Learning Log Proforma for clinical case

Part A
Presentation
Main diagnosis

History taken Yes

Referred for management of chronic hypertension

Chronic hypertension

Patient examined Yes

Where seen (OPD/ER/ Specialty Ward)

When seen (insert date)
Age 30 years
Gender Female

Maternity ward
2071/10/25
Occupation Government Employee

History of presenting complaints and associated features

According to the patient she had cessation of menstruation for past 7 months. She had
her urine pregnancy test done at a nearby medical hall after 5 weeks of cessation of
menstruation and it turned out to be positive. She presented to hospital for her first
ANC the next day of having her urine pregnancy test positive. Her current pregnancy
is planned.
During first trimester of her pregnancy, She had pain in the lower abdomen which
started on the 7th day of her last menstrual period and continued for three months. The
pain was insidious, cramping, gradually progressive, non radiating and there was no
aggravating or relieving factors. She was prescribed some pain medications by her
doctor. She had heart burn for which she took Ranitidine 150mg BD for 15 days. She
had no nausea, vomiting, burning micturition, fever, PV discharge or increased
frequency of micturition. She had no exposure to teratogens and radiation during first
trimester. Before pregnancy she was on Amlodipine 5 mg for her hypertension
diagnosed 3 years back and her medications were changed to Methyldopa 250mg, PO,
TDS. Her routine blood tests, urinalysis and USG (obstetric scan) was done and were
normal.
During second trimester, she had no history of fever, burning micturion, PV discharge
or any other symptoms. She was prescribed iron and calcium supplementation, her
Methyldopa was continued with addition of Nifedipine 20mg PO, BD. She perceived
fetal movement at 5th month of pregnancy. She received 2 doses of tetanus toxioid
vaccine and a single dose of Albendazole. Her USG scan was normal.
During third trimester, she had no history of fever, burning micturion, PV discharge,
headache, abdominal pain, blurring of vision, loss of vision, seizure like activities,
altered mental status, loss of consciousness, skin rashes, itching. hematuria or
decreased urine output. She perceives normal fetal movement.
Menstrual history
She attained her menarche at 14 years of age. She has bleeding for 2-3 days in a
regular menstrual cycle of 282 days. She uses one pad per day which is partially
soaked. She does not pass clots. She has no history of dysmenorrhea, inter menstrual
or post-coital bleeding.
Last menstrual period: 2071/03/06
Expected date of delivery: 2071/12/13

PoG: 33 weeks of gestation

Obstetric history
G1P0L0A0
She has been married for 3 years.
Contraceptive history
She had not used any form of contraceptives till date.
Past medical and surgical history
Diagnosed with hypertension 3 years back and was on antihypertensive for same
duration. She had not undergone any surgeries in past.
Drug history
Was regularly on .Amlodipine 5mg once a day before pregnancy and after first ANC
visit she is on Methyldopa for six months and Nifedipine for 4 months.
Known drug allergies
No known drug allergy.
Social history
She is a government employee, working as a non-gazzated first class. She does not
smoke or drink alcohol and is a non-vegetarian. She has completed her bachelor's
degree. There are two members in her family; herself and her husband. Her husband is
also a government employee. She is looked after by her husband during pregnancy.
Family history
Her father, mother, elder brother and sister have hypertension. There is no family
history of diabetes, TB, chronic renal diseases.
Summary of history
30 years old married lady, government employee by occupation, gravida 1 at 33
weeks of gestation was admitted to maternity ward due to elevated blood pressure. No
history of headache, blurring of vision, dizziness, loss of consciousness or abnormal
body movements.
Summary of examination
Patient was conscious, alert, lying comfortably supine in bed, and not in distress.
No pallor, icterus, no palpable lymph nodes, clubbing, cyanosis, edema or
dehydration.
She was afebrile; pulse was 76 beats per minute, regular and of good volume;
respiratory rate was 16 breaths per minute; BP measured in sitting position was
140/90 mmHg (left arm) and 150/90 mmHg (right arm); and CRT was less than
seconds.
Abdomen was distended and moving with respiration. Central and inverted umbilicus.
Linea nigra and straie gravidarum were present. No distended veins or visible fetal
movements.
Uterus was 30 weeks size.
Fundal grip: Soft irregular broad mass felt suggestive of buttocks.

Lateral grip: Smooth, curved and resistance felt on left side suggestive of back and
irregular knob like structure felt on right side suggestive of limbs.
1st pelvic grip: Hard, globular and ballotable mass suggestive of head.
2nd pelvic grip: Head not engaged.
Fetal heart sound was 142 beats per minute.

Summary of patients ideas, concerns and expectations

She does not have any idea about the reason for elevated blood pressure, is concerned
if that would adversely affect her baby and expects to have proper management of her
condition.

