Mrs. Guddan, a 34-year-old patient with a history of gestational diabetes and pre-eclampsia, was admitted at 36 weeks and 5 days for monitoring and early termination of pregnancy. Induction was performed at 37 weeks and 2 days due to complications, including hypertension and seizures, leading to an emergency cesarean section and the birth of a healthy male infant. Post-operative care included monitoring in ICU and management of maternal hypertension and diabetes-related concerns.

1. PREGNANCY INDUCED
HYPERTENSION

2. PATIENT PARTICULARS
• NAME : Mrs Guddan
• AGE : 34 yrs
• HUSBAND'S NAME : Hav Nawab Ali
• ADDRESS : Village- Gheja, Uttar Pradesh
• DATE OF ADMISSION : 02/11/2019
• LMP : 19/02/2019
• EDD : 26/11/2019
• OBSTETRIC SCORE : G3P2L2
• GESTATIONAL SCORE : 36 Weeks 05 Days
• DIAGNOSIS : ANC With Pre-eclampsia with GDM

3. PRESENTING COMPLAINTS
• Mrs Guddan, a 34 yr old multigravida, known case
of GDM and pre-eclampsia was admitted at 36
weeks 05 days period of gestation for safe
confinement and early termination of pregnancy with
induction of labour planned after completion of 37
weeks period of gestation

4. PRESENT HISTORY OF ILLNESS
• Known case of GDM and pre-eclampsia, was started of OHA's and insulin therapy
and oral antihypertensives at 31 weeks POG
• Mrs Guddan got admitted to maternity ward on 02/11/2019 for safe confinement and
BP monitoring and early termination of pregnancy after completion of 37 weeks
POG
• Blood sugar and BP monitored throughout her stay- within normal limit
• Induction done at 37 weeks 02 days POG with cerviprime on 07/11/2019 .

5. PAST MEDICAL/SURGICAL HISTORY OF
ILLNESS
• No known significant medical history
• Fracture humerus(left) operated in 2016
FAMILY HISTORY OF ILLNESS
• No significant medical or surgical history of illness

6. PERSONAL HISTORY
• NUTRITION
 Dietary Habits : Non Vegetarian
 Meal Pattern : 3 meal pattern
 Smoking : Non Smoker
 Alcohol : Non Alcoholic
• HYGIENE
Patient performs all activities of daily living herself and
was well groomed

7. PERSONAL HISTORY
• SLEEPING PATTERN
Normal sleeping pattern, slept 1-2 hours in the afternoon and around 6-7
hours at night everyday
• ELIMINATION
No history of constipation. No history of urinary retention or incontinence

8. PERSONAL HISTORY
• ALLERGIC REACTION
No known history of any allergic reactions
• CONTRACEPTIVE HISTORY
No contraceptives used post marriage

9. MENSTRUAL HISTORY
• Menarche : 15 years
• Cycle : 28-30 days/ 4-5 days and regular
• LMP :19/02/2019
• EDD :26/11/2019
MARITAL HISTORY
• Patient married at the age of 19 years
• Married since past 12 years
• Had a non consanguineous marriage

10. OBSTETRIC HISTORY
• PAST OBSTETRIC HISTORY
• PRESENT OBSTETRIC HISTORY
1. 1st TRIMISTER
 Booked case, her first visit at MH Jalandhar was on 13/06/19 at 16 wks 04
days POG
 Vomiting and nausea present during first trimester
SL NO YEAR CONCEPTION PREGANCY OUTCOME PUERPARIUM DETAILS OF
CHILD
1. 2011 Spontaneous Normal Vaginal Delivery Uneventful Male
3.5kg
2. 2012 Spontaneous Normal Vaginal Delivery Uneventful Female
3.5kg
3. 2019 Spontaneous Present Pregnancy

11. OBSTETRIC HISTORY
2. 2nd TRIMESTER
 Quickening felt at 19 weeks POG
 Two doses of Inj TT taken
3. 3rd TRIMESTER: Presence of GDM and PIH detected
 30 weeks: Derranged blood sugar level, started on OHAs
 31 weeks 02 days: Had raised Blood pressure, admitted for BP and Blood
sugar monitoring to Maternity ward. Started on antihypertensives
 35 weeks : Started on Lispro and Glargin and added Tab Labetatol, due
to persisteantly raised Blood sugars and BP

