AR, a 25-year old pregnant woman, was admitted to the hospital with shortness of breath, cough with blood-tinged sputum, and vaginal bleeding. She was diagnosed with placenta previa and severe pulmonary hypertension due to rheumatic heart disease. During her hospital stay, she received furosemide and iron supplements to manage her symptoms and improve her hemoglobin levels. Her condition stabilized with treatment and monitoring of her vital signs, lab work, and echocardiograms. The goals of care were to improve her symptoms, prevent further bleeding, and delay delivery to avoid preterm birth.

1. sever pulmonary HTN
By Temesgen Kusse

2. Outline
 Demographic Information
 Case Summary
 Assessment
 Medication on Admission
 Current status
 Current medication
 Rationale of drug therapy
 Drug therapy problems
 Desired therapeutic outcomes
 Out come evaluation
6:01:14 AM By Temsgen K. 2

3. Patient demography
Name: AR
Age: 25 years old
Date of admission: 16/08/2009
Ward: C6 (710/4)
Card No: 465286
Weight: 54 kg
6:01:14 AM By Temsgen K. 3

4. Patient demography
 C/C: Referred from Tirunesh Bejing Hospital(TBH)
 HPI:AR is a 25years old primigravida mother who's LNMP
was 20/01/2009 making GA age of 32+5 weeks. She had
regular ANC follow up at near HC since the last 02 months
and took TT 2x and with a base line investigation of :
– BG/Rh= O +ve
– HBSAg = NR
– PICT = NR
– VDRL = NR
6:01:14 AM By Temsgen K. 4

5. Cont.…
 AR was health two weeks back at which time she had
stated to have SOB, orthopnea, cough associated with
blood tingle sputum, and also she had bright red
painless, foul smelling vaginal bleeding since 01 week.
For this complications he was taken to TBH she
diagnosed by Obest U/S showed that she had Placenta
Previa(PP) at 2
nd
TMP.
6:01:14 AM By Temsgen K. 5

6. • Otherwise she have no Hx of DM, HTN, LOC,
yellowish discoloration of urine, diarrhea,
Headache, known medical illness, blurred
vision, decreases in fetal movement .
6:01:14 AM By Temsgen K. 6

7. P/E
 G/A : comfortable
 V/S : BP :110/70 PR: 68 RR: 24 𝑻 𝒄
𝑶
: ATT
 HEENT: - Pink conjunctiva, NIS
 LGS : NO LAP .
 Chest: clear and resonant
 CVS: S1 and S2 well heard, no murmur or gallop
 Abdomen: -31 weeks size gravida pregnancy
Longitudinal line
Cephalic presentation
FHB 135 bpm
6:01:14 AM By Temsgen K. 7

8. Cont.…
GUS: There is no clotted blood around
perineum and NMEGT
MSS : No edema
IS: no rash
CNS: COTPP
6:01:14 AM By Temsgen K. 8

9. V/S
V/S
Date
16/08/09 17/08/09 19/08/09 20/08/09 22/08/09 25/08/09
BP(mmH
g)
110/70 100/75 110/75 110/70 100/70 110/75
RR 24 20 20 23 18 21
PR 68 74 74 82 80 78
𝑇𝐶
0 ATT ------- ------- ATT ---------- ATT
6:01:14 AM By Temsgen K. 9

10. Lab investigations
Lab Values DATE Reference Range
16/08/2009 25/08/2009
WBC ((cells/l) 8.63 10.2 3.2 – 11.3 *103
RBC (cells/l) 4.02 3.81 3.5-5.5x106
Hgb (g/dl) 10.8 12.6 12-16
Hct () 34.5 35.1 37-51
MCV (fl) 90.5 91.4 76-100
MCH (pg/cell) 27.8 31.3 26-34
MCHC (g/dl) 33 34.2 32-37
Neutrophils () 67 75.5 40-75
Lymphocytes () 12.2 12.5 20-40
Plt (cells/l) 2.49 2.22 1.5-4.5x105
6:01:14 AM By Temsgen K. 10

11. Organ function test
RFT 19/08/2009 Reference range
Urea
( mg/dl)
21 15-41
Cr
( mg/dl)
0.7 0.5-1.2
LFT 19/08/2009 Reference
SGOT 19 <35
SGPT 12 -40
ALP 214 <270
6:01:14 AM By Temsgen K. 11

12. Serum electrolyte
Serum electrolyte 19/08/2009 Reference range
K 3.77 3.5-5.5
Na 135.6 135-145
Cl 104.2 98-108
6:01:14 AM By Temsgen K. 12

13. Other investigations
Date Investigation Report
12/08/2009 Obest U/S Placenta Previa at 2nd TMP
16/08/2009
Echocardiogra
phy
shows that RHD (sever MS, mailed MR &
mailed AR) + moderate functional TR + sever
pulmonary HTN and LV EF (55-60%)
ECG Normal
6:01:14 AM By Temsgen K. 13

14. Assessment
Early 3rd TMP
+
Primigravida
+
APH 𝟐 𝟎
to PP partial
+
NYHA class II CHF 𝟐 𝟎
RHD (sever MS, mailed MR &
mailed AR) ppt by Anemia
+
sever pulmonary HTN
6:01:14 AM By Temsgen K. 14

15. Medications
Date Medications
17/08/2009 Dexamethasone 6mg IM QID for 48 hr. only
Furosemide 20mg IV BID
Ferrous gluconate 325mg 2tabs po/day
Switched to PO
20/08/2009 Furosemide 20mg PO BID
Currently she is on
25/08/2009
Furosemide 20mg IV BID
Ferrous gluconate 325mg 2tabs PO/day
6:01:14 AM By Temsgen K. 15

16. Desired Therapeutic Outcomes
Improve sign and symptoms
Improve Hgb and maintain hemodynamic state
Prevent vaginal bleeding
Bed rest and limitation of activities
6:01:14 AM By Temsgen K. 16

17. Therapeutic Alternatives
Dexamethasone
– Prednisolone
– Hydrocortisone
 Ferrous gluconate
– Ferrous sulfate
Furosemide
– Bumetanide
6:01:14 AM By Temsgen K. 17

18. Pharmaceutical care plan
Subjectively:
Complains fatigability while walking
Objectively:
Placenta Previa
RHD
pulmonary HTN
6:01:14 AM By Temsgen K. 18

19. Assessment:
Early 3rd TMP
+
Primigravida
+
APH 𝟐 𝟎
to PP partial
+
NYHA class II CHF 𝟐 𝟎 CRVHD ((sever MS, mailed MR &
mailed AR) ppt by Anemia
6:01:14 AM By Temsgen K. 19

20. plane
Iron-rich diet
Bed rest and limitation of activities
Daily fetal and maternal monitoring
Minimize hemorrhage during childbirth and
pregnancy
Postponed the timing of delivery to prevent
preterm delivery
6:01:14 AM By Temsgen K. 20

21. Parameters to Evaluate the outcome
Symptom improvements
VS(BP, RR, PR, T)
CBC with differentials
Echocardiography
6:01:14 AM By Temsgen K. 21

22. Reference
1. Williams Gynecology, 3rd Edition 2016
2. Up-to-date version 21.6
3. Management protocol on selected obstetrics topics FMOH
2010
4. Ethiopian Standard Treatment Guideline 2014
6:01:14 AM By Temsgen K. 22

23. 6:01:14 AM By Temsgen K. 23