Case Summary Hypertension In Pregnancy Health And Social Care Essay

Case Summary Hypertension In Pregnancy Health And Social C ar EssayMdm. SM is a 30-year-old Malay female of large(predicate)a 5 parity 3+1 who is at 37 weeks and 5 brassreal days of motherhood. She was diagnosed to have hypertension in maternalism during antenatal bite fol upset-up in Klinik Kesihatan Simpang Renggam at 36 weeks and pre-eclampsia ( stock certificate embrace 160/100mmHg, water dipstick albumin 1+) 3 days in the beginning admission. She was admitted to infirmary Kluang and started on Tab. methyldopa 250mg TDS. She was advised for induction of drudge in view of preeclampsia at term and she requested to be transferred to hospital Batu Pahat (HBP). She did non have whatever(prenominal) signs and symptoms suggestive of surd preeclampsia or labour. During admission to HBP, tablet prostin 1.5mg was inserted into the posterior fornix twice to induce labour precisely there was no change in cervical os and symptoms of labour. Decision was made to try artifica l rupture of membranes. However, following the procedure, inseparable monitoring detected foetal distress and as unwritten delivery was non imminent, Mdm. SM was agreeable for tinge lower section caesarean section under general anaesthesia. A healthy infant boy was delivered (weight 2.9kg, Apgar score 91105) and there were no intra or post- shamus complications. Following the surgery, both m some other and infant were well in the ward. Mdm. SM was ambulating and tolerating orally and by the 2nd post-op day, both had passed urine and motion. contuse inspection on day 2 showed clean, non-gaping affront. As she was well, decision was made to discharge her and she was addicted appointment to review her blood blackjack and operative lesion at the postnatal clinic at KKSR. On discharge, her blood force per unit area was cxl/70mmHg (without medication) and urine dipstick albumin was trace. Analgesia given on discharge were mefenemic acid and paracetamol. educatee comprise capi tal of Minnesota Kong Fu-Xiang ID NO M0508129 score OF SUPERVISOR Dr. Sharifah Sulaiha ROTATION Obstetrics gynecologyPATIENTS DETAILSI/C NUMBER 800318015794 AGE 30SEX womanly DATE OF ADMISSION 20/6/2010R/N 13585932) CLINICAL HISTORYChief ComplaintElevated blood pressure detected in maternity at 36 weeks of gestation. news report of Present IllnessMdm. SM is a 30-year-old Malay female of gravida 5 parity 3+1 who is soon at 37 weeks and 5 days of gestation. She was referred to hospital Kluang from Klinik Kesihatan Simpang Renggam (KKSR) for proud blood pressure detected on routine antenatal follow-up and ulteriorly transferred to Hospital Batu Pahat (HBP) for induction of labour in view of her development of high blood pressure in pregnancy. Her elevated blood pressure was start-off detected during her routine antenatal follow-up at Klinik Kesihatan Simpang Renggam 10 days before admission to HBP. During this visit, her blood pressure was recorded as 150/90mmHg and she alike complained of slight two-sided swelling of her feet but otherwise had no other complaints. The feet swelling resolved after 3 days. Throughout the next 7 days, she went to KKSR every alternate day for monitoring and 3 days before admission to HBP, her blood pressure was noted to be 160/100mmHg with presence of albumin 1+ on urine dipstick that was previously not present. She was immediately given tablet labetolol 100mg and admitted to Hospital Kluang where she was subsequently started on tablet methyldopa 250mg 8-hourly. Three days after admission to Hospital Kluang, she was advised by the doctor to undergo induction of labour and she thus requested to be transferred to HBP so her family members in Batu Pahat could take care of her. During the course of these events, she did not experience shortness of breath, judgementache, blurring of vision, epigastric pain, seizures, abdominal pain, vaginal bleeding, nausea, vomiting, palpitations, or recurrence of the foot swelling. At time o f admission, she did not experience contraction pain, show, leaking of liquor. Fetal movements were good.systemic ReviewMdm. SM did not have fever. Her appetite was good and her urinary and bowel habits were normal. Her sleep was unaffected.Antenatal HistoryThis was an unplanned but wanted pregnancy. Mdm. SM realized she was pregnant when she missed her period, of