring of vision, pain in upper abdomen between the ribs, sudden swelling of face, hand and feet which will indicate about the severity of the disease. On examination I will see her general appearance, any facial puffiness,her weight to note any sudden increase in weight, will check her blood pressure with appropriate size cuff semi reclining position at korotkoff phase v.Per abdomen fundal height, epigastric tenderness, presentation of fetus and fetalheart, palpate for any contraction or any tenderness , to look for any abnormal bleeding and pedal edema. fundoscopy, reflexes and neurological examination may be indicated.CTG to be done at the time of diagnoses. Then I will send FBC, LFT and RFT(urea and electrolytes) and iuf platelet <100 for coagulation studies. I will counsel her that she needs urgent admission for stabilizing her condition   as there is increase risk for eclampsia.

b)I will admit this case into crtical care 2  and will involve senior obstetrician/ anesthetist/ midwife and paediatrician.I will do blood pressure monitoring 4-6 hourly and will send FBC, LFT , RFT  to check any low platelet and raised transaminase and repeat three times /week , I will not quantify proteinuria as it is already given. I will start labetalol as 1st line management drug to control hypertension , other alternatives methyldopa and nifedipene can be considered , aim is to bring systolic <150 and diastolic between 80-100mmhg. CTG to be done at the time of diagnoses.Ultrasound for liquor, fetal growth, and umbilical artery Doppler to be done Corticosteroids to be considered  as in view of prematurity. If any alarming  symtoms and signs of impending eclampsia ( severe headache, flashing of light, epigastric pain, low platelet sudden raise of liver enzymes ) then magnesium sulphate should be considered& if delivery is imminent within 24 hours If blood pressure not controlled to assess her again  , if cervix favourable aim for vaginal delivery, if poor bishops score then cesarean section to be done.

  If results of fetal monitoring are abnormal then consultant obstetrician to be involved and Plan care to be written in her notes mentioning timing and nature of fetal monitoring, fetal indication for delivery, if and when steroids to be given, when discussion with anaesthetist and paediatrician  should take place.If results of fetal monitoring are normal then Ultrasound for growth, liquor, Doppler to be done once in 2 weeks and CtG not more than once weekly.

c)The patient to be transferred in level 1 critical care after delivery for observation. Her blood pressure to be checked daily for first 2 days then at least once a  day on 3-5th day as 44%of Eclampsia occurs in post partum period. Continue antihypertensive treatment and if on magnesium sulphate for 24 hrs post delivery.If on methyldopa to stop within 2 days  as  causes depression. Consider reducing antihypertensive if B.P.<140/90, Reduce antihypertensive if <130/80mmhg. If not on any treatment then start treatment if B.P. > 140/99. Debreifing about her delivery events to be done, chance of recurrence and follow up during post natal counselling.Care plan to be discussed and written and G.P. to be informed while discharging for community care mentioning who will take care, when to reduce and stop antihypertensive medication. To arrange follow up care after 6-8 weeks with specialist care for hypertension.

Posted by sadaf A.

A healthy 32 year old woman has been referred by her community midwife because her BP is 168/99 mmHg and there is 2+ proteinuria at 32 weeks gestation. (a) Discuss your assessment of this woman [6 marks]. (b) Discuss your subsequent antenatal care given that hypertension and proteinuria are confirmed [9 marks]. (c) Discuss her post-natal care given that she eventually has a normal vaginal delivery [5 marks].

A)FIRST OF ALL I WILL TAKE HISTORY OF PT INCLUDING PARITY,ANY SYMPTOM LIKE HEADACH,VOMITTING,BLURRING OF VISION OR FLASH OF LIGHTS,EPIGASTIC BURNING OR SUDDEN SWELLING OF FACE ARM OR FOOT, IS SHE HAVING GDM IN THIS PREG.REGARDING PAST OBST HX I WILL ASK FOR ANY H/O PIH IN PREV PREG,IS THERE ANY H/O ESST HTN OR DM?H/O ANY RENAL FROBLEM.FAMILY H/O HTN.I WILL RECHECK HER BP TO MAKE DIAGNOSIS OF PRE-ECLAMPSIA  DIASTOLIC BP SHOULD B  >90MM OF HG .IN EXAMINATION I WILL DO ABDOMINAL EXAM FOR EPIGASTRIC TENDERNESS AND HOF.I WILL CHECK FOR OEDMA,REFLEXES AND ALSO FUNDOSCOPY TO CHECK FOR PAPILLODEMA.FOR LAB INVESTIGATION I WILL SEND FBC,LFT RFT U.ACID,24 HOURS URINARY PROTIENS ANF CLOTTING PROFILE IF PLT ARE <100.I WILL DO CTG TO ASSESS FOETAL WELLBEING,DOPPLER SCAN WILL B PERFORMED TO ASSESS FOETAL WEIGHT,PLACENATAL GRADING,AMOUNT OF LIQUR AND UMBILICAL ARTERY DOPPLER.

B)AS THIS PT IS HAVING PICTURE OF PRE-ECLAMPSIA SO I WILL ADMIT THE PT FOR TOXEMIA REGIEME ANG FOETAL MONITRING.I WILL START ANTI HTN THERAY LINE LABETOLO IF SHE IS NOT ASTHEMATIC.OTHER OPTIONS LIKE METHYLDOPA AD NIFIDIPINE CAN B STARTED.I WILL ADVISE TO BP MONITORING FIRST HALF HOURLY THEN HOURLY AND WHEN SETTLED 4 HOURLY,INTAKE AND OUTPUT CHARTING.CTG FOR FOETAL MINITORING.ONCE BP IS CONTROLLED WITH MEDUCATION <150/100-80 AND ALL LABS R UNDER NORMAL LIMIT MONITORING SHOULD B DONE TO PROLONG THE PREG TILL 37WKS.DOPPLER SHOULD B DONE AFTER 2WKS.LABS SHOULD B REPEATED TWICE WKLY.

BUT IF LABS AND DOPPLER R NOT FAVOUABLE TO PROLONG PREG I WILL GIVE BETAMETHASONE FOR FOETAL LUNG MATIRITY.NEONATOLOGIST SHOULD B INFORMED FOR POSSIBILTY OF PRETERM DELIVERY.PT SHOULD B ASSESSD FOF NVD AND IOL IF FOETAL AND MATERNAL CONDITIONS ALLOWS

C)IF PT DELIVERED BY NORMAL DELIVERY WE SHOULD INFORM PT THAT SHE CAN VE ECLAMPSIA AS 44% OCCUR IN POSTPARTUM PERIOD.WE SHOULD CHECK  ON 1ST TWO DAYS AND ONCE ON 4TH DAY.IF PT ON METHYDOPA IT SHOULD B CHANGED TO LABETOLOL OR ATENOLOL.BREAST FEEDING SHOULD B ENCOURAGED.ON DISCHARGED PT SHOULD B ADVISED FOR  BP MONITORING ONCE A WK AND TO TALE MEDICATION FOR 3WKS.IF CONDITION PERSIST SHE SHOULD B REFERRED TO PHYSICIAN.RISK OF PRE ECLAPSIA IN NXT PREG SHLUD B EXPLAINED

C)

Essay Posted by Samira  K.

a-It is a case of severe preeclampsia.Her clinical records should be reviewed to check if she has any risk factors for Preeclampsia like her obstetric history (her parity,previous history of preeclampia, PreviousGestational HTN,Previous IUGR baby,)

During her antenatal visits any high reading of BP or proteinurea,Record of her fetal growth checked by fundal heights to see any evidence of IUGR.Her BMI.Sudden increase in her Wt.

We should ask if she is having any sign or symptoms of preeclampsia like headache,pain below the ribs,vomiting,flushes infront of her eyes,blurred vision.

We will check her BP 4 hrs apart to confirm severe HTN,check BMI of this patient.Spot protein:creatinine ratio or 24 hrs urine collection to confirm finding of urine dipstick.Abdomen should be examined for fundal height,epigatric tenderness,Cardiotocograph,Fetal growth scan,Amniotic fluid index,uterine artery dopplers for fetal well being should be done.Tendon reflexes and clonus to be checked and vaginal examintion to be done to decide mode of delivery in case she needs to be delivered.FBC(platelets),Aminotransferases,Renal function tests with electrolytes,bilirubin to be done.

b-This patient should be admitted.Senior obstetrician,noenatologist,anaesthesiologist consulted and patient should be given chance to discuss with neonatologist in case she needs to be delivered prematurely.AntiHTN(labetolol) started .Aim to keep her BP <150/80-100mm/hg.Betamathasone( preferably )to be given 12mg Q24 hrs for 2 doses.If BP controlled and preeclampsia profile is normal, patient can be managed expectantaly until 34 wks or more according to neonatal facalities.In case of expectant management,BP should be checked every other day on an outpatient basis,Protinurea to be checked every Wk.Preeclampsia profile to be done 3 times a Wk.Fetal growth Scan,AFI and UA dopplers every 2 Wks.Patient should be informed if she develop any sign of imminent eclampsia like severe headahe,vomiting,pain under ribs,blurred vision to report to hospital immediately.Mode of delivery at 34 wks should be discussed with patient .Induction of labour is preferable and C-Section reserve for maternal or fetal indication.During expectant management any sign of hematological or biochemical or fetal detoriation or very high BP to be started on magnesium salphate and to be delivered after stabilizing the patient and Magnesium salphate to be continued for 24 hrs after delivery.

c-Post natally her AntiHTN to be continued and she should be advised to continue breast feeding as labetolol is safe.If she was on methldopa it should be changed in 2 days and started on any other AntiHTN safe for breast feeding .Check BP 6 times a day while inpatient.If BP<130/80 to stop AntiHTN..Bp should be checked every 3-5 days  and if it is >150/100 to start ANTIHTN medications.Asses braest feeding for 1st 2 days.Repeat preeclampsia profile after 2 days and if normal do not repeat. Consel patient to monitor symptoms of preeclampsia.2 wks review to assess need of AntiHTN if still on AntiHTN medications.6 wks medical review should be offered.Encourage her to keep her BMI between 18-25kg/m2.Patient should be given support and information on events and her risks of preeclampsia in future pregnancy should be discussed .

If BP <150/100,Preeclampsia profile normal,and no symptoms of preeclampsia refer back to community midwife after 6 wks.

Essay 344 Posted by Murad A.

 

The presentation is suspecious of Pre-eclampsia ( PET)  , I will first repeat the Bp , I will use a manual device rather than an automated device. I will take History, including history of medical illnesses i.e." HTN , SLE , Renal diseases .." , the use of medications/ illicit drus  during and before pregnancy . The parity of the patient and whether she had History of Pre-eclampsia ( PET)  in a previous pregnancy and special attention to mode of previous deliveries in case i have to deliver her . Symptomes of sever PET need to be explored i.e" blurring of vision, headach , epigstric pains ". The antenatal records need to be reviewed , to check early pregnancy screening , Bp and protienuria . And to review the anomaly scan . On examination the pulse , Respiratory rate and Temperature need to be documented. I will assess the  general status, do Chest exam  and obstetric exam to assess the fundal hight and fetal heart . Lower limbs need to be checked for edema though it has no prognostic value . I will repeat the urine analysis and check for evidence of urinery tract infection . I will order an  Ultrasound to be done to check for the fetal growth and doppler studies of the umbilical and uterine arteries

 The patient need to be admitted to a Labour ward as a high dependency unite , CTG on admission , Bp to be done every 30 minutes. If Bp confirmed and persisted to be more than 160/110, Magnesium Sulfate need to be initiated as per local protocol" 2-4gms bolus and 1-2g / hour as maintainance " and an antihypertensive medication started " Labetelol , Nefidipine or Hydralazine " . The management  of sever PET after 32 weeks is delivery . I will do a vaginal exam to assess the cervical status and to decide the mode of delivery , vaginal delivery being preferred if no other obstetric indications . The MgSO4 need to be continued through labour and to continue 24 hours postpartum . The Assessment intrapartum should include continuous CTG , Bp every 15 mins and urine out Check and screening for MgSO4 toxicity" Respiratory rate, Knee reflexes " . Antihypertensives to be given when needed . Regional anesthesia is not contraindicated. I will give dexamethasone to enhance lung maturity ..

If the Bp repeat was less than given and mild PET is diagnosed , conservative management can be offfered after assessment in the labour ward come satisfactory . I will give steroid , I will start the patient on oral antihypertensive " Methyl dopa or Nefidepine " and the patient can have an outpatient management with close follow up, Serial Ultrasounds  and a planned delivery at 38 weeks , earlier if she needed increasing doses or  combined medications . The value of prolongation of pregnancy after 34 weeks in cases of PET is questionable .   

Postnatally , The Bp need to be monitored carefully in the first 24 hours ,, Antihypertensives need to be continued for at least 4 weeks post partum with home Bp monitory ,,The choice of medications is wider than during pregnancy " Any Anti-HTN " needed can be offerred . The patient can discontinue medications if hypotension events occured . The patient shoul be taught instructed to seek medical advice if she noticed any signs of increasing Bp . I will inform her about the risks of eclampsia and what warning signs exists , Breast feeding is not contraindicated . I will provide the patient with available leaflets concerning PET and i will offer contraception and advise her about recurrence rsiks . If Bp or protienurea persists after 4-6 weeks postpartum the patient is likely to have an essentiak HTN or renal disease respectively and then she should follow up accordingly  

 

 

anuradha n Posted by anuradha N.

a)She has been referred for preeclampsia.My initial assessment includes whether there is history of headache,vomiting,epigastric pain,blurring of vision.If above symptoms are present she could be in imminant eclampsia,needs close monitering of BP,prophylactic MgSO4 as per unit protocol,I/O chart,informing senior obstetrician,anesthetist,senior midwife,NIcu specialist for further planning and delivery.My priority is to contorl her blood pressure and prevent eclampsia.