Provisional diagnosis
30 years old lady, G2P1L1A0 with gestational hypertension
Summary of investigations
Hematology: Normal hematocrit and platelet count.
Blood chemistry: Normal creatinine, uric acid and alanine transterase level.
Urinalysis: No albumin, sugar, red cell cast or bacteria.
Management including medications
The patient was admitted to hospital as she had persistently elevated systolic blood
pressure above 160 mm of Hg and diastolic above 110 mm of Hg. Her blood pressure
and fetal heart sound were monitored every 4 hours. Ultrasonography revealed fetus
slightly small for gestational age. She was administered Methyldopa and Nifedipine.

Medications (complete one section for each medication, add/remove as

necessary)
Drug name Methyldopa
Dose, route, and frequency Tab; 500 mg; PO; TDS
Indication and planned duration
Elevated blood pressure; Until delivery
Class of drug and mechanism of action
Class: Centrally acting sympatholytic
MOA: Methyldopa is metabolized to -methylnorepinephrine, which is stored in the
secretory vesicles of adrenergic neurons. Methylnorepinephrine probably acts as an
agonist at presynaptic 2 adrenergic receptors in the brainstem, reducing the output of
vasoconstrictor adrenergic signals to the peripheral sympathetic nervous system.
Main side effects and monitoring
Sedation, lethargy, reduced mental capacity, lactation (due to hyperprolactinemia)
Notes
Contraindicated in depression.

Drug name

Nifedipine

Dose, route, and frequency Tab; 20 mg; PO; BD

Indication and planned duration
Elevated blood pressure; Until delivery
Class of drug and mechanism of action
Class: Calcium channel blocker (dihydropyridine)
MOA: Blockage of voltage sensitive L-type channel prevents excitation
contraction coupling of smooth muscle decrease peripheral resistance of blood
vessel.
Main side effects and monitoring
Flushing, dizziness, headache, tachycardia
Notes

Part B
What causes this condition (summarize the pathophysiology)?
Chronic hypertension is defined as systolic pressure 140 mmHg and/or diastolic
pressure 90 mmHg that antedates pregnancy, is present before the 20th week of
pregnancy, or persists longer than 12 weeks postpartum.
The pathogenesis of primary, or essential, hypertension is poorly understood. A
variety of factors have been implicated, including:

Increased sympathetic neural activity, with enhanced beta-adrenergic

responsiveness.

Increased angiotensin II activity and mineralocorticoid excess.

Hypertension is about twice as common in subjects who have one or two

hypertensive parents and multiple epidemiologic studies suggest that genetic
factors account for approximately 30 percent of the variation in blood pressure
in various populations.

Reduced adult nephron mass may predispose to hypertension, which may be

related to genetic factors, intrauterine developmental disturbance (eg, hypoxia,
drugs, nutritional deficiency), and post-natal environment (eg, malnutrition,
infections).

A variety of risk factors have been associated with essential hypertension:

Hypertension in maternal, paternal or both parents.

Excess sodium intake increases the risk for hypertension, and sodium
restriction lowers blood pressure.

Excess alcohol intake is associated with the development of hypertension.

Obesity and weight gain are major risk factors for hypertension and are also
determinants of the rise in blood pressure that is commonly observed with
aging.

Physical inactivity increases the risk for hypertension, and exercise is an

effective means of lowering blood pressure.

Dyslipidemia, independent of obesity is associated with hypertension.

Hypertension may be more common among those with certain personality

traits, such as hostile attitudes and time urgency/impatience, as well as among
those with depression.

Vitamin D deficiency is associated with an increased risk of hypertension

Commonly presenting features

The patients may be asymptomatic.
The presenting features may include:
o Headache
o Dizziness
o Loss of consciousness
o Edema
o Visual changes or blurred vision
o Difficulty in breathing
Natural history/prognosis
Chronic hypertension is associated with several adverse maternal and perinatal
outcomes.
Maternal
Fetal
Superimposed preeclampsia
HELLP syndrome
Stroke
Acute kidney injury
Heart failure, Myocardial infarction
Hypertensive cardiomyopathy
Placental abruption
Maternal death

Fetal death
Growth restriction
Preterm delivery
Neonatal death

Most useful investigations (look at literature for evidence)

The diagnosis of chronic hypertension is clinical.
The main goals in the initial evaluation of pregnant women with hypertension are to
determine whether hypertension is mild or severe, and to distinguish gestational
hypertension from preeclampsia. It is considered severe when sustained elevations in
systolic blood pressure of 160 mmHg or more and/or diastolic blood pressure of 110
mmHg or more are present for at least six hours.

