NEESHANTHI SUNDARESON 012012100240

KRISHNA RAO A/L LETCHUMANAN - 012012100251

PATHMASHALINI A/P TIAGARASU - 012012100031
NASYRAH BT ISKANDAR 012012100229
ATHINA NASHRAH BINTI ABDULLAH- 012012100001
DEVINA DEVI GUNALAN - 012012100023

History taking
By, Neeshanthi Sundareson
012012100240

PATIENT IDENTIFICATION

Name : Jamuna Devaraj

Age
: 25 years old
Sex
: Female
Race
: Indian
Status : Married
Occupation: Staff nurse at Mediviron clinic
Residence : Kapar, Klang

PATIENT IDENTIFICATION (cont..)

Gravida : 2
Parity : 0
Abortion : 1
LMP
: 21ST March 2014
EDD
: 28TH December 2014
POA
: 29 weeks
Date of admission : 13th October 2014
Date of clerking : 16th October 2014

Chief complain
Referred case from Mediviron clinic to Htar
due to severe headache for one day at 29
weeks of period of gestation.

History of presenting illness

On 12th October, patient undergoes an onset of
severe headache.
She experienced the pain on the frontal lobe of
her head.
She complained of fatigue due to the headache.
She went to Mediviron clinic for consultation and
was given nifedipine .
She was then referred to emergency department
of Hospital Tengku Ampuan Rahimah and to be
kept under observation .

History of presenting illness (cont..)

Modified Oral Glucose Tolerance Test (MOGTT)
was done. Her glucose level was 9 mmol/l.
She also had her blood pressure to be checked.
Her pressure was 145/100 mmHg
She had mild relief after given paracetamol and
mefenamic acid.
She denied of having labour pain, leaking of
the liquor and any vaginal discharge.
She is now in diet controlled and is on insulin
therapy with 12 units twice daily on week 29.

History of presenting pregnancy

1st trimester ( week 1-12)
This is her second pregnancy.
Pregnancy was detected by:
* missed period
* conducted urine pregnancy test two days after her
missed period and shows positive result
Minor ailments : vomiting before eating.
She had to eat on time to avoid vomiting.
Weight : 60kg.
Height : 152 cm
Confirmation of pregnancy Klinik Kesihatan Kapar
At 6th week of pregnancy.

Booking :
1) Early dating ultrasound was done and confirmed her
pregnancy at 6th week of period of gestation.
2) Hematological test
i.
blood type: B
ii. Hb level : 10.0 g/Dl
iii. VDRL / HIV / HEPATITIS B / SYHPHILIS: negative
3) Urine test
i. Glucose : 9mmol/L
ii. Albumin : nil
She was diagnosed with gestational diabetes mellitus after
being tested with Modified Oral Glucose Tolerance Test
(MOGTT)

History of presenting pregnancy

2nd trimester ( week 13-28)
Quickening was felt at 20 weeks of gestation.
Tetanus toxoid immunization was given
She had her ANC visit 2 week once due to her
gestational diabetes mellitus and always regular for the
check up.
She was advised to control her diet and no medication
was prescribed.
Gender of the baby was known at week 20 during the
ultrasonography scan.
Anomaly scan was normal.
She had constipation at 20th week of gestation and
enema was taken when necessary.

History of presenting pregnancy

3rd trimester (week >28 )

Fetal movement : >10 / day

Growth of the fetus is normal
No complications detected.
Minor ailments: frequent micturition
Weight : 70 kg

Past obstetrical history

Obstetrical score G2P0A1
G

YEAR

PREGNANCY

LABOUR

2013

SPONTANEOUS
D&C
MISCARRIAGE AT
8TH WEEK

2014

PRESENT
PREGNANCY

PURPERIUM

BABY

REMARK

Menstrual history
She attained her menarche at the age of 13.
her menstrual cycle is 3 days in duration and
28 days in cycle length.
There is no clots during her menses and she is
sure of her last menstrual period.
She did not use any form of contraception.

Gynecological history
She has no history of sexually transmitted
infections (STIs)
She also denied of presence of any abnormal
abdominal mass, any vaginal discharge and
abnormal bleeding.