If she is asymtomatic,I would take history of gravidity,parity,H/O pre-eclampsia,eclampsia in previous pregnancies,H/O long standing hypertension,diabetes.I will check her present antenatal records,her booking BP,anomaly scan report at 20 weeks,or earlier scan if she has(fetus corresponds with dates or not).Time of onset of hypertension,,proteinuria,using any antihypertensives.H/O decresed urine output,painabdomen,bleeding per vagina(Abruption),Whether she is appreciating good fetal movements or not.

Exam-General well being,BP,BMI,CVS/RS.Abdomen exam-Level of fundal height,fetal presentation,FHS,clinical estimated fetal weight,liqour.P/V if she is in labour or bleeding.Fundoscopy for papilledema.Fetus is assessed by CTG,Ultrasound for wellbeing,liqour,weight and umbilical artery Doppler for signs of compromise.

b)Having diagnosed pre-eclampsia,iI will admit her,Record her BP 4 hourly ( if symptomatic every 15 mins in initial phase).i will consider antihypertensive oral labetelol so as to keep BP 150/80-100 mm hg so as to prevent cerebral hemorrhage,eclampsia.

I will send baseline blood tests,group and save, FBC,urea creatinine,electrolytes,liver function tests,serum uriacid,(to assess multi organ dysfunction)coagulation studies if platelet count < 100x10 6/l.24 hr urine protein is measured.Fetus is assessed with CTG,scan and umbilical artery doppler.Detailed plan of delivery is made.SEnior Obstetrician,NICU specialist,anesthatist are involved ,futher management discussed .Woman and relatives are fully informed about her condition,balancing risks of continuing pregnancy vs prematurity of the fetus.A course of prophylactic steroids is given as early delivery may be  required.daily she is monitered with symptomps of eclampsia,fetal movements,bleedig.BP is checked 4 hourly,daily urine output,proteinuria.Blood tests are repeated 3 times a week.Fetus is asseessd with kick count,weekly CTG (earlier if reduced movements,maternal bleeding).Scan is repeated once in 2-3 weeks for fetal growth.If the mother is asymptomatic,maternal and fetal wellbeing tests are satifactory,BP well controlled,expectant management is adopted until 36-37 weeks.

Between 32-36/37 weeks early delivery is decided if BP uncontrolled despite antihypertensives,signs of imminant eclampsia/eclampsia,abruption,labor starts,detiorating maternal biochemical tests (falling platelet<100x10 6/l,raising liver enzymes AST>150 iu/l-HELLP syndrome,rasing creatinine),evidance of fetal compromise CTG changes,severe oligomnia,absent/reversal of flow on umbilical artery.Route of delivery  is decided by maternal /fetal condition,urgency of delivery and cervical status.I will advice the nursing staff to recognise warning symtomps early,to be fully equipped with resuscitative measures if eclampsia starts,to inform at earliest.

c)After her delivery,prophylactic oxytocin should be given(risk of hemorrhage)ergometrine should be avoided(sudden rise in blood pressure).She is at risk of post natal eclampsia hence BP should be controlled <140/90(not<130/80).Oral labetelol can be continued.Methyl dopa si avoided as it can cause post natal depression.Adequte hydration,mobility is encouraged to prevent DVT,LMW heparinX 7 days is considerde if other risk factors are present such as BMI>35.Her BP checked daily will be obseved for at least 5 days.She is at risk of post natal psychosis good supportive care from relatives adviced,breast feeding encouraged,perinael hygine adviced.Contracetion advice given.Her BP and proteinuria are assessed again after 6 weeks to rule out underlying chronic hypertension.She is adviced about recurrence risk in subsequent pregnancy,weight reduction (if obese)

 

 

Posted by vaneeza K.

A. Pre-eclampsia is associated with increase in maternal mortality if patient is not assessed and treated promptly.History of headache,blurring,nausea,vomiting and epigastric pain are indicative of severity of disease.She should be asked about foetal movements and any vaginal bleeding or leaking. BP should be rechecked,if systolic is still >160 mmHg immediate antihypertensive treatment must be started.BP should be monitored every 15 mins initially than after 30 mins.I will check her BMI and ankle clonus if >5beats ,patient is at risk of having fits.Abdominal examination will be carried out for epigastric tenderness,uterine size and tenderness. I will assess haematological and biochemical status doing FBC,for baseline HB and platelet count, LFTs ,RFTs ,and clotting if platlet count is <100x10*9/L and abnormal liver function tests.Protein uria will be assessed by spot urine protein:creatinine followed by 24 hrs urinary proteins.Foetal wellbeing will be assessed by CTG  and USS for foetal growth,liquor volm and umbilical artery doppler.

B.Patient will be admitted for BP controll and will be managed by MDT including consultant obstetrician,anaesthetist.neonatologist and senior midwife. Anihypertensive treatment will be started. Labetalol  (both alpha & beta antagonist) 200mg orally ,dose can be repeated after 30 mins  if no initial response.Methyl dopa and nifedipine can also be given .ACE inhibitors ,ARBs and sublingual nifedipine should be avoided.Diuretics used only for treating pulmonary odema .If her BP is refractory to treatment or patient is symptomatic along with low platelet <100x10*9 /L,AST,ALT >70IU/L MGSO4 ,4G iv bolus over 5 min followed by 1g/hr infusion and patient should be delivered after steriod  by CS.  If her BP is controlled she will be managed conservatively.BP will be monitored 4 times daily with an aim to maintain BP 150/80-100 mmhg. there is no need to repeat protein uria.RFTS,FBC,transaminases and electrolytes will repeated three times /week . Foetus will be monitored by CTG weekly or more frequently if mother complains of decreased foetal movements,vaginal bleeding and or abd pain.USS foetal growth,liquor  volm and umbilical artery doppler should  be repeated every 2 wks .Plan should be doccumented in her notes about maternal indications for early delivery like eclampsia  HELLP syn and abnormal LFTS ,KFTS.Foetal threshold (abnormal doppler &CTG) for delivery should also be mentioned.If patient remain stable should be induced at 37 wks.aim is vaginal delivery.

3.During postnatal period i will measure her BP  daily for 2 days ,at least once between day 3 and day 5.Treatment should be continued.switch over to labetalol if patient is on methyl dopa with in 2 days of delivery as it causes postnatal depression.she should be asked about headache ,nausea,vomiting and epigastric pain every time when her bp is checked.Reduce antihypertensive treatment if her BP fall below 130/80.Platelet count,transaminases and creatinine should be repeated 48-72 hrs after delivery if normal no need to repeat.She will be reassured that antihypertensives are safe during breast feeding except  ARBs,amlodipine,ACE inhibitors other than captopril and enalaprilshe will be told that risk of recurrence of gestational hypertension in future pregnancy is 16%-47% and pre eclampsia is 2% -7%. so she will be advised to keep BMI with in normal range before next pregnancy.

she will have medical review 6-8 wks postnatal and if still need treatment .follow up after 3 month to hypertension clinic.

ans Posted by sarabjeet G.

initial assessment would include inquiring about symptoms indicating severity (blurring ,epigastric pain, nausea,headache ) any change in perceived fetal movement s and past obstetric history. Family history and past medical history should be taken. examination would include confirmation of hypertension using the correct technique and appropriate sized cuff and looking for signs of epigasric tenderness,exagerated reflexes (clonus) ,assessment of fetal growth .review of past sonograms should be done.

 admission and quantification of proteinuria along with baseline maternal and fetal investigations should be done. full blood count liver and kidney funtion tests , electrolytes, fundoscopy should be done. 

Posted by Bee Fong C.

 

            Headache, visual disturbance and peripheral oedema should point to preeclampsia with raised blood pressure and proteinuria. She may also complain about epigatric pain, nausea, vomiting and generally feeling unwell suggesting severe preeclampsia.

            Examination may reveal papilloedema, epigastric tenderness, hyperreflexia indicating preeclampsia. More than 3 beats of clonus point toward severe preeclampsia. Fetal wellbeing is assessed with presence and frequency of movement and fetal electronic monitoring. Ultrasound is performed to assessed growth velocity and liquor volume.

            Full blood count and blood film will reveal anaemia, haemolysis and thrombocytopenia. Renal and liver function should be assessed. Haemolysis, raised transaminase enzyme and thrombocytopenia points to HELLP syndrom. Uric acid should be performed as a baseline and for monitoring preeclampsia.

            Either 24 hour urine collection for proteinuria or protein:creatinine ratio should be performed to quantify proteinuria.

 

(B)             she should be advised to stay in for observation of her blood pressure every 4 hourly. As her blood pressure remains above 150/100 and proteinuria, labetalol needs to be started provided she does not have asthma or cardiac condition.

            Daily CTG needs to be performed whilst she is in hospital to assess fetal wellbeing. Ultrasound every 2-4 weeks can be performed to monitor fetal growth velocity and liquor volume and Doppler umbilical artery if abnormal growth.

            There should be  a balance between delivering her baby due to severe preeclampsia or prematurity of her baby. Antenatal steroids is given if delivery is imminent to prevent respiratory distress, necrotising enterocolitis and intraventricular haemorrhage.

            Delivery will depend on whether she has had previous vaginal delivery. Vaginal delivery is more successful at later gestation and with previous vaginal delivery. Caesarean section done at 32 weeks can be difficult and need experienced staffs.

            Any signs of severe preeclampsia warrants magnesium sulphate and delivery should be imminent.

            Most of the time her blood pressure is under controlled and pregnancy is allowed to continue. If so, bloods should be repeated 2-3days. If patient is stable she should be involved in deciding either to be monitored as inpatient or outpatient. This will depend where she lives, her social circumstances and the availability of community midwife. Warning signs and symptoms need to be educated for prompt referral to the hospital by herself or community midwife.

 

(C)            she needs to be debriefed about the events of the pregnancy and documented in the nates. Risk factors need to be identified to prevent recurrence. Hoever, it is difficult to identify and may still happen again or she can be fine and have normal pregnancy. Support should be given to her and her partner.

            Daily blood pressure needs to be checked for 1st 2 days. This can be done in the postnatal ward or if she had severe preeclampsia on high dependency care unit, more frequent blood pressure measurements. The antihypertensive should be continued postnatally. Methyldopa should be changed to prevent postnatal depression.  Considering stopping antihypertensive if blood pressure is below 130/80. It is not contraindicated to breast feed.

            Contraception need to be discussed until her hypertension is stable and the cause of her severe preeclampsia investigated. Follow up should be arranged for this reason. Appropriate physician should be involved if any investigation is abnormal outside pregnancy.

            Her community midwife and general physician need to be aware of her pregnancy to monitor her blood pressure postnatal after discharge and refer back to hospital if necessary.

Posted by Dr Dyslexia V.

X

ESSAY 344

a)      I will take history in regards to her parity and if any previous outcome of her previous pregnancy such as eclampsia, intrauterine growth restriction, still birth and need for premature delivery. History in regards to current underlying kidney disease, auto immune disease such as SLE, diabetes must be taken.  Drugs such as antihypertensive, aspirin, or low molecular heparin should also be enquired. I will enquire symptoms of severe pre-eclampsia such as headache, vomiting, blurring of vision, epigastric pain. Examination would include general condition, her body mass index, her blood pressure should be reassessed with a sphygmomanometer, pulse rate, saturation of oxygen, cardiovascular examination and lung examination. Symphsiofundal height discrepancy should be assessed for presence of IUGR. CTG should be done to assess fetal condition. Blood investigation should be taken which include full blood count to assess for thrombocytopenia, liver function test to assess for transaminase level, and renal function for baseline assessment. A 24 hour urine protein should be assessed for quantification of proteinuria if not done before. An ultrasound for growth, amniotic fluid index and Doppler of the umbilical artery done.

 

b)      Patient with severe hypertension with pre-eclampsia should be admitted for further management. She should be assessed if she requires a level 2 assessment in which if she is moderate to severe pre-eclampsia and mild pre-eclampsia could be managed in level 1 critical care. She could be started on oral anti hypertensive such as labetolol or nifedipine depending on her side effect profile. The treatment is aimed to maintain blood pressure less than 150/80-100mmHg. The blood pressure has to be taken 4 times a day. Blood should be taken to test for kidney function, full blood count, liver function test to assess transaminases 2-3 times a week depending on severity. Initial assessment of the fetus with ultrasound for growth, amniotic fluid index and umbilical artery Doppler should be done and carried 2 weekly if she requires. Since she is 32 weeks if delivery is anticipated in view of refractory hypertension or maternal or fetal indication, fetus could be given betamethason 12 mg 24 hours apart for lung maturation. She would be ideally managed conservatively with documented plan in regards to threshold for delivery in regards to maternal or fetal indication. Neonatologist and anesthetist should be informed if delivery is planned. She would be delivered ideally after 37 weeks if no problems arises till then.

c)She should be ideally stepped down care from critical care to post natal ward. Blood pressure should be monitored 4 times a day and platelet count, transaminasas and renal profile should be measured 48-72 hours post delivery. During this period symptoms of sever pre-eclampsia such as headache and epigastric pain should be inquired. Methyldopa if used should be discontinued and other antihypertensive used if required. She should be transferred to midwife care if BP<150/100 and not symptomatic. Women should be encouraged breastfeeding and information of the safety of antihypertensive is informed. Blood pressure should be monitored up to 1 to 2 days for about 2 weeks. Medical review should be offered it still taking antihypertensive. If she is still proteinuric after 3 months than she should be referred for kidney assessment. Offer referral to hypertensive clinic if still requiring hypertensive after 6-8 weeks. She should be advised in regards to contraception wihich are progestogenic  like, etonogesteral implant or POP. She should also be advised to take aspirin in her next pregnancy and explain te risk of recurrence which is  ½ to 1/8  chance of recurrence. 

essay Posted by j  .