which the last was 28/12/09. She bought a pregnancy test kit and it tested positive. She subsequently did her booking at KKSR at 7 weeks of period of amenorrhoea. At booking, her blood pressure was 120/80mmHg, hemoglobin 13.4g/dL, sugar undetected, and urine albumin negative. Infective screening was negative and blood fount O positive. Her expected due date was given as 14/8/10. During follow-up 1 month previous(a)r, she had her first ultrasound scan which run aground her uterus to be larger than dates. Her due date was revised to 6/7/10. Modified glucose tolerance test d one and only(a) twice during pregnancy were nega tive. She go through morning sickness and vomiting during the first 3 months of pregnancy but it was not implike and she could cope without medication. Throughout the pregnancy, she was diagnosed to have urinary tract transmittal twice and was treated with antibiotics. A further 3 ultrasound scans were done and all were normal. She was also compliant to the supplements given throughout pregnancy. thither were no other problems during the antenatal follow-up until the detection of elevated blood pressure 10 days before admission to HBP.Past Obstetric HistoryThis is her fifth pregnancy and her last childbirth was in 2008. She has 3 children, 2 boys and a girl, of whom all were born via vaginal delivery at postdate after induction of labour. give birth weights ranged from 2.7 to 3.0kg, all are healthy with no complications and were breastfed. However, during her 3rd pregnancy, she suffered a miscarri jump on during the 12th week and dilatation and curettage was performed during tha t admission.Gynae Menstrual HistoryMdm. SM achieved menarche at the age of 12. Her menstrual cycles have always been regular with 28 days per cycle and 5 to 7 days of flow. She does not experience menorrhagia or dysmenorrhoea. She has never had a cervical smear done and has never used oral contraceptive pills. She has not required medical exam attention for any gynecologic problem.Past checkup HistoryMdm. SM has never been diagnosed with any chronic disease such as diabetes, hypertension, and asthma before. She has also never been admitted for non-pregnancy related reasons. She also does not have any known food or drug allergies.Family HistoryMdm. SM is the eldest of three siblings. Her youngest sister also had gestational hypertension. Her preceptor has hypertension and her mother had diabetes, but passed away 2 years ago due to tuberculosis. All family members have been screened and all tested negative for tuberculosis.Social HistoryMdm. SM is now a housewife. She formerly wor ked in a factory but decided against returning to work following her last pregnancy in 2008 for her childrens benefit. She is a non-smoker and does not consume alcohol. Her husband is a short-haul lorry driver and smokes, but tho outside their home. They live somewhat off Kluang, and it takes them slightly everyplace an hour to reach HBP, and 15 minutes to reach KKSR.STUDENT NAME Paul Kong Fu-Xiang ID NO M0508129NAME OF SUPERVISOR Dr. Sharifah Sulaiha ROTATION Obstetrics Gynaecology3) FINDINGS ON CLINICAL EXAMINATION(Mdm. SM was examined by me on the 2nd day of admission)Mdm. SM was alert, conscious and cooperative. She was not in any pain or distress. She was sit down comfortably on her bed. On examination, there was no pallor, jaundice or pedal edema. Her reflexes were not b pretend. Her clinical parameters areBlood Pressure 124/80 mmHg heart and soul Rate 95 beats per minute. Regular rhythmRespiratory Rate 20 breaths per minuteTemperature 37CExamination of the cardiovasc ular system, respiratory system, fundus, thyroid and breasts were normal.On examination of the abdomen, it was distended with gravid uterus as evidenced by linea nigra, and striae albicans. There was no striae gravidarum, scars, or pulsations noted. On palpations, the abdomen was soft and non-tender, uterus non-irritable, and fetal parts felt. The symphysio-fundal height was 36cm, which corresponds to dates. On examination, this is a singleton fetus at longitudinal lie with cephalic presentation, with the fetal back on the maternal left. The fetal head was four fifths palpable. Estimated fetal weight is 2.8 to 3.0kg. Liquor is adequate. Fetal heart was heard and the rate was 142 beats per minute.Vaginal examination (by medical officer on admission) revealed no