Preeclampsia

1. CASE 2: SEVERE PRE-ECLAMPSIA WITH UNFAVOURABLE CERVIX;
STABILISATION AND EMERGENCY CAESAREAN SECTION
NAME: Mrs. E.O.P
HOSPITAL NUMBER: 263082
AGE: 23 Years
OCCUPATION: Housewife
ETHNICITY: Igbo
RELIGION: Christianity (Roman Catholic)
HIGHEST EDUCATIONAL LEVEL: Senior School Certificate
PARITY: G1P0 A0
LAST MENSTRUAL PERIOD: 15/11/2020
EXPECTED DATE OF DELIVERY: 22/08/2021
DATE OF PRESENTATION/ADMISSION: 13/07/2021
DATE OF DELIVERY: 13/07/2021
DATE OF DISCHARGE: 18/07/2021
BOOKING STATUS: Unbooked

2. PRESENTING COMPLAINT
She was referred from a peripheral hospital on account of elevated blood pressure
of 210/120mmHg and headache of 3days duration at a gestational age of 34 weeks
and 2 days.
HISTORY OF PRESENTING COMPLAINTS:
She was apparently well until three day prior to presentation when she noticed she
had headache, which was generalized and was progressively increasing in
intensity. It was not relieved by paracetamol. There was no associated fever,
nausea or vomiting. She had blurring of vision, which was also becoming worse.
She had ankle and periorbital swelling, which increased rapidly. There was no
epigastric pain, convulsion or reduced urinary volume. There was no history of
labour pains or drainage of liquor. She felt fetal kicks. Due to worsening of
symptoms, she was taken to a peripheral hospital, where her blood pressure was
noted to be markedly elevated (210/120mmHg) and protein(++) was seen in her
urine. She was placed on tablet methyl-dopa 500 miligram thrice daily, nifedipine
tablet 20 miligram daily and given a shot of im dexamethasone 12mg, before she
was referred to the NAUTH for expert care.
HISTORY OF PRESENT PREGNANCY
Pregnancy was desired and spontaneously achieved. She enjoyed the supportof her
husband. She booked for antenatal care at the referral hospital at about 22 weeks
gestation. She could not remember her booking parameters though she was told the
blood pressure was normal. Her blood group is O Rhesus D positive with a

3. hemoglobin genotype of AA. She could not remember results of other booking
investigations but was told that they were all normal. She received 2 doses each of
tetanus toxoid and intermittent prophylactic therapy for malaria at unknown
gestational ages and she had not been compliant with her antenatal visits and
medications. She was noted to have raised blood pressure in index pregnancy at
about 30 weeks gestation.
PAST OBSTETRIC HISTORY:
She was a primigravida
PAST GYNAECOLOGICAL HISTORY
She attained menarche at the age of 13years and has a four day menstrual flow in a
28 day regular menstrual cycle. There was no history of dysmenorrhea,
dyspareunia, dysuria or abnormal vaginal discharge. She was aware of
contraception and her husband used male condoms. She was not aware of
Papanicolaou test and breast self-examination. There was no history of female
genital mutilation or sexual assault.
PAST MEDICAL AND SURGICAL HISTORY
She was not a known hypertensive or diabetic patient.
There was no history of surgery or blood transfusion in the past.

4. DRUG HISTORY
There was no history of drug allergy.
FAMILY AND SOCIAL HISTORY
She is married in a monogamous family setting to a 32 year old trader with
secondary level of education. There was no family history of hypertension,
diabetes mellitus, or twinning. She does not take alchohol or tobacco in any form.
REVIEW OF SYSTEMS
Non contributory.
PHYSICAL EXAMINATION
She was a young woman. She was afebrile, anicteric, not pale, not dehydrated and
had bilateral pitting leg oedema up to the knee.
BREAST AND NECK EXAMINATION
There was no neck mass.
Both Breasts were normal.
RESPIRATORY SYSTEM

5. The respiratory rate was 22 cycles per minute. The chest was clinically normal.
CARDIOVASCULAR SYSTEM
Her pulse rate was 88 beats per minute, full volume and regular. The blood
pressure was 210/130mmHg. The heart sounds I and II only were heard.
ABDOMEN
The abdomen was uniformly enlarged and moved with respiration. There were no
areas of tenderness. The liver and spleen were not palpably enlarged and the
kidneys were not ballotable. The symphysio-fundal height was 33cm which was
compatible with the gestational age of 34 weeks. The uterus harboured a
singleton fetus in longitudinal lie, cephalic presentation and a descent of five fifth.
The fetal heart rate was 140 beats per minute and regular.
VAGINAL EXAMINATION
She had normal vulva and vagina. The cervix was firm, posterior and uneffaced.
The cervical os was closed and station was 0-3.
The Bishops score was 0/13.
Bedside Urinalysis done revealed proteinuria (+++) but negative for glucose.

