SAN BEDA UNIVERSITY

COLLEGE OF MEDICINE

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

PACIA, THEA DIVINA RACHEL PELAYO, LARA FAIYE R.

PAGLINAWAN, DRINA B. PENARROYO, KYLE ANGELA
PAJARES, CHARLOTTE PENAS, ANDREA KATRINA
PANUMPANG, NUR JAMEENAH D.

Distribution of parts:

Leader: Pacia, Thea Divina Rachel

Panumpang, Jameenah -History, Physical Examination, Diagnosis

Paglinawan, Drina & Pelayo, Lara - Diagnostics & Management
Pacia, Thea & Peñarroyo, Kyle - Differential Diagnosis
Pajares, Charlotte & Peñas, Andrea - Discussion
Pelayo, Lara - Journal

History:

General Data:

Name: RM Nationality: Filipino

Age and Gender: 38/ F Religion: Roman Catholic

Gravidity, parity & OB score: Marital status: Married

G4P3 (3002)

Address: Quezon City Occupation: Housewife

Birthday: September 8, 1982 Blood Type: O+

Informant: Patient

Chief Complaint:

“Sumakit ang ulo ko”

History of Present Illness:

● 2 weeks PTC:
- On her 4th prenatal check-up, the patient was noted to have a 140/80
mmHg blood pressure.
 - Her normal blood pressure was noted to be always /80 mmHg.

● One day PTC:

- Patient started experiencing headaches to which she would only drink
paracetamol (biogesic) to relieve it. It was characterized to be
throbbing and would radiate from the front of her head to the back of
her neck. The severity was 8/10.
- No other danger signs were present.

● On the day of Consult:

- Patient experienced a persistent headache, prompting her to get a
consult.
- Her blood pressure was 160/100.
- When asked if this has ever happened to her before, she stated that
she has had preeclampsia from her first pregnancy.
- No other danger signs were present.

Antenatal History:
First Trimester:
● There is no data because the patient has not yet learned of her pregnancy.

Second Trimester:
● The patient experienced a quickening in her fifth month.
First prenatal check-up:
● Done in a lying-in clinic when she was 16 weeks and 5/7 days pregnant.
● The pregnancy was confirmed through Ultrasound and the fetus was noted to
be okay. The same day she learned of her pregnancy marked her first
prenatal check-up as well.
● The patient stated that this is her first child with her second partner and that
the pregnancy was planned and wanted.
● On her first prenatal check-up, she was prescribed ferrous sulfate and
multivitamins to be taken once a day for both.
● A urinalysis and CBC were requested and came out normal.
● VDRL and HIV tests were not performed.

Second prenatal check-up:

● Done in a lying-in clinic on her 6th month of pregnancy.
● A repeat urinalysis was done on the patient. The result showed that she had a
urinary tract infection, only had burning urination as her symptom, and so was
prescribed to take Ce2nd-hour500 mg 3x/day, every 8 hours, for 1 week. The
patient stated she was compliant and the infection was treated.
● The patient's blood sugar was also tested. The results showed her fasting
blood sugar was 4.7 mmol, 2nd hour glucose tolerance test was 8 mmol, and
 the 3rd hour glucose tolerance test was 6.5 mmol. All were in the normal
range.

Third Trimester:
Third prenatal check-up:
● Done in a lying-in clinic on her 8th month of pregnancy.

Fourth prenatal check-up:

● Done in a lying-in clinic when she was 33 weeks pregnant.
● Her blood pressure was taken and came out to be 140/80 mmHg.

Other information from the antenatal history are as follows:

● The patient has gained weight during her pregnancy. Her pre-pregnancy
weight was 69 kilograms and her current weight is 85 kilograms.
● She has no known exposure to teratogens, has not been vaccinated during
the pregnancy, does not like to go out of her house, and does not experience
any other symptoms such as nausea, vomiting, urine disturbance, fatigue,
breast tenderness, tingling, chloasma and/or melasma.