12. PHYSICAL EXAMINATION
 VITAL SIGNS:
 Temp : 98.4F
 Pulse : 90/min
 Respiration : 22/min
 BP : 144/90 mmHg
 Nutritional status : Good
 Build : Average
 Height : 164cm
 Weight : 68kg
 BMI : 26.5 kg/m2

13. CONTINUED
 Pallor : Not present
 Icterus : Not present
 Breast : Enlarged in size, primary and secondary areola
present, montgomery tubercles prominent, no colostrum seen
 Thyroid : Not enlarged
 Pedal edema : Present
 Varicose vein : Not present
 Heart, liver & spleen: NAD
 Lungs : No signs of breathlessness, normal lung sounds

14. ABDOMINAL EXAMINATION
 INSPECTION
• Size : Appropriate for period of gestation
• Shape : Ovoid
• Contour : Even
• Fetal movements : Visible fetal movements
• Skin : Linea niagra and straie gravidarum
present
• Umbilicus : Slightly protruded

15. CONTINUED
 PALPATION
• Lie : Longitudinal
• Presentation : Cephalic
• Position : LOA
• Engagement : Not Engaged
• Abdominal Girth : 88 cm
• Fundal Height : 36 cm
 AUSCULTATION
• FSH : 144/min

16. INVESTIGATIONS
SL NO INVESTIGATIONS PATEINT VALUE NORMAL VALUE REMARKS
1. Hb 11.2 12-16 mg/dl Normal
2. TLC 7600 4000-11000 cumm Normal
3. PLATELET 1,53,000 1.5-3 lakh/cumm Normal
4. S.Bil 0.3 0.1-1 mg/dl Normal
5. SGOT 25 upto 40 Normal
6. SGPT Kit NA upto 40 -
7. Urea 22 10-50 mg/dl Normal
8. Creatinine Kit NA 0.5- 1.4 mg/dl -
9. Uric acid 5.4 <4.5 mg/dl >4.5 indicative of pre-
eclampsia
10. 24 Hours urine protein 325 <300mg Proteinurea
11. PBS for hemolysis NAD No hemolysis Normal
12. LDH 552 200-400 s/o hemolysis
13. Urine for ketones Negative Negative Normal

17. INVESIGATIONS
SUGAR PROFILE 21/09/19 23/09/19 22/10/19 31/10/19
FASTING
PP
BL
AL
BD
AD
3AM
HBA1C
99mg/dl
115mg/dl
93mg/dl
126mg/dl
156mg/dl
142mg/dl
-
8% (4.5-6.3%)
120mg/dl
111mg/dl
148mg/dl
132mg/dl
143mg/dl
166mg/dl
-
112mg/dl
155mg/dl
93mg/dl
103mg/dl
116mg/dl
158mg/dl
-
90mg/dl
100mg/dl
88mg/dl
104mg/dl
110mg/dl
102mg/dl
95mg/dl
USG at 31 weeks: Gravid uterus showing single live fetus,
Adequate amniotic flow
Placenta posterior, away from the internal os
Normal flow in umbilical artery and maternal uterine arteries

18. TREATMENT
SNO3. NAME OF DRUG DOSE FREQUENCY TIME
1. TAB METFORMIN 1g BD 7-7
2. TAB LABETALOL 100mg TDS 10-2-10
3. TAB ECOSPRIN 75mg OD 2pm
4. TAB CALCIUM 1 BD 10-10
5. TAB AUTRIN 1 OD 10am
6. INJ LISPRO 6U-6U-6U TDS With meals
7. INJ GLARGIN 6U HS 10pm

19. INTRAPARTUM MANAGEMENT
• Induction done at 37 weeks 02 days POG with cerviprime on 07/11/2019
cervix- 2cm, Effacement- 20% Head station- -3 , Membranes intact
• Augmented labor with ARM and inj pitocin infusion
• Sugar and BP monitored throughout the period of labour
• Patient gave complaint of uneasiness, BP recorded 150/98mmHg
• At 1730 hours patient had an episode of seizures (GTCS), Inj MgSO4 4g IV stat
administered over 3-5 min and infusion started @1g/hr and oxygen supplemented
via nasal prongs and shifted to OT for emergency LSCS

