CASE REPORT

Supervised by: dr. Arie Adrianus Polim,D.MAS, SpOG(K)

Presented by:
Belinda Anabel (2015-061-002)
Christiandi Budiman (2015-061-007)
Anastasia Limanto (2015-061-008)
Patients Identity
Name : Ms. E
Date of birth/age : December 18, 1980 / 37 years old
Ethnic : Javanese
Nationality : Indonesian
Address : Muara Baru
Education : elementary school
Marital status : married
Occupation : - (housewife)
Religion : moslem
Date of admission : February 21, 2017
Anamnesis
Chief complaint: vaginal bleeding 1 day prior to
admission
Present illness
Patient complained of sudden vaginal bleeding 1 day prior to
admission, then decided to go to the nearest primary
healthcare center and referred afterwards. Vaginal bleeding
was not heavy, only occured once, and was only blotches of
fresh red blood on the undergarments of the patient. Mucus
was present along with blood, but contractions were not
present. This was the first time vaginal bleeding happened
since the start of pregnancy. There was also a complaint of
worsening abdominal pain since 8 hours prior to admission.
Ingested medication at the time of admission, medicine taken
Anamnesis
History of past illness
No history of hypertension
No history of diabetes mellitus
No history of allergy
No history of heart disease
No history of liver disease
No history of kidney disease
No history of epilepsy

No history of hematological disease

No history of asthma
No history of surgery
No history of curettage
No history of smoking
No history of trauma
Anamnesis
Contraception history : never used
Antenatal care
Antenatal care was done 3 times at the nearest midwife from
home. The first visit was on around the second month of
pregnancy, the second around the sixth month of pregnancy,
and the third was around the eighth month of pregnancy.
There was no maternal or fetal abnormality detected one the
first visit. There was high blood pressure recorded on the sixth
month and eighth month of pregnancy, however patient was
not sure about the blood pressure measurement, only
remembered it was about 160/100. USG was not performed.
Further data cannot be completed as the patient loses her
pregnancy book, and can not remember data accurately.
Anamnesis
Menstruation history
Menarche : 14 years old
Menstrual cycle: regular cycle every 35 days, duration of 7
days, dysmennorhea (-)
Total pads : 2-3 pads (50-75 mL)
First day of last menstrual period : 16th May 2016
Marital history
Married twice:
1st marriage lasts for 14 years
2nd marriage until now (9 years)
Anamnesis
Gestational history
Gestational Birth Breast
No. Year Labor History Sex
Age Weight Feeding
Breastfed
Spontaneous Femal 2500
1 1995 34 weeks until 2.5
vaginal delivery e grams
months old
Breastfed
Spontaneous Femal 3800
2 2000 34 weeks until 2.5
vaginal delivery e grams
months old
3 Current pregnancy (40 weeks)
Physical Examination
General condition: moderately ill
Consciousness : compos mentis
Blood pressure : 140/90 mmHg
Heart rate: 100 bpm
Respiratory rate : 24 x/minute
Temperature: 36,5C
Weight : 70 kg
Height: 159 cm
BMI : 26 kg/m2 (Overweight)
General Examination
Eyes : anemic conjunctiva -/-, icteric sclera -/-
Mouth : wet oral mucosa membrane
Thorax
Heart :regular 1st and 2nd heart sounds, murmur -, gallop -
Lung
Inspection : symmetric chest expansion in both static and dynamic
breathing
Percussion : sonor on both lungs
Auscultation : vesicular breath sounds +/+ regular, rhonchi -/-,
wheezing -/-
Mammae : hyperpigmentation of areola +/+, nipple retraction -/- breast
milk -/-
General Examination
Abdomen
Inspection : convex, striae gravidarum +, linea nigra +
Palpation : supple in all abdominal region, tenderness -
Auscultation : bowel sound +, 5x/minute
Extremities
warm, edema -/-/-/-
physiological reflex +/+/+/+
pathological reflex -/-/-/-
Obstetric Examination
ANC : 3 times at midwife clinic
First day of last menstrual period : May 16th, 2016
Expected day of delivery : February 21st, 2017
Fundal height : 32 cm
Expected birth weight : (32-11) x 155 = 3255 gram
Fetal heart rate : 144 bpm
Fetal presentation : head presentation
His : 4x/10 minutes, 35 seconds each, medium intensity
Leopold I : buttocks (on right side of upper abdomen)
Leopold II : back on the right, extremity on the left
Leopold III : head
Leopold IV : divergent, 4/5
Obstetric Examination
Inspection : vulva edema -, secrete +, blood +, cicatrix -
Inspeculo : not performed
Digital vaginal examination
Vulvovagina: normal
Portio : anterior position, cervical dilatation 8-9 cm, effacement 80%, soft cervix consistency, intact
amniotic membrane, Hodge III, head presentation