Past Personal and Medical History:

● The patient has unrecalled childhood illnesses and immunizations, both
childhood and adult.
● Four years ago, when the patient was 34 years old, she was diagnosed with
hypertension, her blood pressure at that time was 150/90. Because of this,
she was prescribed amlodipine, once a day. She was compliant for a year
before stopping it voluntarily due to not experiencing any symptoms.
● Patient has no known illnesses such as Diabetes Mellitus, Stroke,
Cardiovascular diseases, Arthritis, Goiter, or Cancer. She has never
experienced any surgical procedures, any trauma, blood transfusions, does
not have allergies and is not taking other medications.

Family History:
● The patient's father is in his 60’s and is hypertensive. Her mother is also
known hypertensive and her sibling, who is 35 years old, has current kidney
disease.

Personal and Social History:

● The patient is a housewife. She only does housework and looks after her
younger child. She finished 1st year of college and usually eats beef or pork
with vegetables. She also drinks one cup of coffee every day.
● She does not drink alcohol and does not smoke. She has not taken any illicit
drugs and has no recent travel history.

Obstetric History:
 GRAVIDITY Date / Gestational Mode of Place of Birth Fetal Complications Neonatal
Year of age at delivery delivery attendant outcome (maternal/ fetal/ Problems/
delivery delivery (weight, delivery or Current
sex) operative health of
complications) children

G1 2000 37 weeks Normal Fabella Doctor Boy Preeclampsia Died after a

Hospital 2 kg week due to
sepsis

G2 2001 37 weeks Normal Lying in Midwife Girl None Was sent

3.1 kgs home after
giving birth

G3 2013 37 weeks Normal Lying in Midwife Boy None

2.8 kg

G4 2021 Current
pregnancy

Menstrual History:
● The patient’s menarche was when she was 17 years old. The interval is 30
days. Duration is 3-4 days and the number of napkins used is usually 2-3 per
day. The napkins were noted to be fully soaked. No associated symptoms
were felt during menstruation.

Sexual History:
● Patient’s coitarche was when she was 18 years old. She has had 2 sexual
partners and has used birth control pills after giving birth to her second baby.

Gynecologic History:
● A Papanicolaou smear was done on the patient back in 2014 and the results
yielded normal. She has not been vaccinated against Human Papilloma Virus.

Review of Systems:
● General:
○ Aside from weight change, the patient does not experience fatigue,
night sweats, dizziness, fever, or chills.
● Skin:
○ Patient does not have any rashes, hives, itching, pigmentations, moles,
and sores.
● Head and Neck:
○ Aside from headache, the patient does not have swelling in the head,
experienced trauma, pain, or stiffness.
● Eyes:
○ Patient does not experience blurring, dryness, diplopia, redness,
scotoma, tearing, visual dysfunction, nor use glasses.
● Ears:
 ○ Patient does not have difficulty in hearing, vertigo/ dizziness, tinnitus,
pain, or discharges.
● Nose:
○ Patient does not have epistaxis, obstruction, dryness, smell
dysfunction, sneezing, and discharges.
● Mouth:
○ The patient does not experience soreness, dryness, pain, doesn’t have
mouth ulcers nor have hoarseness.
● Breasts:
○ Patient does not have discharges, infection, lumps/ masses, pain or
bleeding.
● Respiratory:
○ The patient does not have cough, cyanosis, dyspnea, wheezing or
asthma, hemoptysis, sputum production.
● Cardiovascular:
○ Aside from hypertension and edema, the patient does not have chest
pain, palpitations, fatigue, syncope, orthopnea, or PND.
● Gastrointestinal:
○ The patient does not experience anorexia, hematemesis, nausea,
vomiting, dysphagia, and heartburn.
● Renal:
○ The patient does not experience dysuria, hematuria, nocturia,
incontinence or urinary frequency.
● Musculoskeletal:
○ Patient does not experience muscle pain, stiffness, joint pain, cramps,
or weakness.
● Endocrine:
○ Aside from the weight change, the patient does not experience heat or
cold intolerance, polyuria, polydipsia, or polyphagia.
● Nervous:
○ Aside from the headache, the patient does not experience syncope,
seizure, weakness, memory loss or disturbances in sensory or motor
function.
● Psychiatric
○ The patient does not experience mood changes, extreme sadness, or
mental/ behavioral changes

