Case: Severe Pre-Eclampsia

A) Patient Details:

Name: Londeka Bungane Hospital No. : 860526

Age: 30 years old Address: Pietermaritzburg
Gravidity-Parity: G3P1+1 Date of Admission: 19/04/2017
Gestational Age: 32 Weeks (by dates) Hospital: Grey’s Hospital
Relationship status: Unmarried but in a Occupation: Unemployed
stable relationship.

Date of clerking: 19/04/2017

B) History:
Main Complaint:
Ms Londeka Bungane presented to Grey’s Hospital on 19/04/2017 (Wednesday), after being
referred from Northdale Clinic for severe pre-eclampsia as evidenced by a blood pressure of
168
and 2+ proteinuria found on urine dipstick.
113 mmHg

She presented to Northdale clinic due to experiencing the following symptoms:

 Headache – frontal area; 6 day duration; not relieved by aspirin.

 General body swelling – one day duration.

Systemic Enquiry

Neurological System
 No blurred vision; no seizures.

Respiratory System
 No difficulty breathing.

Cardiovascular System
 No chest pain; no orthorpnoea or paroxysmal nocturnal dyspnea.

Gastro-intestinal System
 No nausea; no vomiting; no abdominal pain.

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Urinary System
 No dysuria; no haematuria; no lower abdominal pain.

Obstetric History
 Maternal age: 30 years old.
 G3P1+1
 Patient had a termination of pregnancy in 2014.
 No previous miscarriage, intrauterine fetal death or ectopic pregnancy.

Past Obstetric History

 1st Pregnancy:
 1998 – Gave birth to a healthy full term baby.
 Normal Vaginal Delivery at Kokstad Hospital.
 No complications.
 2nd Pregnancy:
 2014 – Termination of Pregnancy at 12 weeks because the patient did not know who the
father of the child was.
 No complications.

Current Obstetric History

 Last Normal Menstrual Period: 3 September 2016 (sure of dates).
 Gestational Age: 32 weeks.
 The current pregnancy is unplanned but welcomed.
 Antenatal Care:
 Patient was booked and had her first antenatal visit at the local clinic. She has had 4
antenatal visits prior to admission. Her first booking was at approximately 5 weeks
gestation.

 Booking blood results:

 Rhesus: Positive
 Rapid Plasma Reagin: negative
 HIV Positive – diagnosed in February at 1st antenatal visit; on treatment; unknown
Viral Load and CD4 count.
 Haemoglobin: 10.8 g/dL (reference range 12-15) – Anaemic
 No abnormalities detected on urine dipstick

 Patient was given supplements to take from her first antenatal visit:
 Ferrous Sulphate 200mg, orally daily.
 Calcium Carbonate 500mg, orally daily.

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  Folic Acid, 5mg, orally daily.

 Fetal Movements: patient reports feeling foetal movements at 17 weeks gestation. She
continues to feel foetal movement.

Gynaecological History

Menstruation
 Age of Menarche: 14 years old.
 Menstrual Cycle: Regular cycles lasting 28 days, with menstruation lasting 3-4 days, C4/28.
No abnormal bleeding.
 Menstrual blood: Reports light bleeding; heaviest on the second day. She uses
approximately 3 pads/day.

Pain
 No dysmenorrhoea. No dyspareunia.

Sexual Activity
 Coitarche: 20 years old.
 Since sexual debut she has had 5 sexual partners. She currently has one sexual partner (the
father of her current unborn baby).
 Variable condom use.

Contraception
 Used the injectable contraception for 2 months post-delivery of her son.
 No other history of contraceptive use other than occasional condom use.

Infections
 Previous history of a sexually transmitted infection in 2015 for which she was treated at the
clinic.
 No history of urinary tract infections – no dysuria, no lower abdominal pain.
 She has not had a pap smear before.

Past Medical History

 No history of any known chronic medical conditions (Hypertension; Diabetes Mellitus;
Epilepsy), other than HIV. She is currently on anti-retroviral treatment (fixed dose
combination).
 No past admissions to hospital.
 No known Tuberculosis or previous Tuberculosis infection.
 No known allergies.

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Past Surgical History
 No previous surgeries.

Drug History
 Supplements taken for current pregnancy:
 Ferrous Sulphate 200mg, orally, daily.
 Calcium Carbonate 500mg, orally daily.
 Folic Acid, 5mg, orally, daily.
 Anti-retroviral treatment: Fixed dose combination:
 Tenofovir (TDF)
 Emtricitabine (FTC)
 Efavirenz (EFV).
 No over-the-counter or traditional medication taken.