J reply

I will take a detailed history of her symptoms including headache, epigastric pain and blurring of vision which might indicate the imminent signs of eclampsia. I will also enquire about foetal movements and constant abdominal pain which may point towards abruption. I will take a detailed past obstetric history including preeclampsia in previous pregnancies because of the increased risk of recurrence. I will review her hand held notes to look for any medical disorders and any events in her pregnancy till now.
 
I will perform an abdominal examination to assess the growth and liquor volume by assessing SFH as there is a risk of IUGR in preeclampsia. Repeat blood pressure measurements will be done in the sitting posture. I will assess the fetal wellbeing by doing the fetal CTG.


b.I will admit the patient for both maternal and fetal monitoring. I will monitor her blood pressure  initially every 15 min  and then 30 min and then every 4 hours. Review of her symptoms and careful enquiry about fetal movements will be done. Investigations for preeclampsia like full blood count to rule out thrombocytopenia in HELP syndrome, U&E , serum uric acid and LFT to assess the baseline function. Urine PCR will be done and if more than 30 then 24 hour urinary protein estimation is indicated. Oral Labetolol will be started if diastolic blood pressure more than 100 mmHg. I will inform her about the maternal risk of preeclampsia like abruption and foetal risk like IUGR, iatrogenic prematurity. Uss to be done for growth and  and Liquor volume of fetus. If BP is controlled and her PCR and PET bloods normal then the patient can be considered for outpatient management. Weekly/Biweekly BP check-up and urine protein assessment will be advised. Plan for her antenatal visit will also be made at discharge.I f is uncontrolled or evidence of fetal compromise cosideration should be given for delivery of baby after steroids and careful assessment of cervix.Intravenous magnesium sulphate will be considered will be condired in case of imminent symptoms and severe PET.

C.Postnatally patient blood pressure should be monitored every day for the initial 2 days and then alternatively for the next 3 days.I will ccontinue antihypertensive treatment.Methyldopa if started antenatally will be changed to labetalol.If Bp falls to less than 130/80 dose will be reduced.Medical review will be planned at 2 weeks to describe the events,time to discontinue medication.6 weeks review will be planned in specialist clinic to review her mediaction,BP and any persistent proteinuria if present will need referral to the concerned specialists.    If IIiday for the forst 2 daya

essay 344 Posted by naila A.

 

A) She need assessment for the severity of her condition to evaluate the risk to her and to the fetus and plan delivery at most appropriate time for both the mother and the baby. I’ll obtain details of her past deliveries if they were complicated with pre eclempsia and its complications. If any previous pregnancy was complicated with eclempsia or HELLP syndrome the risk of recurrence for such complication is 20%.The mode of deliveries and the age of last born is important  to decide for the mode of delivery. I’ll review her notes for booking blood pressure and BMI and review early dating scan and growth scan. I’ll check her BP BMI and edema. I’ll palpate abdomen for the fundal height and fetal lie and presentation and check fetal heart by CTG. I’ll request investigations for FBC, renal and liver function test, electrolytes blood group and save serum  and urinalysis for protein creatinine ratio.

B) I’ll admit her. She’ll need multidisciplinary care involving physician, senior obstetrician anesthetist and neonatologist. Oral labetalol is drug of choice .If she is asymptomatic and blood pressure is controlled conservative management is planned. Injection betamethasone intramuscular is given. If her BP remains controlled with normal biochemistry she’ll need daily BP monitoring, with biochemistry twice a week and 24 urine proteins. Fetal monitoring will be with CTG in acute situation followed by weekly ultrasound for liquor and umbilical artery Doppler. If blood pressure remain elevated in spite of adequate treatment with iv labetalol or hydrallazine or she become symptomatic with headache, vomiting, epigastric pain or blurring of vision she’ll need urgent delivery by c/s. If biochemistry becomes abnormal delivery will be needed. If fetal compromise is detected the management is urgent deliver by c/s.

C) Active managementof third stage is by early cord clamping and intramuscular syntocinon. Ergometrine should be avoided. BP is monitored as clinically indicated as the risk of eclempsia  post partum is 44%.Need to continue antihypertensive medication is assessed, if she is on methyldopa it should be changed to another medication as there is risk of post partum depression. She is discharged with clear plan for BP monitoring ,review by physician, and instructions to continue the medication or reduce the dose when BP fall below 130/90.Contraception is discussed .POP is the drug of choice for breast feeding mothers.

Reference for essay 344 please discuss Posted by sofia  S.

 

post natal care preeclampsia NICE

 1. If methyl dopa used to treat   preclampsia stop within 2days

2.ask about severe headach and epigastric pain each time BP is measured

3.if mild or moderate preeclampsia or step down from critical care, measure  platlet ,serum transaminase  and creatinine 48-72 hrs after birth or step down.repeat as clinically indicated. do not repeat if results normal.

4.do not measure fluid balance if creatinine normal after step down from level 2.

5.offer transfer to community midwifery care if BP < 150/80,Blood test stable or improving and no symptoms of preeclampsia.

if no antenatal hypertensive treatment measure BP 4 TIMES A DAY  WHILE INPATIENT.

at least once 3-5 daysafter birth

alternate days  if BP  abnormal after 3-5 days after birth.

6. write care plan

7.measure BP 1-2 day after transfer to community care till antihypertensive treatment stopped or no hypertension.

 

Posted by sofia  S.

measuring BP ONCE DAILY FOR 2 DAYS is for gestational hypertension and not for preeclampsia as per nice guideline. the case senario in present question is of preeclampsia.

please clarify paul. thanks

 

Posted by zaitouni L.

A)Assessment :

I will admit the pationt  ,Iwill take obestetric  history  including interpregnancy interval ; prevouse preclampsia .Past history of  chronic hypertention. I will take family history of preeclampsia or hypertention .Gestational age 32ws put the patient at increased risk of prematurity and placental abruption I will ask about  sever  headache visual symtoms as blurring of vision or flashing  before the eyes,sever pain just below the ribs . Iwill ask about vomiting and sudden swelling of  face ,hands and feet. . 

Examination of the patient : I will take blood pressure  body mass indix ,fundal hieght, Iwill chick for ,epigastric tenderness fundoscopy ,reflexes and neurological examination may be required.

Investigations : FBC,liver and renal function tests including electrolytes  coagulation teste are required if plateles cout is below 1oo

B)  Subsequent antenatal care :

 I will admit the patient because she suffers from moderate preclampia .I will give her oral labetalol aim to systolic blood pressure below150 and diastolic pressure between 80-100mmhg. Iwill monitor blood pressure every 6 houres. Iwill take blood tests 3 times a week.,

I will do conservative managment .CTG should be done at diagnosis .Iwill do  Ultrasound fetal growth +amniotic fluid volum and umbilical artery doppler and if normal  they should not be repeated more than every 2 weeks.  .

If the resultes of all foetal invetigations are normal  CTG should be repeated once aweek.CTG should be repeated if change of foetal movementes 

,vaginal bleeding .abdominal pain or deterioration of maternal condition occured.

If the resultes of any foetal monitring is abnormal ,aconsultant obstetrician should be informed.

Plan of care should be written lncluding the timing and nature of delivary fetal indicatins of delivary ,when corticosteroidesshould be given ,when discussion with neonatologist and anaesthetest should take place..

Posted by zaitouni L.

The woman should be monitored carefully as there is risk of siezure following delivary specialy in the first 4 days following delivary .Antehypertensive treatment should be continued as dictated by BP. Contraception should be ciscsed before discharg. At 6ws postpartum BP and protienuria should be measured . In case of persistent hypertention or protienurea the woman may have renal diseaseand further investigations should be performed.precoceptional counselling shoud be offered  where eventes occcured ,risk factors and any preventive therapy can be disscused. .

Jamil Posted by PAUL A.

A healthy 32 year old woman has been referred by her community midwife because her BP is 168/99 mmHg and there is 2+ proteinuria at 32 weeks gestation. (a) Discuss your assessment of this woman [6 marks]. (b) Discuss your subsequent antenatal care given that hypertension and proteinuria are confirmed [9 marks]. (c) Discuss her post-natal care given that she eventually has a normal vaginal delivery [5 marks]. 

Ans-- First i would repeat BP of this patient . I will take history of increased risk factors for PIH How does the presence / absence of risk factors alter your management in a woman who has already developed hypertension? If it will not then there will not be any mark for it, i.e. previous pregnancy PIH, previous preeclampsia, history of  SLE, renal diseases, diabetes mellitus, chronic hypertension. Also if her BMI>35, she is at risk is she not at risk if her BMI is less than 35??. I would enquire about symptoms of headache, epigastric pain, blurring of vision, abdominal pain (1) etc as all these in this patient indicate high risk for pre eclamsia (no, they do not. These are symptoms of severe disease). Repeat BP if again high with an appropriate cuff and preferably manually taken necessitates admission . Send FBC, renal function test, coagulation (not necessary), bilirubin (why???), platelets,transaminases, spot urine protein/creatinine ratio and start 24 hr urine protein collection (1).  Inform the woman about the high risk of eclampsia and that she might need urgent delivery. (will you do an obstetric examination? Hx, exam, Invest)

b) I will admit this patient  and check all her results. Meantime after informing her that she may need an urgent delivery , i will adminster a course of steriods for lung maturity (is a diagnosis of pre-eclampsia at 32 weeks an indication for corticosteroids?). Also i would send request for  neonatologist and paediatricians (are these different people? Why do you need both?) to come and counsel her about the risks and outcome for preterm delivery.  I will start antihypertensives for her. If the repeat BP was > 160/110, IV hydralazine (NO – you treat with oral anti-hypertensives) can be given slow IV over 20 minutes ( to prevent a sudden fall in BP), if < 140/100 , oral labetolol can be given and repeated every 1 hour (is this the threshold for treating hypertension in the NICE guidelines?). Aim to keep BP < 140/90 (NO – see NICE guidelines / notes). USG and doppler to evaluate the foetus - growth, liq, placental insufficiency. CTG also to be done at admission (1). Evaluate her results, if all normal and prot/creat ratio is normal, patient can be managed as outpatient once her BP is controlled (NO – SEE NICE GUIDELINES / NOTES!!!).

              If BP still high, or protein more than 3 gm/litre, she will need urgent delivery (ABSOLUTELY NOT – proteinuria is not an indication for delivery ). Till delivery her BP should be checked >4 times/day(1), investigations checked atleast 3 times / week. Check for HELLP- hemolysis, elevated transaminases, low platelets. Document a care plan inconsultation with multidisciplinary team. Involve hematologist early if hellp is suspected as patient has chances of going into DIC. Anaesthesia consultant should be notified (1).

                  If high BP, proteinuria and unwell or epigastric pain etc, magnesium sulphate should be started prophylactically 4 gm IV stat and 1 gm/hrly. Bp should be checked hrly. If she is multi and favourable os, induction after explaination and consent should be done, but if primi, more chances of failed induction at 32 weeks , so LSCS is better.

                 In case patient was sent home(this should not happen) to follow as an outpatient, a documented care plan should be informed to her, written in all her case notes, her GP should be informed. Also her subsequent visits( weekly preferably), who will see her, the antihypertensive drugs and their effects on baby should all be informed.  In this case USG and doppler to be done every 2 weeks if normal. Consider thromboprophylaxis in all cases depending upon risk factors.

c) BP might fall in the first 24 hours followed by a rise again so BP check every 4 hours . To be vigilant  about  eclampsia as the risk is high. Encourage the patient for breastfeeding and help her if she is having any problems. To consider thromboprophylaxis if any other risk factor like BMI>30, any other medical disorders, if she received thromboprophylaxis antenataly etc.  If she was on methyl dopa, this should be stopped and other antihypertensive like labetolol can be given( as methyl dopa can cause depression) (1) . The risk for eclampsia is highest in 1st four days so frequent monitoring (how frequent? What are you monitoring?) in this time. SOme patients may need antihypertensives even upto 3 months.  If BP still high at 6 wks visit, review with physicians should be done(1). If  proteinuria persistent at 6 wks visit, referral to nephologist should be done.

      The mother should be counseled about  diet modifications, lifestyle before she is discharged. The role of exercise is to be emphasized (what is the role?). This is a part of healthy lifestyle but more stress should be given in those with BMI>30. Importance of breastfeeding (what is the importance with reference to pre-eclampsia??) and reassurance about the drugs prescribed should be done. Documented plan of care is essential part of any follow up and should be done before the patient is discharged. It should include information about her further visits, with whom, drugs prescribed. All this information should be sent to her GP also.


 

Miss T Posted by PAUL A.

(a)

This woman most likely is suffering from pre-eclampsia but further assessment is needed to confirm or refute the diagnosis (waste of time & space).

I will take detailed history from her the parity, LMP, personal or family h/o pre-eclampsia, pregnancy interval if she is multip, (what difference will any of these make to your management??)  inquiry about any symptom like head ache, visual disturbance, pain just below ribs, lower abdominal pain (why?)  etc (waste of time). and I will review her antenatal follow up how her Bp use to be and if she is already on any hypertensive treatment (? Fetal movements).