6. DIAGNOSIS
Pre-eclampsia with severe features in an unbooked primigravida with unfavourable
cervix at 34 weeks gestation.
MANAGEMENT:
She was counseled on the diagnosis and management option.
She was admitted into the labour ward.
Intravenous access was secured and specimens were collected for investigations;
Packed cell volume was 40%. Retroviral screening was negative. Serum
electrolytes, urea, creatinine and uric acid as well as liver function test result were
within normal ranges. Clotting profile and platelet count were within normal
ranges.
A urinary catheter was passed and retained to monitor urine output.
She was commenced on Seizure prophylaxis with magnesium sulphate using
Pritchard’s regimen of Intravenous MgS04 4g in 20% strength slowly over 15
minutes and Intramuscular 5g in each buttock as loading dose, then Intramuscular
5g in alternate buttocks every 4 hours for 24 hours after delivery.
The deep tendon reflexes, respiratory rate and urine output were monitored and
remained normal.
She was placed on intermittent Intravenous hydrallazine 5 mg over 5 minutes
every 30 minutes until diastolic blood pressure is below 110mmHg.
She was given a dose of intramuscular dexamethasone 12mg.
Strict input-output chart was kept and aim to give 2 litres of Ringer’s lactate over
24 hours and she achieved optimal urine output of at least 30mls per hour.

7. About 4 hours later, she was adjudged to have been stabilized as her blood pressure
was 150/100mmHg.
Informed and written consent was obtained for an emergency caesarean section
being expedient means on account of severe preeclampsia with unfavorable cervix.
Two units of blood were cross-matched.
The neonatologist, anaesthetist and theatre nurses were informed.
She subsequently had an emergency lower segment ceasarean section.
OPERATION (13/07/2021; 8:10pm)
Caesarean section
ANAESTHESIA
Spinal anaesthesia.
INTRA-OPERATIVE FINDINGS
Clean peritoneal cavity.
Formed lower uterine segment.
Clear liquor amnii
Live female baby with Apgar scores of 7 at 1 minute and 9 at 5 minutes and
a birth weight of 2.1kg.

8. The placenta was complete and weighed 0.4kg
Normal looking fallopian tubes and ovaries.
Estimated blood loss was 400mls.
PROCEDURE FOR THE SURGERY
Patient was placed in supine position with left lateral tilt after spinal anaesthesia
was given. Routine sterile cleaning and draping was done. A Pfannenstiel incision
was made on the skin. This was deepened into the subcutaneous fascia. The rectus
sheet was incised and the rectus muscles separated digitally at the midline. The
parietal peritoneum was picked up at two points by two artery forceps, rubbed to
exclude intestines and subsequently incised to gain entrance into the peritoneal
cavity. Dextro-rotation of the uterus was checked for and corrected. The bladder
was retracted downwards with the self-retaining Doyen’s retractor. On the lower
uterine segment, the loose utero-vesical peritoneal reflection was then picked with
a pair of non-toothed dissecting forceps and incised. McIndoe’s scissors was
inserted under the reflection and the incision extended laterally on both sides. The
Doyen’s retractor was re-applied to retract the peritoneum and bladder away from
the operation field. A curve-linear incision was made on the exposed lower
segment of the uterus until it was adequate to take the delivery. The membranes
were ruptured and the baby was delivered cephalad. The umbilical cord was cut in
between clamps. The baby was subsequently handed over to the neonatologist.
Intravenous oxytocin 10IU was given after the delivery of the baby. The placenta
and fetal membranes were delivered by cord traction. The baby was transferred to
the special care baby unit for evaluation.

