Where you are:
You are F2 in OBG.
Who the patient is:
Laila, aged 29, who is 36 weeks pregnant, has been referred to the hospital. The mid-wife has seen the lady and made a note.
Vitals:
BP 160/110,
Urine protein (+++).
This must be reviewed by a doctor.
Other information:
The patient’s BP in her first booking was 110/70.
What you must do:
Please talk to the patient, assess her condition, discuss your further management with the patient and address her concerns.
Doctor: I can see from my notes that you are referred by the mid-wife. Could you please tell me why you went to the mid-wife at the first place?
Patient: I went for my check up and I was sent here by the midwife because of my blood pressure and protein in my urine.
D: Could you confirm the age of your pregnancy?
P: 36/38 weeks.
D: Is this your first pregnancy?
P: Yes. (Risk factor)
D: Have you attended all your antenatal check-ups?
P: Yes.
D: How has your pregnancy been so far?
P: Fine.
D: Have you developed any complications?
P: No.
D: Have you got any symptoms now?
P: No.
D: Have you had any scans done?
P: Yes.
D: Are you having twins in this pregnancy? (Risk factor)
P: No.
D: Can you feel the movements of your baby?
P: Yes.
(Ask about symptoms of pre-eclampsia and pregnancy complications)
D: Any headache?
P: No.
D: Any vision problems such as blurring?
P: No.
D: Any swelling of feet, ankles or face?
P: No.
D: Do you feel sick?
P: No.
D: Any vomiting?
P: No.
D: Any excessive weight gain?
P: No.
D: Any tummy pain?
P: No.
D: Any vaginal bleeding?
P: No.
D: Any pain or burning sensation during urination?
P: No.
D: Do you go to the loo frequently?
P: No.
D: Do you feel tired?
P: No.
(P2)
D: Have you got any medical illness during pregnancy?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Any high blood pressure, diabetes, or kidney problems?
P: No.
DESA
D: Tell me about your diet.
P: I eat healthy food.
D: Do you smoke?
P: Yes/No
D: Do you drink alcohol?
P: Yes/No
D: Have you been taking any recreational drugs?
P: No.
D: What do you do for a living?
P: Office job.
D: May I know who you live with?
P: My partner.
MAFTOSA
D: Are you currently taking any regular medications, over-the-counter drugs or
supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Any previous hospital stays or surgeries?
P: No.
D: Any surgical procedures?
P: No.
D: Has anyone in your family been diagnosed with any medical condition?
P: No.
D: Did your mother or sister have any complications during their pregnancies? (Risk factor)
P: No.
Examination
D: I would like to check your vitals including blood pressure and do an Antenatal Examination if that’s OK with you? I would like to send for some initial investigations including routine blood test and urine test.
Provisional diagnosis
From my assessment you seem to have developed a condition called pre-
eclampsia. It is a condition that affects some pregnant women, usually during the second half of pregnancy (from around 20 weeks) or soon after their baby is delivered.
Early signs of preeclampsia include having high blood pressure and protein in your urine. We checked your blood pressure and its high and your urine test shows there is protein in your urine.
This condition can be serious if not treated.
Management
Pre-eclampsia can only be cured by delivering the baby. If you have pre-eclampsia, you’ll be closely monitored until it’s possible to deliver the baby.
Admit, you need to stay in hospital until your baby can be delivered.
Senior.
Monitoring in hospital:
While you’re in hospital, you and your baby will be monitored by:
- regular blood pressure checks to identify any abnormal increases.
- regular urine samples taken to measure protein levels.
- various blood tests – for example, to check your kidney and liver health.
- ultrasound scans to check blood flow through the placenta, measure the growth of the baby, and observe the baby’s breathing and movements
- electronically monitoring the baby’s heart rate using a process called
cardiotocography, which can detect any stress or distress in the baby.
Medication for high blood pressure:
- To lower your blood pressure. These medications reduce the likelihood of serious complications, such as stroke.
- Labetalol is specifically licensed for use in pregnant women with high blood pressure.
- Possible alternatives to labetalol (methyldopa and nifedipine ) we may recommend one of them if we think it’s the most suitable medication for you. You should be made aware that the medication is unlicensed in pregnancy and any risks should be explained before you agree to treatment, unless immediate treatment is needed in an emergency.
Other medications:
- Anticonvulsant medication may be prescribed to prevent fits if you have severe pre-eclampsia and your baby is due within 24 hours, or if you have had convulsions (fits).
- They can also be used to treat fits if they occur.
Delivering your baby:
- In most cases of pre-eclampsia, having your baby at about the 37th to 38th week of pregnancy is recommended.
- Labour needs to be started artificially (known as induced labour) or you may need to have a caesarean section.
- This is recommended because there’s no benefit in waiting for labour to start by itself after this point and delivering the baby early can also reduce the risk of complications from pre- eclampsia.
- If your condition becomes more severe before 37 weeks and there are serious concerns about the health of you or your baby, earlier delivery (premature births) may be necessary and babies born before this point may not be fully developed.
Safety netting:
Please inform us if you have any tummy pain or you feel drowsy or confused.
Note:
- Pre-eclampsia is thought to be caused by the placenta not developing properly due to a problem with the blood vessels supplying it. The exact cause isn’t fully understood.
- Some factors have been identified that could increase your chances of developing pre- eclampsia. These include:
• having an existing medical problem - such as diabetes, kidney disease, high blood pressure, lupus or antiphospholipid syndrome.
• previously having pre-eclampsia.
• it’s your first pregnancy.
• it’s been at least 10 years since your last pregnancy.
• you have a family history of the condition.
• you’re over the age of 40.
• you were obese at the start of your pregnancy.
• you’re expecting multiple babies, such as twins or triplets.