Physical Examination:
● General Survey: Conscious, coherent, ambulatory, not in cardiorespiratory
distress
● Vital Signs:
○ Blood Pressure: 160/100 (Hypertensive)
○ Heart Rate: 90 bpm
○ Respiratory Rate: 18 cpm
 ● Anthropometrics:
○ Height: 5 ft
○ Pre-pregnancy Weight: 69 kg
■ Pre-pregnancy BMI: 29.7 (Overweight)
○ Current Pregnancy Weight: 85 kg
● Skin and HEENT yielded normal results
● Respiratory:
○ Clear breath sounds
● Cardiovascular:
○ Normal apex beat 5th ICS
○ No murmurs
○ S1 & S2 were distinct
● Abdomen:
○ Fundic height: 35 cm
○ Leopold’s Maneuver:
■ LM1: Breech
■ LM2: Fetal back at right
■ LM3: Cephalic
■ LM4: Flexed
○ FHT: 140 bpm
■ FHT location: LLQ
● Genitourinary:
○ Internal examination: Not performed

1. What are the salient features of the case?

Pertinent Positives Pertinent Negatives

Age: 37 y/o (-) Diabetes Mellitus

OB score: G4P3 (3002) (-) Pulmonary edema
LMP: January 13, 2021 (-) Chest pain
AOG: 35 2/7 weeks (-) Danger signs:
(+) Headache - (-) Fever
- Throbbing quality - (-) Blood or Watery vaginal
- Radiates to the back of the neck discharge
- 8/10 in severity - (-) Decreased fetal movements
- Medicated with paracetamol - (-) Abdominal pain
(biogesic) but was unrelieved - (-) Visual disturbances
(+) Hypertension - (-) Convulsions/Seizures
- Diagnosed at 34 years old - (-) Dysuria
- BP at that time: 150/90 (-) Cough
- Non-compliant to the medication (-) Dyspnea
(+) History of UTI (-) Non-alcoholic
- Diagnosed at her 6th month of (-) Non-smoker
 pregnancy (-) Cardiorespiratory distress
- Prescribed with Cephalexin 500 (-) Internal Examination
mg 3x/day for every 8 hours, 1
week
- Compliant to medication
(+) History of Preeclampsia
- From first pregnancy with the first
partner
(+) Exposure to two different paternal
genes
(+) Family history of hypertension
(+) Sedentary lifestyle
(+) Conscious, coherent, ambulatory
Vital Signs:
- BP: 160/100 (Hypertensive)
- HR: 90 bpm
- RR: 18 cpm
BMI
- Pre-Pregnancy: 29.7 (Overweight)
Leopold’s maneuver:
- LM1: Breech
- LM2: Fetal back at right
- LM3: Cephalic
- LM4: Flexed

2. What is your complete OB diagnosis?

G4P3 (3002), Uterine Pregnancy, 35 weeks 2/7 days, AOG by LMP,

Cephalic Presentation, not in labor, preeclampsia on superimposed
chronic hypertension with severe symptoms

3. What is your plan of management?

A. INITIAL MANAGEMENT AND STABILIZATION
a. Initial Management
● Patient must be admitted to a ward or obstetric ward.
● The first step for the plan of management, after collecting history
and physical examination, is to assess if the patient should be
admitted or not. The patient is classified as severe preeclampsia
due to new onset of hypertension (BP 160/100) and headache
that requires hospitalization.
 Table 2. Indicators of Severity

Table 2 is used to determine the severity of the patient’s

condition. In our patient, the patient had a systolic bp of greater than or
equal to 160 mmHg and also had a headache, which means the patient
has severe features of preeclampsia. It is important to know the
severity of the patient’s case, as this will guide us with the
management.

● Hospitalization is indicated in cases:

● Systolic blood pressure (SBP) >150 mmHg
● Diastolic blood pressure (DBP) > 100 mmHg
● Heavy proteinuria
● Persistent maternal symptoms