Past medical history

She has no history of diabetes mellitus,
hypertension, renal disease, heart disease,
tuberculosis and UTI.

Past surgical history

She undergoes scope for D & C ( dilation and
curettage procedure)
She had giddiness due to blood loss.

Drug history
She takes 12 units of insulin twice a day
In the morning and night

Family history
Her father and her grandmother (fathers
mother) has diabetes mellitus.
Her husband has no diabetes mellitus.
There is no family history of hypertension in
her family.

Diet history
Patient is a non vegetarian. She loves to eat
ice cream and pastry.
Now she is on strict diet and tried to avoid
food with high sugar content.

Social history
Patient lives with her husband and 5 other
family members.
She is non smoker , non- alcoholic. There is no
history of drug abuse.
Her monthly income is around RM 3000.

PHYSICAL
EXAMINATION
Pathmashalini A/P Tiagarasu
012012100031

GENERAL EXAMINATION

Patient lying comfortably in supine position assisted with

one pillow
Conscious, alert and well oriented with time, place and
person
Average built, not fully flanked abdomen and well
nourished

Vital parameters

Temperature
: 36.8 degree Celsius
Pulse rate : 95 beats per minute
Blood pressure
: 145/100 mmHg
Weight
: 60kg
Height
: 152cm
BMI
:

Face
o Has chloasma
Eyes
There is no pallor and no yellowish sclera, meaning no
icterus
Mouth
Hydration status is adequate
Good oral hygiene
No angular stomatitis
No glossitis
Neck
Carotid pulse is felt and there is no JVP raise
No thyroid or lymph node enlargement
Leg
No edema during the examination, but according to
patient, she gets edema when she walk and stands too
long
Varicose vein present since 2010, but no pain.

SYSTEMIC EXAMINATION

Cardiovascular examination
Inspection
Chest wall move symmetrically with respiration.
Palpation
Apex beat was located at 5th intercostal space left
midclavicular line. No heave and thrill.

Auscultation
S1 and S2 heard and no murmurs

Respiratory examination
Inspection
Chest wall move symmetrically with respiration and not in respiratory
distress
Palpation
Trachea was centrally located.

Normal chest expansion and tactile vocal fremitus.

Percussion
Resonance

Auscultation
Air entry is equally bilateral and normal vesicular breath sound heard.
There were no rhonchi heard.

OBSTETRIC EXAMINATION
Inspection
Abdomen is distended by gravid uterus as evidenced
by linea nigra and striae gravidarum and striae
albicans. The umbilicus is centrally located and
flattened, flank is not full. There is no scars and foetal
movement is prominent.
Palpation
On superficial palpation the abdomen is soft and non
tender.
Clinical fundal height : 30 weeks
Symphysio fundal height :16 cm

LEOPOLD S maneuvers
1. fundal grip- there is a broad soft irregular mass at
the left side suggestive of fetal breech
2. lateral grip
Right lateral grip - there are small knob like
structure suggestive of fetal limbs
Left lateral grip - there is smooth curved resistance
suggestive of fetal back
3. 1st pelvic grip - There is ballotable smooth hard
globular mass suggestive of fetal head
4. 2nd pelvic grip - Confirms the 1st pelvic grip

Auscultation
Fetal heart rate 130 beats per minute heard along
the spinoumbilical line.
Summary
This is case of Mrs.Jamunah Devaraj at the 29th
week of gestation. Height of fundal is 29 weeks,
symphysio fundal height 16 cm with singleton fetus
on longitudinal lie in cephalic presentation head is
not engaged. The liqour amnii amount is adequate,
fetal heart rate 130 beats per minute and estimated
weight of the fetus is 4433 grams and no labor pain.

KRISHNA RAO LETCHUMANAN

012012100251
PRESENTING:
PROVISIONAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS.
INVESTIGATION
MANAGEMENT

PROVISIONAL DIAGNOSIS
Madam Jamuna Devaraj, 25 years old
with gravida-2 parity-0 abortion-1 at 29
weeks of POA and EDD at 28Th Dec
2014 with singleton fetus diagnosed
with Gestational hypertension,
Gestational diabetes and also Anemia.