20. POST OPERATIVE MANAGEMENT
• Extracted a healthy alive baby
 TOB- 1836 HOURS
 DOB- 07/11/2019
 SEX - Male
 B.wt - 3kg
• Observed closely at ICU for 24 hours, continued on MgSO4 infusion
• Monitored hourly- BP, knee jerk, respiration and urine output
• Started on IV antibiotics
• Shifted to maternity ward after 24 hours

21. PREGNANCY INDUCED HYEPERTENSION

22. INCIDENCE
• 3.7% of pregnancies
• 16% of pregnancy related death
• Eclampsia 1 in 2000 deliveries

23. CLASSIFICATION OF HYPERTENSION IN
PREGNANCY

DISORDER DEFINITION
1. HYPERTENSION
2. GESTATIONAL
HYPERTENSION
3.PRE-ECLAMPSIA
4. ECLAMPSIA
5. CHRONIC
HYPERTENSION
6. SUPERIMPOSED PRE
ECLAMPSIA/ECLAMPSIA
BP ≥ 140/90 mmhg measured 2 times with atleast a 6 hr interval
BP ≥ 140/90 mmhg for the first time in pregnancy after 20 weeks,
without proteinuria
Gestational Hypertension with proteinuria
Women with pre-eclampsia complicated with convulsions
Known hypertension before pregnancy or hypertension diagnosed first time
before 20 weeks of pregnancy
Occurence of new onset of proteinuria in women with chronic hypertension

24. PRE-ECLAMPSIA
• Multisystem disorder of unknown etiology characteristized by development
of hypertension to the extent of 140/90 mmHg or more with protienuria
after 20 week in a previously normotensive and nonproteinuric women
DIAGNOSTIC CRITERIA
• Hypertension
• Oedema: Pitting edema over the ankles over 12 hours bed rest or rapid
weight gain 0.5 kg a week
• Proteinuria: Presence of total protein in 24 hours urine of more than 0.3g
or ≥ 2+ (1g/L) on atleast two random clean catch urine samples tested ≥ 4
hours apart in the absence of any UTIs

25. CLINICAL TYPES
• MILD PRE-ECLAMPSIA
 BP ≥ 140/90 mmHg but less than
160/110mmHg without significant
proteinuria
• SEVERE PRE-ECLAMPSIA
 Persistent BP ≥ 160/110 mmHg
 Protein excretion > 5g/24 hrs
 Oliguria <400ml/24 hours
 Platelet < 100,000/mm3
 Cerebral or visual disturbances

26. ECLAMPSIA
• Pre-eclampsia when complicated with generalized tonic-clonic
convulsions and or coma is called eclampsia
• May appear before, during or after labor

27. RISK FACTORS
• Primigravida: Young or elderly
• Family history
• Placental abnormalities: excessive
exposure to chorionic villi- molar
pregnancy, multiple pregnancy,
diabetes
• Obesity
• Pre-existing vascular diseases
• Thrombophilias

28. PATHOPHYSIOLOGY

30. PATHOPHYSIOLOGY

31. CLINICAL FEATURES
 Mild symptoms:
• Slight swelling over the ankles
• Gradually extending to the face, abdominal
wall, vulva and even the whole body
 Alarming symptoms:
• Headache
• Disturbed sleep
• Oliguria
• Epigastric pain
• Blurring/dimness of vision

32. SIGNS
• Weight gain
• Persistent rise of BP > 140/90mmHg
• Edema over ankles
• Pulmonary edema
• Abdominal examination: scanty liqour or IUGR (chronic placental
insufficiency)
• Eclamptic Fit or Convulsions
 PREMONITORY STAGE
 TONIC STAGE
 CLONIC STAGE
 STAGE OF COMA

33. INVESTIGATIONS
• Urine: Proteinuria is the last feature of pre-eclampsia to
occur
• Ophthalmic examination: Retinal edema, constriction of
the arterioles,hemorrhage etc
• Blood values: Serum uric acid >4.5 mg/dL
 Serum creatinine maybe >1mg/dL,
 Urea normal to slightly raised,
 Thrombocytopenia,
 Abnormal coagulation profile and
 Hepatic enzymes maybe elevated