Cardiotocography
Baseline : 140 bpm
Variable : normal
Acceleration : (-)
Deceleration : (+) once in 20 minutes
Fetal movement : (-)
His : (+) 3 times in 20 minutes
Result : suspicious
Laboratory Test
Hematological
Test Result Normal Values Unit
Hemoglobin 10.5 12.0 - 15.6 g/dL
Hematocrite 32 36 - 48 %
Platelet 383 165 - 415 thousands/uL
Leukocyte 18.2 3.54 - 9.06 thousands/uL
Erythrocyte 4.01 4.0 - 5.2 fL
MCV 76.6 79 - 93.3 pg
MCH 26.1 26.7 - 31.9 g/dL
MCHC 33.2 32.3 - 35.9 -
Laboratory Test
Urinalysis
Test Result Normal Values Unit
Complete Urine
Test
Glucose Negative Negative mg/dL
Protein Negative Negative mg/dL
Bilirubin Negative Negative -
Urobilinogen Negative Negative -
pH 7.0 5.0 - 9.0 -
Density 1,010 1003 - 1025 -
Occult blood + Negative -
Ketone +++ Negative mg/dL
Nitrite Negative Negative -
Diagnosis
Differential Diagnosis
Gestational hypertention
Chronic hypertention

Working Diagnosis
G3P2A0, 36 years old, gestational age 40 weeks old
according to first day of last menstrual period, in partu
active first stage, with gestational hypertension, with
single living intrauterine fetus, head presentation
Therapy
Observation of parturition
IVFD RL 500 mL + 1 amp, initial treatment is 8 dpm
then observe contractions per 15 minutes, if
contractions are inadequate, add up the dose by 4 tpm
every timem with the maximum dose of 40 dpm.
Methyldopa tab 3 x 500 mg
Delivery Report
1. Patient was positione in a lithotomy pisition, and a sterile doek was
placed in the mothers abdomen.
2. If the babys head had reached the vulva with a diameter of 5-6 cm,
place a sterile doek beneath the mothers behind.
3. Place a hand layered with sterile doek on the perineal area of the
mother, while the other hand keeping the babys deflected position
and helping the delivery of the head.
4. Guide the mother to do Valsava maneuver, breathe shortly and
quickly, checking if there is any placental cord around the babys
neck. If it is strangling the baby, put 2 clamps on the cord and cut
between the 2 clamps, then wait for the baby to do external rotation.
Delivery Report
5. After the baby did external rotation, hold the baby biparietally. Guide the
mother to do Valsava maneuver while contractions happened.
6. Gently point the head inferiorly and distally until the front shoulders
appears in the pubic arc, and then point the body part superiorly and
distally to deliver the back part of the shoulders.
7. After both shoulders are delivered, displace the helpers lower hand to
the mothers perineum to support the babys head and upper arm on
the down side. Use the upper hand to hold the upper arm on the upper
side.
8. After the body and the arms are delivered, proceed to help the delivery
of the backside, behind, extremities and foot. Dry the baby and place it
on the mothers body.
Delivery Report
9. Check if there is any other baby inside the uterus, and
give necessary medication.
10.Around 2 minutes after the delivery, clamp the
placental cord 2 cm distally from the first clamp, and
hold it with one hand.
11.Expand and the placental cord, then push it dorsally
and cranially until the placenta deattach. When the
placenta appears in the vaginal introitus, hold and
twist the placenta until the sac is separated, and
deliver it.
Final Diagnosis
Final working diagnosis
P3A0, 36 years old, post-partus maturus with spontaneous vaginal
delivery with gestational hypertension.