perineal, vulval or vaginal abnormalities. Cervical os was 1 cm with cervix tubular, soft and axial, station high and membrane intact. Bishops score was 3/10.STUDENT NAME Paul Kong Fu-Xiang ID NO M0508129NAME OF SUPERVISOR Dr . Sharifah Sulaiha ROTATION Obstetrics Gynaecology4) PROVISIONAL AND DIFFERENTIAL DIAGNOSES WITH REASONINGProvisional DiagnosisPreeclampsia in pregnancyMdm. SM developed new onset elevated blood pressure of 160/100mmHg at 36 weeks of gestation and urine dipstick albumin of 1+ (300mg/L). This fits the minimum requirement of preeclampsia among the hypertensive diseases in pregnancy. However, Mdm. SM did not experience any symptoms to suggest a severe preeclampsia or be eclampsia such as headache, visual disturbances, epigastric pain, vomiting, liver tenderness. The urine dipstick for albumin is not the best way to detect proteinuria required for the diagnosis of preeclampsia 3 and is usually only used for screening, but as the blood pressure and urine albumin were persistently elevated, it is better to err on the side of caution and treat Mdm. SM as such since unhurrieds with relatively mild preeclampsia can rapidly further into severe disease 1. Following the perennial positive detection of urine albumin of only 1+, more definitive tests should be performed to better quantify her proteinuria 2,3.Differential DiagnosisPregnancy-induced hypertension, late onsetAs Mdm. SM has been compliant to her antenatal follow-ups and did not have elevated blood pressure detected at any time before 36 weeks of gestation, it is likely that she has developed the onset of a hypertensive disease in pregnancy and it appears to be of late onset as it developed only after 32 weeks gestation. However, as subsequent visits showed urine dipstick albumin of 1+, indicating the onset of proteinuria (although poor predictive value and not as evidential as 2+) 3, it might prove wiser to be more vigilant and assume that Mdm. SM does indeed have preeclampsia as it would be anserine to dismiss these warning features despite the fact that she does not demonstrate any suggestive symptoms because it is possible that even patients with no prodromal signs may suddenly progress into eclampsia 1,3.Essential hypertension in pregnancy with superimposed preeclampsiaAnother possibility that we may entertain is that Mdm. SM has had previously undiagnosed essential hypertension with currently superimposed preeclampsia. However, this seems quite an unlikely. Firstly, Mdm. SM is young at the age of 30 and unlikely to suffer from essential hypertension as this disease viridity presents after the age of 40. Secondly, at no time throughout antenatal follow-up did she have elevated blood pressure recorded before that bad-tempered visit at 36 weeks of gestation. However, following delivery of her infant, she should have her blood pressure re suppressed during postnatal follow-up care at 6 to 12 weeks post-delivery. If her blood pressure if still elevated at that time, then it will be more likely that she has essential hypertension.STUDENT NAME Paul Kong Fu-Xiang ID NO M0508129NAME OF SUPERVISOR Dr. Sharifah Sulaiha ROTATION Obstetrics Gynaecology5) IDENTIFY AND PRIORITISE THE PRO BLEMS1. Elevated blood pressure and its implications in pregnancyMdm. SM has newly discovered elevated blood pressure at 36 weeks of gestation. This is considered late onset but is not uncommon, and gives rise to a spectrum of hypertensive disorders in pregnancy. While it seems that at first she has gestational hypertension, the mildest of the disease spectrum, she demonstrated proteinuria on her subsequent antenatal visit, therefore concluding that she has preeclampsia. Hypertensive disorders in pregnancy have the potential to roll both mother and infant at amplifyd stake of mortality. Its complications are elaborated below. During admission, Mdm. SM should be monitored for any change in her condition as she may quickly progress into severe disease states and this would require urgent intervention, the most definitive being the delivery of the infant. Ward management includes close note of both mother and infant, and medication to control the elevated blood pressure.2. facilit y of labour in view of preeclampsia at termTermination of the pregnancy is the only definitive sure for preeclampsia. On presentation, Mdm. SM has features categorized as mild