b. Treatment
● Antihypertensive Therapy
○ Hypertensive therapy aims to keep SBP between 140-155
mmHg and DBP between 90-105 mmHg.
○ First Line Antihypertensive Agents- immediate or emergent
therapy for acute onset hypertension
■ Hydralazine (IV)
● In our case, this would be given as it is available
locally and drug of choice according to NHBEP;
long experience of safety and efficacy
● 5 mg, IV or IM, then 5 to 10 mg every 20 to 40
minutes; once BP controlled repeat every 3 hours;
for infusion: 0.5 to 10.0 mg/hr; If no success with
20 mg IV or 3o mg IM, consider another drug
■ Labetalol (IV)
 ● 10-20 mg IV, then 20-80 mg IV every 10-30
minutes until goal blood pressure is attained. Max
dose 300 mg.
● Not available in the Philippines
■ Nifedipine (oral)
● 10 to 30 mg PO, repeat in 45 minutes if needed
● Should be used with caution if concomitantly used
with MgSO4
● Anti-seizure Prophylaxis
○ Give Magnesium sulfate (MgSO4) to prevent convulsions
○ Dose: 4 grams for 5-10 mins and further infusion of 1 gram /
hour maintained for 24 hrs
○ Route: continuous IV or intermittent IM injections
● Corticosteroids
○ Given for fetal lung maturation
○ Betamethasone and dexamethasone
● Fluids
○ In usual circumstances, the fluids should be limited to 80
ml/hour or 1 ml/kg/hour
○ Fluid restriction is advisable to reduce the risk of fluid overload
in the intrapartum and postpartum periods.
c. Monitoring
● Control of Hypertension
○ BP monitoring
○ Antihypertensive Therapy - prolongs pregnancy as a gram/hour
near term as possible

B. DIAGNOSTICS
a. Diagnostic criteria for Preeclampsia Superimposed on Chronic
Hypertension
● Chronic hypertension is a condition wherein the patient has
hypertension before pregnancy or before 20 weeks of gestation. Our
patient was diagnosed with hypertension at the age of 33 years old,
and she took medications but stopped after 1 year of taking
antihypertensive drugs. It is a condition that predisposes pregnant
women to develop preeclampsia. To elaborate chronic hypertension
on pregnant women, the following are observed:
a. Hypertension (140/90 mm Hg or greater) antecedent to
pregnancy;
b. Hypertension detected before 20 weeks of gestation; or
c. Persistent hypertension long after delivery
● Superimposed preeclampsia is defined as new-onset or worsening
baseline hypertension and new-onset proteinuria or other findings
 related to maternal end-organ dysfunction like thrombocytopenia,
renal insufficiency, etc., which can be seen in Table 1 below.
● Preeclampsia syndrome is a condition that can affect virtually every
organ system. In this case, the patient has several risk factors that
increase her chance to develop preeclampsia like, previous
pregnancy with preeclampsia, age of > 35 years, and chronic
hypertension. To diagnose preeclampsia, it requires that the patient
has a, blood pressure of >140/90 mmHg on at least 2 occasions, 4
hours apart, and either the patient has proteinuria or evidence of
maternal organ dysfunction like renal dysfunction, hepatocellular
necrosis, and thrombocytopenia. The table here is used to classify
and diagnose pregnancy-related hypertension.

CONDITION CRITERIA REQUIRED

PREECLAMPSIA: BP > 140/90 mmHg

HYPERTENSION PLUS
PROTEINURIA ≥ 300 mg per 24-hr urine collection or
Urine protein: creatinine ratio ≥ 0.3 or
Dipstick 1+

Or

THROMBOCYTOPENIA Platelet count of <100,000/ul

RENAL INSUFFICIENCY Creatinine level of > 1.1 mg/dL or doubling of baseline
LIVER INVOLVEMENT Serum transaminase level twice than normal
CEREBRAL SYMPTOMS Headache, visual disturbances, convulsions
PULMONARY EDEMA

Table 1: Classification and Diagnosis of Pregnancy-Associated Hypertension

LABORATORY TESTS:

FOR PREECLAMPSIA ASSESSMENT:

This is to assess maternal organ dysfunction, which is common among

women with preeclampsia. It is a condition wherein it affects multiple organs
hence, different laboratory tests may be done to check for the condition of the
patient.

