NAME: NUR JAMILAH

SEX: FEMALE
AGE: 31
ETHNICITY: MALAY
MARITAL STATUS: MARRIED
DATE OF ADMISSION: 15 SEPTEMBER 2016
OCCUPATION: HOUSEWIFE
ADDRESS: DATO KERAMAT

LMP 7 JANUARY 2016

EXPECTED DATE OF DELIVERY 12 OCTOBER 2016
GRAVIDA - 2
PARA - 1
GESTATION 38 weeks + 1 days
:

Chief Complaint
Madam Siti, 31 year old housewife Gravida 2 para 1 at 38 weeks and 1 day of gestation was
admitted due to high blood pressure.
History of Presenting Illness
She was referred from antenatal clinic during follow up in KK Dato Keramat on 15
September 2016. During the check up at the follow up, her vital sign showed she was
afebrile, pulse rate of 90 beats per minute and blood pressure was noted to be 160/100mmHg
and no abnormality was found in the urine.
During booking her blood pressure was noted to be 100/70mmHg and she was normotensive
throughout the pregnancy up until at 38 weeks and 1 day of period of gestation.

She denied symptoms of impending eclampsia such as headache,blurring of vision, epigastric

pain and vomiting. There was also no dizziness, shortness of breath, chest pain, reduced urine
frequency and leg swelling.

Antenatal History
This is an unplanned but wanted pregnancy. She had a period of amenorrhea for 4 weeks and
as such she did a self urine pregnancy test brought from the pharmacy and it came out
positive. Subsequently, she went to a private clinic to reconfirm and the result was consistent.
Early dating ultrasound scan was also done and confirmed her pregnancy at 18 weeks period
of gestation. There were no fetal abnormalities detected. At 21 weeks period of gestation, she
went to Klinik Kesihatan Dato Keramat for booking. Antenatal screening done showed that:
Blood Pressure : 110/70mmHg
Haemoglobin level : 12.8g/dL
Height : 158cm
Weight : Pre : 62kg Current : 69kg
Blood Group : O Positive
VDRL/HIV/HEP B : Non Reactive
Urine Albumin/Sugar : Nil
MGTT : Normal blood sugar level
Latest scan done at 38weeks and 1day period of gestation and all parameters are correspond
to date. It was a singleton fetus on longitudinal lie and cephalic presentation. Fetal heart and
fetal movement are seen. Amniotic Fluid Index are 11. Estimated fetal weight was 3.3kg and
placenta was on anterior upper segment.
Otherwise, antenatal visits are uneventful.

Menstrual History

She attained her menarche at the age of 12 with 28 days regular cycle with 5 to 7 days of
bleeding. The amount was about 2-3 pads fully-soaked. She denied dysmenorrhoea,
menorrhagia, intermenstrual bleeding, dyspareunia and postcoital bleeding.

Past Obstetric History

On November 2010, she had a full term normal pregnancy and delivered a baby boy by
spontaneous vaginal delivery at HKL and weight of the baby was 2.6kg and is alive and well.
She breastfed for 4 months.

Past Gynaecology History

She uses contraception Implanon for 4 years from 2011 to 2015. She had never had pap
smear done before.

Past Medical History

She has no diabetes mellitus, hypertension, heart disease or any underlying medical
condition.
Past Surgical History
She has not undergone any surgery before.

DRUG & ALLERGY HISTORY

No known drug allergy or food allergy. She was on folic acid, vitamin B complex, Vitamin C
and iron tablet as prescribed by the doctor during the pregnancy
Family History
Her mother is now 50 years old and was diagnosed to have diabetes mellitus and
hypertension and currently on medication whereas her father has no known chronic illness.
She is the only child.
No family history of breast tumor, endometrial, cervical, or any other tumors related to
female reproductive tract, no congenital abnormalities like Down Syndrome.