Social History
 Patient is in a relationship with her current partner for 2 years, but unmarried. Her partner
is 32 years old, unknown HIV status and is unemployed.
 Patient is unemployed and is supported financially by her Aunt and the child support grant
that she receives. Her highest level of education is matric.
 She resides in a 2 bedroom house with her aunt and child in Pietermaritzburg, with access
to all basic amenities.
 Before pregnancy, the patient consumed alcohol (ciders and wine) on weekends. She has
not drank alcohol during her pregnancy. She does not smoke or take any recreational drugs.
 She eats a diet consisting of minimal meat, mostly fruits and vegetables.

Family History
 Positive family history of hypertension in patient’s mother.
 No other family history of chronic diseases.
 No history of pregnancy induced complications.
 No history of congenital abnormalities.

Summary of History
Ms Londeka Bungane is a 30 year old, G3P1+1 at a gestational age of 32 weeks by dates, who
presented to Grey’s Hospital with severe pre-eclampsia. She is HIV positive on treatment, with
other booking bloods normal. She has a family history of hypertension in a first degree relative.

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C) Examination
General Examination
 General appearance – patient is conscious, co-operative and well-orientated. Attached to
her left hand is an IV line and blood pressure cuff. She also has a pulse oximeter on her right
hand. A cardiotocograph was present.

 Vitals:
 Pulse: 85 beats/minute; regular; normal volume (normal).
 Respiratory rate: 18 breaths/min (normal).
 Blood Pressure: 106/73mmHg (normal).
 Saturation: 94% on room air (normal).
 Temperature: 36.6 ⁰C (normal).
 Weight: 71kg
 Height: 1.6m
 BMI = 24.14kg/m2 (normal).
 GCS: 15/15

 Appears well nourished and hydrated.

 Mild periorbital and ankle oedema.
 No signs of jaundice, clubbing, cyanosis, pallor or lymphadenopathy.

Neurological Examination
 Patient orientated to time, place and person. GCS = 15/15
 No signs of meningism.
 Cranial nerves 1-12: intact.
 No abnormalities detected on Motor examination (tone, power, reflexes, no clonus).
 No abnormalities detected on sensory or cerebellar examinations.
 Fundoscope unavailable.

Cardiovascular Examination
 All pulses present and equal bilaterally.
 Jugular venous pressure (JVP) 2cm - normal.
 Inspection: No visible pulsations. No scars. No deformities
 Palpation: Apex beat: 4th intercostal space, anterior axillary line. Character:
normodynamic. No thrills. No parasternal heave. No palpable P2.
 Auscultation: S1 and S2 normal. No added sounds. No murmurs noted.

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Respiratory Examination
 No signs respiratory distress or respiratory failure.
 Inspection: No chest deformities, no scars, symmetrical chest expansion.
 Palpation: Trachea central. Apex beat 4th intercostal space, anterior axillary line. Normal
chest expansion.
 Percussion: Resonant in all lung fields. Normal cardiac and liver dullness.
 Auscultation: Good and equal air entry bilaterally. Normal breath sounds bilaterally. No
additional sounds.

Obstetric/Abdominal Examination
 Inspection:
 Abdomen is gravid
 No scars
 Linea nigra present
 Striae gravidarum present
 Umbilicus is normal
 No visible foetal movements

 Palpation:
 Abdomen non-tender in all nine regions.
 Mass palpable – Uterine pregnancy.
 Symphysis-fundal height – 29cm.
 No contractions were palpable.

 LEOPALDS MANOUVRES

 Fundal content: buttocks (soft and irregular)

 Lie: longitudinal
 Presentation: Cephalic
 Engagement: 5/5 above the pelvic brim
 Attitude: unable to ascertain
 Liquor volume: adequate

 Auscultation:
 Foetal heart present, regular, 140 beats per minute (normal).
 Normal bowel sounds presents

Gynaecological Examination
 Vaginal Examination

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  Inspection: No external abnormalities detected. Appropriate hair distribution, no vaginal
bleeding, no rashes, warts, ulcers, abscesses or excoriations.
 Speculum Examination: Cervix is central. Os is closed, absence of vaginal bleeding, no
discharge.
 Per Vaginal Examination (digital examination): not done as patient refused (As per file:
no cervical changes were noted).

Thyroid Examination
 No visible swellings, scars or abnormalities
 No mass/goitre/ nodules palpated

Breast Examination
 Inspection
 Breasts are symmetrical
 No scars.
 No visible masses, swelling or overlying skin changes.
 No nipple inversion or nipple discharge.