A. Urinalysis and Urine Protein Measurement

a. For the urine protein measurement, to meet the criteria for
preeclampsia, 1 of the following must be observed:
i. Urine protein of ≥ 300 mg over 24 hours
 ii. Urine protein to creatinine ratio ≥ 0.3
iii. Urine dipstick of 1+: this is only recommended if other
methods are not available
B. Complete blood count (Platelet count)
a. To check for infection and thrombocytopenia
i. For thrombocytopenia, the platelet count is <100,000/ul
ii. Patients with preeclampsia have endothelial cell injury
which makes them prone to form thrombi in the
microvasculature that would cause increased use of
platelets in the circulation causing thrombocytopenia.
C. Blood Chemistry:
a. Kidney Function Tests (Creatinine, BUN)
i. Serum creatinine level of > 1.1 mg/dL or doubling of
baseline
ii. Patients who are suspected to have preeclampsia may
have glomerular damage due to local vasospasm that
leads to hypoperfusion.
b. Liver Function Tests (AST, ALT, and Bili):
i. Liver enzymes such as AST and ALT were abnormally
elevated or twice the normal concentration
ii. Elevated levels of the liver enzymes may be due to liver
involvement and damage
c. Serum Electrolytes
i. To check for sodium, potassium, and chloride
ii. To assess renal damage and insufficiency for
preeclampsia
D. COVID-19 RT-PCR
i. Routine diagnostic test for COVID-19

SURVEILLANCE FOR FETAL GROWTH:

This is to assess the fetal well-being to ensure that the fetus is not in distress and
also to evaluate the fetal weight, fetal growth, and amniotic fluid index.

A. Doppler Ultrasonography
○ This is to assess the movement of blood in the blood vessels and to
study the circulation of blood in the fetus, placenta, and uterus. This
can also be used to check for fetal growth restriction.
○ Patients with preeclampsia have defective placentation which impairs
the placental blood flow which might lead to fetal growth restriction.
B. Cardiotocography
○ This is to assess and monitor fetal heart rate and the presence or
absence of contractions
C. Biophysical Profile Score
 ○ This is to assess fetal well-being, with the use of cardiotocography and
ultrasound. It has 5 parameters, it includes fetal breathing patterns,
gross body movement, fetal tone, amniotic fluid volume and nonstress
test.

B. BIRTH PLAN

● Plan of delivery - VAGINAL DELIVERY

● In our patient, no internal examination was done but when assessing
the fetal heart tone and Leopold’s Maneuver, no abnormalities were
noted, thus the probable mode of delivery is vaginal delivery.
● Route of delivery is assessed based on gestational age, fetal
presentation, cervical status, obstetric history, and maternal and fetal
condition.
● Cesarean delivery is recommended for standard obstetric indications
(eg, unfavorable cervix, oligohydramnios) and should be individualized.
● Essential Intrapartum and Newborn Care (Unang Yakap)
● Series of time-bound chronologically ordered standard procedures that
a baby receives at birth
● A basic component of the DOH’s Maternal, Newborn, and child health
and nutrition strategy
● Represents the highest standard for safety and quality care for birthing
mothers and healthy newborns.
● EINC CORE STEPS:
1. Immediate & thorough drying of newborn
a. 30-60 seconds
b. Sequence of drying is as follows (5 seconds each): face,
head, trunk, back, arms, legs
2. Early skin-skin contact between mother and the newborn
a. By next 30 sec, prevents heat loss by conduction
b. Initiates maternal-infant bonding
c. Allow transfer of maternal flora to newborn
d. Delaying washing/bathing for at least 6 hours of life
3. Properly timed cord clamping
a. Delaying or until cord pulsation stops (1-3 mins)
b. Decrease anemia on 6th hr
c. Increase stores of iron
d. Prevents intraventricular hemorrhage
4. Non-separation of mother and newborn until first breastfed
a. Non-separation for 90 minutes after birth or after the first
full breastfeed
b. Facilitates latching-on and subsequent breastfeeding
c. Colostrum is beneficial to newborns
C. POSTPARTUM MANAGEMENT

● Blood pressure should be recorded shortly after birth and check if normal
again within 6h (q15, q30, etc.), and laboratory exams must be repeated until
stable.
● The optimum length of inpatient postnatal stay is not clear but the risk of late
seizures may happen until the 4th postpartum day. Magnesium sulfate must
be continuously given.
● All women should have BP recorded and discharge deferred for at least 24 h
or until vital signs are normal and/or treated or referred. Any woman with an
obstetric complication and/or newborn with complications should stay in the
hospital until both are stable.
● Agents commonly used in the antepartum period may be used or continued
postpartum such as the amlodipine taken by the patient as maintenance.
● Anti-hypertensive drugs should be given if the BP exceeds 150 mmHg systolic
or 100 mmHg diastolic in the first 4 days of postpartum.
● Diuretics can be used during the postpartum period but must not be given
during pregnancy.
● Avoidance of NSAIDs must also be noted in postpartum women who are
hypertensive.
● Surveillance and follow-up must be advised for the patient and the baby.
● Vitamins and minerals must also be given to both the mother and baby.