Social History
She is a housewife. She does not smoke or drink alcohol. Her husband is 35 years old
working as a driver with an income of RM2000 monthly. He does not smoke or drink alcohol.

REVIEW OF SYSTEMS
General

No headache, no seizure, fever, no weight loss

CVS

No chest pain, no palpitation, no pedal edema

Respiratory

No dyspnea

Urinary

Polyuria, no dysuria

GIT

Polyphagia, no constipation, no diarrhea, no abdominal pain, no

nausea, no vomiting, no epigastric pain

Reproductiv
e

No bleeding, no foul-smelling discharge, no itchiness

MSK

Backache, no other joint pain or weaknesses, had pedal edema

before, now not anymore

CNS

No headache, no blurred vision, no numbness

Endocrine

No temperature intolerance, polydipsia

SUMMARY
Madam Nur Jamilah, 31 year-old Malay, gravida 2 para 1 at 38 weeks 1 days period of
gestation was admitted to Hospital Kuala Lumpur for blood pressure stabilization due to
gestational hypertension.

PHYSICAL EXAMINATION
General
Patient was lying flat in supine position, supported with one pillow. She was conscious, alert,
cooperative, and responsive to time, place and person. Her palm was warm, no pallor, no
koilonychia, no clubbing and no peripheral cyanosis. Capillary refill time was less than 2
seconds No pedal edema..
Vital Signs

Blood Pressure

: 142/92mmHg

Pulse

: 91 beats per minute with regular rhythm and good volume

Respiratory Rate: 18 breaths / min

Temperature

: 37.3C

Head & Neck

Eyes

: No sign of jaundice and no pallor

Mouth

: Lips were moist, no angular stomatitis, no glossitis

Thyroid

: Not enlarged

Lymph node : Not palpable

.
Cardiovascular System
On inspection, the chest was symmetrical and normal in shape. There was no scar, no
precordial bulging, no visible apex beat and no prominent dilated veins.
On palpation, the apex beat was located in the 5 th intercostal space, at the midclavicular line.
There was no thrill and heave. The peripheral pulses were present with normal rhythm and
volume.
On auscultation, the first and second heart sounds were normal. There were no murmurs
heard.
Respiratory System
On inspection, the chest moved symmetrically with respiration with no deformity seen. There
was no sign of respiratory distress. There were no scar, prominent dilated.
On palpation, the chest expansion and vocal fremitus were equal anteriorly and posteriorly at
all three zones of the lung.
On percussion, the lung was resonant bilaterally, anteriorly and posteriorly. There were
normal liver and cardiac dullness.
On auscultation, there were vesicular breath sound anteriorly and posteriorly at all three
zones. No added sounds heard
Neurological System
She was orientated to time, place, and person. All cranial nerves were intact. Both her upper
and lower limbs were normal. Muscle tones, power, and reflexes were all good and normal.

Abdominal Examination
On inspection, the abdomen was distended by gravid uterus as evidenced by linea nigra and
striae gravidarum. The umbilicus is centrally located and flat. No scars noted and no dilated
veins seen. Fetal movement was seen
On palpation, her abdomen was soft and non tender. Symphysio fundal height height was
37cm which correspond to the gestational age.
Palpation of the fetus showed that it was a singleton in longitudinal lie with cephalic
presentation. The head was 3/5 palpable and not engaged. The fetal back was on the maternal
left side. The liquor was adequate and estimated fetal weight was 3.2 to 3.4kg. Fetal heart
sound was heard by using Pinnard stethoscope.

Provisional Diagnosis
Gestational Hypertension:
She develop hypertension which is a blood pressure of 140/90mmHg aand above recorded on
2 separate occasions at least 4hours apart.
Hypertension occur in second half of pregnancy which is after 20weeks of gestation.
She is previously normotensive.
There is absence of proteinuria
She had risk factor; family history of hypertension.