preeclampsia. Normally, severe preeclampsia would dictate the need for antihypertensive and anticonvulsive therapy followed by subsequent delivery and symptoms such as headache, epigastric pain, and visual disturbances may indicate this. The fetal age is usually an important deciding factor when it comes to inducing labour as the treatment goals seek the best outcome for both mother and infant. As Mdm. SM is already at term and there have been no issues previously detected regarding the health of her fetus, it should be safe to proceed with induction of labour. There is also no reason to prolong the pregnancy as the assay of eclampsia increases. If for any reason an obstetric reason arises e.g. fetal distress, delivery should proceed via caesaren section.3. Impending eclampsia and other potential complication sWarning signs and symptoms of impending eclampsia or severe preeclampsia include headache, visual disturbances, epigastric pain, reduced urine output, edema and ultimately, convulsions. These symptoms should be recognized early so the necessary intervention can take place. Seizures increase the risk of maternal and perinatal morbidity and mortality rates. Some maternal complications are placenta abruption, neurological deficits, aspiration pneumonia, pulmonary edema, cardiopulmonary arrest, and acute nephritic failure. different major complications that may occur as a result of severe preeclampsia are HELLP syndrome, pulmonary embolism and stroke. Fetal complications include growth restriction, fetal distress, and death.4. Risk of post-partum eclampsiaIt is possible for eclampsia to occur in the postnatal period especially when the patient has reached term. In such cases, up to 44% of eclampsia occurs postpartum 3. As the risk is quite high, Mdm. SM should continue to be monitor ed in the ward for the development of any signs and symptoms. As she is comfortable and relatively symptom free while in the ward, it appears unlikely that she may worsen into an eclamptic state but the risk should not be afforded. As there are no guidelines to suggest an optimum postpartum inward observation period, it would depend on her clinical situation during the subsequent days following her delivery.5. Hypertension in pregnancy and its long term implicationsAs Mdm. SM has developed preeclampsia during this pregnancy, she is at increased risk to develop hypertensive or metabolic complications in future pregnancies. The risk of recurrence is in the main higher in earlier onset preeclampsia. At the same time, she should be evaluated in the postpartum period for the possibility of essential hypertension at the 6 week postnatal review. Also, women with preeclampsia are at an increased risk for developing hypertension, diabetes, hyperlipidemia, chronic renal disease, stroke and i schemic heart disease. Mdm. SM should be made aware of all these implications and should be educated on how she can prevent these via the modification of her lifestyle. She should also be advised to attend preconceptual counseling in the event of a future pregnancy and to come early for booking.STUDENT NAME Paul Kong Fu-Xiang ID NO M0508129NAME OF SUPERVISOR Dr. Sharifah Sulaiha ROTATION Obstetrics Gynaecology6) PLAN OF INVESTIGATION, JUSTIFICATIONS FOR THE SELECTION OF TESTS OR PROCEDURES, AND INTERPRETATION OF RESULTS1. water supply Dipstick for AlbuminTo look for the presence of albumin in the urine firstly, to confirm proteinuria, and secondly, to evaluate the severity of the preeclampsia. Urine dipstick for albumin should be repeated daily in the ward. Also, if in doubt, further investigation to quantify proteinuria can be done e.g. urine protein/creatinine fleck test 2,3.Results Urine dipstick albumin on admission was trace. Results at KKSR showed 1+.Interpretation This res ult could be due to the fact that the blood pressure has displace as Mdm. SM has been started on methyldopa and her blood pressure is under control. This does not mean that she no longer has preeclampsia. She should be checked daily for any changes in both blood pressure and proteinuria.2. Full Blood CountTo look for anemia which may require correction, haemoconcentration which may indicate severe preeclampsia 1, and platelet levels as HELLP syndrome is a complication that may arise in preeclampsia. This may also serve as baseline in case operative procedures are required.Result