# Clinical Cases: Hypertensive Disorders in Pregnancy ## Case 1: Preeclampsia with Severe Features ### Patient Demographics - **Age:** 28 years - **Sex:** Female - **Occupation:** Teacher ### Chief Complaint "I have a terrible headache that won't go away and I'm seeing spots." ### History of Present Illness The patient is G1P0 at 34 weeks 3 days gestation. She noticed a persistent frontal headache starting yesterday that is not relieved by acetaminophen. This morning she noted visual disturbances described as "flashing lights" in her peripheral vision. She has also noticed increased swelling in her hands and face over the past week. At her prenatal visit last week, her blood pressure was 128/82 mmHg. ### Past Medical History - No prior hypertension - No diabetes - First pregnancy (nulliparity is a risk factor for preeclampsia) ### Risk Factors for Preeclampsia - Nulliparity (strongest risk factor) - First pregnancy with this partner (immunologic theory) ### Physical Examination Findings - **Vital Signs:** BP 168/108 mmHg (repeated: 172/110 mmHg), HR 88 bpm, RR 18, SpO2 99% - **General:** Alert, appears uncomfortable, periorbital and facial edema - **Cardiovascular:** Regular rhythm, no murmurs - **Abdomen:** Gravid, non-tender, fundal height 33 cm - **Neurologic:** Hyperreflexia (3+ deep tendon reflexes with 2 beats of clonus) - **Extremities:** 3+ pitting edema of hands and lower extremities ### Diagnostic Workup - **Urinalysis:** 3+ protein - **Spot urine protein/creatinine ratio:** 1.2 (>0.3 is significant) - **Complete Blood Count:** Hgb 12.1, Platelets 145,000 (low-normal) - **Complete Metabolic Panel:** Creatinine 0.9 (normal), AST 42, ALT 38 (mildly elevated) - **LDH:** 280 (mildly elevated) - **Uric Acid:** 7.2 mg/dL (elevated) - **Fetal Assessment:** NST reactive, AFI 12 cm, EFW 2,100 grams ### Diagnosis **Preeclampsia with Severe Features** at 34 weeks - Severe-range blood pressure (>160/110 mmHg on multiple readings) - Neurologic symptoms (severe headache, visual disturbances) - Hyperreflexia with clonus - Significant proteinuria ### Management Plan **Immediate Blood Pressure Control:** - IV Labetalol 20 mg bolus - BP after 10 minutes: 158/102 (inadequate response) - IV Labetalol 40 mg bolus - BP after 10 minutes: 142/88 (goal <160/110 achieved) **Magnesium Sulfate for Seizure Prophylaxis:** - Loading dose: 4 g IV over 20 minutes - Maintenance: 2 g/hour continuous infusion - Monitor: reflexes hourly, urine output, respiratory rate **Antenatal Corticosteroids:** - Betamethasone 12 mg IM now, repeat in 24 hours - For fetal lung maturity (34 weeks) **Delivery Planning:** - Preeclampsia with severe features at 34 weeks: delivery indicated - Allow 24-48 hours for corticosteroids if maternal/fetal status stable - Assess cervix for induction candidacy ### Hospital Course **Hours 0-24:** - Blood pressure controlled on labetalol 200 mg PO every 8 hours - Magnesium continued, no signs of toxicity - First betamethasone dose given - Symptoms (headache, visual changes) improved - Serial labs stable **Hours 24-48:** - Second betamethasone dose given - Cervix: 2 cm, 50% effaced, -2 station (Bishop score 5) - Decision: proceed with induction of labor **Induction and Delivery:** - Cervical ripening with Foley bulb - Oxytocin augmentation - Magnesium continued throughout labor - Vaginal delivery after 14 hours of labor - Female infant, 2,050 grams, Apgar 8/9 **Postpartum:** - Magnesium continued for 24 hours after delivery - Blood pressure initially elevated, required labetalol continuation - Symptoms resolved - Discharged on postpartum day 3 on labetalol with BP monitoring - Follow-up in 1 week for BP check ### Counseling - Risk of recurrence in future pregnancies: 20-40% - Low-dose aspirin recommended starting at 12 weeks in future pregnancies - Long-term cardiovascular risk monitoring recommended ### Clinical Image ![Preeclampsia Features](case_01_image.jpg) **Image Description:** Clinical illustration depicting the multi-system effects of preeclampsia including hypertension, proteinuria, neurologic symptoms, and