Neonatal diagnosis
Female term neonate, appropriate for gestational age, birth weight
2.820 grams, birth length, APGAR score 7/9, gestational age 38-39
weeks according to New Ballard Score, healthy neonate.

Placenta
Placental measurement 18 x 18 x 2 cm, intact membrane, hematoma
(-), stll cell (+), calcification (-), umbilical cord length 48 cm, marginal
implantatopm, blood 780 cc, weight 860 grams.
Post-delivery Therapy
Cefadroxil tab 3 x 500 mg
Methyldopa tab 3 x 250 mg
Methyl ergometrin tab 3 x 0.125 mg
Mefenamic acid tab 3 x 500 mg
Diet high in protein and calories
Gradual increase in mobilization
Vital sign observation
Follow-up
February 21, 2017 (16.00)
Subjective
Post partum pain VAS 2/10, no complaints

Objective
General condition: mildly ill appearance
Consciousness : compos mentis
Blood pressure : 140/100 mmHg
Heart rate : 88 bpm
Respiratory rate : 16 x/minute
Temperature : 36,5C
Follow-up
February 21, 2017 (16.00)
Assessment
P3A0, 36 years old, post-partus maturus with spontaneous vaginal
delivery with gestational hypertension.

Planning
Nifedipine as needed (if the blood pressure 140/100 mmHg)
Captopril tab 2 x 12.5 mg
Mefenamic acid tab 3 x 500 mg
Ferrous sulfate tab 1 x
Cefixime tab 3 x 200 mg
Follow-up
February 22, 2017 (05.00)
Subjective
Post partum pain VAS 2/10, no complaints

Objective
General condition: mildly ill appearance
Consciousness : compos mentis
Blood pressure : 140/100 mmHg
Heart rate : 88 bpm
Respiratory rate : 16 x/minute
Temperature : 36,5C
Follow-up
February 22, 2017 (05.00)
Assessment
P3A0, 36 years old, post-partus maturus with spontaneous vaginal
delivery with gestational hypertension.