TWBC 12.0 x109/L (neutrophils 8.20, lymphocytes 2.70)Hemoglobin 10.7 g/dL Hematocrit 32.3% Platelets 354 x 109/LInterpretation The total white cell count is slightly raised, but this is to be expected in pregnancy. The hemoglobin is slightly low but this is also expected in pregnancy and should be monitored especially if the patient requires surgery or experiences anemic symptoms. There is no haemoco ncentration and the platelets are normal.3. Prothrombin Time, INR, Activated Partial Thromboplastin Time (PT/INR/APTT)To obtain a baseline of the clotting profile in case operative procedures are required and also to look for potential coagulopathy as it is a possible complication of preeclampsia.Result PT 12.3s INR 1.05 APTT 39.6sInterpretation PT/INR/APTT is within normal range. Coagulopathy appears unlikely in Mdm. SM given that her platelets are also normal and her preeclampsia is not severe.4. Renal visibilityTo assess renal functions to look for elevation of creatinine as that would indicate severe preeclampsia and also to detect acute renal failure which is associated with increased risk of HELLP syndrome, placenta abruption and postpartum hemorrhage 1.Result Urea 1.3mmol/L Sodium 140mmol/LPotassium 3.7mmol/L Creatinine 51mol/LInterpretation Mdm. SM renal profile is normal and creatinine is not elevated, adding to the indicators that her preeclampsia is of the mild ca tegory. Low urea levels and good urine output also rules out acute renal failure.5. liver-colored Functions TestTo assess liver functions and its components such as liver enzymes and bilirubin which would be raised in severe preeclampsia or HELLP syndrome in which there is hemolytic anemia and elevated liver enzymes.Result Total protein 73g/L Albumin 33g/L Globulin 40g/LTotal bilirubin 0.5mg/ml reign bilirubin 0.2mg/ml Indirect bilirubin 0.3mg/mlALP 121U/L ALT 7 U/L GGT 7 U/LInterpretation Liver enzymes (ALT) and bilirubin levels are not elevated, indicating a mild preeclampsia and no biochemical evidence of HELLP syndrome. The ALP is slightly elevated, but this could be due to compression of the gravid uterus on the hepatobiliary tree.6. Serum Uric AcidElevated serum uric acid is an early biochemical sign of preeclampsia 1 and may help to predict maternal complications in preeclampsia 4.Results Serum uric acid 103mol/L Interpretation Serum uric acid levels are not eleva ted and are in fact, slightly lowered. This result indicates low likelihood of severe preeclampsia or maternal complications.7. Serum Lactate DehydrogenaseTo check for elevated levels which should indicate hemolytic anemia, a component of HELLP syndrome.Results Not done during this admission.8. Cardiotocograph (CTG)Done on admission as a baseline for fetal monitoring.Results service line fetal heart rate was 130 beats per minute, baseline variability was 5 10, accelerations present with no decelerations.Interpretation CTG is excited with no signs of any fetal compromise. CTG should be repeated following each procedure e.g. prostin insertion, AROM or if fetal compromise is suspected.9. Transabdominal UltrasonographyThis should be done to confirm fetal age, as hinderance of fetal age is important when it comes to deciding whether or not to induce labour in preeclampsia. Also to check for fetal well-being and growth restriction, but these requires repeated scans and plotting of grow th chart over a period of time.Result No ultrasonography was done during this admission. The last scan was done in Hospital Kluang before patient was transferred to HBP. The last scan reports fetal age corresponding to dates, AFI of 9, and no abnormalities detected with no mention of other findings.Interpretaion As fetal age is corresponding to dates and there is no suggestion of fetal compromise or restriction, it is safe to proceed with induction of labour.10. Urinalysis (UFEME)To check the levels of proteinuria which may be more quantitative than urine dipstick.Results Leukocytes, nitrite, protein, glucose, ketone, urobilinogen, and bilirubin were not detected.Interpretation No proteinuria was detected. This could mean that the patient does not have preeclampsia but rather gestational hypertension, or it could be undetected as the blood pressure has also become well controlled with medication. However, no risks should be taken and Mdm. SM should be closely observed in the ward. Either