 Palpation
 Regular consistency bilaterally. No masses noted bilaterally.
 No lymphadenopathy palpated (axillary or supraclavicular regions)

D) Differential Diagnosis

1. Late-onset Severe Pre-eclampsia

Factors for: blood pressure criteria (≥ 140 mmHg systolic and/or ≥ 90 mmHg diastolic),
proteinuria 2+, patient symptoms (frontal headache). Presence of the following risk factors:
family history of hypertension
Factors against: No oliguria or renal insufficiency.

2. Imminent Eclampsia
Factors for: increased blood pressure, frontal headache.
Factors against: no epigastric pain, no blurred vision.

3. Gestational Hypertension
Factors for: No differentiating signs of symptoms.
Factors against: Requires absence of proteinuria in urinalysis.
4. Chronic Hypertension
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 Factors for: Blood pressure is ≥ 140 mmHg systolic and/or ≥ 90 mmHg diastolic.
Factors against: No evidence pre-existing hypertension prior to 20 weeks gestational age.

5. Nephrotic Syndrome
Factors for: Periorbital oedema; persistent proteinuria.
Factors against: Patient is not normotensive; no ascites or pleural effusion; no history of any
kidney/glomerular disease.

E) Management
Problem List
1. Severe Pre-eclampsia.
2. HIV Positive: unknown compliance.
3. Family history of hypertension.

Immediate Investigations

Bedside
 Urine dipstick
 Reason: assess for persistent proteinuria.
 Results: persistently 2+

Haematological
 Full Blood Count (FBC):
 Reason: patient has palmar pallor, thus requiring assessment of Haemoglobin, mean cell
volume (MCV), mean corpuscular haemoglobin (MCH) and mean corpuscular
haemoglobin concentration (MCHC) to elucidate the type of anaemia, and hence identify
a possible cause. Also to assess the haematocrit and platelet count (evidence of
haemolysis and thrombocytopaenia)
 Results:

Parameter Day 1 Reference Ranges Comment

Red cell count (RCC) 3.39 3.80 – 4.80 x 1012/L Mildly low
Haemoglobin 9.2 12.0 – 15.0 g/dL Low
Haematocrit 0.285 0.36 – 0.46 L/L Low
MCV 84 78.9 – 98.5 fL Normal
MCH 27.2 26.1 – 33.5 pg Normal
MCHC 32.4 32.7 – 34.9 g/dL Normal

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 Platelet Count 182 186 – 454 x 109/L Mildly low

 Comment: Patient has normocytic normochromic anaemia.

 Urea and Creatinine (U&E):

 Reason: Patient has severe pre-eclampsia, assess for renal insufficiency.
 Results:

Parameter Day 1 Reference Ranges Comment

Sodium 129 136 – 145 mmol/L Low
Potassium 4.5 3.5 – 5.1 mmol/L Normal
Chloride 102 98 – 102 mmol/L Normal
Bicarbonate 21 23 – 29 mmol/L Low
Anion Gap 11 9 – 16 mmol/L Normal
Urea 4.9 2.1 – 7.1 mmol/L Normal
Creatinine 96 49 – 96 µmol/L Normal

 Comment: no evidence of renal insufficiency .Evidence of hyponatraemia.

 Liver Function Test (LFT), Lactate dehydrogenase (LDH):

 Reason: to assess liver enzymes [alanine transaminase (ALT) or aspartate transaminase
(AST)], serum bilirubin and LDH (haemolysis).
 Results:

Parameter Day 1 Reference Ranges Comment

Total bilirubin 33 5 – 21 µmol/L High
ALT 8 7 – 35 U/L Normal
AST 25 13 – 35 U/L Normal
LDH 304 208 – 378 U/L Normal
Total protein 81 60 – 78 g/L High
Albumin 14 35 – 52 g/L Low

 Comment: No evidence of haemolysis or elevated liver enzymes. Presence of

hypoalbuminaemia.

Radiological and Other

 24 Hour Urine Analysis:

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  Reason: more accurate in determining proteinuria. Assess severity of proteinuria.

 Ultrasound:
 Reason: assess foetal compartment (fetal growth and amniotic fluid volume).
 Results: no evidence of intrauterine growth restriction.

 Cardiotocography:
 Reason: assess foetal wellbeing.
 Results: No abnormalities detected.

