Case presentation of obstetrics with salient features

Case Presentation on Obstetrics

1. Group 1 (Chronic
Hypertension)
Group 2 (Gestational
HTN)
Group 3 (Chronic
HTN with
superimposed pre-
eclampsia)
Group 4 (Pre-
eclampsia with
Severe Features)
Group 5 (Eclampsia) Group 6 (HELLP
Syndrome)
Age 31 42 30 36 45 36
AOG By LNMP: 9 wks, 4d
By UTZ: Same
By LNMP: 26 wks, 6d 30 weeks By LMP: 29 wks By LMP: 33 weeks
LMP August 1, 2024 April 2, 2024 March 18-21, 2024 Feb 5-7, 2024 Feb 12-14, 2024
CC • Increased fatigue
• Nausea and vomiting
• SOB
• Mild headaches
• Intermittent
headaches
• Occasional dizziness
• Persistent headache
• Swelling of legs
• 12h PTC: mild to
moderate headache
• 6h PTC: severe
dyspnea
• Seizure with blurring
of vision
• RUQ pain
• One fetus died in
utero
• Emergency CS with
subarachnoid block
Past Medical
History
• Pre-pregnant BP
elevations to 150/95 mmHg
• On maintenance Losartan
50 mg OD
• Hx of HTN for 3 yrs

• Poorly-controlled
HTN

Family History • Mother: HTN
• Father: Heart disease
• Mother: HTN, pre-
eclampsia
• Father: DM
• Father: HTN
• Mother: DM
• Father: HTN
• Mother: DM
• Mother + sister: pre-
eclampsia
• Father: HTN
• Mother: HTN
• Father: HTN
Personal &
Social History
• Smoker (10 cigs/day for 8
yrs); 4 PY
• Occasional alcohol
drinking
• Age at first coitus: 23

Occupation
• Retail manager
• Husband: mechanic
• Occasional alcohol
drinking

Occupation
• Bank teller
• Husband: office
employee
Prenatal Records
• SBP: 100-130 mmHg
• DBP: 70-90 mmHg
Occupation
• College instructor

Obstetric
History
G3P1(2-0-1-2)
• Dec 9, 2020
• AGA (2550g + 2600g)
• Dichorionic diamniotic
possible; fraternal twins
• CS
• 1 girl/1 boy

Second preg: Abortion
G2P1(1-0-0-1)
• February 2, 2012
• Boy
G2P1(1-0-0-1)
• January 1, 2022
• 3000g (AGA)
G2P1(0-1-0-1)
• Emergency CS d/t
pre-eclampsia
• 33 wks AOG
• 1.9 kg (SGA)
• 9 y/o girl
G1P0

G1P0
• Menarche @13 y/o
VS • BP: 150/90 mmHg
• HR: 87 bpm
• Temp: 36.5
• RR: 16 cpm
• O2 Sat: 99% at room air
• BP: 150/95 mmHg
• PR: 88 bpm
• Temp: 36.4
• RR: 18 bpm

• BP: 140/90 mmHg
• +2 pitting edema
• BMI: 35.8 kg/m2

• BP: 160/114 mmHg
• HR: 105 bpm
• Temp: 37.2
• RR: 40 bpm, labored
• O2: 90%
• BP: 160/110 mmHg
• PR: 100 bpm
• RR: 20 cpm
• BP: 140/90 mmHg
• PR: 120 bpm
• RR: 26 cpm
• Temp: 36.5
PE • Height: 5’4”
• Weight: 125 lbs
• BMI: 21.5 (normal)
• Height: 5’2”
• Weight: 194 lbs
• BMI: 35.5 (obese)

• Fundic ht: 26 cm
• Fetal small parts on
right
• FHT: 140 bpm @
LLQ
• Fundal ht: 30 cm
• FHT: 130 bpm @
RLQ


BMI:
• Pre-preg: 22 (63.7
kg)
• During preg: 26.3
(gained 12.5 kg; 76.2)

• Fundic ht: 26 cm
• Cephalic
• Height: 150 cm
(4’11”)
• Weight: 75 kg (165
lbs)
• BMI: 33.3 (obese)
• Icteric sclera

• Height: 5’2”
• Weight: 187 lbs
• BMI: 34.2 (obese)

2. • FHT: 130 bpm@
RLQ
Laboratory
Findings
• Urine Protein: 2+
(proteinuria)
• Platelet count:
150,000/uL
• Serum crea: 1.1
mg/dL
• UPCR: 0.6
• ALT: 84 IU/L (<35
norms)
• AST: 90 IU/L
• Platelet:
80,000/mm3
• BUN: 24 mg/dL
• LDH: 1,080
• Bilirubin: 3.0 mg/dL
• ALT: 184 u/L
• AST: 158 u/L
• Protein in urine: 500
mg/24h
Imaging UTZ (Sept. 7, 2024)
• Di/di twins