way, induction of labour and delivery would still be ideal for her as she has already reached term.STUDENT NAME Paul Kong Fu-Xiang ID NO M0508129NAME OF SUPERVISOR Dr. Sharifah Sulaiha ROTATION Obstetrics Gynaecology7) WORKING DIAGNOSIS AND PLAN OF MANAGEMENT ON ADMISSIONWorking DiagnosisInduction of labour at term in view of mild preeclampsia in pregnancyComment As Mdm. SM has elevated blood pressure and urine dipstick albumin 1+ but has no physical or biochemical features suggestive of severe preeclampsia, the working diagnosis is mild preeclampsia. However, she should be monitored closely in the ward for any symptoms indicative of disease development. As she has reach term, it would also be wise to induce labour in her, especially given her history of postdates as delivery would be the only definitive management in such cases.Plan of management on admissionContinue T. Methyldopa 250mg 8-hourlyDaily urine albumin dipstickVital signs monitoring 4-hourlyBaseline cardiotocog raph on admissionFetal kick charting andLabour progress chartingTo notify immediately if spontaneous rupture of membranesTo notify immediately if strong contractions commenceEncourage orallyFor induction of labour with T. Prostin 1.5mg as Bishops score unfavourableTo notify immediately if any symptoms occurSTUDENT NAME Paul Kong Fu-Xiang ID NO M0508129NAME OF SUPERVISOR Dr. Sharifah Sulaiha ROTATION Obstetrics Gynaecology8) SUMMARY OF INPATIENT PROGRESS (INCLUDING MAJOR EVENTS, reposition OF DIAGNOSIS OR MANAGEMENT AND OUTCOMES)Throughout the first two days of admission, Mdm. SM was comfortable in the ward with no development of any symptoms of severe preeclampsia, eclampsia, or labour. Her vital signs were stable with blood pressure ranging 122-138/70-84. On the morning of the 2nd day, tablet prostin 1.5mg was inserted into her posterior fornix under aseptic technique. Cardiotocograph was reactive and vaginal examination 6 hours post-insertion showed cervical os 3cm, cervix 2cm, soft and axial, and high station. Therefore, a 2nd tablet of prostin was inserted on the morning of the 3rd day. Once again, post-insertion cardiotocograph was reactive and vaginal examination 6 hours later showed no changes to before. Mdm. SM still did not experience any signs and symptoms of labour. She also did not have any symptoms indicating progression of her preeclampsia. On the morning of the 4th day, it was decided that Mdm. SM should undergo artifical rupture of membranes (AROM) rather than have a 3rd prostin tablet inserted. Cardiotocograph monitoring had been difficult so decision was made to insert fetal scalp electrode at the same time for internal monitoring. Following the AROM, internal monitoring revealed a drop of fetal heart rate from 130 to 100 beats per minute with no accelerations. Cervical os was still 3cm with no symptoms of labour. Decision was made to proceed with emergency lower section caesarean section (ELSCS) under general anaesthesia and Mdm. SM gave h er consent. Via ELSCS, a healthy baby boy was delivered weighing 2.9kg with Apgar score of 91105. There were no intra or post-operative complications. Post-operative medications given include IV ampicillin 500mg QID, subcutaneous heparin 5000 units BD, IV pitocin 40 units QID, IM pethidine 50mg PRN, Tab. paracetamol 1g QID and Tab. Mefenemic acid 500mg TDS. Throughout the next 2 days, Mdm. SM was comfortable in the ward and had mild operative site pain with no other symptoms and vital signs were stable. All medications except analgesia were stopped. She was ambulating well, tolerating orally and had passed urine and motion by the 5th day. As for the baby, breastfeeding had commenced and he had also passed urine and motion. The uterus was well contracted at 22 weeks size and dressing was not soaked. Inspection of the wound on the 6th day revealed a clean and non-gaping wound. She was counseled on contraception and indicated a gustatory modality for intrauterine contraceptive device. As she was well, she was fired with appointment to return to postnatal clinic at KKSR to review her blood pressure and operative wound in 1 weeks time. On discharge, her blood pressure was 140/70mmHg and urine dipstick albumin was trace.STUDENT NAME Paul Kong Fu-Xiang ID NO M0508129NAME OF SUPERVISOR Dr. Sharifah Sulaiha ROTATION Obstetrics Gynaecology9) DISCHARGE PLAN, COUNSELLING AND MOCK prescription