9. The uterus was exteriorized and hemostasis was secured by the use of Green–
armytage applied to the angles and bleeding edges of the uterine incision. The
uterus was closed in 2 layers with vicryl 2 suture. The first layer was interlocked
and continuous to achieve hemostasis, while the second layer was closed
continuous, non-interlocking, burying the first layer and maintaining hemostasis.
The visceral peritoneum was sutured with vicryl size ‘2/0’. The mops and Doyen’s
retractor were removed and counted by the scrub nurse. The rectus sheath was
closed with nylon ‘2’. The subcutaneous layer was closed with vicryl ‘2/0’. The
skin was closed in a subcuticular fashion with vicry ‘2/0’. The wound was cleaned
and a dry sterile dressing was applied over the wound. The vagina was evacuated
of blood clots.
IMMEDIATE POST-OPERATIVE MANAGEMENT
Her vital signs were monitored every 15 minutes until it became stable except for
her blood pressure which was140/100mmhg, then every 30 minutes for another
four hours, thereafter they were done 4 hourly.
She was maintained on nil per os until reviewed further.
Pain relief was achieved with intramuscular pentazocine 30mg 6 hrly for 48 hours
and rectal diclofenac suppository 100 mg daily for 72hours.
Intravenous ceftriaxone 1g daily was given for 48 hours.
She also received intravenous metronidazole 500 mg 8 hourly for 48 hours.
Fluid maintenance was achieved with 1 litre of 5% Dextrose water alternated with
1litre of normal saline 8 hourly for 48 hours.
Seizure prophylaxis with magnesium sulphate according to pritchards regimen was
continued for 24 hours after delivery.
Strict input-output chart was kept which showed adequate urine output.

10. Intermittent intravenous hydrallazine therapy was continued, given as 5 mg every
30 minutes if the diastolic blood pressure rises up to 110mmHg.
Daily bedside urinalysis was done.
FIRST POST-OPERATION DAY (14-07-2021)
She complained of pain at the operation site. Her bedside urinalysis showed
proteinuria of 2(++) her blood pressure was 140/100 mmHg. The urine output was
1100mls. The urethral catheter was removed after completing the MgSO4. Vulva
pad showed normal lochia discharge.. Bowel sounds were normoactive and she
was commenced on graded oral sip which was well tolerated. The baby was
doing well and was discharged from special care baby unit.
SECOND POST-OPERATION DAY (15-07-2021)
She had no complaints. Her bedside urinalysis showed protenuria of 1(+) while
post operation PCV was 33%. Her blood pressure was 140/90 mmHg.
She was also commenced on oral medications viz: Tabs cefuroxime 500 mg 12
hourly for 5 days, Tabs Metronidazole 400mg 8hourly for 5 days, Tabs α-
methyldopa 500mg 8 hourly for 5days, Tab Paracetamol 1g 8hourly for 3 days,
Tabs Vitamin C 100mg tds for 14 days, Tabs Fersolate 200mg tds for 14 days,
Tabs folic acid 4mg daily for 14 days.
She had a good post operative recovery with no post operative complications. The
subsequent post operative days were uneventful.

11. DISCHARGE (20-07-2021)
She was discharged on the 7th day after surgery when the blood pressure was
140/80mmHg and urinalysis showed no trace of proteinuria. She was discharged
on tablets α- methyldopa 250mg 8 hourly and hematinics for 2 weeks. She was
scheduled for one week postnatal clinic visit.
1st
POSTNATAL VISIT (27-07-2021)
She was seen one week after discharge. She had no complaints. Her blood pressure
was 120/80 mmHg and urinalysis showed no proteinuria. The abdominal wound
had good healing and uterus was about 12 week size. Baby had no problems,
weight 3.2 kg and had received the first doses of immunization according to the
national progrmme on immunization schedule. She was counseled again on the
need for exclusive breast feeding, immunization and family planning. The
antihypertensive was stopped but the haematinics were continued for the next 4
weeks.
SIX WEEKS POST NATALVISIT (24-08-2021):
She had no complaints. Her menses was yet to resume. Her blood pressure was
110/70mmHg and urinalysis done showed no proteinuria. The abdominal wound
had healed by primary intention and the uterus was not palpable per abdomen. The
baby weighed 5kg and was adequately immunized for age. She was encouraged

12. and counselled to continue on exclusive breastfeeding, immunization. She was
discharged to the family planning clinic.