34. COMPLICATIONS
• IMMEDIATE: MATERNAL
• ECLAMPSIA: Injuries, pulmonary failure, neurological deficits, cardiac and renal
shutdown, coagulopathies, postpartum psychosis
DURING PREGNANCY DURING LABOR PUERPERIUM
a. Eclampsia
b. Antepartum hemorrhage
c. Acute renal failure
d. Cardiac failure
e. Dimness of vision or even
blindness
f. Preterm labor
g. HELLP Syndrome
h. ARDS
a. Eclampsia
b. Postpartum hemorrhage
a. Eclampsia
b. Shock
c. Sepsis

35. COMPLICATIONS
• IMMEDIATE: FETAL
a. Intrauterine fetal death
b. Intrauterine growth retardation
c. Asphyxia
d. Prematurity
• REMOTE: MATERNAL
a. Residual hypertendion
b. Recurrent pre-eclampsia
c. Chronic renal disease
d. Risk of palental abruption

36. PREVENTION
• Regular antenatal checkup
• Antithrombotic agents: Tab Ecosprin 75mg daily in
potentially high risk patients
• Heparin or Low Molecular Weight Heparin is useful in
women with thrombophilia and with high risk
pregnancy
• Calcium supplementation 2gm per day
• Antioxidants: Vitamin E and C
• Balanced diet rich in protein

37. MANAGEMENT
• HOSPITAL MANAGEMENT
i. Rest
ii. Continuous BP monitoring - every 4 Hourly
iii. Blood investigations: Platelet, coagulation profile, uric acid, creatinine,
LFT and 24 hour urine protein
iv. Daily urine dipstick
v. Ophthalmoscopy
vi. Fetal well being assessment: DFMC, NST, CTG, Biophysical profile and
USG-Doppler
vii. Antihypertensives: Diastolic BP over 110mmHg

38. MANAGEMENT
ANTIHYPERTENSIVES
DRUG DOSE SCHEDULE MAXIMUM DOSE
 Tab Labetalol
 Tab Nifedipine
 Tab Methydopa
 Tab Hydralazine
100mg qid
10-20 mg bd
250-500mg tds or qid
10-25 mg bd
HYPERTENSIVE CRISIS- BP ≥160/110 mmHg or MAP ≥ 125 mmHg
 Inj Labetalol
 Inj Hydralazine
 Tab Nifedipine
 Inj NTG
 Inj Sodium nitropruside
10-20 mg IV/10 min
5mg/30 min
10-20 mg oral, can be repeated
in 30 min
5µg/min IV
0.25-5µg/kg/min IV
300mg
30 mg
240 mg/24 hrs
} Only used when other drugs
have failed

39. MANAGEMENT
COMPLETE CONTROL BP PERSISTENTLY
HIGH
PERSISTENTLY ↑BP
EVEN WITH ANTI-
HYPERTENSIVES
ADDITIONAL
OMNIOUS SYMPTOMS
• PRETERM: Discharge
and attend ANC Clinic
• TERM: Hospitalization
≥ 37 weeks then
deliver
Try to continue
pregnancy till 37 weeks
or atleast 34 weeks then
deliver
• Couple counseling
• Transfer to tertiary care center
• Prophylactic anticonvulsant therapy
• Delivery, irrespective of POG
• Steroid if < 34 weeks
METHOD OF DELIVERY
 Induction of labour
 Cesarean

40. MANAGMENT: ECLAMPSIA
• Maintain: airway, breathing and
circulation
• Oxygen administration 8-10 l/min
• Arrest convulsions
• Ventilatory support (if needed)
• Prevention of injuries
• Hemodynamic stabilization
• Organize investigations
• Deliver by 6-8 hours
• Prevention of complications
• Postpartum care

41. MANAGMENT: ECLAMPSIA
FIRST AID OUTSIDE THE HOSPITAL MEDICAL and NURSING MANAGEMENT
• Shift to tertiary cary hospital immediately
• All maternal documents
• Stabilize BP, arrest convulsions
• MgSO4 : Pritchard/Zuspan
• Inj Labetalol 20 mg IV
• Diuretics: Pulmonary edema
• Diazepam 5 mg: Avoid apnoe or cardiac
arrest
• Trained medical personnel or a midwife
• Supportive care: Management during fits
• Detailed history
• Examination: General, abdominal and vaginal
examination
• Monitoring: Half hourly-pulse, respiration and
BP
hourly- Urine output
• Fluid balance: Total fluid previous UO +
1000ml (RL)
• Antibiotics: In Ceftriaxone 1g BD