I need to check her blood pressure. Pre-eclampsia is diagnosed if there are 2 readings of diastolic >90 mmHg or single reading >110mmHg. I will take her height and weight for body mass index, reflexes(1), abdominal palpation for epigastric tenderness, fundal level(1). Pelvic assessment is not needed unless she has associated complaint of labour pains or vaginal losses. Fundoscopic and neurological examination may be needed.

I will request investigations full blood count for Hb and platelets, biochemistry for liver and renal function tests, uric acid(1). Coagulation screen only if platelets come <100. Quantification of proteinuria by 24 hour urine collection for proteins. A CTG trace for fetal well being and USS for growth and liquor and umbilical artery Doppler(1).

(b)

When confirmed pre-eclampsia this woman is at risks of eclampsia, multi-organ failure, cerebral hemorrhage, and her fetus is at risk of IUGR, prematurity, pre-term delivery, placental abruption. (not necessary)

Aim of management is to stabilize maternal condition and deliver the baby at appropriate time balancing the risk of fetal prematurity with deterioration in maternal condition.

She need to be admitted in hospital (1) and given multidisciplinary care involving senior obstetrician, neonatologist, senior midwife, and may need physician and anesthetist assessment later.

Antihypertensive therapy (1) need to be started. Labetolol is first line if patient not asthmatic. Methyldopa and Nifedipine may also be used. Aim should be to keep blood pressure at <150/80-100 mmHg.

I will give her corticosteroids (2 doses of betamethaose, 12 hours apart) as her condition may prompt immediate delivery(NO – diagnosis of pre-eclampsia at 32 weeks is not indication for corticosteroids). There is evidence that it promotes fetal lung maturity and reduces respiratory distress syndrome, interventricular hemorrhage, NICU admission and stay.

Fluid intake will be restricted to 80ml/hr(NO – do you restrict fluid intake in pre-eclamptic women on your antenatal ward????). Monitoring include Bp every 4 hours, input output charting(why? Is this recommended??). Blood tests three times a week(1). Weekly CTG unless there is an indication like abdominal pain or vaginal bleeding. USS for growth every 2 weeks and liquor and Doppler every week (1).

Seizure prophylaxis is not needed in all cases of pre-eclampsia and it will be considered if delivery of fetus is considered. Magnesium sulphate is effective in preventing seizures (Magpie) and if started need HDU care with hourly monitoring of respiratory rate, urine output, reflexes.

Expectant management is an option with close monitoring of maternal and fetal condition aiming to prolong pregnancy till 34 weeks (NO – 37 weeks) and avoiding prematurity as much as possible.

Consider delivery if there is evidence of maternal or fetal compromise, uncontrolled blood pressure(1), and abnormal lab results (? High urate??), eclampsia. Decision and mode of delivery will be made by senior obstetrician involving women and taking her wishes into consideration. SCBU need to be notified. Induction of labour is an option but cesarean delivery is needed as rapidly deteriorating maternal condition may not permit time consumption in induction.

When in labour, hourly Bp monitoring is needed. Ergometrine will be avoided for third stage management.(antenatal care)

(c)

After delivery she is still at risk of eclampsia as 44% of cases occur postpartum.

Her blood pressure will be monitored and treated accordingly. Anti hypertensives may need to be continued for up to 3 months.(not necessary)  If she was on methyldopa it need to be changed to either labetolol or nifedipine in 2 working days, as there is risk pf post partum depression(1). ACE inhibitors are safe but diuretics and ARB should be avoided.

Her Bp will be checked daily for first 2 days and once between day 3 & 5(SEE NICE GUIDELINES). On discharge a letter will be given to GP detailing her care and treatment. If she is still in anti hypertensive a follow up at 6 weeks is arranged what about review at 2 weeks?.

She will be given counseling detailing events of her delivery. And recurrence risk in further pregnancy that is up to 16%. No contraindication to breast feeding and it will be encouraged. Contraception will be discussed with her.

DHARSHITHA Posted by PAUL A.

 

(a)The initial assessment include assessing the mother and the foetus using detailed history , proper examination, and investigations. (waste of time & space)

Mother is assessed regarding symptoms of severe PET including severe headache, vomiting,visual disturbances, epigastric pain (1) and good foetal movements are assessed to confirm the foetal well being(1).

Examination includes measurement of BMI and  weight to assess weight gain, BP (1) measurement using WHO standards with accurate positioning(either sitting or left lateral ) and appropriate sized cuff. Also funduscopy to exclude retinal haemorrhages and papiloedema, neurological examination including assessment of reflexes and clonus carried out.

Assessment of level of oedema (swelling of face hands , feet), and measurement of urine out put also important.

Abdominal palpation to assess the fundal height, foetal heart auscultation and clinical assessment of liquor volume are important to assess foetal well being (1) ? epigastric tenderness.

Investigations include-24hour urine protein collection, and serum urate  levels to confirm the diagnosis of PET (not useful – see NICE guidelines). Also  FBC to assess haemoglobin level and platelet count to exclude HELLP syndrome. LIver function tests to assess rising ALT AST levels-(a sign of PET and HELLP syndrome).

In addition serum electrolytes and blood urea, serum creatinine to assess renal function. Clotting profile is advocated only if platelet count is below 100 000(1).

Foetal well being is assessed by u/s scan for growth and liquor volume and umblical artery doppler and CTG  to exclude acute foetal distress(1).

(b)This is a case of severe to moderate PET, and she needs admission (1) to the ward for close monitoring and investigation.

Involvement of an senior experienced midwife, senior obstetrician, anaesthetist is important to plan the care -multi desciplinary involvement. Ideally she should be managed in HDU setting in her initial period (why???).

Mother is first assessed as above and monitored closely , using MEOWS chart. BP is checked 4 hourly, fluid balance chart is maintained to assess input / output to prevent fluid overload (not necessary. What will you do? Fluid restrict her??). Urinalysis carried out daily to assess deterioration (NO – not necessary.).IV access and bloods for group and save should be done if any signs of severe PET.

Anti hypertensives are used to control the BP. The aim is to bring the BP down to 150/100mmhg or below (NO – see NICE guidelines / notes).

Anti hypertensive of first choice is labetalol either oral or IV (why is iv therapy needed?). Also hydralazine can be used in acute settings, to bring the BP down. Methyl dopa can also used  during the pregnancy.

Steroids are considered (who will make this decision?) due to possibility of iatrogenic preterm delivery (Betamethazone IM 12mg bd). Also should discuss and inform to the neonatalogist and the SCBU. If no facilities available in scbu, consider transfer of the baby after delivery (ex-utero transfer)

Urgent delivery/ termination of pregnancy (would you terminate pregnancy at 32 weeks???? The woman would think you are going to kill her baby) is considered if signs of severe PET/ HELLP syndrome or foetal compromise(1). Delivery either by LSCS or induction of labour if cervix is favourable.Intrapartum continues BP monitoring  and continues CTG monitoring are considered during the labour(you were asked about antenatal care).

Magnesium sulphate is considered if signs of severe PET  and decision to terminate the pregnancy (????) is taken to prevent eclampsia. It is given as initial bolus dose 5g iv and continued as an infusion for 24hours after delivery. However close monitoring with respiratory rate , reflexes and urine out put are necessary.

If the patient become stable , she is debriefed regarding the events and the outcome and clear plan of management is documented in her notes including foetal indications to delver, when to involve neonatalogists, regarding foetal monitoring (1) and assessment in the rest of the pregnancy.

She will be reviewed three time a week (so you will have this woman in hospital and only review her 3 times a week???) to assess the BP, urinalysis and blood tests including FBC, liver function tests to assess any deterioration.No more 24 hour urine protein collections necessary once diagnosis of PET is established.

CTG can be performed, but not more than once a week  and u/sscan for growth and liquor and umblical artery doppler not more than once in two weeks to assess foetal well being and growth(1).

Mother is advised to  review ,if symptoms-(swelling of hands , feet face, vomiting severe headache,epigastric pain) presents.

Urgent delivery indicated if any deterioration, signs of severe PET, or fetal compromise during the follow up (you have already written this).

Delivery depend on the favourability of the cervix- if favourable for induction of labour if not for emergency LSCS (you have already written this). Continues BP monitoring and continues CTG monitoring recommended during the labour

(c)The risk of eclampsia is still high even after the delivery and she needs close postpartum observation  of BP, urine output, and signs of severe PET , in first two days.

BP should be checked at least once daily in first 2 days and then once in 3 to 5 days(SEE NICE GUIDELINES). The aim is to maintain the BP at or below 140/90mmhg .

If she is on methyl dopa convert it to another anti hypertensive (when?). eg; Labetalol, atenelol, as methyl dopa assosciate with mood changes and high profile of side effects.

Debrief regarding events and counsel regarding risk of PET in next pregnancy and explained the importance of follow up.

Consider tailing off of medications if BP normal in next 2 weeks.

Follow up review by GP at 6-8weeks postpartum to make sure BP has come to normal.

Rami Posted by PAUL A.

 

A)The likely diagnosis is pre eclampsia which is associated with risk of maternal  and perinatal mortality and morbidity. She should be asked about head ache, vomiting, disturbances of vision and epigastric pain or pain below the ribs which indicate severe pre eclampsia (1). Enquiry is made if she noticed sudden swelling of face and hands.  Examination is done to record blood pressure in sitting position with appropriate cuff for the arm placed at the level of the heart. BMI (1) is assessed along with the assessment of other risk factors for VTE. Abdomen is examined for uterine height and epigastric tenderness(1). Fundoscopy is arranged to detect papilloedema. Reflexes are tested to identify clonus.  Investigations include estimation of FBC, Renal, liver function tests and clotting screen (not indicated). The platelet count, transaminases, and serum creatinine are useful indicators for progression of severe pre eclampsia. Although it doesn't have any additional value, (so what is the point in doing something that you know has no value???) raising serum uric acid is associated with severe pre eclampsia and is a weak predictor of eclampsia, severe hypertension and low birth weight. Urine is tested for protein : creatinine ratio and 24h urine protein quantification (1) but there is a weak association between proteinuria > 5 g/24 hours and stillbirth, admission to the neonatal unit and low birth weight Fetal well being is assessed initially by CTG and later by ultrasound measurement of fetal parameters, amniotic fluid depth, umbilical artery Doppler(1)  studies. B)  The aim of the treatment is to control BP to prevent morbidity and to prolong pregnancy to improve the perinatal outcome. Management should follow the local unit protocol. She should admitted (1) to achieve control of BP , for maternal and fetal monitoring.Labetalol appears to be as effective and safe as other antihypertensives and is licensed for use in pregnancy used as first-line treatment. It is aimed to keep systolic BP 100 x 109/L (??). It is not required to repeat proteinuria quantification. If the results of all fetal monitoring are normal, there is no need to  repeat cardiotocography more than weekly.  Ultrasound fetal growth + amniotic fluid volume assessment + umbilical artery Doppler are repeated every 2 weeks(1).  Appropriate counselling is undertaken by consultant obstetrician, neonatologist, anaesthetist and midwife. Regarding timing of birth,Consultant obstetric staff should document in the woman's notes  the maternal (biochemical, haematological and clinical) and fetal  thresholds for elective birth before 34 weeks (1). The reasons for delivery include severe hypertension refractory to treatment, deteriorating renal function as evidenced by biochemical results or fetal compromise(1). It is essential to maintain good communication between obstetrician and SCBU. Corticosteroids are administered (when?) to the mother  for fetal lung maturity. If BP is well controlled with normal biochemical results and  in the absence of fetal compromise, delivery can be induced after 37 weeks(1). C)  BP should be measured at least four times a day while the woman is an inpatient. Antenatal antihypertensive treatment  is continued which is reduced  if their blood pressure falls below 130/80 mmHg(1). Methyldopa is avoided because of the risk of depression. Appropriate thromboprophylaxis is administered according to the risk profile. She should be transferred to the community care once there are no symptoms of pre-eclampsia, blood pressure, with or without treatment, is 149/99 mmHg or lower  and blood test results are stable or improving (1).  While transferring her to community care, care plan for women should be written in detail regarding who will provide follow-up care, including medical review if needed,  frequency of blood pressure monitoring ( every 1–2 days for up to 2 weeks until the woman is off treatment and has no hypertension), thresholds for reducing or stopping treatment,  indications for referral to primary care for blood pressure and review self-monitoring for symptoms. Platelet count, transaminases and serum creatinine are measured 48–72 hours after birth (1) and repeated as clinically indicated and at the postnatal review (6–8 weeks after the birth). In case of proteinuria (1+ or more)  at the post natal review, she should be offered assessment of kidney function and referral to renal physician (what about hypertension? This is more likely). Appropriate contraception is offered at the post natal visit.

Bahawana Posted by PAUL A.

 

A) My initiall assessment would be to confirm raised B.P. and proteinuria by measuring B.P with appropiate size cuff and urine dipstick.I would assess severity of symptoms by taking history including headache, visual disturbances, epigastric pain (1), facial, hand and paedal oedema especially recent increase in oedema (? value),felling unwell in  herself. I will also ask about abdominal pain, PV bleed ( to rule out abruption),and will enquire about signs of labour and fetal movements(1).I will look into growth chart to assess foetal growth.

I will perform abdominal examination to assess SFH (  to assess for Small for gestational age baby),any uterine tenderness (? Epigastric tenderness),( abruption) and lie and presentation of baby.I will examine patient for exaggerated knee reflexes and look for any clonus.( neurological irritability)(1)

Cardiotocography to assess foetal well-being(1).Investigations will include Full blood count ( haematocrit, platelets), renal and liver function tests ( deranged in severe PET, HELLP) and uric acid. Protein creatinine ratio/ 24hr urine protein collection to quantify proteinuria(1).

