Kristina Karylle S. Araojo
December 21, 2011
Medical History GENERAL OBJECTIVE: To present a case of Pre-eclampsia.
SPECIFIC OBJECTIVES:
Present the clinical manifestations of pre-eclampsia.
Explain its pathophysiologic mechanisms.
Describe its Diagnostic approach.
Elaborate the management and prevention of this disease .
General Data: Name: Norma Canoy
Date of Consultation: December 1, 2011
Age: 35 years old
Reliability: 90 %
Sex: Female Address: Purok 4, Lakewood, Zamboanga del Sur Marital Status: Married Occupation: Housewife Religion: Roman Catholic Nationality: Filipino Chief Complaint: Headache
History of Present Illness: 1 week prior to consult, patient experienced constricting headache which is bilateral in location with a pain scale of 5 / 10 and lasted for approximately ten (10) minutes. It is non-radiating and not aggravated by physical exertion. There are no associated signs and symptoms such as dizziness and vomiting. The patient did not take any medications and no medical consult was done.
2 days prior to consult, patient again experienced headache with same characteristics. The patient took Paracetamol 500 mg tablet for pain with no relief; still no consult done. Hours prior to consult, headache worsened which prompted patient to seek consult at the Rural Health Unit.
Past Medical History: Patient has no history of previous hospitalization and surgery. No known allergies to food and medications.
Family History: No known heredo familial diseases such as asthma, hypertension, diabetes mellitus and cancer.
Personal and Social History: Patient is a 35 year old G7P5 housewife, married to Jesus Canoy, a farmer. Patient does not smoke nor drinks alcoholic beverages. Patient has no regular exercise. Her usual meal is composed of rice, vegetables and meat.
Menstrual History: The patient had her menarche when she was 13 years old. Her menstrual period was regular with an interval of 28 days and consumes 3 - 4 pads a day. Her subsequent menses w as still of the same characteristics.
Pre- natal History: Patient has regular prenatal check ups. Has 5 doses of Tetanus Toxoid and takes ferrous sulfate.
Obstetrical History: G7P5 TPAL (6- 0 – 1- 6 )
G1 (1996) G2 (1998) G3 (2000) G4 (2002) G5 (2007) G6 (2010) G7 ( PRESENT)
TT
AOG
TT1, TT2 TT3 TT4 TT5
3 months FULL TERM FULL TERM FULL TERM FULL TERM FULL TERM
TYPE OF DELIVERY NSVD NSVD NSVD NSVD NSVD
PLACE OF DELIVERY HOME HOME HOME HOME HOME
GENDER OF CHILD MALE MALE FEMALE FEMALE MALE
COMPLICATIONS Abortion NONE NONE NONE NONE NONE
Review of Systems: GENERAL SURVEY: (-) fever, (-) weakness, (-) loss of appetite, (-) weight loss, (+) facial edema SKIN: (-) itchiness, (-) rashes HEENT: Head: (-) dizziness, (+) headache Eyes: (-) itchiness, (+) blurring of vision, (-) pain Ears: (-) hearing changes, (-) ear pain Nose: (-) discharges, (-) epistaxis, (-) nasal congestion Throat: (-) difficulty swallowing, (-) sore throat, (-) bleeding gums, (-) hoarseness
RESPIRATORY: (-) dyspnea, (-) cough, (-) hemoptysis CARDIOVASCULAR: (-) chest pains, (-) palpitations URINARY: (-) urinary frequency, (-) dysuria, (+) oliguria EXTREMITIES: (-) joint pain, (-) bone pain, (-) cramps, (-) bipedal edema NEUROLOGIC: (-) memory loss, (-) loss of consciousness, HEMATOLOGIC: (-) easy bruising, (-) lymph node swelling ENDOCRINE: (-) excessive hunger, (-) excessive thirst, (-) excessive urinating
Physical Examination: GENERAL SURVEY: patient is awake ,afebrile, coherent and not in respiratory distress VITAL SIGNS: Temperature: 37.4 C Blood pressure: 200 / 110 mmHg Respiratory Rate: 13 cycles/ minute Pulse rate: 101 beats/ minute Weight: 69.2 kgs
