HPI Patient is 30 yo old G6P4013 at 365 is here in clinic with concerns for weight gain intermittent headachesepigastric discomfort nausea and increased swelling More history Symptoms started together approximately 1 week ago and per patient has gained approximately 15 pounds ID: 1032150
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1. OB/Gyn Chair roundsMengzhi Wu
2. HPIPatient is 30 yo old G6P4013 at 36+5 is here in clinic with concerns for weight gain, intermittent headaches/epigastric discomfort, nausea and increased swelling.
3. More historySymptoms started together approximately 1 week ago and per patient has gained approximately 15 pounds. The swelling is pitting is localized to mostly to her hands and feet and has been having trouble closing her handsThe headaches are bilateral and tension like in character and are different than her baseline chronic migraines which have been in control on her home fioricetShe notes that she has been having blurry vision and spots with these headachesShe notes worsening epigastric pain particularly after eating and while laying flatThere have been some infrequent contractions but denies VB, LOF, and good fetal movements.
4. PMH/SH/FHPMH: Chronic HTN not treated on any medicationsMigraines on FioricetGERD on PepcideHep C (Viral load <1.08 a few months ago)Hx of Herion use (not in last 3 years)Benign previous obstetrics historySH:Lives at home with her childrenCurrent ½ pack a day smoker down from 1 pack prior to pregnancy.Denies Alcohol/Recreational drugsFH: Nothing of note
5. ObjectiveVitals: Afebrile. Initial BP 153/85; repeat 146/80.PE: Consistent with historyNADLungs - CTABHeart - RRRAbdomen - Gravid, soft, NT, mild epigastric tenderness to palpation, no RUQ tendernessExt - warm, NT, tr edema bilaterally, non-pitting. Some non-pitting UE edema, erythematous papular rash on bilateral handsNeuro - 2+ DTR in bilateral upper and lower extremitiesPelvic exam: Cervix: 2/50/-2
6. Hypertensive states of PregnancyGestational HypertensionPreeclampsiaSevere preeclampsiaChronic HypertensionChronic Hypertension w/superimposed pre-clampsiaHELLP syndromeAFLP
7. Preeclampsia- HTN, ProteinuriaGeneralized arteriolar constriction and intravascular deplentionDiagnosis: BP, Proteinuria, SymptomsMild preeclampsia: BP SBP >140 or DBP >60 and Proteinuria >300 mg/24 hr or >1 to 2 plus on dipstickSevere preeclampsia: BP plus systemic issuesNeuro: SEVERE headache not relieved by acetaminophen, visual changes, scotomataPulmonary edemaRenal: Acute renal failure with rising creatinine; Oliguria < 400 ml/24 hr or <30mL/hr; 24hr Protein >5gm or 3+ on dipstickGI: RUQ pain, elevation of AST/ALTHeme: Hemolytic Anemia, Thrombocytopenia DICFetal: IUGR, abnormal umbilical dopplersEclampsia: SeizuresHEELP: Hemolysis, elevated liver enzymes, and low platelets (schitocytes, elevated LDH, elevated Total Bilirubin)
8. ComplicationsMaternal: Seizure, Cerebral hemorrhage, DIC and thrombocytopenia, Renal Failure, Hepatic failure or rupture, Pulmonary edema, Uteroplacental insufficiency, Placental abruption, Prematurity and C sectionFetal Complications: Acute uteroplacental insufficiency: Placental infarct and/or abruptionIntrapartum fetal distressStillbirthChronic uteroplacental insufficiencyAsymmetric and symmetric SGA fetusesIUGROligohydramnios
9. Risk FactorsDisease related:Chronic HypertensionChronic Renal DiseaseCollage vasvcular Disease (SLE)DiabetesAfrican AmericanMaternal age (<20 or >35)Immunogenic Related: NulliparityPrevious preeclampsiaMultiple gestationAbnormal PlacentationNew paternity or cohabitation less than 1 year
10. Labs/ImagingSent Patient to Triage to rule out SI pre E. Normotensive in Triage (138/79)CBC WNLCreatinine: 0.52Spot Urine: negative for proteinStarted 24 hr Urine Collection undetectable proteinsMRI: normalUtox positive for Barbituates (fioricet- Acetaminophen / Butalbital / Caffeine)Ultrasound:VertexAnterior placenta, appears to have hyperechoic areas that appear calcification-likeAFI 8.2FHT: 115 bpm, moderate variability, + accels, no decelsToco: quiet
11. A/PG6P4102 at 36+6 weeks with intractable headache, CHTN, Hep C concerning for atypical SI pre E with severe features (no objective evidence- normal labs 24 hr urine benign, MRI normal)Betamethasone given at 36+5Induction of Labor at midnight 37 weeks for atypical SI preE with severe features24hr Magnesium