B) I will admit the patient preferably in HDU setting (why?). This will be a case of multidisciplinary involvement involving anaesthesist, senior midwife, consultant obstetrician and neonatologist.Assuming that airway and breathing is fine (is there any reason why it should not?), I will acheive IV access (why???). Stabilisation of B.P by giving oral/Iv labetalol, oral nifedipine or IV hydralazine can be done (why do you need iv therapy??).Continuous B.P monitoring either by arterial /central venous line should be done (NO – not indicated. Can you measure BP using a CVP line???) ( By anaesthesist)Input/output should be measured and urinary catheter should be inserted (not needed (-1). Fluid restriction to 80ml/hr (why???????) because of risk of pulmonary oedema should be done.Magnesium sulphate should be considered (why???) as it reduces risk of eclapmsia in severe PET.Appropiate thromboprophylaxis will be considered.

Continuous monitoring of Foetal heart is indicated till B.P is stable .Steroids should be given (should be considered) as delivery might be considered early.Neonatologist should be involved and preferably talk to the mother regarding effects of premature delivery.Bloods should be reviewed and decision for delivery should be ideally discussed or made by consultant obstetrician with entire clinical picture.

If decision for delivery is made, cervical assessment and Induction of labour should be done, emergency caesarean will be considered in cases of foetal distress/failed induction.There is little place for conservative management in this case (NO, NO – see NICE guidelines. You treat her BP and aim for delivery at 37 weeks unless early delivery is indicated) ( may be done till steroids have their effect).If however, conservative mangement is planned (You should plan conservative management), there should be clear documentation by consulatnt obstetrician regarding close follow up(as inpatient),B.p and protein monitoring, repeat bloods thrice weekly(1), USG for growth, EDF, Liquor volume (how often?).

C)Post-partum period is very crucial as most cases of eclampsia happen in post-partum period. B.P monitoring daily for first 2 days and then alternate days for next 3-5 days  (is this what the NICE guidelines state?) and then according to clinical pictureshould be done. PET bloods should be repeated if any clinical signs or raised B.p. Consider reducing medication if B.P.<140/90 and stopping the anti-hypertensives if B.P <130/80. If on methyldopa , change it to other antihypertensive as soon as possible /at least within 2 days(1).Consider appropiate thrombophylaxis, early mobilisation and thrombo-embolic dettrent stockings.

Communication to midwife in community and G.P and arrange follow up with midwife for B.P monitoring as mentioned above.and in 2weeks with G.P for review of medication.Advise about contraception will be given. She should be reassured that labetalol, atenolol,nifedipine has no proven side-effect in breastfeeding.
Also she should be counselled about increase recurrence rate in next pregnancy- the risk of both Pregnancy induced hypertention and pre-eclampsia are increased.

Hanaa Posted by PAUL A.

 

A

After referral from the community midwife with hypertension and protinuria .the patient should go through assessment of her condition by making sure that her blood pressure is high so repeated blood pressure reading on 2 occasions 4hrs apart (you are going to keep her for 4h before making a decision?) should take place with the appropriate cuff. BP systolic more than 160 mmgh is considered moderate to severe type in relation to the diastolic less than 100 it is considered moderate type of preeclampsia] (? meaning)

Her urine is also measured for protinuria using either protein /creatinine ration or collection of her 24hrs urine(1), condition with protinuria more than 300mg with hypertension is diagnosed as preeclampsia.

Detailed history taking about her age , parity, BMI on booking, multiple pregnancy ,previous preeclampsia, hypertensive conditions , renal disease, diabetes , SLE , vasculitis  should be clear. (HEALTHY 32 year old woman)

Previous family history of preeclampsia or autoimmune disease in her family should be also known.

 She should be asked about sudden arise of symptoms like headache, swelling of her face ,feet or hands (? value), diplopia of vision (is diplopia a feature of pre-eclampsia??) or epigastria pain.

Examination includes BMI, abdominal for fundal height and epigastric  pain (tenderness), fundoscopy , reflexes and neurological examination (1)

Investigation should be done to exclude HELLP syndrome and to assess the severity of the condition, FBC, LFT, uric acid  and clotting factors (not necessary. ? renal function).

B

Subsequant antenatl care after making sure of her BP and protinuria should include admission (1) for treatement of her Bp,  by using either labetalol or alpha methely dopa (which one would you use?) with regards to the side effect of each one  depression for methyl dopa and thrompocytopenia .

Labetalol is much preferred  as it decrease the risk of sever hypertension.

Blood pressure should be monitored  4 times a day(1).

Fetal monitoring by CTG, US fetal growth , AFI and UA dopplar studies (how often?)

IF all investigation came to be normal  then CTG 2 times a week (NO – see NICE guidelines / notes), and other US , AFI , Doppler is repeated every 2 weeks.

More frequent if deterioration of maternal conditions, decreased fetal movement, vaginal bleeding

or pain  arise.

iN case of adjustement of BP she can go home(NO – SEE NICE GUIDELINES / NOTES)  and follow up on outpatient basis, after teaching her worning symptoms.

Delivery plan should be written in her chart including time of her delivery, mode of delivery, it is not necessary by cs , vaginal delivery is allowed after 39 weeks(NO – SEE NICE GUIDELINES / NOTES)  .

If investigation came to be abnormal, consultant alert should take place, more intense monitoring of her blood work and chemistry.

Steroid should be discussed with the patient especially she is below 34 weeks.

Discussion with the neonatologist and risk of prematurity is explained to the parents.

Delivery plane should be written clearly in patient chart. Its timing and mode of delivery also at the best place ,and best time and in the best environment.

Discussion of delivery should be assessed according to the mother situation and severity of the condition in relation to gestational age.

Condition warrant delivery includes deterioration of maternal condition, signs of eminent eclampsia, reversed of absent Doppler flow in the UA and DA.(??)

During labor (ANTENATAL CARE), BP , CTG and blood chemistry is monitored well, with the use of antihypertensive , IV labetallol can be used in severe cases better than hydrazine .

Magnisum sulphate  in labour is having a statistically  results in prevention of seizures in labour than placebo. its use is accompanied by better neonatal outcome  high apgar scores more than 7 in 1,5 minutes and less neonatal stay in the NICU than 7 days . 4grms as initial dose followed by 1-2 grm iv for 24 hrs post natal,  monitored by clinical signs of decreased urine output, maternal confusion, depressed respiratory rate and lost reflexes .antidote Ca gluconate  given as iv bolus if signs of toxicity appears after stopping of the Magnesium sulphate.

Cs is for obstetric causes and fetal distress.

C

Post partum care, should include BP monitoring, for 3 days  in the hospital (NO – SEE NICE GUIDELINES), antihypertensives can be used till 3 month post partum. Breast feeding is encouraged and it is not affected by the medication.labetalol, nifidipine , metheldopa can be used.

Follow up of her investigation till normal (what does this mean?) if it was abnormal.

Risk of eclampsia is increased in the post natal period 30%.

Recurrence in the next pregnancy can occur.1-4 (? Meaning??) if sever preeclampsia had occurred.

Contraception offered POP is suitable for breast feeding moms and can be started as early as 3 weeks post partum.


 

Sofia Posted by PAUL A.

 

Ans a;  assessment of patient will include taking history of any symptoms suggestive of imminent ecclampsia such as headach,blurring vision, epigastric discomfort nausea and vomiting (1). review of patients record to  determine  other high risk factors  like  high BMI  and multiple pregnancy. Examination include measurement of BP initially every  half hourly till patient is stable followed by 4 hourly if asymptomatic and conservative management is planned. Single measurement of diastolic BP >110mm of Hg  Or two records of diastolic BP>90 mm of Hg 4hrs apart with significant protienuria (1+ on automated reagent strip reading) is suggestive of pre-eclampsia.p/a examination for fundal height (? Epigastric tenderness) and fetal heart rate for fetal wellbeing. Presence of ankle clonus(>3 beats)  would indicate  risk of imminent eclampsia. Investigations would include, quantification  of protienuria (24 hr urinary protein or protein creatinine ratio)(1). Blood test are kidney function,electrolytes ,FBC transaminase and bilirubin. Ctg and  ultrasound for biometry,fluid volume and umbilical artery Doppler(1).

Ans b: I will admit the women to hospital (1). Multideciplinary care involving consultant  obstetrician,neonatalogist,anesthetist,intensivist and specialist midwife. aim is to balance risk of prematurity with risk of preclampsia and try to prolong pregnancy.treat hypertension with oral labetalol  as first line (other options are nifedipine and hydralizine)with aim to keep BP< 150/80-100 mmHg(1). Corticosteroids for fetal lung maturity as preterm delivery may be required (1).magnesium sulphate would be required if symptoms and signs suggestive of imminent ecclapsia or  in case of eclampsia. Fluid restriction to 80ml/hr to avoid pulmonary edema. (are the pre-eclamptic women on your antenatal ward fluid restricted?)  Monitoring would include 4 hourly BP measurement pulse temp,saturation ,input output charting (why??? Not necessary in the antenatal period) using early obstretics warning chart. Blood investigations to be repeated 3 times a week  (1) or earlier in case of abnormality. Ultrasound should not be repeated more than every 2 weeks and ctg every week (1) if results are normal.plan  of care should be documented  in notes that would include maternal (uncontrolled BP,Imminent ecclampsia,HELLP syndrome)and fetal indications (abnormal ctg, severe iugr with abnormal doppler)of elective birth before 34 wks (1) and plan for antenatal fetal monitoring..     timing for delivery will depend on response to antihypertensive treatment,hematological and biochemical parameters and result of fetal monitoring. Earlier delivery may be required if severe refractory hypertension or maternal or fetal indication develop as defined in plan. If her BP  is controlled she should be offered delivery between 34 to 36+6 wks (NO – SEE NICE GUIDELINES / NOTES). Aim for vaginal delivery but mode of delivery will depend on bishop score and blood pressure control and fetal factors.level 2 critical care would be required if patient  requires iv antihypertensive treatment, or develops HELLP syndrome,eclampsia,severe oliguria, coagulopathy, neurological symptoms or signs of pulmonary edema.clear communication between the team would improve perinatal and maternal out come.

Ans c: postnatally measure BP every 4 hourly till inpatient. continue antenatal anti hypertensive treatment(if methyldopa used stop within 2 days)(1). consider reducing dose if BP falls to <140/90 or reduce if< 130/80mmHg.ask patient about  severe headach and epigastric pain each time BP is measured.thromboprophylasxis after assessment of risk factors. Measure platlet count, transaminase and creatinine 48-72 hrs after birth (1). Transfer to community care if BP <150/100 mmHg, blood test stable and improving and no symptoms of preeclampsia (1). Write care plan to include frequency of BP monitoring and indications for referral and communicate with GP and community midwife.. BP  monitoring 1-2 days for 2 weeks or till antihypertensive treatment given.  Support and advice to maintain breasfeeding and information about safety of drugs. Contraceptive advice should be given. medical review after 2 week. Postnatal review a 6-8 weeks including medical review.specialist advice is sought if anti hypertensive still needed (1) or protienuria >1+. Repeat platlet  tranaminase and creatine if treatment still   required. inform regarding risk of recurrence in subsequent pregnancy and  role of asprin .advice regarding healthy lifestyle and weight reduction if obese. Written information should be provided.

Saro K Posted by PAUL A.

 

Ans to essay344:

(a)I will get a detailed history about parity ,prior gestational hypertension /pre eclampsia,family history of preeclampsia ,singleton /multiple pregnancy (how will this affect your management? Will you manage a hypertensive woman with risk factors differently from a woman without risk factors??),headache,blurring of vision,epigastric pain,vomiting,sudden swelling of hands, legs and face (why?).I will examine her blood pressure with appropriate size cuff in sitting position ,uterine fundal height,tenderness or rigidity,deep tendon reflexes,fundoscopy and respiratory rate (you have simply written lists with no context. What is the significance of uterine tenderness or rigidity???).I will do urinary spot protein/creatinine ratio or 24 hrs urinary protein(1).Blood tests includes FBC,RENAL FUNCTION TESTS,Liver function tests.Fetal assessment includes CTG,Fetal biometry,amniotic fluid volume and umbilical artery Doppler(1).

(b) I will admit (1) her as she is moderate pre eclampsia   as multi disciplinary team  consisting of obstetrician,anesthetist neonatologist and senior midwife.I will start antihypertensive therapy with labetolol 100 mg .Aim is to reduce severe hypertension and does not have any side effects on the fetus.Other option s includes methyldopa and nifidipine.I will monitor her bp 6th hrly and maintain between SBP less than 150 mmHg and DBP less than 80-100 mmHg (1).I will follow up the investigations and plan for clotting profile if platelet count is less than 100.If found to be normal plan for conservative management. I will give a course of steroids (consider) as she might need need delivery at any time. I wont repeat proteinuria quantification   if more than 3gm /24 (??) hrs as it is not going to influence  future management.I will inform the patient and relatives about  the maternal and fetal  condition  in detail if found to be normal and write a  care plan for conservative management.Disharge her (ABSOLUTELY NOT) and ask her to continue antihypertensives  with repeat blood investigation three times a week (1),fetal montoring –CTG weekly ,  fetal growth scan,amniotic fluid volume  and  umbilical artery Doppler every 15 days(1).  I will write abt time of delivery, mode of delivery , neonate counselling and anesthesia consult.I will assess her risk of VTE and start prophylxis if more than 2 antenatal risk factors.