LMP: March 27, 2011 EDC: January 4, 2012
SKIN: Dry with good skin turgor , no rashes, no lesions HEENT: Head: No lesions. Head is normocephalic and no mass palpated, facial edema Eyes:
Pink palpebral conjunctivae, anicteric sclerae with pupils equally reactive to light and accommodation
Ears:
no lesions, no aural discharges
Nose:
midline, no nasal discharges
Throat: no mass, no lesion, tonsils not enlarged, no cervical lymphadenopathies
CHEST AND LUNGS: no gross deformities, no lesions, symmetrical chest expansion, no chest lagging, no chest indrawing, no intercostals retractions, no use o f accessory muscles, clear breath sounds on both lung fields, equal vocal and tactile fremiti th
HEART: Adynamic precordium. PMI at the 5 ICS Left Midclavicular line. No heaves. No thrills. Regular rate and rhythm. S1 > S2 at the apex. S2 > S1 at the base. No murmurs.
ABDOMEN: gravid abdomen, with abdominal striae , evident linea nigra FHT: 140 bpm @ LLQ Fundic Height: 27 cms L1: breech L2: Fetal back (left) L3: not engaged L4: cephalic (flexion)
EXTREMITIES: Full pedal pulses, good capillary refill time, no bipedal edema,
Diagnosis:
G7P5 (6-0-1-6) Pregnancy Uterine, 35 4/7 weeks AOG, NIL ; severe pre- eclampsia
Bases for diagnosis: (+) Headache (+) Blurring of vision (+) Facial edema (+) Oliguria (+) BP: 200 /110 mmHg Differentials: Rule in
Rule out
Eclampsia
Bp: 200 / 110 mmHg (+) Headache (+) blurring of vision (+) facial edema (+) oliguria
(-) seizures
Gestational Hypertension
BP: 200 / 110 mmHg
Chronic Hypertension
BP: 200 / 110 mmHg (+) Headache
Cannot be totally ruled out Proteinuria should be present Bp should return to normal < 12 weeks’ postpartum Final diagnosis made only postpartum (-) hx of previous hypertension
Tension Headache
(+) Constricting quality of pain Bilateral location Not aggravated by physical exertion / activity (-) Nausea or vomiting
(+) increased BP (+) Blurring of vision
Management:
Advised Hospital Delivery
Advised to reduce physical activity.
Ample protein and calories should be included in the diet.
Sodium and fluid intakes should not be limited or forced.
Hydralazine 25 mg tablet NOW
Methyldopa 25 mg tablet TID *patient refused treatment
Ideal Management: Basic management objectives for any pregnancy c omplicated by pre eclampsia are:
Termination of pregnancy with the least possible trauma to mother and fetus.
Birth of an infant who subsequently thrives.
Complete restoration of health to the mother.
EARLY PRENATAL DETECTION
Increase the frequency of pre natal visits during the third trimester to facilitate early detection of pre eclampsia
For those with overt hypertension ( 140 / 90 mmHg or greater) should be admitted to the hospital for 2- 3 days to evaluate the severity of new-onset hypertension
Women with persistent severe disease are observed closely, and many are delivered.
Women with mild diseases are often managed as outpatients.
Women without overt hypertension but in whom early pre eclampsia is suspected during routine prenatal visits, consists primarily of increased surveillance.
TERMINATION OF PREGNANCY
Delivery is the cure for pre eclampsia.
Prime objectives are:
o
forestall convulsions
o
prevent intracranial hemorrhage
o
prevent serious damage to other vital or gan
o
deliver a healthy infant
Anti hypertensive medications 1. Hydralazine ( direct arteriolar vasodilator) 2. Labetalol ( non-selective Beta blocker)