D. Non-Pharmacologic treatment

● Lifestyle modification
○ It is the cornerstone for the management of hypertension and its
involves altering old habits like poor eating habits and physical
activities.
● Diet
○ Dietary Approaches to Stop Hypertension (DASH) meal plan which
is low in sodium and high in dietary potassium, can be
recommended for all patients with hypertension without renal
insufficiency.
○ The DASH diet is rich in fruits, vegetables, low-fat dairy, fish, whole
grains, fiber, potassium, and other minerals at recommended levels
and low in red and processed meat, sugar, sweetened foods and
drinks, saturated fat, cholesterol, and sodium
● Physical activity
○ According to the CDC, it is recommended for postpartum women to
have at least 150 minutes of moderate-intensity aerobic physical
 activity per week (e.g brisk walking) and (dynamic) resistance
exercises.
○ Significant weight loss of 5% of the baseline weight for those who
are overweight or obese.
● Patient education
○ Awareness about the alarming signs and symptoms of preeclampsia
if ever they are planning to conceive again.
○ Compliance with the medications and follow-up checkups.
○ Raise awareness of the possible complications such as maternal
complications including neurologic complications (stroke, cortical
blindness) and hepatic complications (liver dysfunction, hepatic
rupture) or obstetric and fetal complications such as abruptio
placentae, preterm birth, IUGR, and stillbirth.

Differential Diagnosis

Eclampsia

Eclampsia is the occurrence of new-onset, generalized, tonic-clonic seizure or coma

in patients with preeclampsia or gestational hypertension. It typically occurs during or
after the 20th week of gestation or in the postpartum period.

Pertinent Positive Pertinent Negative

● Previous history of preeclampsia ● (-) Seizures

● Age (>35 years old) ● (-) Visual disturbances (blurred
● Obesity vision and photophobia)
● Chronic hypertension ● (-) Abdominal pain
● Severe headache
● Symptoms showed during the third
trimester

Gestational Hypertension

Gestational hypertension occurs when your blood pressure rises in the second half
of your pregnancy, or earlier if you’re carrying twins. Blood pressure is the force of
blood pushing against artery walls through blood vessels. When this force measures
more than 140/90 mm Hg and is first spotted at 20 weeks or later in pregnancy,
doctors consider your blood pressure to be high.

Pertinent Positive Pertinent Negative

● Headache ● (-) vision changes

 ● Edema ● (-) epigastric pain
● Normal blood pressure before ● (-) oliguria
pregnancy (120/80 mmHg)
● Present blood pressure (160/100
mmHg - hypertensive)
● History of UTI

Pheochromocytoma

Pheochromocytoma is a catecholamine-secreting tumor that is rare during

pregnancy, with the prevalence of 1 in 54 000 pregnancies. The classical
presentation of pheochromocytomas such as paroxysmal hypertension, headaches,
sweating, and palpitations may not simultaneously present during pregnancy. Aside
from hypertension, there is an altered renal function and proteinuria caused by
catecholamine-mediate renovascular abnormalities, common in pheochromocytoma.

Pertinent Positive Pertinent Negative

● Hypertension ● Rare
● Severe headache ● No generalized sweating
● Symptoms showed during the third ● No palpitations
trimester ● No tremor
● No dyspnea
● No generalized weakness

Discussion

RM is a 38-year-old G4P3 who came in for consultation due to severe

persistent headache. It started a day before consultation as a throbbing pain
radiating from the front of the head to the nape, with a severity of 8/10, for which she
took Paracetamol (Biogesic) for relief.