Final Dx G3P1 (2-0-1-2), uterine
pregnancy, 9 wks 4 d AOG
by UTZ, with chronic HTN
G2P1 (1-0-0-1),
uterine pregnancy, 26
6/7 wks by LMP,
cephalic, gestational
HTN
G2P1 (1-0-0-1),
uterine pregnancy, 30
wks AOG, cephalic,
chronic HTN with
superimposed pre-
eclampsia
G2P1(0-1-0-1) uterine
pregnancy, 29 wks by
LMP, pre-eclampsia
with severe features
G1P0, uterine
pregnancy, 35 wks by
LMP, diamniotic-
dichorionic twin
pregnancy, cephalic-
cephalic, eclampsia
G1P0, uterine
pregnancy, 33 wks by
LMP, multi-fetal
gestation, cephalic,
one intrauterine fetal
demise, HELLP
syndrome
Risk Factors • Previous HTN
• Father is HTN-ive
• Smoker (4 PY)
• Occasional drinking
• Advanced maternal
age (>40)
• Prolonged
interpregnancy interval
(12 y; cutoff: 10)
• Family hx of pre-
eclampsia, HTN
(mother)
• Obesity
• Chronic HTN (3 y)
• Obese
• Father with HTN

• Advanced maternal
age
• Hx of pre-eclampsia
• Hx of LBW baby
• Chronic HTN
• Fam hx of DM and
HTN
• Advanced maternal
age (45 y/o)
• Multifetal gestation
• Obese
• First pregnancy
• Fam hx of pre-
eclampsia and HTN
• Advanced maternal
age
• Multifetal gestation
• Obese
• Fam hx of HTN

Diagnostics • Routine BP
• Baseline workups (CBC,
AST/ALT, Urinalysis, OGTT
75g
• NST, BPP, Doppler UTZ if
abnormal
• 140/90 mmHg on
two separate
occasions at least 4
hours after 20 weeks
of pregnancy
• Severe: 160/110
• + yung atin
• Routine BP
• + yung atin

24h urine collection
• Gold standard
• >300 mg

UPCR
• > 0.3 mg/dL

PIGF
• Lower in women with
SPE (superimposed
pre-eclampsia)
• Pre-eclampsia +
→ Thrombocytopenia
→ Impaired liver
function
→ Renal insufficiency
→ Pulmonary edema
→ Visual disturbances


• Same lang sa iba
• LDH: >600 IU/L
indicate HELLP
• PT, aPTT

Triad of Lab
Abnormalities in
HELLP:
• Microangiopathic
hemolysis
→ Schistocytes
→ Decreased Hgb,
platelet
→ Elevated
reticulocyte, LDH,
bilirubin
• Liver dysfunction
→ AST >70 IU/L
→ AST > ALT
• Thrombocytopenia
→ <100,000

Workups
• CBC
• Peripheral blood
smear
• PTT, aPTT

3. • Crea/BUN
• Urinalysis
• Blood glucose
• Liver function
• Bilirubin
Management • Switch to methyldopa or
labetalol
• DOC: Nifedipine
→ Acute: 10 mg; repeat
every 45 min; max: 50 mg
→ Maintenance: 20 mg

Antenatal Management
• Ca++ supplementation
• ASA (before 16 weeks;
150 mg OD before bed)

Timing of Assessment
• Monitor BP, Proteinuria,
NSR, AFV with each visit
• CBC monitoring if sharp
increase in BP or proteinuria
develops
• UTZ monitoring at start of
3
rd
trimester

Delivery
• Previable AOG:
→ Termination
→ Expectant management
• Viable AOG:
→ Stable + no drugs: >38
to 39 6/7 wks
→ Stable + drugs: >37 to
39 wks
→ Severe: 34 to 36 6/7;
accdg sa trans: 34 wks

Postpartum
• Furosemide 20mg PO
OD for 5 days
• If received MgSO4,
continue for first 24h
Acute
• DOC: Nifedipine
• Others: Labetalol &
Hydralazine

Management
• DOC: Nifedipine
• Others: Labetalol &
Methyldopa

Antenatal
• Blood pressure
monitoring
• NST, AFV
• Ancillary tests

Timing of
Assessment
• BP: 2x/wk
• Proteinuria: 1x/wk
• CBC: if proteinuria is
present, sharp inc. in
BP
• NSR and AFV:
1x/wk
• UTZ, AFV, Doppler:
every 2-4 wks; more
freq. if abnormal

During Labor
• Close surveillance
lahat ng parameters

Delivery
• Suggested time of
delivery: >37 weeks

Postpartum
• Samey-same
• Thromboprophylaxis
(kasi obese)
Seizure prophylaxis
• MgSO4 (4g IV initial;
1g after)
• Pritchard (4g IV +
10g IM; 5g IM after 4h)

Postpartum
• Thromboprophylaxis
(if >4d; obese, CS)

• Check trans for anti-
HTN
• Seizure prophylaxis

Antenatal
Corticosteroids
• Beta 12mg IM BID
q24
• Dex 6mg IM QID q12

Postpartum
• NSAID for analgesia


• MgSO4

Delivery
• Definitive treatment


Mississippi
Classification
• For ALL classes:
→ AST/ALT: >70 IU/L
(except 3: >40)
→ LDH: >600 IU/L

Class 1
• Platelet: <50,000

Class 2
• Platelet: <50,000 to
100,000

Class 3
• Platelet: 100,000 to
150,000
• AST/ALT: >40 IU/L

Tennessee
Classification

Complete or True
• Platelet: <100,000
• AST: >70 IU/L
• LDH: >600 IU/L

Partial
• basta wala isang
letter sa HELLP

Indications for
Platelet Transfusion
• >50 x 10^9/L (not
indicated if NO
bleeding)
• <50 x 10^9/L
(transfuse)
• <20 x 10^9/L
(platelet transfusion
before CS and
delivery)