Puan Rahayu, a 32-year-old housewife at 34 weeks and 5 days of gestation, was admitted to the hospital due to giddiness, headache, and bilateral leg swelling for 1 day. She has a history of gestational hypertension and was diagnosed with pregnancy induced hypertension. On examination, her blood pressure was normal and she had mild pitting edema. Laboratory tests showed mild anemia. She was admitted for blood pressure monitoring and fetal heart monitoring to determine an appropriate management plan.

1. Hypertensive
InPregnancy
Disorders

2. Case Scenario

3. PatientProfile
RahayubintiAman
Name:
Age:
Occupation:
Period of Gestation:
Parity Index:
LMP:
EDD:
Date of Admission:
Clerk on:
Rahayu binti Aman
32 y/o
Housewife
34 weeks 5 days
G3 P1+1
28th October 2015
4th August2016
28th June 2016
29th June 2016

4. ChiefComplaint
1
Giddiness for 1 day
(2-3 hours)

5. History of PresentingIllness
The patient was apparently well until one day ago when she experienced giddiness
sensation after she awoke for ‘sahur’; around 4.30am. It was sudden in onset &
worsening in nature. She complaint that she only slept 2-3 hours prior to the onset
of the headache & was not associated with head or body position changes.
Both her leg swells up to both ankle & leaves a dent in the skin after she press the
area with a finger.
She also complaint of having a mild headache. Frontal headache. Sudden onset and
continuous in nature. Not related posturally.
Subsequently she was brought to A&E by her husband for further evaluation. BP was
taken and the reading was 169/94mmHg. In here, she was given tablet medication,
ECG, CTG, blood & urine sample was done but was uneventful. She was then
admitted.
She is not diabetic. Other than that, there’s no previous history of viral illness, no
fever, blurry of vision, no syncope, no abdominal pain, no nausea, no vomiting. No
decrease in urine output. No bleeding per vaginal, no any other fluid discharge.

6. SystemicReview
Respiratory Symptoms
• No cough,
• No SOB,
• no wheezing,
• no hemoptysis
Cardiovascular Symptoms
• Bilateral pitting edema
• No breathlessness
• No PND
• No Chest Pain
ENT
• No blurring of vision
• No ear discharge
• No tinnitus
• No ear pain
CNS symptoms
• No faints
• No history of seizure
• No muscle/limbs weakness
Gastrointestinal Symptoms
• No loss of appetite
• No bowel and bladder symptoms
Genitourinary Symptoms
• No frothy urine
• Normal urine color

7. History of PresentPregnancy
• Quickeningfelt at 20weeks
• BP monitoring was done twice a week
• MGTT was done during 4th and 7th months
• Her Hb level was normal
• Tetanus injection has been given at 20+ weeks
1st Trimester
2nd Trimester
• This is unplanned pregnancy. She noticed it when she missed her period for one cycle and proceed
with urinepregnancytest. Thepregnancythenwas confirmed at KlinikPeringgit.
• Booking visit was also done at Peringgit. Routineurineand USGwas done and was uneventful.
• No fever, Noexcessive vomiting, no discharge PV.
• Was told that herEDD will be in 4th of August 2016
3rd Trimester
• She nevermisses herantenatal check-ups
• Growth scans appears to be normal.No anyother active complaints
• Fetal movements was satisfactory according to mother.
• She only starts herObimin supplement at 31weeks (Hb: 10.5)

8. Past Obstetric History
First Pregnancy
Second Pregnancy
• 1st pregnancy 2010
• Term delivery, SVD
• ♀
• 2.5kg
• Breastfed lasted only for onemonth. Nomilk produced from mother.Switched to formulated milk.
• Now 5y/o, asthmatic, otherwise normal.
• 2nd pregnancy 2013
• 8weeks of gestation  missed abortion
• No active symptoms, no pain, no bleeding PV.
• D&Cwas done in Hospital Melaka.
• Admitted because of DengueFever.

9. MenstrualHistory
• She attained her menarche at 11 years old
• Menstrual cycle
• 30 days duration with 7 days of bleeding
• Regular
• Normal amount of flow
• No blood clot
• No dysmenorrhea
• No history of contraceptive usage
• PAP smear: done once after her first pregnancy (2012)
• Result was normal

10. Past Medicaland SurgicalHistory
During first pregnancy, she wasadmitted for one day due to high BP. Otherthan that, she is not
diabetic,noheartdisease,thyroidproblems,epilepsy,TB
Diagnosedashypertensivesince2011
• On T.Methyldopa250mgTDS.Compliancetohermedication.
• On T.Aspirin 25mgOD
Noprevious surgerydone(e.g: C-sec.appendicectomy,ovariotomy,etc)
Nohistoryof allergytodrugsandfoods

11. SUCCESS• •• •
FamilyHistory
Her husband is a 33y/o guy, works as a clerk in a national sewerage company. Their first child,
suffered from bronchial asthma but under medications. Her late father (‘98) got DM and her
latemother(‘15)gotHPT,diedfromstroke.
Other than that, there is no history of premature menopause, menorrhagia, dysmenorrhea,
thyroiddisorderorovariancancer.
Noconsanguinity.Twins:Cousin

12. Personal History
• Marriedfor9 years.Sheis ahousewife.Currentlystayingwith
her husbandandchild.
• Sheatebalanceddiet.No decreasein appetite.No significant
weight loss.
• Noprevioussleep disturbances
• Family wageis enough tosupportwholefamily
• Economicallystable
• Notasmoker,non-alcoholic

13. Summary
Puan Rahayu, 32 years old, G3P1+1, currently 34 weeks
and 5 days was admitted on 28th June 2016 due to
giddiness for 1 days, also comes with headache and
bilateral leg swelling. Other than that, no other impending
eclampsia symptoms History of miscarriage on 2nd
pregnancy in 2014. diagnosed with Pregnancy Induced
Hypertansion (PIH). She is admitted for further
investigation and monitoring. She is now under evaluation
for appropriate management plan. Her blood pressure
currently normalize.

