Learning Log Proforma for clinical case

Part APresentation Referred for management of chronic hypertension Main diagnosis Chronic hypertension

History taken Yes Patient examined Yes

Where seen (OPD/ER/ Specialty Ward) Maternity wardWhen seen (insert date) 2071/10/25Age 30 years Gender Female Occupation Government Employee

History of presenting complaints and associated featuresAccording 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 historyShe attained her menarche at 14 years of age. She has bleeding for 2-3 days in a regular menstrual cycle of 28±2 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: 2071/12/13PoG: 33 weeks of gestation

Obstetric historyG1P0L0A0

She has been married for 3 years.

Contraceptive historyShe had not used any form of contraceptives till date.

Past medical and surgical historyDiagnosed with hypertension 3 years back and was on antihypertensive for same duration. She had not undergone any surgeries in past.

Drug historyWas 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 allergiesNo known drug allergy.

Social historyShe 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 historyHer father, mother, elder brother and sister have hypertension. There is no family history of diabetes, TB, chronic renal diseases.

Summary of history30 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 examinationPatient 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 patient’s ideas, concerns and expectationsShe 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 diagnosis30 years old lady, G2P1L1A0 with gestational hypertension

Summary of investigationsHematology: 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 medicationsThe 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 MethyldopaDose, route, and frequency Tab; 500 mg; PO; TDSIndication and planned durationElevated blood pressure; Until delivery Class of drug and mechanism of actionClass: Centrally acting sympatholyticMOA: 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 monitoringSedation, lethargy, reduced mental capacity, lactation (due to hyperprolactinemia)NotesContraindicated in depression.

Drug name NifedipineDose, route, and frequency Tab; 20 mg; PO; BDIndication and planned durationElevated blood pressure; Until delivery Class of drug and mechanism of actionClass: 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 monitoringFlushing, dizziness, headache, tachycardiaNotes

Part BWhat 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 featuresThe patients may be asymptomatic.The presenting features may include:

o Headacheo Dizzinesso Loss of consciousnesso Edemao Visual changes or blurred visiono Difficulty in breathing

Natural history/prognosisChronic hypertension is associated with several adverse maternal and perinatal outcomes. Maternal Fetal

Superimposed preeclampsia Fetal deathHELLP syndrome Growth restrictionStroke Preterm deliveryAcute kidney injury Neonatal deathHeart failure, Myocardial infarctionHypertensive cardiomyopathyPlacental abruptionMaternal 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 beta-blockers. 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.