Obstetric Patient with Concerns for Weight Gain and Hypertensive States in Pregnancy
A 30-year-old gravid 6 para 4 patient at 36 weeks and 5 days presents with weight gain, headaches, epigastric discomfort, nausea, and swelling. Symptoms started a week ago, with notable pitting edema in hands and feet, blurry vision, and epigastric pain. Past medical history includes chronic hypertension, migraines, GERD, and previous heroin use. Physical exam shows mild epigastric tenderness, non-pitting edema, and a papular rash. Differential diagnosis includes preeclampsia given the hypertensive state and symptoms.
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OB/GYN CHAIR ROUNDS MENGZHI WU
HPI Patient is 30 yo old G6P4013 at 36+5 is here in clinic with concerns for weight gain, intermittent headaches/epigastric discomfort, nausea and increased swelling.
MORE HISTORY Symptoms started together approximately 1 week ago and per patient has gained approximately 15 pounds. The swelling is pitting is localized to mostly to her hands and feet and has been having trouble closing her hands The headaches are bilateral and tension like in character and are different than her baseline chronic migraines which have been in control on her home fioricet She notes that she has been having blurry vision and spots with these headaches She notes worsening epigastric pain particularly after eating and while laying flat There have been some infrequent contractions but denies VB, LOF, and good fetal movements.
PMH/SH/FH PMH: Chronic HTN not treated on any medications Migraines on Fioricet GERD on Pepcide Hep C (Viral load <1.08 a few months ago) Hx of Herion use (not in last 3 years) Benign previous obstetrics history SH: Lives at home with her children Current pack a day smoker down from 1 pack prior to pregnancy. Denies Alcohol/Recreational drugs FH: Nothing of note
OBJECTIVE Vitals: Afebrile. Initial BP 153/85; repeat 146/80. PE: Consistent with history NAD Lungs - CTAB Heart - RRR Abdomen - Gravid, soft, NT, mild epigastric tenderness to palpation, no RUQ tenderness Ext - warm, NT, tr edema bilaterally, non-pitting. Some non-pitting UE edema, erythematous papular rash on bilateral hands Neuro - 2+ DTR in bilateral upper and lower extremities Pelvic exam: Cervix: 2/50/-2
HYPERTENSIVE STATES OF PREGNANCY Gestational Hypertension Preeclampsia Severe preeclampsia Chronic Hypertension Chronic Hypertension w/superimposed pre-clampsia HELLP syndrome AFLP
PREECLAMPSIA- HTN, PROTEINURIA Generalized arteriolar constriction and intravascular deplention Diagnosis: BP, Proteinuria, Symptoms Mild preeclampsia: BP SBP >140 or DBP >60 and Proteinuria >300 mg/24 hr or >1 to 2 plus on dipstick Severe preeclampsia: BP plus systemic issues Neuro: SEVERE headache not relieved by acetaminophen, visual changes, scotomata Pulmonary edema Renal: Acute renal failure with rising creatinine; Oliguria < 400 ml/24 hr or <30mL/hr; 24hr Protein >5gm or 3+ on dipstick GI: RUQ pain, elevation of AST/ALT Heme: Hemolytic Anemia, Thrombocytopenia DIC Fetal: IUGR, abnormal umbilical dopplers Eclampsia: Seizures HEELP: Hemolysis, elevated liver enzymes, and low platelets (schitocytes, elevated LDH, elevated Total Bilirubin)
COMPLICATIONS Maternal: Seizure, Cerebral hemorrhage, DIC and thrombocytopenia, Renal Failure, Hepatic failure or rupture, Pulmonary edema, Uteroplacental insufficiency, Placental abruption, Prematurity and C section Fetal Complications: Acute uteroplacental insufficiency: Placental infarct and/or abruption Intrapartum fetal distress Stillbirth Chronic uteroplacental insufficiency Asymmetric and symmetric SGA fetuses IUGR Oligohydramnios
RISK FACTORS Disease related: Chronic Hypertension Chronic Renal Disease Collage vasvcular Disease (SLE) Diabetes African American Maternal age (<20 or >35) Immunogenic Related: Nulliparity Previous preeclampsia Multiple gestation Abnormal Placentation New paternity or cohabitation less than 1 year
LABS/IMAGING Sent Patient to Triage to rule out SI pre E. Normotensive in Triage (138/79) CBC WNL Creatinine: 0.52 Spot Urine: negative for protein Started 24 hr Urine Collection undetectable proteins MRI: normal Utox positive for Barbituates (fioricet- Acetaminophen / Butalbital / Caffeine) Ultrasound: Vertex Anterior placenta, appears to have hyperechoic areas that appear calcification-like AFI 8.2 FHT: 115 bpm, moderate variability, + accels, no decels Toco: quiet
A/P G6P4102 at 36+6 weeks with intractable headache, CHTN, Hep C concerning for atypical SI pre E with severe features (no objective evidence- normal labs 24 hr urine benign, MRI normal) Betamethasone given at 36+5 Induction of Labor at midnight 37 weeks for atypical SI preE with severe features 24hr Magnesium