42. MANAGMENT: ECLAMPSIA
• MANAGEMENT DURING FITS:
 Placed in a railed cot, mouth gag to be placed in premonitory stage
 Lateral decubitus position
 Clear air passage to avoid aspiration
 Oxygen 8-10 l/min
 Continous monitoring
 ABG if oxygen saturation < 92%
 STATUS EPILEPTICUS: Inj Thiopentone sodium 0.5 g dissolved in 20
ml 5%D IV slow
Anesthesia, muscle relaxants and assisted ventilation

43. ANTICONVULSANT AND SEDATIVE
REGIMEN LOADING DOSE MAINTENANCE DOSE
INTRAMUSCULAR
(PRITCHARD)
4g IV, over 3-5 min followed by
10g deep IM (5g in each buttock)
5g IM 4 hours in alt buttock
INTRAVENOUS (ZUSPAN OR
SIBAI)
4-6g IV over 15-20 min 1-2g/hr IV infusion
Recurret fits: 2g repeat IV bolus over 5 min in the above regimen

44. MANAGEMENT: ECLAMSIA
 ECLAMPSIA : IN LABOR
• ARM: Forceps, ventose
• Cesarean: Uncontrolled fits, unconscious patient with poor prospect of
vaginal delivery, malpresentations
• ECLAMPSIA: NOT IN LABOR
FITS CONTROLLED FITS NOT CONTROLLED (6-8 HOURS)
• Term: Deliver- Induce or CS
• Preterm: Steroid then deliver
• Dead: Induce and deliver
Deliver
• Favourable vaginal findings: ARM, oxytocin
• Unfavourable finding: CS

45. NURSING MANAGEMENT: ASSESSMENT
• Early prediction and prevention: Look for
omnious signs and symptoms
• Intensive monitoring of the patient
i. Continuous fetal monitoring
ii.Assess vital signs
• Ask patient to tell if she develops a
headache, blurred vision, dizziness or
epigastric pain
• Age and parity
• Predisposing factors

46. NURSING DIAGNOSIS
• Altered tissue perfusion related to decreased uteroplacental perfusion,
maternal hypovolemia
• Fluid volume deficit related to decreasing plasma colloid and ongoing
renal shutdown
• Decreased cardiac output related to hpovolemis/decreased venous return
and increased systemic vascular resistenace
• Ineffective airway clearance related to possible chances of aspiration due
to convulsions
• Risk for maternal injury related to tonic clonic convulsions
• Impaired physical mobility related to decreased muscle strength
• Risk for fetal injury
• Risk for infections

47. NURSING INTERVENTION
• Faciliate early prenatal care
• Assess physical parameters
• Provide diet instructions
• Instruct regarding medications
• Anticipate seizure:Prompt seizure prophylaxsis
• Maintain IV assess, catheterize the patient
• Special considerations during MgSO4 infusion: Continue infusion only if
Knee jerks are present, Urine output is >30ml/hr and RR is >12/min
• Therapeutic serum magnesium level is 4-7mEQ/L
• Administer Inj calcium gluconate for MgSO4 toxicity
• Prepare for labour induction or cesarean
• Continue MgSO4 for 24 hours after delivery

48. HEALTH EDUCATION
• Regular antenatal checkup
• Drug compliance
• Dietary changes: High protein diet
• Teach and patient about the alarming signs of PIH
• Seek care immediately
• Counselling: Possible early termination of pregnancy, premature new born
• Family support

49. SUMMARY
• Mrs Guddan, 34 year old multigravida, known case of pre-
eclampsia with GDM got admitted to MH JRC at 36 weeks 06
days POG for safe confinement and induction of labor at 37
weeks POG. During labor after induction as planned, she
developed eclampsia, immediate care was given and shifted
for emergency LSCS. Postpartum continued to have ↑BP.
She was diagnosed as a case of Chronic Hypertension and
was diacharged after 10 days on Tab Amlodipine 5mg OD