 Investigations to be done at a later stage:

 CD4 count and Viral Load – monitor adherence and effectiveness of Anti-retroviral
Treatment.
 Pap smear – patient is HIV positive, increased risk, she is 30 years of age – due for a pap
smear. Continue to have pap smears every year.

Principles of Management
 Admit patient. Blood Pressure reduction and control.
 Prevent eclampsia.
 Assess maternal condition.
 Evaluate foetal compartment.
 Control timing and method of delivery.

Acute Management
 Admit patient. Connect to a blood pressure machine. Take blood pressure reading.
 If blood pressure ¿ 160 systolic∨¿ 110 diastolic :Administer Nifedipine 10mg, orally,
stat. Thereafter commence Methyldopa 500mg, orally, 6 hourly. Monitor blood
pressure after 20 minutes and then half hourly until controlled.
140 150
o Goal: Blood pressure of − mmHg.
90 90
 Establish Intravenous access. Insert Foley’s catheter and plot urine output hourly.
 Administer Magnesium Sulphate (MgSO4) loading dose if not administered already.
Zuspen Regimen:
o Loading dose of 4g in 200ml Normal Saline over 15-20 minutes.
o Maintenance dose of 8g in 200ml Normal Saline at 27ml/hour (1g/hour).
o Document the time that Magnesium Sulphate was administered. Stop 24 hours
after the first dose was administered.
 Monitor patient hourly for Magnesium Sulphate toxicity.
o Respiratory rate

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 o Reflexes
o Urine output
o GCS (Glasgow Coma Scale
o If Magnesium Toxicity occurs – STOP Magnesium Sulphate. Administer 10ml of
10% Calcium Gluconate over 10 minutes.
 Conduct investigations (as previously discussed).
 Ensure adequate patient counseling in terms of condition and management.
 Ensure proper documentation of all details pertaining to patient management.

Intermediate Management
 Patient is at 32 weeks gestation (viable pregnancy), therefore delivery of foetus is
indicated.
 Administer corticosteroids:
o 2 doses of Betamethasone 12mg Intramuscularly 12 hours apart.
o Deliver 24 hours after last dose of betamethasone.
 Once patient is stable – induction of labour:
o Perform cardiotocography before administration of Misoprostol and after every
dose.
o Multigravida: commence oral regimen
 Misoprostol 20µg, orally, 2 hourly for 4 doses.

Long-term Management
 6 weeks postpartum: assess blood pressure; if elevated administer antihypertensive
medication (hydrochlorothiazide; amlodipine; enalapril).
 Ensure correct breastfeeding techniques.
 Counsel patient about importance of yearly pap smears.
 Offer contraception if not done antenatally:
o Determine preferred size of family.
o Explain types of contraception available (side effects, benefits, etc.)

F) Follow-up
 20/04/2017
 Patient is stable in the ward. Blood pressure is under control.
 Given corticosteroids – expected to deliver 24 hours after last dose of betamethasone.
 Haematological results within normal range.

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 22/04/2017
 Induction of labour – patient delivered a baby boy weighing 2kg. Baby is well and
healthy.
 Patient is stable. Blood pressure is controlled. Urine output and blood pressure being
monitored in the ward.

G) Reflection
As a 5th year Obstetric student, experiencing obstetrics for the first time at Grey’s Hospital this
case was very informative for me. I found it beneficial to study a case that may affect my family;
friends or even myself in the future. This case not only broadened my knowledge practically but
theoretically as well.

In addition I learnt:
- The approach, history-taking and the examination, to a pregnant woman as well as the
importance of adequate help-seeking behaviour and the mother presenting to the clinic
when she thinks that she is experiencing danger signs.
- The importance of a multidisciplinary team approach in managing all patients to
individualise management and treatment.
- This case also taught me the importance of early and regular antenatal care monitoring in
order to improve both maternal and foetal outcomes. Adequate counselling is mandatory
when it comes to instances like this as the patient requires great support structures to cope
with this illness.

This was a great learning experience and I am grateful to my patient for her wonderful co-
operation and to the ever-helpful doctors and nursing practitioners at the obstetrics and
gynaecology department of Grey’s Hospital.

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H) References

1. HS Cronje, JBF Cilliers, MS Pretorius (Eds). Clinical Obstetrics: A South African

Perspective, fourth edition, Van Schaik Publishers; 2016.

2. National department of health, Republic of South Africa. Guidelines for maternity care in
South Africa, Fourth edition; 2015.

3. Grey’s Hospital Protocol 2016

Kushal Brijnath
213502461

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