Two weeks prior to consultation (33 weeks AOG), the patient was noted to
have elevated blood pressure (140/80) for the first time this pregnancy, in contrast to
her usual blood pressure of 120/80 mmHg. On the day of consultation, her headache
persisted prompting consult. Upon physical examination, the patient's BP was
severely elevated (160/100 mmHg). No other danger signs were present such as
vomiting, fever, bloody vaginal discharge, and epigastric pain. Prior to pregnancy,
the patient weighed 69kg with a BMI of 29.7, classified as overweight. In overweight
pregnant women, the average weight gain is only 6.8-11.4kg. However, the patient’s
current weight gain already reached 16kg, which is above the normal range. This
increase in weight is due to the expanded blood volume, development of the fetus,
and changes in the uterus. The patient’s fundic height (35cm) is consistent with her
gestational age. The rest of the physical examination findings are normal.

The patient had her first prenatal check-up on May 10 where she was already
on her second trimester. It was stated that this is her first child with her second
husband. The patient had four prenatal check-ups in total and on the second one,
her urinalysis showed urinary tract infection, and was prescribed with Cephalexin,
once every 8 hours for 1 week, where the patient was compliant and the infection
was treated. During this time the patient's blood sugar was also tested and was
within the normal range.

Prior to the patient's fourth pregnancy, she was diagnosed with hypertension
at 34 years old with a BP of 150/90 mmHg. She was prescribed with Amlodipine
once a day and has been compliant for a year before stopping due to the absence of
symptoms. No other illnesses were reported. The patient has a family history of
hypertension on both her parents’ sides. No alcohol, smoking, and illicit drug use
history was noted. The patient was diagnosed with preeclampsia during her 1st
pregnancy wherein she was only 18 years old. Young age and nulliparity may be one
of the risk factors in developing preeclampsia for this patient. The child was delivered
full term but has a low gestational weight (2 kg) and has died a week after delivery
due to sepsis.

The patient’s history and clinical presentation are consistent with

preeclampsia superimposed on chronic hypertension. Chronic hypertension is where
the patient has elevated blood pressure (>140mmHg systolic, >90mmHg diastolic)
on two separate occasions before pregnancy or before 20 weeks of gestation. On
the other hand, superimposed preeclampsia is defined as new-onset hypertension or
worsening baseline BP (>140mmHg systolic, >90mmHg diastolic) that occurs after
20 weeks of gestation or postpartum, accompanied by either proteinuria (greater
than 300 mg/24 hours) or other maternal organ dysfunction such as
thrombocytopenia (platelet: <100,000/mm), elevated levels of liver transaminases,
and worsening renal function or symptoms of right upper quadrant pain, pulmonary
edema, or severe headache. Young and nulliparous women are particularly
vulnerable to developing preeclampsia whereas older women are at greater risk for
chronic hypertension with superimposed preeclampsia.

Preeclampsia’s pathophysiology stems from the abnormalities in the

development of placental vasculature early in pregnancy which may result in relative
placental underperfusion/hypoxia/ischemia. This can then lead to the release of
antiangiogenic factors into the maternal circulation that alters maternal systemic
endothelial function and causes hypertension and other manifestations of the
disease.

Risk factors that are present in our patient according to order of relative risk
are the following: Prior preeclampsia, chronic hypertension, patient’s BMI, and
advanced maternal age. Chronic hypertension increases susceptibility to
preeclampsia due to preexisting endothelial cell damage. The patient’s current
weight gain, on the other hand, has exceeded the expected range in overweight
pregnant patients, possibly inducing chronic inflammation and endothelial
dysfunction. These may coordinate with placental angiogenic factors to induce the
microangiopathic features of preeclampsia. Lastly, the patient’s age is already
considered advanced and is associated with increased maternal complications.
Another risk for developing preeclampsia despite being in her fourth pregnancy is
due to exposure to a new paternal antigen from her second husband. The patient is
already immunized against preeclampsia from previous exposure to paternal
antigens from prior pregnancy from her first husband.

The presence of a urinary tract infection (UTI) during pregnancy may induce a
systemic inflammatory response posing a risk in the development of preeclampsia.
This is also supported by a systematic review and meta-analysis of observational
studies concluding that urinary tract infection and periodontal diseases increased the
risk of developing preeclampsia.

The patient’s headache, which persists and progresses despite analgesic

therapy, may be explained by the sequelae of endothelial dysfunction in the
vasculature of target organs, such as the brain. This severe headache together with
the patient’s severe blood pressure elevation (160/100), could be considered as
severe features of preeclampsia.