If Bp is not under control and investigation are not normal with fetal deteiration I will stop conservative management and plan termination of pregnancy (The woman will think you are going to kill her baby) which is the definitive treatment.I will   involve consultant obstetrician and anesthetist ,neonatologist.I will make sure abt the availability of beds in SCBU.

Indication  of termination of pregnancy (??) includes uncontrolled Bp, signs and symptoms of imminent eclampsia,eclampsia, abnormal LFT and RFT (not necessarily),coagulation abnormalties,  fetal growth restriction with abn umbilical artery Doppler (not necessarily)   ,abruptio placenta . I will plan MODE OF DELIVERY   depending on the cervical status,fetal doppler and CTG ,any emergent situation like abruption or eclampsia  that necessitate urgent delivery along  with magnesium sulphate regimen. I will alert for a bed  in LEVEL 2 CRITICAL CARE.

Intrapartum Care (YOU WERE NOT ASKED ABOUT THIS):  I will continue antihypertensive therapy  with  BP hrly  and  continuous CTG monitoring. Proper analgesia is mandatory throughout labour  with active management of third stage. Avoid ergometrine .Prophylactic  forceps if Bp is very high .Continue MGso4 if already started with  monitoring urine output ,DTR and respiratory rate.I will inform the condition of mother and baby and progress  of labour periodically to the relatives.

(c)I will check her Bp daily for first 2 days and atleast once between  D3-D5 (see NICE). Frequently as per previous BP /change of drugs.Continue labetolol  but change methyldopa within 2 days  if used antenatally as it increases depression.I will consider reducing drug if less than 140/90 mmHg and stop if less than 130/80 mmHg. I will reassess her risk of VTE  and start /continue prophylaxis  if needed for 6 weeks postnatally. Repeat blood tests to check if everything is normal if raised early.She should be in the hospital till 5 days as chance of poatpartun eclampsia is 44percent (Is there a 44% chance this woman will have eclampsia??) and can be transferred  to community Midwife with proper plan .  I will plan postnatal medical review  for all at 6 weeks and  if they needed drug for more than 2 weeks (if they did not need treatment, will 6 weeks review be unnecessary?).I will counsel her that  chance of recurrence in  next pregnancy is very high and need to start on Low dose Aspirin  from 12 weeks until delivery.Continous surveillance is needed as chance of hypertension is more later life.I will counsel about contraception.I will document in the notes.(See NICE guidelines)


 

Ali Naveed Posted by PAUL A.

 

a). I will the history where I will ask about the present pregnancy, confirm the gestation by comparing the dates with an early ultrasound (accept the gestation age given in the question otherwise you will have to write this in every obs answer), go through  record and investigations done previously, history of previous visits and blood pressure record, headache, epigastric pain, visual disturbances, dizziness and confusion. History of urinary tract infection, lower abdominal pain, vaginal discharge (why???). In the past history I will look forchronic renal disease, preexisiting hypertension (HEALTHY woman),  outcome of previous pregnancies , any history of preterm births and still births , IUGR along with the gestation at which it happened. In the family history I will look for hypertention in the first degree relatives, pregnancy induced hypertension in the family, autoimmune disease, renal disease diabetes (this is a waste of your time & space. There are 2 marks for Hx and your ability to take family Hx… is not being tested). I will ask for use of medication in the past and any history of smoking etc. I will recheck her blood pressure , recheck the proteinurea , assess the signs of severe preeclampsia epigastric and right hypochondrial  tenderness, make a fetal assessment by assessing the symphysiofundal heigh(1) t, fetal heart rate. I will admit this lady if her blood pressure and proteinuria are the same or increased . I will recheck her blood pressure every four hours ask for  full blood count to look for platelets, 24 hour urinary proteins, creatinine , liver function tests (1). Fetal ultrasound and fetal umbilical artery doppler , cardiotocography.(1)

b) This lady needs to be managed by using multidisciplinary approach, with the early involvement of physician (why???), heamatologist and nephrologists (why???). In case of eclapmsia, or development of HELLP syndrome early delivery followed by ICU care will be arranged .  If the blood pressure is persistently raised or increasing upon two readings taken four hours apart or there is persistent protein urea (is proteinuria a reason for treating hypertension?) I will start an antihypertensive medication like labetalol , or methyl dopa (which is preferred?), continue to monitor blood pressure and if there is deterioration or persistant rise , epigastric pain , with deterioration in liver function tests , reduction in platetlet count  below 100000/mil , raised proteinurea ++ or +++, > 500mg/ 24 hours (not an indication for corticosteroids or delivery), I will give corticosteroid cover for fetal lung maturity and for severe progressive disease with uncontrollable blood pressure or eclampsia I will deliver  her on urgent basis.

Now if the blood pressure has been controlled and the tests are also with in normal limits I will discharge her form the hospital on medication (NO – SEE NICE GUIDEINES / NOTES) and check the blood pressure , proteinurea by dipstick on every visit renal function tests and platelets twice weekly.  Ultrasound and fetal Doppler will be carried out  every week till 37 completed weeks (NO – SEE NICE GUIDELINES / NOTES) if all is well. I will explain to her that it is important for her and the fetal wellbeing that her blood pressure should be controlled and she should continue to attend the hospital for antenatal care. I will discuss delivery plan with in next 1 to 2 weeks and in the absence of obstetric contraindications. I will plan induction of labour and aim for vaginal delivery .

c) In the post natal period I will recheck her blood pressure every day for 2 days , and day 3 and 5 , a t least twice weekly assessment of blood preseure in the community (SEE NICE GUIDELINES). I will give written information and make a care plan for her community transfer of care . if the blood pressure is raised in the postnatal period alongwith proteinurea a medical review , nephrologist visit will be arranged (NO – SEE NICE GUIDELINES). There is a 40 percent chance of developing eclampsia in the postnatal period  (ARE YOU SURE??? So 40% of women with pre-eclampsia will have eclampsia after delivery???) all symptoms and signs of eclampsia will be explained to the patient and the partner . If the blood pressure has returned to normal (what is normal? What do the NICE GUIDELINES say about this?) as it usually does I will stop or reduce her antihypertensive medication.  I will encourage her to breastfeed her baby and in case of an adverse outcome like a still birth I will advice her for early booking in the next pregnancy and start of intensive monitoring at least 02 weeks before the onset of symptoms in this pregnancy i.e 30 weeks. Contraception will be discussed in the postnatal period.

Sherif N Posted by PAUL A.

 

a) assessment of the patient by proper history taking whether she has hypertension, diabetes mellitus, history of DVT (HEALTHY woman), thrombophilia disorders, previous PIH (if she is multi) or previous eclampsia, any medical disorder

if she is taking any medications, antihypertensives, anticoagulants, low dose aspirin, corticposteroids (HEALTHY woman)

general examination to recheck her BP in proper position, with proper cuff size if she is obese, measure her BMI(1), check for lower limb oedema

abdominal examination for fundal level (if corresponding to period of amenorrhea or smaller) , fetal presentation, any uterine activity or contractions (epigastric tenderness)

local PV examination for bony pelvis (if primi (why????)), cervix and its bishop score

US for the amount of liquor AFI, fetal growth and compare it with previous serial growth assessment (why should these have been done?) to detect any element of IUGR, placenta and whether there is any retroplacental haematoma (??? Do you expect to detect this on ultrasound??). Doppler study for umbilical artery flow to detect any resistance

CTG if the patient complains of decreased fetal movement or if there is abdominal pain (will you not do a CTG otherwise???)

investigations: liver and kidney functions, coagulation profile (not indicated), FBC and platelet count, urine analysis and total protein in urine in 24hrs urine collection(1)

b) antenatal care:

admit (1) the patient to control her BP, aim is to reach a BP of 140/90 (see NICE)

give her antihypertensive, labetalol

corticosteroids to promote the fetal lung maturity if there will be a need of premature delivery

do lab test 3 times a week (WHICH TESTS?), but no need to repeat ptn quatification in urine

US and Doppler for serial fetal growth, AFI, umbilical artery resistance done every 2weeks(1)

CTG not to be repeated(SEE NICE / NOTES)  except if there is decreased fetal movement or starting abdominal pains

low dose aspirin if taken by the patient, will be continued till delivery

if her BP is controlled, labs are fine, US and Doppler are good, patient is allowed to continue pregnancy with close follow up of her BP and labs twice weekly (you wrote 3 times earlier), US and Doppler every 2weeks until delivery

if BP isn't controlled or worsen, her labs or US or Doppler are not good, decision of termination of pregnancy (she will think you are going to kill her baby) will be taken, but this needs involvement of multidisciplinary team including senior obstetrician, senior anaesthetiologist, neonatologist, senior mid-wife, haematologist, and inform NICU about possibility of baby admission

NB: magnesium sulphate may be needed if patient develops imminent eclampsia during induction of labour

c) postnatal care:

post normal delivery, she needs level 2 critical care (why???) with close follow up of her BP every 6hours durinf the first 3 days, and at least once between day 3 and day 5 (the peak BP is reached at this time) (SEE NICE GUIDELINES)

continue antihypertensive ttt (???) but consider decreasing the dose if BP falls to 130/80 (? NICE)

there is more risk of postpartum haemorrhage, so close observation for her pulse, amount of vaginal bleeding, uterine contraction is needed

follow up visit post discharge after 2 weeks to check her BP, stop antihypertensive ttt if BP returns to normal

explain to the patient what happened, answer her inquiries, counsel her about the risk of recurrence of PIH in subsequent pregnancies, how to prevent or minimise this by intake of low dose aspirin starting from 12th week gestation until delivery

Preethi Posted by PAUL A.

 

History symptoms of severe preeclampsia (like what?) and previous obsterics history regarding parity ,previous mode of delivery and associated medical disorders (healthy) to be enquried

Multiple BP recordings (how many and why??) to be taken with appropriate size cuff and position taking korotoffs phase  5 sounds for diastole measurements

Headache and abdominal pain are the symptoms of worsening disease indicating involvement of cerebrovascular and hepatic system

Clonus if present may indicate risk of convulsions but maternal tendon hyperreflexia might not be suggestive 

Oxygen saturation measurment cotinously with pulse oximetry (not needed) may help detecting pulmonary edema early

24hr urine protein or serum protien creatine ration (do you need serum or urine??) are more accurate and  to be  considered as 2+ urine protenuria is  significant but dipstick is associated with high false positive result 

More than 0.3gm/24hrs or 30 gm/mmoul of protien confirms significant  protenuria

Full blood count to check for platelet count and if more than 100 x106 do not require coagulation screen to be performed

Hepatic and renal function test as a base line to done and if normal to be repeated dialy (NO – SEE NICE / NOTES)

Renal failure ie raised creatinine indicate heamorrhage ,HELLP syndrome, sepsis or underlying ranal condition

Raised AST and ALT of above 150iu/l are associated with increased risk of maternal morbidity

HELLP syndrome severe form can be diagnosed by heamylsis evident on blood film or raised LDH levels.deranged hepatic function and low platelets

Fetal assessment with cardiiotocoghraphy in acute situation and by ultrasound for growth liquor volume and umbilical artery Dopplers (1) You need a logical approach with Hx, exam, invest

 

 

b)

 

Admission to labour ward  (why does she need to be on the labour ward??) for, stabilisation, continued monitoring and delivery at the optimal time for the mother and her baby

 Senior obstetric and anaesthetic staff and experienced midwives should be involved

BP to checked every 15minutes untill stablised and 4hrly in conservative management is opted

Antihypertensives like labetalol intravenously or orally or nifedepine orally or hydralazine intravenously to used as per unit protocol in acute situation (you should start with oral therapy)

Prophylactic magnesium sulphate to considered  if associated with risk factors like headaches visual distrubances epigastria pain pressence of 3 beats of clonus and moderate to severe BP as MAGPIE trial has shown 58%reduction in convulsions

Steroids 2x doses of betamethasone of 12mg intramuscular injection at 12hrly intervals to enhance fetal lung maturation tto be given if risk to the mother are well balanced (? meaning)

|As her gestation is 32 weeks delivery to be deferred until 34 weeks (NICE SAYS 37 WEEKS) and conservative mangement with antihypertensive medication to reduce maternal risk of cerebrovascular accident

Prolonging pregnancy if gestation less than 34 weeks helps steroid to help reduce the fetal respiratory morbidity, neonatal unit to be more organised or to transfer the patient where there is cot available only if mother is stable

Vaginal birth is the aim and IOL  considered if more than 34 weeks , cephalic presention 

Ceasearean section if gestation is less than 34weeks or non cephalic presention

Syntometrin to be avoided for prevention of PPH as it is associated with severe vasoconstrition leading to rapid raise of BP and cerebrovascular accidents

 

3)Women who deliver with severe pre-eclampsia (or eclampsia) should have continued close observation postnatal as eclampsia has been reported up to 4 weeks postnatally, (NOT NECESSARY)

Inpatient monitoring until the incidence of eclampsia and severepre-eclampsia falls ie after the fourth postpartum day (no – see NICE)

Magnesium sulphate if commenced to be continued 24hrs post delivery

Antihypertensive to be considered even in postpartum period to reduce the risk

Persistent raised BP for 6 weeks  postpartum may have underlying renal disease and needs further investigation 

Debriefing and explaing the events to patients is importand explaining the risk of chronic or essention hypertension risk

Leila Posted by PAUL A.