Differential Diagnosis
Pre-eclampsia:
Points for:
Hypertension at least 140/90mmHg recorded on 2 separate occasions at least 4hours apart.
Hypertension occur at second half of pregnancy, after 20weeks gestation.
She is previously normotensive.
She had risk factor; family history of hypertension.

Points against:
There was absence of proteinuria of at least 300mg Protein in a 24hour collection of urine.
She had no risk factor such as pre-existing hypertension or pre-eclampsia.
Chronic Hypertension:
Points for:
She has a family history of hypertension.
Points against:
She is normotensive prior to pregnancy.
She had no other disease such as renal or connective tissue disorders that can lead to
hypertension.
Investigations
Full Blood Count
To exclude HELLP syndrome

White Cell Count - 14.2 x 10^9/L

Red Cell Count - 4.18 x 10^12/L
Haemoglobin 12.3 g/dL
MCV 37.1%
MCH 88.7 Fl
MCHC 29.3 Pg
RDW 33.0 g/dL
Mean Platelet Volume 8.0 Fl
Platelet 302 x 109 /L
Neutrophils ++ 10.3 x 10^9 /L

Eosinophils 0.4 x 10^9 /L

Basophils - 0.0 x 10^9 /L
Lymphocytes 2.6 x 10^9 /L
Monocytes 0.9 x 10^9 /L
Nucleated RBC 0 x 10^9 /L
Result:
There is a reduction of Red Cell count. This is due to pregnancy, as there is haemodilutional
effect due to an increase in plasma volume. Patient is not anaemic as haemoglobin is on the
normal range. Platelet level is normal.

Renal profile
To exclude secondary cause of hypertension due to renal damage.
To detect abnormality in the level of serum urea and creatinine that will indicate renal
damage or failure.
Sodium 139 mmol/L
Potassium 4.0 mmol/L
Urea - 2.3 mmol/L
Creatinine 54 umol/L
Comment:
There is hypouremia. This is normal in pregnancy, as there will be an increase in Glomerular
Filtration Rate (GFR), therefore there will an increase in clearance of urea in the body.
Besides that, a reduction in deamination process in the maternal body will also cause blood
urea to be reduce.

Liver Function Test

To see whether patient had any liver damage

Albumin - 33 g/L
Total Protein 68g/L
Bilirubin toral 6 umol/L
ALT 19 u/L
ALP + 141 u/L
Comment:
There is hypoalbuminaemia. There is increase level of Alkaline Phosphatase (ALP) due to
placenta production. Thus, making it a normal physiological reaction.

Serum Uric Acid

Serum uric acid is a sensitive indicator of renal damage in pre-eclampsia.
Uric Acid 371 umol/L
Comment:
Serum uric acid level is normal. Suggesting there is no renal damage.

Pre-eclampsia Chart
To monitor her blood pressure on lying and standing
To monitor her urine whether there is albuminuria or not.
To detect pre-eclampsia.
Result:

Other than the increase in blood pressure, there is no albuminuria noted. Therefore, patient
did not have pre-eclampsia.
Cardiotocography (CTG)
To monitor the heart rate and contraction of the uterus to detect abnormalities in the
pregnancy.
Result: Reactive
Ultrasound
To assess the fetal growth.
Result: Normal fetal growth with good liquor volume

.
Management
Admit to ward for BP monitoring and stabilization.
Monitor for any signs and symptoms of impending eclampsia.
Bed rest.
BP monitoring 2hourly for 24hours. If blood pressure reduce or return to normal patient can
be discharge and to come again for antenatal follow up. Bed rest continued if persistent.
Antihypertensive medication given if BP consistently noted to be 150/100mmHg. Preferred
agent are alpha and beta blockers agent such as labetolol or methyldopa.
Pre-eclampsia chart to exclude pre-eclampsia.
CTG and ultrasound
Gestational hypertension not resolve, induction of labour is recommended.
If induction of labour fails or spontaneous delivery is not possible, prepare for lower segment
caesarean section (LSCS).
Discussion