Differential diagnosis
Urinary tract infection ( UTI)

Pre-eclampsia
Eclampsia

Diabetes mellitus
Hypertension

Urinary tract infection (UTI)

POSITIVE
HISTORY
Frequency in
urination.
High of glucose
level.
High risk for
asymptomatic
bacteriuria.

NEGATIVE
HISTORY
Normal level of
protein.
Pain and
itchiness in
vagina.
Vaginal
discharge.
Bloody and
cloudy urination.

PRE-ECLAMPSIA
POSITIVE
High blood
pressure.

NEGATIVE
Absence of
protein in urine
Low blood
platelet count.
No presence of
pitting edema.

ECLAMPSIA
POSITIVE
High blood
pressure.
Headaches
Muscle pain
Presence of
gestational
diabetes.

NEGATIVE
Absence of
seizures
Protein level are
normal.
Has no edema
Age is more than
20 years old.
Not being
pregnant with
twins.
Absence of

DIABETES MELLITUS
POSITIVE
Maternal age
Elevated blood
glucose level
family history of
diabetes.
Polyuria
She had
previous history
of gest.diabetes

NEGATIVE
Had history of
normal level of
glucose in
previous
pregnancy.
Not overweight
Not smoking or
around smokers

HYPERTENSION
POSITIVE
BP results more
than normal
range
(145/100mmhg)
Headache
Nausea and
vomitting.
Absence of
protein in urine

NEGATIVE
No family history
of hypertension.
Had no
hypertension
history in
previous
pregnancy after
miscarriage.
No recorded
renal disease

INVESTIGATION
BLOOD TEST

URINE TEST (PROTEIN& GLUCOSE)

SCREENING TEST

- HIV
- HEPATITIS (HBSAG)
- VDRL ( SYHPHILIS )

BLOOD TEST
WBC :14.7x103 /L

:4.05 x106 /L
HB
:10.0g/dl
HCT :30.5g/dl
MCV :75.3g/dl
MCH :24.7g/dl
MCHC :32.8g/dl

RBC

URINE TEST
ALBUMIN LEVEL: normal ( 0.6-1.2mg/dl)

BLOOD GLUCOSE TEST

GLUCOSE (MOGTT ) : 9.0mmol/l

Cont
Blood group ; B +

Rhesus was positive.

SCREENING TEST
HIV

:NEGATIVE
HEPATITIS (HBSAG) :NEGATIVE
VDRL ( SYHPHILIS ) :NEGATIVE

ULTRASOUND
Ultrasound was done on 20 weeks of gestation.

Single fetus pregnancy was found.

The gender was determined as male.
The fetus was on the tranverse lie.
The fetus heart works normal.
Congenital Anomalies absent.

MANAGEMENT
NIFEDIPINE 10mg given stat at 10.30 am on 12

Oct 2014 referred to HTAR Hospital due to the

hypertension (145/100mmhg)
At HTAR Tab.PCM 1gm stat was given at 1.30 pm
due to the severe headache.
Followed by Tab.ponstan 500mg was given every
four hours for two times due to the severe
headache.

Discussion
Hypertensive disorders in
pregnancy
-Gestational hypertensionAthina Nashrah binti Abdullah
012012100001

Contents
Definition
Types
Criteria

Definition
Hypertensive disorders in pregnancy is
defined as having blood pressure of 140/90
mmHg or more during pregnancy.

Types
Disorder

Definition

Chronic hypertension

Known hypertension of 140/90 mmHg

before pregnancy or hypertension
diagnosed before 20 weeks of pregnancy

Pre-eclampsia / Eclampsia

BP 140/90 mmHg with proteinuria after

the 20th weeks in a previously
normotensive and nonproteinuric woman
/ Women with pre-eclampsia complicated
with convulsions and/or coma

Pre-eclampsia superimposed on chronic

hypertension

Occurrence of new onset of proteinuria in

women with chronic hypertension

Gestational hypertension

BP 140/90 mmHg for the first time in

pregnancy after 20 weeks, without
proteinuria

Gestational Hypertension
Criteria
Unassociated
with preeclampsia
Absence of
underlying
cause of
hypertension

Not associated
with raised uric
acid level

> 37 weeks of
pregnancy

BP return
to normal

DEVINA DEVI GUNALAN

012012100023

OUTLINE
CAUSES
RISK FACTORS
DIAGNOSIS & TEST

Causes

The cause of gestational hypertension is unknown.