Planning
Nifedipine as needed (if the blood pressure 140/100 mmHg)
Captopril tab 2 x 12.5 mg
Mefenamic acid tab 3 x 500 mg
Ferrous sulfate tab 1 x 300 mg
Cefixime tab 3 x 200 mg
Analysis
Comparison Theory Case
Definition New onset of blood pressure It was discovered that the patient
after 20 weeks of gestation in
had a high blood pressure about
the absence of accompanying 150/100 at her second visit to the
proteinuria. midwife, at her gestational age of
Blood pressure comes back toabout 24 weeks. For return to
normal after 12 weeks post- normal values, more time is
partum. needed to observe the patient in
the next 12 weeks.
Risk Factor Older maternal ages (> 40 Young maternal age (38 years
years old) old)
High BMI (> 29.0/30.0) Multiparity
Primiparity No renal disease, or diabetes
Renal disease mellitus
Diabetes mellitus No history of pre-eclampsia on
History of pre-eclampsia on previous pregnancies
previous pregnancy(ies)
Clinical Asymptomatic Asymptomatic
presentation
Diagnosis New onset of blood pressure New onset of blood pressure
after 20 weeks of gestation in after 20 weeks of gestation in
the absence of accompanying the absence of accompanying
proteinuria. proteinuria.
Blood pressure comes back to No thrombocytopenia
normal after 12 weeks post- No new-onset proteinuria
partum. No new-onset cerebral or visual
No new-onset proteinuria disturbances
No thrombocytopenia Liver transaminase and kidney
No elevated blood levels of liver function were not tested
transaminase to twice the Chest x-ray was not taken to
normal concentration exclude pulmonary edema
No new development of renal
insufficiency (elevated serum
creatinine greater than 1.1
mg/dL or a doubling of serum
creatinine in the absence of
other renal disease)
Management Methyldopa 0.53 g/d orally Observation of parturition
in two to three divided IVFD RL 500 mL + 1 amp
doses oxytocin, initial treatment
is 8 dpm then observe
contractions per 15
minutes, if contractions
are inadequate, add up
the dose by 4 tpm every
time (maximum dose 40
dpm)
Methyldopa tab 3 x 500
mg
Literature Review
 GESTATIONAL HYPERTENSION
Blood pressure (BP) in normotensive pregnant women
is dynamic, varying throughout the day and over the
course of the pregnancy.
Normal circadian fluctuations seen in non-pregnancy
patients = pregnant population, daily blood pressures
being lowest in the morning and peaking during the late
afternoon and evening.
Diastolic BP reaches its nadir around 1822 weeks of
gestation.
Systolic blood pressure gradually demonstrates a slight
 GESTATIONAL HYPERTENSION
In labor, blood pressure can transiently increase up to
35 mmHg systolic and 25 mmHg diastolic.
Hypertensive disorders are becoming increasingly
common in pregnancy, primarily because of the
increase in the number of patients with chronic
hypertension who become pregnant.
Gestational hypertension is characterized most often by
new-onset elevations of blood pressure after 20 weeks
of gestation, often near term, in the absence of
accompanying proteinuria. The failure of blood pressure
to normalize postpartum requires changing the
 DEFINITION
It is defined as the finding of hypertension (blood
pressure at least 140 mmHg systolic and/or 90 mmHg
diastolic) without proteinuria on at least two occasions
at least 6 hours apart after the 20th week of gestation in
women known to be normotensive before pregnancy
and before 20 weeks of gestation.
 EPIDEMIOLOGY
Prevalence between 6 and 15% in nulliparas and 24%
in multiparas.
New-onset hypertension during pregnancytermed
gestational hypertensionis followed by signs and
symptoms of preeclampsia almost half the time, and
preeclampsia is identified in 3.9 percent of all
pregnancies.
WHO : 16 percent of maternal deaths were reported to
be due to hypertensive disorders.
 CLASSIFICATION
Mild or severe
Severe : sustained blood pressure elevations of systolic
blood pressure to 160 mmHg or more and/or diastolic
blood pressure to 110 mmHg or more.
A rigorous definition of severe gestational hypertension
requires that the elevated blood pressure should be
observed for at least 6 hours.
 PATHOPHYSIOLOGY
Similar to preeclampsia
Gestational hypertension before 30 weeks frequently is severe, advances to preeclampsia,
and has a guarded perinatal prognosis.
Gestational hypertension after 34 weeks is usually a benign condition that rarely becomes
severe, progresses to preeclampsia, and results in uniformly good perinatal outcome.
Early gestational hypertension shares with preeclampsia a high incidence of poor placentation
with histologic evidence of placental ischemia and hemodynamic changes characterized by
vasoconstriction and decreased cardiac output (CO).
Late gestational hypertension occurs more frequently in obese women and in multiple
pregnancies, and the placentas do not show histologic changes consistent with ischemia.
In late gestational hypertension, the fundamental hemodynamic changes are increased
plasma volume, increased CO, and normal peripheral vascular resistance (PVR). The
fundamental problem behind early gestational hypertension is poor placentation, while late
gestational hypertension corresponds to a poor maternal adaptation to the physiologic
changes of pregnancy.
Diagnosis
Hypertension is diagnosed empirically when BP is >140 mmHg
systolic or >90 mmHg diastolic.
Previously, incremental 30 mm Hg systolic or 15 mm Hg diastolic from
midpregnancy blood pressure values had also been used as diagnostic
criteria, even when absolute values were < 140/90 mm Hg.
These incremental changes are no longer recommended criteria because
evidence shows that such women are not likely to experience increased
adverse pregnancy outcomes.
That said, women who have a rise in pressure of 30 mmHg systolic or
15 mmHg diastolic should be observed more closely because
eclamptic seizures develop in some of these women whose BP have
stayed < 140/90 mmHg.
Diagnosis
A woman must have an elevated BP >20th week of
gestation without proteinuria or other laboratory
abnormalities.
Elevated BP during pregnancy is defined as a systolic BP
>140 mmHg or a diastolic blood pressure >90 mmHg.
Women diagnosed with gestational hypertension do not
have a history of elevated blood pressure prior to the
20th week of gestation and their blood pressure
normalizes within the first 12 weeks of the postpartum
period.
Diagnosis
This diagnosis is made in women whose BP reach 140/90 mm Hg or
greater for the first time after mid pregnancy, but in whom
proteinuria is not identified.
Almost half of these women subsequently develop preeclampsia
syndrome, which includes findings such as headaches or epigastric
pain, proteinuria, and thrombocytopenia.
Even so, when blood pressure increases appreciably, it is dangerous
to both mother and fetus to ignore this rise only because
proteinuria has not yet developed.
Finally, gestational hypertension is reclassified by some as transient
