GESTATIONAL HYPERTENSION

 Name : Shaharbana
 Age : 26
 Address : Paravoor
 Occupation : Housewife
 Blood group : O+ve
 Obstetric score : G1 P0 L0 A0 – Primigravida
 LMP : 10th July 2019
 EDD : 17th April 2020
 GA : 36 weeks
PRESENTING COMPLAINTS
 She came for her regular antenatal check up
HISTORY OF PRESENT PREGNANCY
She is a primigravida
 FIRST TRIMESTER -
 Pregnancy was confirmed by UPT, 1week after missing her
Periods . she then visited a hospital and booked her pregnancy
 No history of excessive vomiting, bleeding, pain, fever with rash,
urinary tract infection ,radiation exposure, drug intake.
 folic acid tablets were taken
 Usg scan done at 12th week and found to be normal (GA
corresponds to POG)
 SECOND TRIMESTER(13-28 weeks)
 • Quickening felt at 20th week with regular fetal movements there
by
 USG taken at 7 months and found to be normal
 No history of diabetes, hypertension, bleeding, edema or over
distension,head ache,blurring of vision,fever with rashes,UTI
 • Folic acid tablets, iron and calcium tablets taken

 THIRD TRIMESTER (>28 Weeks)

 MENSTRUAL HISTORY
 Menarche at the age of 14
 Regular 28 days cycle with bleeding for 4-5 days and uses 3
pads/day
 No history of dysmenorrhoea /menorrhagia
 LMP – 10th July 2019
 No relevant Premenstrual signs and symptoms
 MARITAL HISTORY
 Married at the age of 24 yrs
 No consanguinous marriage
 No history of contraceptives/treatment for infertility
 PAST MEDICAL AND SURGICAL HISTORY
 No history of HTN,Diabetes,TB ,Asthma,Epilepsy ,Thyroid
diseases
 No history of previous surgeries
 PERSONAL HSTORY
 Mixed diet
 Normal appetite
 Normal bowel and bladder movements
  Normal sleep
 FAMILY HISTORY
 No history of HTN , Diabetes in family
 No history of TB, multiple pregnancies, malignancies,
congenital anomaly or any psychological illness in family.
 GENERAL EXAMINATION
 Patient is Conscious, cooperative and well oriented to
time ,place and person
 Moderately built and nourished
 Height – 152cm , weight – 62 kg ,BMI – 26.6 kg/m2
 No Pallor, icterus, cyanosis, clubbing, lymphadenopathy
 Bilateral pedal edema present
 Skin, hair and nail found to be normal
 No Thyroid swelling
 Breast examination - normal
 Spine - Normal
 No varicose veins
 VITALS
 Pulse -94/min, regular rhythm, good volume , normal
character,All peripheral pulses are felt
 RR – 16/min
 BP – 146/96 mmHg
 Temperature
 SYSTEMIC EXAMINATION
 Respiratory system – normal vesicular breath
sounds heard
 Cardiovascular system - S1S2 heard ,No murmur
 Central nervous system – No focal neurological
deficit ,deep tendon reflexes normal
 Gastrointestinal tract -
  OBSTETRIC EXAMINATION
➢ INSPECTION
 Abdomen distended longitudinally
 Flanks not full
 Umbilicus - central, normal and everted
 Stria gravidarum, linea nigra present
 No scars and dialated veind
 No Visible pulsations, peristalsis
 Abdomen pendulous
 Hernial orifices normal
➢ PALPATION
 • After emptying bladder and leg in semiflexed position
 No focal rise in temperature
 No tenderness
 Fundal height – 36 weeks
 Symphysio fundal height – 34 cm
 Abdominal girth – 110 cm
o Fundal grip
• Broad, soft, irregular, non-ballotable mass suggestive
of podalic pole of the baby
o Umbilical grip
• Uniform resistance felt on left side suggestive of back
• Multiple limb nodules on right side suggestive of limbs
o First pelvic grip
• Hard, round, ballotable mass suggestive cephalic
pole ,mobile
o Second pelvic grip
• Confirms the findings of first pelvic grip
 • Head is not engaged
 • Head flexed (flexed -sinciput is at a higher level than
occiput)
 Estimated fetal weight : adequate on clinical
examination and according to
 johnson's formula is 3410g
 (Johnson formula : symphyseofundal height in cms
minus 12, if the head is unengaged and minus 11, if the
head is engaged, multiplied by 155 gives estimated
weight in grams)
 Liquor – adequate on clinical examination
 AUSCULTATION
 Fetal heart sound heard on left side below the umbilicus
 FHR – 146 bpm and good fetal heart sound
 SUMMARY
 • A26year old patient with obstetric score G1P0L0A0,of
gestational age 36 weeks,
 LMP 10/07/2019 , EDD -17/04/2020 came to OPD for regular
antenatal checkup found to have raised blood pressure
146/96 mmHg during 3rd trimester and is on medication
 No relevant family /medical history
 Bilateral pedal edema present
 •On obstetric examination : fundal height_m36 weeks,
single live intrauterine pregnancy, longitudinal lie, cephalic
presentation, left occipitoanterior position(LOA), FHR – 146
bpm
 DIAGNOSIS
 26 year old Primigravida , gestational age of 36 weeks LMP
on 10/07/2019 ,EDD on 17/04/2020, with single live
intrauterine pregnancy, longitudinal lie, cephalic
 presentation, LOA position, complicated with Gestational
hypertension