Hypertension in pregnancy is defined as Blood Pressure more than or equal to 140/90mmHg

in previously normotensive women that occur in 20th week of gestation without proteinuria
until 6weeks postpartum. Or alternatively, a rise in systolic BP of more than 25mmHg or
diastolic BP of more than 15mmHg compared with booking BP. Hypertension in pregnancy
caused an increase in maternal and perinatal morbidity and mortality.
Normal BP usually never went beyond 120/80mmHg. However in pregnancy plasma volume
increases on an average 1200ml. So vasodilatation is needed to maintain the peripheral
pressure. If the vasodilatation action is counteract by arterial spasm, hypertension occurs and
lead to reduction in perfusion to all organ. This includes the uterus and placental site.
Hypertension in pregnancy can be divided to pre-eclampsia, gestational hypertension, chronic
hypertention, pre-eclampsia superimposed of chronic hypertension.
Pre-eclampsia is defined as hypertension of at least 140/90mmHg recorded on 2 separate
occasions with the significant proteinuria of more than 300mg in 24hours urine collection
after 20weeks of gestation in a previously normotensive women and resolve completely by
6weeks postpartum. Eclampsia is a serious complication and life threathening complication
of pre-eclampsia. It is defined as convulsions occurs in a woman with pre-established preeclampsia in the absence of any neurological or metabolic cause.
Chronic hypertension is caused either due to essential hypertension or secondary
hypertension. Secondary causes include renal artery Stenosis, glomerulonephritis, cushing
syndrome and pheochromocytoma. Chronic hypertension is a hypertension diagnosed prior to
20weeks of gestation or history of hypertension preconception and de novo hypertension in
late gestation that fails to resolve postpartumly.
Pre-eclampsia superimposed on chronic hypertension is diagnosed when there is:

De novo proteinuria after 20week gestation

Sudden increase in magnitude of hypertension

Appearance of features of pre-eclampsia-eclampsia

Sudden increase in proteinuria in women with preexisting proteinuria in early

gestation in women with chronic hypertension.

Risk factors for women to develop hypertension in pregnancy can be divided into obstetric,
medical and social aetiology. In obstetric aetiology, the risk factor can be further divided into
maternal and fetal risk factor where:
Maternal risk factors are:

Nulliparity or primigravida

Advanced maternal age or extreme age (<15 or >35year old)

Family history of hypertension, pregnancy induced hypertension, pre-eclampsia and

eclampsia.

Previous history of gestational hypertension, pre-eclampsia, eclampsia.

Maternal obesity (>80kg)

Fetal risk factors are:

Multiple pregnancy

Molar pregnancy

Hydrops fetalis

From medical aetiology the risk factors are:

Diabetes mellitus or gestational diabetes mellitus

Established hypertension

Connective tissue disease

Renal disease: glomerulonephritis, renal artery Stenosis

Endocrine disease: cushing's syndrome, pheochromocytoma.

From social aetiology the risk factors are:

Smoking

Alcohol consumption

Complication that can arise from hypertension in pregnancy are eclampsia, intrauterine
growth restriction, renal failure, thrombocytopenia, abruption placenta, subcapsular
haemrrhage and liver dysfunction.
Treatment wise, patient need to be admitted to hospital first for BP monitoring and
stabilization. Used of antihypertensive agents that may be used in hypertension in pregnancy
is labetolol, which is a combined alpha and beta blocker. By blocking alpha adrenoreceptor in

the peripheral arteries, it reduced the peripheral resistance. At the same time beta blocking
effect protects the heart from reflex sympathetic drive normally induced by peripheral
vasodilatation. Nifedipine, a calcium channel blocker can be use as an alternative. Delivery is
the ultimate treatment of hypertensive in pregnancy and its timing is dependent on the
observation of fetal and maternal well being. Prolongation of pregnancy by drug therapy may
reduce the risk of prematurity and improves the chances of delivery.