The first differential diagnosis considered in this patient is Eclampsia. This has
similar symptoms with preeclampsia but without the presence of new-onset,
generalized, tonic-clonic seizure or coma. Another differential diagnosis is
gestational hypertension due to the presence of elevated BP (>140mmHg systolic,
>90mmHg diastolic) after 20 weeks of gestation. However, this was ruled out due to
a history of prior preeclampsia, very high BP (160/100mmHg), and severe persistent
throbbing headache which are pointing more to preeclampsia. Pheochromocytoma,
a catecholamine-secreting tumor, was also considered in this patient due to
hypertension and severe headache which appeared during the third trimester. This
was again ruled out because of its rarity and the absence of sweating, palpitations,
tremor, dyspnea, and generalized weakness.

The therapeutic plan of management is based on the findings previously

stated. Seeing as the patient already has a BP of 160/100 accompanied by
headache, this requires hospitalization under a regular ward. The goal is to keep the
SBP between 140-155 mmHg and DBP between 90-105 mmHg with
antihypertensives such as Hydralazine per IV, Labetalol per IV, Nifedipine PO along
with continuous monitoring of the blood pressure. Hydralazine is the drug of choice
and the one available in the Philippines. Magnesium sulfate may also be given to
prevent convulsions but careful consideration because too much may cause
hypermagnesemia. If the patient’s blood pressure cannot be controlled,
corticosteroids may be given to promote fetal lung maturity. Fluid restriction is also
advised at 80 ml/hr. Atenolol, angiotensin-converting-enzyme (ACE) inhibitors,
angiotensin receptor blocking drugs (ARB), and diuretics should be avoided during
pregnancy. Along with these, standard checkups must be followed along with the
intake of vitamins.

Continuous monitoring must be made throughout the entire hospital stay due
to the increased blood pressure with severe symptoms. Vaginal delivery is the still
preferred route of delivery unless indications are stated otherwise. After delivery,
EINC or Essential Intrapartum Newborn Care must be followed, and close monitoring
of the blood pressure upon delivery. Antihypertensive drugs are given if BP exceeds
150 mmHg SBP or 100 mmHg DBP. Furthermore, lifestyle changes need to be
made in order to control hypertension and prevent worsening postpartum. The
recommended diet plan for the patient is the DASH or Dietary Approaches to Stop
Hypertension meal plan which is low in sodium and high in dietary potassium.
Another lifestyle modification to be made is the inclusion of physical activity having at
least 150 minutes of moderate exercise unless contraindicated. Lastly, continuous
intake of antihypertensives must be instructed along with the possible complications
that may arise from hypertension.

Journal

Pregnancy Outcomes in Women with Preeclampsia Superimposed on Chronic

Hypertension with and without Severe Features

The objectives of the study were met, which was to investigate the validity of
the new definition of superimposed preeclampsia by comparing adverse pregnancy
outcomes of those with severe features and without severe features.
The study design and methods were valid, they performed a secondary
analysis of a randomized trial evaluating the use of low dose aspirin for preeclampsia
prevention. It was noted that the aspirin did not influence the risk of preeclampsia in
this study. The number of participants in this study were 774 pregnant women with
chronic hypertension, which may not be sufficient number of data to represent the
whole population. Multivariable logistic regression was created, in order to
determine the association of severe features with the adverse pregnancy outcomes.
The outcome of the study reflect that the adverse pregnancy outcomes
between the two groups were not significantly different, however, it was observed
that those with severe features have higher rates of small for gestational age (SGA).
In our case, the patient was diagnosed with superimposed preeclampsia with
severe features. And with that, we want to determine whether there would be more
severe pregnancy outcomes in our patient since she developed severe features.
With the result of this study, it gives us awareness of the possible pregnancy
outcomes of those with or without severe features and it was observed that the rate
of small for gestational age (SGA) were significantly higher in those with severe
features as compared to those without severe features. In our patient, based on the
fundic height, it was appropriate for the age of gestation, ruling out the possibility of
SGA. After considering all of the factors, in general, we could advise to watch out or
monitor for potential SGA in those with severe features of superimposed
preeclampsia.