potential progression to eclampsia or HELLP syndrome. **Attribution:** Educational illustration. Public domain medical education resource. --- ## Case 2: Eclampsia ### Patient Demographics - **Age:** 22 years - **Sex:** Female - **Occupation:** Student ### Chief Complaint The patient is seizing in the labor and delivery unit. ### History of Present Illness The patient is G1P0 at 38 weeks gestation admitted for labor. She had mild preeclampsia diagnosed at 36 weeks managed as outpatient with close monitoring. Her blood pressure has been 145-150/90-95 mmHg at prenatal visits. She presented in early labor 2 hours ago. While being monitored, she suddenly developed a generalized tonic-clonic seizure witnessed by the nurse. ### Pre-Seizure Status - Blood pressure: 162/104 mmHg (had been 148/92 on admission) - Complained of sudden severe headache just before seizure - Not yet on magnesium sulfate (was being assessed for induction) ### Seizure Description - Generalized tonic-clonic seizure - Duration approximately 90 seconds - Postictal confusion - No prior history of seizure disorder ### Immediate Management (ABCDE Approach) **A - Airway:** - Positioned patient on left side (recovery position) - Suction available, airway maintained - Oxygen via face mask at 10 L/min **B - Breathing:** - Spontaneous respirations resumed after seizure - SpO2 95% on oxygen **C - Circulation:** - IV access confirmed - Blood pressure post-seizure: 180/115 mmHg **D - Disability:** - Postictal state, not responding to commands initially - Improving mental status over 5 minutes **E - Exposure:** - Fetal heart rate: Initial bradycardia (80 bpm) during seizure - Recovering to baseline 140 bpm after 5 minutes ### Diagnosis **Eclampsia** (new-onset seizure in setting of preeclampsia) ### Pharmacologic Management **Magnesium Sulfate:** - Loading dose: 6 g IV over 20 minutes (higher dose for eclampsia) - Maintenance: 2 g/hour IV continuous - If seizure recurs: additional 2 g bolus **Blood Pressure Control:** - IV Labetalol 20 mg, then 40 mg - Blood pressure reduced to 148/94 mmHg - Goal: <160/110 to prevent stroke **Do NOT Give:** - Benzodiazepines (unless magnesium fails) - Phenytoin (magnesium is superior in eclampsia) ### Fetal Assessment - Fetal heart rate returned to baseline after 5 minutes - Transient bradycardia during seizure is expected and usually self-limited - Do NOT rush to cesarean during or immediately after seizure unless prolonged abnormality ### Delivery Decision - Eclampsia is an indication for delivery after maternal stabilization - Patient's cervix: 4 cm, 80% effaced, 0 station - Decision: Continue labor with close monitoring - If fetal heart rate abnormalities persist or maternal status deteriorates: cesarean delivery ### Clinical Course **Post-Seizure Recovery:** - Mental status returned to baseline within 15 minutes - No recurrent seizures on magnesium - Blood pressure controlled - Labor progressed **Delivery:** - Vaginal delivery 6 hours after eclamptic seizure - Male infant, 3,150 grams, Apgar 8/9 - Estimated blood loss 400 mL **Postpartum:** - Magnesium continued for 24 hours after delivery - No further seizures - Blood pressure gradually improved - MRI brain obtained (to rule out posterior reversible encephalopathy syndrome - PRES): normal - Discharged on postpartum day 3 ### Differential Diagnosis of Seizures in Pregnancy - Eclampsia (most likely in this setting) - Epilepsy - Cerebrovascular event (hemorrhagic or ischemic stroke) - Cerebral venous thrombosis - Posterior reversible encephalopathy syndrome (PRES) - Metabolic (hypoglycemia, hyponatremia) - Infection (meningitis/encephalitis) ### Clinical Image ![Eclampsia Management](case_02_image.jpg) **Image Description:** Emergency management algorithm for eclampsia showing immediate stabilization steps, magnesium sulfate protocol, and decision-making for timing of delivery. **Attribution:** Educational illustration. Adapted from ACOG guidelines. --- ## Case 3: HELLP Syndrome ### Patient Demographics - **Age:** 31 years - **Sex:** Female - **Occupation:** Nurse ### Chief Complaint "I have terrible pain under my right ribs and I feel like I might throw up." ### History of Present Illness The patient is G2P1 at 35 weeks 5 days gestation. She developed right upper quadrant pain last night that is severe and persistent. She has been nauseated with two episodes of vomiting. She noticed that she feels "unwell" and more fatigued than usual. She denies headache, visual changes, or contractions. Her pregnancy has been uncomplicated until now with normal blood pressures at all prenatal visits. ### Past Medical History - Prior uncomplicated term pregnancy - No hypertension, diabetes, or other medical conditions ### Physical Examination Findings - **Vital Signs:** BP 152/98 mmHg, HR 92 bpm, Temperature 98.4F - **General:** Uncomfortable, slightly jaundiced sclera - **Abdomen:** Right upper quadrant tenderness to palpation, liver edge tender, gravid uterus non-tender - **Extremities:** 2+ pitting edema ### Diagnostic Workup - **CBC:** - Hemoglobin 10.2 g/dL (was 12.0 at 28 weeks) - Platelets 68,000/mm3 (THROMBOCYTOPENIA) - **Comprehensive Metabolic Panel:** - AST 285 IU/L (ELEVATED) - ALT 312 IU/L (ELEVATED) - Total bilirubin 2.1 mg/dL (elevated) - Creatinine 1.0 mg/dL - **LDH:** 680 IU/L (ELEVATED - indicative of hemolysis) - **Peripheral Smear:** Schistocytes and helmet cells present (HEMOLYSIS) - **PT/PTT:** Normal - **Fibrinogen:** 310 mg/dL (normal, but trending) - **Urinalysis:** 2+ protein - **Fetal Assessment:** NST reactive, EFW 2,400 grams ### Diagnosis **HELLP Syndrome** - complete, meeting all criteria: - **H**emolysis: Elevated LDH, schistocytes on smear, elevated bilirubin - **E**levated **L**iver enzymes: AST 285, ALT 312 - **L**ow **P**latelets: 68,000 Note: Blood pressure only mildly elevated (HELLP can occur with minimal hypertension) ### Risk Assessment - Hepatic hematoma/rupture risk (rare but catastrophic) - DIC development risk - Acute kidney injury risk - Placental abruption risk - Need for emergent delivery ### Management Plan **Immediate Stabilization:** - Two large-bore IVs - Type and crossmatch for 4 units PRBCs - Platelets ordered and available - Anesthesia consultation (regional anesthesia may be contraindicated with severe thrombocytopenia) **Magnesium Sulfate:** - For seizure prophylaxis (HELLP patients at high risk for eclampsia) - Standard loading and maintenance doses **Blood Pressure Management:** - IV Labetalol to maintain BP <160/110 **Antenatal Corticosteroids:** - Betamethasone given, but delivery will not be delayed >48 hours for HELLP **Platelet Threshold for Delivery:** - If cesarean needed and platelets <50,000: transfuse platelets - Current platelets 68,000: acceptable for vaginal delivery or cesarean with general anesthesia **Delivery Decision:** - HELLP syndrome at 35+ weeks: DELIVERY INDICATED - Do not delay for corticosteroids if maternal status deteriorating - Mode: Assess cervix for induction candidacy ### Delivery Course - Cervix 1 cm, 25% effaced, high (unfavorable) - Given thrombocytopenia and severity of HELLP: cesarean delivery chosen - General anesthesia used (epidural contraindicated with platelets 68,000) - Cesarean delivery uncomplicated - Female infant, 2,380 grams, Apgar 8/9 - EBL 800 mL, no transfusion required ### Postoperative Course - Labs initially worsened (expected nadir at 24-48 hours post-delivery): - Day 1: Platelets 52,000, AST 420 - Day 2: Platelets 78,000, AST 280 (improving) - Day 3: Platelets 125,000, AST 98 - Liver enzymes and platelets normalized by day 4 - Discharged postoperative day 4 ### Counseling - Risk of recurrence in future pregnancy: 5-25% - Long-term liver function usually returns to normal - Cardiovascular risk screening recommended ### Clinical Image ![HELLP Syndrome](case_03_image.jpg) **Image Description:** Peripheral blood smear demonstrating microangiopathic hemolytic anemia with schistocytes (fragmented red blood cells) and helmet cells, characteristic findings in HELLP syndrome. **Attribution:** Image from Wikimedia Commons. Educational pathology image. Licensed under CC BY-SA 3.0.