drugDischarge PlanTab. Mefenemic acid 500mg TDS PRNTab. Paracetamol 1g QID PRNFollow-up appointment at Klinik Kesihatan Simpang Renggam (KKSR) Postnatal clinic in 1 week to review blood pressure and operative wound.Follow-up appointment at KKSR in 6 weeks for review, cervical smear, and contraception.Counseling conscious to return immediately to the hospital if Mdm. SM has problems with the caesarean wound e.g. pain, discharge or if she develops any new or worrying symptoms. talk over on the need to be compliant to postnatal follow-up to review Mdm. SMs condition.Advised for cervi cal smear during postnatal follow-up as previously never done.Counseling regarding breastfeeding and contraception.Explain about the nature of pregnancy-related hypertensive disorders and its long term implications.Advised to attend antenatal clinic for preconceptual counseling if future pregnancy is desired, or to come for booking immediately once discovered to be pregnant.Advised to observe a healthy lifestyle in order to prevent development of conditions such as hypertension and diabetes.Mock PrescriptionTab. Paracetamol 1g QID PRN x 1/52Tab. Mefenemic acid 500mg TDS x 1/52STUDENT NAME Paul Kong Fu-Xiang ID NO M0508129NAME OF SUPERVISOR Dr. Sharifah Sulaiha ROTATION Obstetrics Gynaecology10) REFERRAL LETTER (IF APPLICABLE)Medical Officer,Postnatal Clinic,Klinik Kesihatan Simpang Renggam,86200, Simpang Renggam. 20th June 2010Mdm. SM (IC.800318015794)Date of admission 20th June 2010, Date of discharge 25th June 2010Problem Late onset hypertensive disease in pregnancyDear medical o fficer,Mdm. SM is a 30-year-old Malay lady of parity 4+1 who was diagnosed to have preeclampsia at 36 weeks of gestation during routine antenatal follow-up at your centre. During admission to our ward, she underwent induction of labour with tablet prostin and artificial rupture of membranes. However, fetal distress developed, picked up on internal monitoring and Mdm. SM underwent emergency lower section caesarean section under general anaesthesia. She delivered a healthy baby boy (2.9kg, Apgar 91105) with no complications intra- and post-operatively. We are discharging her into your care. Please review her blood pressure as scheduled and also offer contraception and cervical smear as previously never done. She has indicated preference for intrauterine contraceptive device. Do not hesitate to contact us immediately should the need arise. Thank you very much for your attention.Yours sincerely,Paul Kong Fu-Xiang (Final year medical student, IMU),Department of Obstetrics Gynaecology, H ospital Batu Pahat.STUDENT NAME Paul Kong Fu-Xiang ID NO M0508129NAME OF SUPERVISOR Dr. Sharifah Sulaiha ROTATION Obstetrics Gynaecology11) LEARNING ISSUES IN THE 8 IMU OUTCOMES1. Disease prevention and health promotionHypertensive disorders in pregnancy are one of the most common antenatal problems and eclampsia is a major ancestry of maternal mortality. What are the ways in which some element of prevention can be instituted or to decrease the severity of preeclampsia?There harbour been certain strategies touted to prevent or modify the severity of preeclampsia. These are categorized as dietary supplements, antihypertensive medications, antioxidants, and antithrombotic agents 5. As low salt diet is one of the recommended dietary changes for hypertensive patients, De Snoo et al 1 was one of the earliest researchers to study the effects of low salt diet in preventing preeclampsia but this recital was discarded as it yielded no significant change. Knuist et al performed a randomiz ed controlled trial in 1998 and they reported that despite helping control blood pressure in non-pregnant individuals, a sodium-restricted diet was ineffective in 361 women in terms of prevention of preeclampsia 6. The dietary supplementation of calcium of at least 1 gram per day is recommended as class I-A evidence 2. Several studies showed that women with low calcium diets were at significantly increased risk of gestational hypertension 7,8,9. Levine et al performed a large, randomized-controlled trial and they found that there was no significant difference in outcome with calcium supplements versus placebos 10. This suggests that unless a pregnant woman has a low calcium intake, calcium supplements may have no added benefit 5. With regards to fish oil supplements and its cardioprotective fatty a