14. Provisional Diagnosis
• Pregnancy Induced Hypertension

15. Examinations

16. General Examinations
• Patient is conscious, coherent and lying comfortably in supine
position. She is cooperative. Moderately built and moderately
nourished. Her weight currently is 83.3kg and height is 153.3
(BMI :36.87kg/m2)
• Nopalloroverthenail bed.
• Nopalloroverlowerpalpebralconjunctiva
• Goodoralhygiene, tongueismoist andpink
• Noobviousthyroidorcervical lymphnodeswelling
• Not consented for breast examination to look for cracked
nipples,dischargeormass.
• Thereisslight pittingedema uptoankleofbothlegs.

17. General Examinations
VITALSIGNS
• Pulse : 92bpm regular rhythm, normal volume, no vessel wall
thickening.
• Blood pressure : 116/76 mmHg over right arm on lying
position.
• Respiratory rate: 20breathsperminute.
• Temperature: 37°C

18. Obstetric Examinations
INSPECTION
• The abdomen is uniformly distended. The flanks are full.
Linea gravidarum and linea nigra are not seen. The umbilicus
is inverted and centrally located. There is no scar or dilated
veins. Fetal movement is visible. Hernia orifices is intact.
PALPATION
• The clinical fundal height is 34 weeks and SFH is 36cm. The
fundal grip is soft, broad and non-ballotable suggestive of
buttocks. Right maternal grip, small-knob like structures
suggestive of foetal limbs. Left maternal grip, smooth curve
structure suggestive of foetal back. The pelvic grip was
foetal head. The head is 5/5th palpable.
AUSCULTATION
• Fetal heart sound was not auscultable.
CONCLUSION: It is a singleton live pregnancy with longitudinal
lie, incephalic presentation, with head 5/5th palpable.

19. Systemic Examinations
CARDIOVASCULAR SYSTEM
 S1 and S2 heard. Soft systolic murmur audible. Best heard at
mitral area.
RESPIRATORY SYSTEM
 Bilateral vesicular breath sounds heard equally on both
lungs. No adventitious sounds.

20. Investigations
Coagulation Profile (28.6.2016)
PT (ACL TOP 500)
• PT Test 10.7sec (9.3 – 11.5)
• PT Control 11.2sec
• P.R. 1.03
• I.N.R 1.03
APTT (ALC TOP 500)
• APTT Test 27.5sec – Low (26.5 – 35.9)
• APTT Control 31.5sec
• APTT Ratio 0.88

21. SUCCESS• •• • ThispresentationwascreatedbyJohnDoe •
Investigations
Full Blood Count (28.6.2016)
• Haemoglobin 113 g/L (120 - 150)
• RBC 3.92 x10 12/L
• HCT 34.7% (36 – 46)
• MCV 75 fL
• MCH 28.8 pg
• MCHC 32.6 g/dL
• RDW-ED 42.3 fL
• RDW-CV 13.2 %
• Platelets 398 x109/L
• WBC 13.2 x109/L (4 – 10)
• Lymphocytes#1.5 x103/L
• Neutrophils # 10.7 x103/uL (2 – 7)
• Monocytes # 0.7 x103/L
• Eosinophils # 0.3 x103/L
• Basophils # 0.0 x103/uL (0 – 1)
• Lymphocytes%11.5% (20 – 40)
• Neutrophils %80.7% (40 – 80)
• Monocytes % 5.6%
• Eosinophils % 1.9%
• Basophils % 0.3%

22. SUCCESS• •• • ThispresentationwascreatedbyJohnDoe •
Investigations
CTG
Date:28/06/16
Time:0743h
• All parameters are normal

23. SUCCESS• •• • ThispresentationwascreatedbyJohnDoe •
Investigations
Iron/TIBC (28.6.2016)
• Iron (serum) 10.3 µmol/L (6.6 – 26µmol/L)
• TIBC 70.2 µmol/L (41 – 77 µmol/L)
• ECG: Sinus rhythm. No ischemic changes
• Blood Grouping and Cross Matching : Blood Group B+
• Pending for Urine Investigation, LFT and RFT.

24. Management Plan
1) Admit patient for BP monitoring ½ hourly for an hour
2) If turns out normal repeat 2 hourly for 2 times  4 hourly if
still normal
3) Full blood count and recheck haemoglobin level.
4) Continue T. Methyldopa 250mg TDS & T. Aspirin 75mg OD till
36 weeks
5) Daptone (fetal heart monitoring) 4 hourly.

26. Thanks for Listening