 

A

Maternal and foetal wellbeing

physical examination

biochemical

assessment of this patient should start with enquiring her general well being and symptoms of impending eclampsia like headache, visual disturbances, nausea or vomiting, upper abdominal pain(1), malaise, and any ill feeling. Signs of foetal wellbeing including foetal movement (1) should be enquired. Then physical examination to confirm the presence of high blood pressure,  abdominal palpation to check symphisio-fundal height for foetal growth and  to establish any right upper quadrant or epigastric  tenderness  (1) which is associated with severe pre eclampsia . Fundal tenderness associated with placental abruption should be ascertained. Neurologic signs of impending eclampsia should be checked including deep tendon reflex and clonus.  

Laboratory investigation to rule out any multiorgan involvement  including renal function test, full blood count to check for thrombocytopenia, liver function test and urate level. And urine dipstic for proteinuria(1) ? FETAL ASSESSMENT.

B

Admission,

blood pressure monitoring

PCR or 24 hours urine protein

Antihypertensives

Steroids

CTG

Growth scan

Hospital admission is recommended in patient with BP >160/110 (NO – recommended for all pre-eclampsia irrespective of level of hypertension), Anti hypertensives medication should be initiated preferably with labetalol (1) or Nifedipine. Methyldopa is slow in onset of action, therefore is not best option in patient with such high blood pressure. NICU should be informed following admission of the mother and Neonatologist should discuss the prognosis of delivery at this gestation with the couple. Seniour obstetrician, Labour ward co ordinator and senior anaesthetist should be informed.

 Following admission blood pressure should be monitored every 15minutes until less than 160/110.  Then 6 hourly blood pressure monitoring is recommended. The blood pressure should maintained below 150mmHg systolic and between 80-100 mmhg diastolic. Urine sample  should be sent for PCR or 24 urine collection for proteinuria. Also MSSU should be sent to rule out any presence of UTI.

If investigation and clinical examination indicates severe pre eclampsia (what is this?), delivery should be expedited following maternal stabilisation. The patient must be cared in a high dependency level with strict fluid balance chard. Mgso4 for prevention of eclampsia should be started. Corticosteroid administration for prevention of neonatal morbidity is recommended, however this should not delay delivery if maternal condition worsen.  CTG should b e performed for foetal wellbeing.

 In the absence of signs of severe pre eclampsia , with good blood pressure control and normal laboratory investigation, this patient can be managed conservatively. Ultrasound for Foetal growth and amniotic fluid volume should be performed, with or without umbilical artery Doppler studies depending on the foetal growth. (this is not what NICE recommends)   This will be repeated in two weeks time to assess foetal growth(1). If foetal growth is normal at 34 weeks repeat growth scan is not indicated. Weekly CTG for foetal well being is recommended if there is no new concerns like reduced foetal movement PVB, or change in maternal condition.

If the patient stabilises she can be managed as outpatient (absolutely NOT – SEE NICE GUIDELINES / NOTES) with twice weekly blood pressure check, and weekly FBC, LFT, and Urate (SEE NICE / NOTES), and weekly CTG. The aim is delivery after 37 weeks (1) if foetal and maternal condition remains stable. Aiming  to keep systolic BP less than 150mmhg and diastolic BP between 80-100mmhg.

C

Afer delivery this patient is still at risk of eclampsia which occur 44% pos natal,  38% antenatal and 18% intrapartum (NOT NECESSARY). Hence the patient must be monitored in a high dependency level, With hourly  vital signs and fluid balance chart. Mgso4 should continued until 24 hours post delivery or last seizure. Deep tendon reflex should be checked hourly. After 24 hours, blood pressure should be monitored every 6 hours for first 2 days, then once between day 3 and 5 post natal (SEE NICE GUIDELINES), Anti hypertansive should be continued, however if she was taking methyldopa, this should be changed within 2 working days as it increases risk of post natal depression. During discharge a letter should be sent to the GP including her condition and management plan . The patient can the be reviewed by her GP in the community one week post natal. If BP is less than 130/80, anti hypertansives can be stopped by the GP. The patient should be seen  in gynaecology clinic (????) at 6 weeks post natal, To check BP, and laboratory analysis if have returned to normal. Screening for anti phospholipid syndrome is (NOT) recommended.  Counselling regarding the high risk of recurrence of severe pre eclampsia in the future pregnancy.  Use of low dose aspirin once pregnancy confirmed  in the future pregnancy is recommended.  If the patient require medications after six weeks post natal medical review should be arranged to rule out any essential or secondary hypertension. COCP is not contraindicated if this patient test negative for anti phospholipid syndrome.  

MmL Posted by PAUL A.

 

I would like to know whether it is her first pregnancy or any other pregnancies before (WHY? What difference will it make?).  I would like to know the booking blood pressure (? relevance) and booking body mass index.  I will make sure appropriate blood pressure cuff is used and I will try to get more than one readings at 30minutes interval (? Why???).  From the patient I would like to know, whether she has any pre-eclampsia symptoms like headache, flashing lights, double vision (not a feature of severe pre-eclampsia), and epigastric pain (1).  I would like to know whether they are new symptoms and it is persistent inspite of conventional treatment.  From examination, I will check the signs such as pedal edema, reflexes and clonus level. I will check that if she had pregnancies before whether she had the pre-eclampsia before. (? Logic – you are going back to Hx. What difference will it make?)  I will do blood tests such as Full blood count, renal function tests, liver function tests and urate levels.  I will also send mid stream urine specimen for culture and sensitivity and also either 24hour urine for protein level or protein / creatinine ratio (1) depends on my unit protocol.  In above results, I specifically look for platelet level, liver enzyme level and urate level. (? Fetal assessment)

As she is just 32 weeks, I will give her steroid injections times two as per our units protocol (pre-eclampsia is not an indication for steroids).   I will check with special care baby unit to make sure there would be a cot for baby in case early delivery required.  If the blood pressure is persistently high around 168/99mm Hg (is this what NICE recommends?), I will start her on medication, preferably on labetalol after discussing with my consultant.  If she is clinically asymptomatic and does do well with regular blood pressure checks and blood results, I will discharge her (absolutely not – SEE NICE / NOTES) from the admission and arrange for her to be seen at day assessment unit and antenatal clinic at regular intervals (HOW OFTEN IS REGULAR??).   It would be like twice a week or three times a week (WHICH? Twice or thrice??).  I will also repeat the pre-eclampsia blood tests and urine for protein levels (not recommended).  I will arrange for her to have growth scan to check growth and liquor volume.  If there is any concern with growth or liquor volume, I will request for dopplers.  During her regular visits to hospital, I will arrange for her to have regular fetal monitoring – cardiotocograph.  I will clearly advise the patient that if she feels unwell with any of the pre-eclampsia symptoms or reduced fetal movements or pervaginal bleeding, she should come to labour-ward immediately for an assessment. (you need to read the NICE guidelines or the notes)

Now, I would like to know whether she had to have either magnesium suphate or antihypertensive infusion for her intrapartum care.  If that case, I will monitor her in the high dependency unit- checking her pulse, blood pressure, O2 saturation, urine output and reflexes hourly.  I will maintain strict input and output chart and she will have urometer.  I will slowly wean her off from the above medication roughly about 24hours provided her observations are good.  If she had an uneventful intrapartum care, then she will still need to have regular blood pressure monitor (4hourly – depends on the value) and strict input and output care.  I will continue the blood pressure medication like labetalol (1) postnatlly and send her home (around day 3 – 4) with same if her blood pressure remains stable with medication.  I will advise her, she needs postnatal review at 6 weeks and the blood pressure medication could be stopped then (why not earlier?).  First 2 weeks, I will arrange for a community midwife to her at home to check blood pressure every day (NO – SEE NICE GUIDELINES).

H H Posted by PAUL A.

 

This is a case of severe pre eclampsia and should be considered a high risk pregnancy and needs admission. Will take history of headache, visual disturbances, nausea, epigastric or upper abdominal pain (1) and lower limb swelling. Will see her notes to see if had already hypertension being treated and this is a superimposed pre eclampsia or this is a new event. Will take obstetric history for any previous obstetric complications and mode of delivery.

Will perform examination including her BMI, BP(1),pulse ,temp., chest and heart, reflexes, clonus, a epigastric tenderness, Rt hypochondrial tenderness, fundal height, uterine tenderness (1)

Will take blood for FBC , urea and electrolytes. liver function test. If platelets less than 100,000/ml3 or LFT abnormal will do coagulation studies. Will do urine protein :creatinine ratio to confirm proteinuria( above 30 mg/mmol ) (1).

Will do CTG for fetal wellbeing. Will do fetal growth scan and umblical doppler velocimetry at presentation (1)

The ultimate treatment of severe pre eclampsia is delivery ,but I will balance between, the risks of delivery of this baby having prematurity problems if delivered at such gestation, and the risk of conserving ,with risk of maternal morbidity( e.g eclampsia, HELP,cerebral hemorrhage) and mortality.Therefore a multidisciplinary approach needed ,with informing the consultant obstetrician,midwife with one to one approach (HOW DO YOU ACHIEVE THIS ON THE ANTENATAL WARD?),hematologist , neonatologist and anesthetist. Patient information is a must and she should have the chance of talking to neonatologist should delivery is needed at early gestation.

Will lower her BP using oral propranolol (not the recommended drug),with frequent measurement of BP at 4-6 hourly and if no response will give IV propronalol. Should BP be resistant to lowering ,is an indication for deliveryز

Will assess her need for Mgso4 ,should she has symptoms and clonus,but should this be needed ,measures for delivery will be needeed ,monitoring for mgso4 toxicity( loss of patellar reflex,resp depression and urine output ), SCBU informed.

Will chart fluid intake and output and limit fluid intake to 80ml/hr as there is shrinkage of circulation and possibility of pulmonary edema(not indicated).Putting a central line ,by the anesthetist, to avoid fluid overload is of value (no it is not. Haemodynamics are very different because of increased capillary permeability and CVP can be very misleading)

Will give steroids for fetal lung maturity if delivery can be delayed .Will assess her risk of thrombophylaxis and consult with hematologist

Delivery is indicated if there is fetal compromise, unresponse to anti hypertensive treatment, imminent eclampsia with symptoms,eclampsia,HELP,and abnormal hematological and biochemical investigations (1) .

Should conservative management is decided,will measure BP/6hr, do blood tests 2-3 times /wk(1), CTG daily (not recommended) and fetal growth scan and umblical doppler every two weeks.Aim to delay deivery (until when?),if BP is controlled, for fetal benfit,but the risk of eclampsia is not abolished.

Will doument my plan including monitoring, steroid intake and informing SCBU, but not timing or mode of deivery which are dependant on the situation

There is still risk of eclampsia, so mgso4 should be continued for 24hr after delivery (did the question say she was on MgSO4?). BP should be measured 6 hrly and the antihypertensive continued. Patient can breast feed. Will continue fluid balance monitoring, Will assess her risk for for thromboprophylaxis and advise early mobilisation and proper hydration. If she had epidural analgesia,will consult with anesthetist for timing of removal. Will discuss with her follow up in antenatal care in 6 wk time and medical consultation and referral if still has high BP. Will discuss contraception. (see NICE GUIDELINES)

Reena G Posted by PAUL A.

 

a) The most likely diagnoses is moderate to severe preclampsia which is high risk pregnancy and needs admission.I will quickly take her history in which I will ask about her parity, pregnancy interval(if >10 year), , multiple pregnancy, family history of preeclampsia, her past history of preeclampsia or gestational hypertension (WHAT DIFFERENCE WILL THIA MAKE TO YOUR MANAGEMENT?), diabetes, chronic hypertension, SLE, Antiphospholipid syndrome (HEALTHY WOMAN), her booking BMi (>35kg/m2) as all are risk factors for preeclampsia & her presentation  at 32 weeks gestation age further increases her risk and fetal morbidity, I would like to know about any associated symtoms like headache, nausea, vomitting, blurring of vision, pain in upper abdomen between the ribs(1), sudden swelling of face, hand and feet which will indicate about the severity of the disease. On examination I will see her general appearance, any facial puffiness,her weight to note any sudden increase in weight, will check her blood pressure with appropriate size cuff semi reclining position at korotkoff phase v.Per abdomen fundal height, epigastric tenderness(1), presentation of fetus and fetalheart, palpate for any contraction or any tenderness , to look for any abnormal bleeding and pedal edema. fundoscopy, reflexes and neurological examination may be indicated.CTG to be done at the time of diagnoses. Then I will send FBC, LFT and RFT(urea and electrolytes) and iuf platelet <100 for coagulation studies (1). I will counsel her that she needs urgent admission for stabilizing her condition   as there is increase risk for eclampsia.

b)I will admit this case into crtical care 2  (are women with pre-eclampsia not admitted to your antenatal ward?) and will involve senior obstetrician/ anesthetist/ midwife and paediatrician.I will do blood pressure monitoring 4-6 hourly and will send FBC, LFT , RFT  to check any low platelet and raised transaminase and repeat three times /week (1), I will not quantify proteinuria as it is already given. I will start labetalol (1) as 1st line management drug to control hypertension , other alternatives methyldopa and nifedipene can be considered , aim is to bring systolic <150 and diastolic between 80-100mmhg. CTG to be done at the time of diagnoses.Ultrasound for liquor, fetal growth, and umbilical artery Doppler to be done(1 will you repeat it?)  Corticosteroids to be consideredas in view of prematurity. If any alarming  symtoms and signs of impending eclampsia ( severe headache, flashing of light, epigastric pain, low platelet sudden raise of liver enzymes ) then magnesium sulphate should be considered& if delivery is imminent within 24 hours If blood pressure not controlled (1) to assess her again  , if cervix favourable aim for vaginal delivery, if poor bishops score then cesarean section to be done.