CASE DISCUSSION
1. Classification and definition of hypertensive disorders
ofpregnancy
 Chronic HTN – bp≥140/90mmhg predating pregnancy/
before 20 weeks
 Gestational HTN - bp≥140/90 mmHg after 20 weeks and
without significant proteinuria and biochemical or
haematolaogical abnormalities
 Preeclampsia- Bp≥140/90mmhg after 20 weeks with
significant proteinuria anad/ maternal organ dysfunction
and/ uteroplacental dysfunction
 Superimposed preeclampsia – chronic HTN with appearance
of new onset proteinuria or maternal organ dysfunction
consistent with preeclampsia
2. Risk factors –
 Primiparity
 Age<18 yrs
 Advanced maternal age
 High BMI
 Multiple pregnancy,hydatidiform mole,Rh iso
 Maternal medical problems – diabetes,HTN,renal
disease,connective tissue disorder,antiphospholipid
syndrome
 Past h/o ,family h/o pre eclampsia
3. Aetiopathogenesis ---
  Preeclampsia as a two stage disorder
 Abnormal trophoblastic invasion
 Abnormal angiogenesis -angiogenic and anti- angiogenic
proteins
 Endothelial cell dysfunction and vasosoasm
 Alteration in nitric oxide and prostaglandins
 Activation of platelets and coagulation system by tissue
factor
 Loss of maternal immune tolerance to paternally
derived placental and fetal antigens
 Central obesity and insulin resistance
 Common – endothelial cell damage and dysfunction
4. Criteria for severe preeclampsia
 160/110mmHg
 Headache and visual disturbances
 Epigastric pain
 Thrombocytopenia(<100000)
 Elevated liver enzymes
 Serum creatinine>1.1 mg/dL
 Pulmonary edema
5. Liver changes ? – periportal hemmorhhages ,vasosoasm and
infarction around sinusoids
6. Renal chenges – dx proteinuria – reduced gfr,increase in serum
creatinine
7. Cardio vascular &Hematological changes??lv
dysfunction,haemoconcentration,pulmonary edema,pedal and
generalised edema,thrombocytopenia
8. Placental changes?? – lack of trophoblastic invasion,narrowing of
the arteries,necrosis of vessel wall,obstruction of lumen placental
 infarction --- fetal growth restriction,placental abruption,preterm
labour
9. Maternal complication of pre eclampsia
 Placental abruption
 Preterm labor
 Pulmonary edema
 HELP syndrome
 Eclampsia
 Renal failure
10.fetal complication
 Prematurity
 Fetal growth restrictions
 Intrauterine death
 Intrapartum hypoxia
11. Investigations ??
– urine albumin,urine microscopy,platelet count,liver
enzymes,nst,usg
12.Management of non severe HTN (this case)
 Maternal monitoring – as op basis- twice weekly
--monitor bp,urine protein and signs and symptoms of severe
disease
---platelet count and liver enzymes checked once a week
 Fetal surveillance – daily fetal movement count,Nst,bpp,fetal
growth assessment
 Anti hypertensive therapy – labetalol
 Antenatal glucocorticoids – in pts needing delivery before 34
weeks
  Timing of delivery – women with mild elevation
bp(140/90mmhg)------deoivered by 39-40 weeks
----if bp is high(160/100)---37-38 weeks is recommended
13 . Management of severe Gest HTN/ No severe preeclampsia
 Hospitalise
 Maternal monitoring
 Fetal monitoring
 No maternal/fetal compromise --- deliver at 37 weeks
 Maternal / fetal compromise -----deliver <37 weeks
14. Management of severe preeclampsia – delivery
 Immediate – antihypertensives,seizure
prophylaxis,corticosteroids(if ga b/w – 26-34 weeks),Maternal
and fetal evaluation
 Subsequent ---≥34 weeks -delivery
---<26 weeks ---pregnancy terminated after stabilizing
mother
----26/28-34 - delivery 24 hrs after administration of
steroids / immediate delivery within 24 hrs after administration
of steroids /expectant management
15.Mgso4 – dose
---- loading - 4g
----maintenance –1 g
Mode of action –
Therapeutic range ind serum – 5-7 mEq/L
--RR comes down –12 mEq/L
--reflexes goes down --10mEq/L
-How long cntinue---24 hrs after last convulsion
 Mx of mgso4 toxicity- ca gluconate – 10 ml of 10%1g IV given
over 20 minutes
16.prevention of preeclampsia --- low dose aspirin – 150mg/day
Ca supplementation
17.monitoring in subsequent pregnancies ----Uterine artery Doppler
velocimetry at 23-24 weeks