Investigations:
Proteinuria: Measurement of urinary excretion of protein so as to differentiate
from preeclampsia.
Signs and symptoms of severe preeclampsia: Severe headache, visual changes,
epigastric or right upper quadrant pain, nausea/vomiting, or decreased urine
output.
Laboratory evaluation: Changes consistent with severe preeclampsia include
hemoconcentration, thrombocytopenia, and elevation in creatinine
concentration, hepatic transaminases, and/or lactic acid dehydrogenase.
Assess fetal well-being: As with all hypertensive pregnancies, fetal well-being
should be assessed with a biophysical profile or non-stress test with amniotic
fluid estimation. Ultrasonography for fetuses with growth restriction.
Evidence for treatment (quote literature source)
Management goals for chronic hypertension include reductions of adverse maternal or
perinatal outcomes.
Pre-pregnancy advice
Tell women who take angiotensin-converting enzyme (ACE) inhibitors or
angiotensin II receptor blockers (ARBs) and chlorthiazides, that there is an
increased risk of congenital abnormalities if these drugs are taken during
pregnancy and to discuss other antihypertensive treatment with the healthcare
professional responsible for managing their hypertension, if they are planning
pregnancy.
Stop antihypertensive treatment in women taking ACE inhibitors or ARBs if
they become pregnant (preferably within 2 working days of notification of
pregnancy) and offer alternatives.
Tell women who take antihypertensive treatments other than ACE inhibitors
ARBs or chlorothiazide that the limited evidence available has not shown an
increased risk of congenital malformation with such treatments.
Diet:
Encourage women with chronic hypertension to keep their dietary sodium
intake low, either by reducing or substituting sodium salt, because this can
reduce blood pressure.
Treatment of hypertension
In pregnant women with uncomplicated chronic hypertension aim to keep
blood pressure lower than 150/100 mmHg.
Do not offer pregnant women with uncomplicated chronic hypertension
treatment to lower diastolic blood pressure below 80 mmHg.
Offer pregnant women with target-organ damage secondary to chronic
hypertension (for example, kidney disease) treatment with the aim of keeping
blood pressure lower than 140/90 mmHg.
Offer pregnant women with secondary chronic hypertension referral to a
specialist in hypertensive disorders.

Offer women with chronic hypertension antihypertensive treatment dependent

on pre-existing treatment, side-effect profiles and teratogenicity.

Drugs used in pregnanacy to treat hypertension

Methyldopa: Methyldopa has been widely used in pregnant women and its long-term
safety for the fetus has been demonstrated, but it is only a mild antihypertensive agent
and has a slow onset of action (three to six hours). Many women will not achieve
blood pressure goals on this oral agent or are bothered by its sedative effect.
Beta-blockers: Labetalol has both alpha- and beta-adrenergic blocking activity, and
may preserve uteroplacental blood flow to a greater extent than traditional betablockers. It has a more rapid onset of action than methyldopa (within two hours
versus three to six hours). It may be administered orally or parenterally.
Calcium channel blockers: Calcium channel blockers appear to be safe for use in
pregnancy. Long-acting nifedipine (30 to 90 mg once daily as sustained release tablet,
increase at 7- to 14-day intervals, maximum dose 120 mg/day) has been used without
major problems. Although amlodipine is widely used in non-pregnant individuals with
hypertension, there are sparse data of its use in pregnancy.
Hydralazine: Intravenous hydralazine has been used extensively in the setting of
preeclampsia for the acute treatment of severe hypertension. Although a meta-analysis
demonstrated a slightly increased rate of adverse events with hydralazine compared to
labetalol , the evidence was not sufficient to make a definitive recommendation for
one drug over the other. Hydralazine has been widely used for many years in the
setting of acute hypertension in pregnancy and is an acceptable antihypertensive drug
in this setting. However, the hypotensive response to hydralazine is less predictable
than that seen with other parenteral agents.
Reference:
NHS, Hypertension in pregnancy, Issued: August 2010 last modified: January 2011
(Available on: guidance.nice.org.uk/cg107, Accessed date: 2015-02-23)
August.P et.al, Management of hypertension in pregnant and postpartum women,
2013, UpTo Date version 21.2. (Accessed date: 2015-02-23)
Student reflection on patient/presentation
By going through this case, I learned a lot about pre-existing hypertension and its
effect and management during pregnancy. This was a case of pre-existing
hypertension but after going through this case I also went through other forms of
hypertension during pregnancy and I learned about the management of those also.
During our district hospital rotation I have seen a lot of females with pregnancy
complicated with hypertension and were generally referred to the higher centre with
initial management only. I now realized why they were referred but I think the thinks
we missed in the district hospital was proper counselling of the patients. As a lot of
patients with hypertension are asymptomatic and is detected only during the regular
ANC check-up they might not find it urgent or even necessary to go higher centres.

So proper counselling of both pregnant woman and her family members is very
important to ensure they comply with the treatment.
As most of the hypertensive patients are asymptomatic, its identification and
management during pregnancy is of paramount importance, so I will not miss
measuring BP of pregnant women when I will be a practicing doctor.
As pre-pregnancy advice is very important in the women who have been diagnosed
with hypertension and are willing to become pregnant in near future, I will advise
them to consult a doctor for change or adjustment in their anti-hypertensive
medication before pregnancy.
As diet also have some beneficial effect on management of the hypertensive patients,
I will take my time to properly illustrate the benefits of diet modification and will try
to motivate patients to change their dietary habits appropriate for a hypertensive
patients.