Some conditions may increase the risk of developing
the condition, including the following:

Pre-existing hypertension (high blood pressure)

Kidney disease
Diabetes
Hypertension with a previous pregnancy
Mother's age younger than 20 or older than 40
Multiple fetuses (twins, triplets)
African-American race

Risk Factors

Risk Factors
Maternal
Cause

Causes
Family
History

Pregnancy

MATERNAL CAUSES
Obesity
Age 35 years or more.
Past history of D.M,Hypertension and Renal
diseases.
Adolescent pregnancy.
New paternity.
Thrombophilias (anti-phospholoipid syndrome,
protein C/S deficiency, factor V Leiden)

PREGNANCY
Multiple gestation ( twins or triplets, etc.)
Placental abnormalities:
1. Hyperplacentosis: Excessive exposure to
chorionic villi.
2. Placental ischemia.

FAMILY HISTORY
Family history of pre-eclampsia.
Decendent of African American

DIAGNOSIS & TEST

Diagnosis is often based on the increase in blood pressure

levels, but other symptoms may help establish gestational
hypertension as the diagnosis. Tests for gestational
hypertension may include the following:

Blood pressure measurement

Urine testing to rule out preeclampsia
Assessment of edema
Frequent weight measurements
Liver and kidney function tests to rule out
preeclampsia
Blood clotting tests to rule out preeclampsia

TEST
Your blood pressure will be checked during each
doctor's visit. A big rise in your blood pressure
can be an early sign that you might have PIH.
A urine test can tell if there is protein in your
urine.
Blood tests, which may show if you have PIH. If
you have signs of PIH, your doctor may want to
see you at least once a week and possibly every
day.

NASYRAH ISKANDAR
012012100229

Contents
Hypertensive Disorders
Complications
Management

Complications
Women with hypertension in pregnancy have a
higher risk of complications such as:
Abruptio placentae.
Cerebrovascular accident.
Disseminated intravascular coagulation.

The fetus has an increased risk of:

Intrauterine growth restriction.
Prematurity.
Intrauterine death

Management
Management depends on blood pressure, gestational
age and blood flow in the placenta.
Divided into:
-Pharmacological (presence of associated maternal
and fetal risk factors)
-Non-pharmacological

Assess severity:
Mild:
140-149/90-99 mm Hg.
For patients presenting before 32 weeks (or at
high risk of pre-eclampsia) measure BP twice a
week; otherwise, measure BP once a weak
Check urine for protein at each visit

Moderate:
150-159/100-109 mm Hg.
Monitor BP twice a week - start labetolol
(alternatives are methyldopa or nifedipine) to keep
systolic BP <150 mm Hg and diastolic BP between 80-100 mm Hg.
Dip urine for protein at each visit.
Arrange initial blood tests for FBC, electrolytes,
renal function, and LFTs.
Subsequent blood tests are not necessary if there is no
proteinuria.

Severe:
160/110 mm Hg.
Admit to hospital and treat as for moderate
(above) to keep systolic BP <150 mm Hg and diastolic BP
between 80-100 mm Hg.

Measure BP at least four times a day and check

urine for protein daily.
Weekly blood tests for FBC, electrolytes, renal
function, and LFTs.
Check BP and urine twice weekly (and continue
weekly blood tests) when discharged (once BP is in
the target range).

Perform ultrasound examination at 34 weeks to

assess fetal growth and amniotic fluid volume (with umbilical
artery Doppler velocimetry) if mild or moderate gestational
hypertension develops before this time.

Arrange these tests and cardiotocography

urgently whenever severe gestational
hypertension is diagnosed.

Postnatal
Measure BP daily for the first two days after birth, at
least once between day three and day five, then as
clinically indicated.
Continue on antihypertensive medication, but reduce or
stop if BP is seen to be falling - particularly if it falls
below 130/80 mm Hg.
Switch from methyldopa to an alternative within two
days of delivery.
Women with mild hypertension not requiring treatment
during pregnancy should be started on antihypertensive
medication postnatally if their BP is 150/100 mm Hg .