  If results of fetal monitoring are abnormal then consultant obstetrician to be involved and Plan care to be written in her notes mentioning timing and nature of fetal monitoring, fetal indication for delivery, if and when steroids to be given(1), when discussion with anaesthetist and paediatrician  should take place.If results of fetal monitoring are normal then Ultrasound for growth, liquor, Doppler to be done once in 2 weeks and CtG not more than once weekly. (? Timing of delivery)

c)The patient to be transferred in level 1 critical care after delivery for observation. Her blood pressure to be checked daily for first 2 days then at least once a  day on 3-5th day (SEE NICE GUIDELINES) as 44%of Eclampsia occurs in post partum period. Continue antihypertensive treatment and if on magnesium sulphate for 24 hrs post delivery.If on methyldopa to stop within 2 daysas  causes depression. Consider reducing antihypertensive if B.P.<140/90, Reduce antihypertensive if <130/80mmhg. If not on any treatment then start treatment if B.P. > 140/99. Debreifing about her delivery events to be done, chance of recurrence and follow up during post natal counselling.Care plan to be discussed and written and G.P. to be informed while discharging for community care mentioning who will take care, when to reduce and stop antihypertensive medication. To arrange follow up care after 6-8 weeks with specialist care for hypertension (? For all women with pre-eclampsia?? SEE NICE GUIDELINES).

Sadaf Posted by PAUL A.

 

A healthy 32 year old woman has been referred by her community midwife because her BP is 168/99 mmHg and there is 2+ proteinuria at 32 weeks gestation. (a) Discuss your assessment of this woman [6 marks]. (b) Discuss your subsequent antenatal care given that hypertension and proteinuria are confirmed [9 marks]. (c) Discuss her post-natal care given that she eventually has a normal vaginal delivery [5 marks].

A)FIRST OF ALL I WILL TAKE HISTORY OF PT INCLUDING PARITY,ANY SYMPTOM LIKE HEADACH,VOMITTING,BLURRING OF VISION OR FLASH OF LIGHTS,EPIGASTIC BURNING (1) OR SUDDEN SWELLING OF FACE ARM OR FOOT, IS SHE HAVING GDM IN THIS PREG.REGARDING PAST OBST HX I WILL ASK FOR ANY H/O PIH IN PREV PREG,IS THERE ANY H/O ESST HTN OR DM?H/O ANY RENAL FROBLEM (healthy woman).FAMILY H/O HTN (how will this alter management?).I WILL RECHECK HER BP TO MAKE DIAGNOSIS OF PRE-ECLAMPSIA  DIASTOLIC BP SHOULD B  >90MM OF HG .IN EXAMINATION I WILL DO ABDOMINAL EXAM FOR EPIGASTRIC TENDERNESS AND HOF (???).I WILL CHECK FOR OEDMA,REFLEXES AND ALSO FUNDOSCOPY TO CHECK FOR PAPILLODEMA.FOR LAB INVESTIGATION I WILL SEND FBC,LFT RFT U.ACID,24 HOURS URINARY PROTIENS (1) ANF CLOTTING PROFILE IF PLT ARE <100.I WILL DO CTG TO ASSESS FOETAL WELLBEING,DOPPLER SCAN WILL B PERFORMED TO ASSESS FOETAL WEIGHT,PLACENATAL GRADING,AMOUNT OF LIQUR AND UMBILICAL ARTERY DOPPLER(1).

B)AS THIS PT IS HAVING PICTURE OF PRE-ECLAMPSIA SO I WILL ADMIT (1)  THE PT FOR TOXEMIA REGIEME ANG FOETAL MONITRING.I WILL START ANTI HTN THERAY LINE LABETOLO (1) IF SHE IS NOT ASTHEMATIC.OTHER OPTIONS LIKE METHYLDOPA AD NIFIDIPINE CAN B STARTED.I WILL ADVISE TO BP MONITORING FIRST HALF HOURLY THEN HOURLY AND WHEN SETTLED 4 HOURLY,INTAKE AND OUTPUT CHARTING (not necessary).CTG FOR FOETAL MINITORING.ONCE BP IS CONTROLLED WITH MEDUCATION <150/100-80 AND ALL LABS R UNDER NORMAL LIMIT MONITORING SHOULD B DONE TO PROLONG THE PREG TILL 37WKS (1).DOPPLER SHOULD B DONE AFTER 2WKS.LABS SHOULD B REPEATED TWICE WKLY(1).

BUT IF LABS AND DOPPLER R NOT FAVOUABLE TO PROLONG PREG I WILL GIVE BETAMETHASONE FOR FOETAL LUNG MATIRITY(1).NEONATOLOGIST SHOULD B INFORMED FOR POSSIBILTY OF PRETERM DELIVERY.PT SHOULD B ASSESSD FOF NVD AND IOL IF FOETAL AND MATERNAL CONDITIONS ALLOWS

C)IF PT DELIVERED BY NORMAL DELIVERY WE SHOULD INFORM PT THAT SHE CAN VE ECLAMPSIA AS 44% OCCUR IN POSTPARTUM PERIOD.WE SHOULD CHECK  (what?) ON 1ST TWO DAYS AND ONCE ON 4TH DAY (see nice guidelines).IF PT (???) ON METHYDOPA IT SHOULD B CHANGED TO LABETOLOL OR ATENOLOL (when?).BREAST FEEDING SHOULD B ENCOURAGED.ON DISCHARGED PT (???) SHOULD B ADVISED FOR  BP MONITORING ONCE A WK AND TO TALE MEDICATION FOR 3WKS (why 3 weeks????).IF CONDITION PERSIST SHE SHOULD B REFERRED TO PHYSICIAN.RISK OF PRE ECLAPSIA IN NXT PREG SHLUD B EXPLAINE

Samira Posted by PAUL A.

 

a-It is a case of severe preeclampsia.Her clinical records should be reviewed to check if she has any risk factors for Preeclampsia like her obstetric history (her parity,previous history of preeclampia, PreviousGestational HTN,Previous IUGR baby,) (what difference will this make to her management?)

During her antenatal visits any high reading of BP or proteinurea,Record of her fetal growth checked by fundal heights to see any evidence of IUGR.Her BMI.Sudden increase in her Wt.

We should ask if she is having any sign or symptoms (do you ask about signs?) of preeclampsia like headache,pain below the ribs,vomiting,flushes infront of her eyes,blurred vision.(these are symptoms of severe pre-eclampsia)

We will check her BP 4 hrs apart (does not need to be 4h apart) to confirm severe HTN,check BMI of this patient (1).Spot protein:creatinine ratio or 24 hrs urine collection to confirm finding of urine dipstick.Abdomen should be examined for fundal height,epigatric tenderness (1),Cardiotocograph,Fetal growth scan,Amniotic fluid index,uterine artery dopplers for fetal well being should be done(1).Tendon reflexes and clonus to be checked and vaginal examintion to be done to decide mode of delivery in case she needs to be delivered (do you do VE in women admitted at 32 weeks??).FBC(platelets),Aminotransferases,Renal function tests with electrolytes,bilirubin to be done(1).

b-This patient should be admitted(1).Senior obstetrician,noenatologist,anaesthesiologist consulted and patient should be given chance to discuss with neonatologist in case she needs to be delivered prematurely.AntiHTN(labetolol) (1) started .Aim to keep her BP <150/80-100mm/hg.Betamathasone( preferably )to be given 12mg Q24 hrs for 2 doses.If BP controlled and preeclampsia profile is normal, patient can be managed expectantaly until 34 wks or more (37 weeks) according to neonatal facalities.In case of expectant management,BP should be checked every other day (NO – SEE NICE / NOTES) on an outpatient basis(ABSOLUTELY NOT),Protinurea to be checked every Wk (NO NO NO – SEE NICE GUIDELINES / NOTES).Preeclampsia profile to be done 3 times a Wk.Fetal growth Scan,AFI and UA dopplers every 2 Wks(1).Patient should be informed if she develop any sign of imminent eclampsia like severe headahe,vomiting,pain under ribs,blurred vision to report to hospital immediately.Mode of delivery at 34 wks (NO) should be discussed with patient .Induction of labour is preferable and C-Section reserve for maternal or fetal indication.During expectant management any sign of hematological or biochemical or fetal detoriation or very high BP to be started on magnesium salphate (ARE THESE THE INDICATIONS FOR USING MGSO4???) and to be delivered after stabilizing the patient and Magnesium salphate to be continued for 24 hrs after delivery.

c-Post natally her AntiHTN to be continued and she should be advised to continue breast feeding as labetolol is safe.If she was on methldopa it should be changed in 2 days (NO – you do not have to wait 2 days. Within 2 days is different from in 2 days) and started on any other AntiHTN safe for breast feeding .Check BP 6 times a daywhile inpatient.If BP<130/80 to stop AntiHTN..Bp should be checked every 3-5 days (SEE NICE) and if it is >150/100 to start ANTIHTN (??) medications.Asses braest feeding for 1st 2 days (why first 2 days???).Repeat preeclampsia profile after 2 days (1) and if normal do not repeat. Consel patient to monitor symptoms of preeclampsia.2 wks review to assess need of AntiHTN if still on AntiHTN medications.6 wks medical review should be offered.Encourage her to keep her BMI between 18-25kg/m2.Patient should be given support and information on events and her risks of preeclampsia in future pregnancy should be discussed .

If BP <150/100,Preeclampsia profile normal,and no symptoms of preeclampsia refer back to community midwife after 6 wks (WHO IS GOING TO BE LOOKING AFTER HER DURING THESE 6 WEEKS? Do community midwives see women beyond 6 weeks post-partum?).

Murad Posted by PAUL A.

 

The presentation is suspecious of Pre-eclampsia ( PET)  , I will first repeat the Bp , I will use a manual device rather than an automated device (why? Will you be measuring her BP on the ward / in labour manually?) . I will take History, including history of medical illnesses i.e." HTN , SLE , Renal diseases .." (read the question – healthy woman) , the use of medications/ illicit drus  during and before pregnancy . The parity of the patient and whether she had History of Pre-eclampsia ( PET)  in a previous pregnancy and special attention to mode of previous deliveries in case i have to deliver her (what difference will these make?). Symptomes of sever PET need to be explored i.e" blurring of vision, headach , epigstric pains " (symptoms of severe disease). The antenatal records need to be reviewed , to check early pregnancy screening , Bp and protienuria . And to review the anomaly scan . On examination the pulse , Respiratory rate and Temperature need to be documented (why?). I will assess the  general status, do Chest exam (why??) and obstetric exam to assess the fundal hight and (epigastric tenderness) fetal heart . Lower limbs need to be checked for edema though it has no prognostic value (so why waste your time doing it / writing it????). I will repeat the urine analysis and check for evidence of urinery tract infection . I will order an  Ultrasound to be done to check for the fetal growth and doppler studies of the umbilical and uterine arteries(1) will you do any blood tests???

 The patient need to be admitted to a Labour ward (why??/) as a high dependency unite , CTG on admission , Bp to be done every 30 minutes. If Bp confirmed and persisted to be more than 160/110 (THIS IS NOT AN INDICATION FOR MGSO4), Magnesium Sulfate need to be initiated as per local protocol" 2-4gms bolus and 1-2g / hour as maintainance " and an antihypertensive medication started " Labetelol , Nefidipine or Hydralazine " . The management  of sever PET after 32 weeks is delivery (NO IT IS NOT). I will do a vaginal exam to assess the cervical status and to decide the mode of delivery , vaginal delivery being preferred if no other obstetric indications . The MgSO4 need to be continued through labour and to continue 24 hours postpartum . The Assessment intrapartum (YOU WERE ASKED ABOUT ANTENATAL CARE) should include continuous CTG , Bp every 15 mins and urine out Check and screening for MgSO4 toxicity" Respiratory rate, Knee reflexes " . Antihypertensives to be given when needed . Regional anesthesia is not contraindicated. I will give dexamethasone to enhance lung maturity ..

If the Bp repeat was less than given and mild PET is diagnosed (SEVERE HYPERTENSION DOES NOT EQUAL SEVERE PET and you should treat hypertension rather than deliver), conservative management can be offfered after assessment in the labour ward come satisfactory . I will give steroid (why given that you will aim to deliver at 37 weeks), I will start the patient on oral antihypertensive " Methyl dopa (NO – SEE NICE) or Nefidepine " and the patient can have an outpatient management (NO – SEE NICE) with close follow up, Serial Ultrasounds  and a planned delivery at 38 weeks (NO – SO WHY DID YOU GIVE STEROIDS??), earlier if she needed increasing doses or  combined medications . The value of prolongation of pregnancy after 34 weeks in cases of PET is questionable (NOT ACCORDING TO NICE).   

Postnatally , The Bp need to be monitored carefully in the first 24 hours ,, Antihypertensives need to be continued for at least 4 weeks (WHY???) post partum with home Bp monitory ,,The choice of medications is wider than during pregnancy " Any Anti-HTN " needed can be offerred . The patient can discontinue medications if hypotension events occured . The patient shoul be taught instructed to seek medical advice if she noticed any signs of increasing Bp (WHAT ARE THESE??). I will inform her about the risks of eclampsia and what warning signs exists , Breast feeding is not contraindicated . I will provide the patient with available leaflets concerning PET and i will offer contraception and advise her about recurrence rsiks . If Bp or protienurea persists after 4-6 weeks postpartum the patient is likely to have an essentiak HTN or renal disease respectively and then she should follow up accordingly