hypertension if evidence for preeclampsia does not develop and the
blood pressure returns to normal by 12 weeks postpartum.
Maternal and Perinatal Outcome
Maternal and perinatal morbidity are increased in
women with gestational hypertension.
In the study of Gofton et al. (2001) induction of labor
and cesarean section in women with gestational
hypertension were almost double as those in the control
group and were similar to preeclampsia and chronic
hypertension.
However, this study did not differentiate between mild
and severe or between early and late gestational
hypertension.
Maternal and Perinatal Outcome
Barton et al. (2002) found differences in outcome
depending on ethnicity with African-American women,
exhibiting a higher incidence of placental abruption,
stillbirth, and neonatal deaths than in White women.
Also, women with mild gestational hypertension have an
increased incidence of obstetrical interventions such as
induction of labor and cesarean section.
Women with severe gestational hypertension have a
higher incidence of preterm birth and small-for-
gestational-age newborns than in those with normal
pregnancy and with mild preeclampsia.
Maternal and Perinatal Outcome
The most frequent complication of gestational hypertension is its progress to
preeclampsia that is heralded by the development of proteinuria (300 or more
mg of protein in a 24-hour urine collection or at least 30 mg/dl or 1+ in
dipstick in at least two random urine samples collected at least 6 hours, but no
more than 7 days apart).
Approximately 1525% of women with gestational hypertension develop
preeclampsia and this risk varies with the gestational age. Approximately one-
third of women with gestational hypertension present with a severe form of
the condition.
They have a substantial increase in poor maternal and perinatal outcome
when compared with normotensive women. They have increased incidence of
preterm delivery and small-for-gestational-age infants.
They also have an increased incidence of abruptio placentae and admissions
to the neonatal intensive care nursery.
Overall, their outcome is quite similar to that in women with severe
preeclampsia.
Management Initial Evaluation
Women with elevated blood pressure (140 systolic or 90 diastolic)
and no proteinuria by qualitative urine examination require an initial
evaluation to determine whether or not they are at significant risk for a
poor pregnancy outcome.
There are major and minor risk factors. The first and most important
major risk factor to be considered in such evaluation is the degree of
blood pressure elevation.
If the hypertension is severe (160 systolic or 110 diastolic) the
patient has a risk similar to a severe preeclamptic and should be
admitted to the hospital to complete her evaluation and start medical
treatment.
If the blood pressure is not in the severe range, the other components of
the initial evaluation can be assessed on an outpatient basis.
Management Initial Evaluation
Another major risk factor is the gestational age at the
onset of the disease, and the earlier the presentation,
the greater the likelihood of complications and poor
outcomes.
From the fetal side, major risk factors for a poor
outcome are the presence of fetal growth restriction and
abnormal uterine and umbilical Doppler assessment.
Minor factors include Black ethnicity, multiparity,
decreased fluid volume, and significant changes in
placental echographic morphology (grade III placenta,
infarcts).
Management - Gestational
hypertension without risk factors
Women with gestational hypertension and no risk
factors can be managed as outpatients.
The objectives of their prenatal care are the early
detection of preeclampsia and of progression of the
condition to a severe form.
They need to be instructed in the correct way to obtain
their blood pressure at home and are asked to record
their readings and bring this information to each office
visit.
They are given a blood pressure threshold, usually
systolic 150 or diastolic 100, that requires office or
hospital evaluation.
Management - Gestational
hypertension without risk factors
They also need to be instructed in the correct way to perform
qualitative examination of their urine for protein, using dipsticks,
and are asked to test the first urine voided every morning and to
call or come to the office or hospital if the result is 2+.
These women need to be instructed about how to perform daily
fetal movement counts.
No dietary restrictions are necessary and normal activities are
allowed; however, they should be excused from work if it
involves strenuous physical activities, significant stress, or
standing up for prolonged periods of time.
They should have office visits every week.
Management - Gestational
hypertension without risk factors
Performance of nonstress test (NST) is probably unnecessary if
the fetal growth and the uterine, umbilical, and cerebral fetal
Dopplers, as determined in the initial evaluation, are normal and
there is no change in the weekly clinical assessment of the
maternal and fetal condition.
The weekly assessment of patients with gestational hypertension
and no risk factors must include a systematic review of the
maternal and fetal status.
From the maternal side the review includes the levels of blood
pressure at home, the presence or absence of symptoms
suggestive of end-organ damage (blurred vision, epigastric pain),
and the presence of proteinuria.
Management - Gestational
hypertension without risk factors
From the fetal side the review includes daily charting of
fetal movements and measurement of the uterine
fundal height.
Proteinuria (2+) in a random urine sample is
diagnostic of preeclampsia.
When the proteinuria is trace or 1+ it is necessary to
send the random sample to the lab for determination of
the protein/ creatinine and calcium/creatinine ratio.
A protein/creatinine ratio > 0.30 is indicative of
preeclampsia and a value less than 0.20 rules out
significant proteinuria.
Management - Gestational
hypertension without risk factors
Patients with preeclampsia have hypocalciuria and the finding of a
calcium/creatinine ratio < 0.06 strongly suggests that this condition is
present.
The calcium/creatinine ratio in normotensive women is 0.44 0.32, in
chronic hypertension is 0.20 0.18, and in preeclampsia is 0.03 0.03.
The development of proteinuria, elevation of the blood pressure above the
threshold, decreased fetal movements, abnormal fundal growth, or
development of maternal symptoms suggestive of end-organ damage
require admission to the hospital for further evaluation and perhaps
delivery.
Patients with negative evaluations in their weekly assessment may
continue with the pregnancy until they reach 38 weeks. At this time labor
may be induced using cervical ripening agents when the cervix is not ripe.
Gestational HTN with Risk Factors
Objective:

pharmacologic control of BP

early detection of pre-eclampsia, end-organ damage, fetal decompensation

Avoid complication

Initial evaluation (repeat 1-2x/week):

24-h urine collection (check for protein)

Platelet count: if not normal check for PT, PTT, fibrinogen

LDH, liver enzyme

Gestational HTN with Risk Factors
Fetal assessment:

NST twice per week

Umbilical, cerebral Doppler weekly

Fetal movement count

BP should not exceed 150/100

If BP exceed 160 / 110 : require anti-hypertensive,
beta-blocker, diuretic
 Beta-blocker:

Labetalol 3-4x/day (600-2400 mg/hr)

Diuretic
Furosemide: 20-40 mg every 6-12 hr

Hydrochlorothiazide: 25-50 mg daily

Termination of pregnancy if HTN is uncontrolled or there is

evidence of end-organ damage, abruptio placentae, arrest of
fetal growth
Management - Delivery
Gestational hypertension is not by itself an indication for cesarean
section except in severe cases unresponsive to treatment or with fetal
growth restriction before 32 weeks.
Women with gestational hypertension who develop preeclampsia should
be managed as described under preeclampsia.
The route of delivery in women with severe gestational hypertension who
require delivery depends on the results of the digital pelvic examination
and on the cervical length by endovaginal ultrasound examination. If the
cervix is unripe and the cervical length is 2.5 cm it is better to deliver
by cesarean and avoid a prolonged induction.
If the cervix is ripe vaginal delivery will be the best option. For women
with mild gestational hypertension delivered after 37 weeks, induction of
labor and vaginal delivery will be the first choice.
Figure 2. Management of gestational hypertension