Case Study: Hypertension in Pregnancy
Kita Brown is a 36-year-old G1 P0 black female presenting to her local urgent care with
headache and stating her mother took her blood pressure and it was a “little higher than it
should be”. Kita has had an unremarkable pregnancy, which was conceived thru IVF. She is
currently 30 5/7 weeks pregnant and relates she has had no problem with her pregnancy. She
only takes prenatal vitamins, and relates she was on hctz prior to pregnancy for borderline BP
but stopped it when she underwent IVF and her BP has remained “pretty normal”. Sher relates
she was prescribed po labetalol but did not take it regularly as she didn’t want to take anything
that might hurt the baby.
Her initial prenatal screening, including initial labs, and third trimester CBC and glucose testing
have been normal. She additionally at her 1st prenatal visit had baseline PIH (pregnancy
induced hypertension/pre-eclampsia) due to her history of hypertension which were normal
including a protein to creatine ratio.
Upon intake at the urgent care the notes relate she appears in no apparent distress, and she
has reported fetal movement within the past hour. She denies, any other symptoms including
epigastric pain, vision changes or nausea. She states fetal movement has been normal, and
denies leaking fluid, vaginal bleeding, or contractions. She relates slight swelling and her weight
gain date has been 17 lbs. Current BMI is 25.1. BP is 162/90, pulse 82, respirations 16 and
unlabored, temperature 98.2 orally. Kita was transferred to the emergency room due to her
complaints and her gestational age.
Upon arrival to the emergency room 30 minutes later her repeat BP was 166/ 88. It was retaken
15 minutes later and was 162/92. All blood pressures were confirmed with a manual cuff. She
had no additional complaints.
Based on your assigned case study, post a Focused SOAP NOTE with the following:
- Differential diagnosis (dx) with a minimum of 3 possible conditions or diseases.
- Define what you believe is the most important diagnosis. Be sure to include the first priority in conducting your assessment.
- Explain which diagnostic tests and treatment options you would recommend for your patient and explain your reasoning.
Your differential diagnosis, what you believe the most important diagnosis is and why, additional diagnostic tests and treatments and rationales are what this assignment and grading is focused on.
S: Kita Brown, a 36-year-old G1 P0 black female, presents to the urgent care with a headache and elevated blood pressure. She is currently 30 5/7 weeks pregnant and has had an unremarkable pregnancy thus far. She has a history of hypertension, for which she took hctz before pregnancy, but stopped it during IVF. Her initial prenatal screening and labs were normal. She has not taken her prescribed labetalol regularly due to concerns about fetal harm.
O: BP is 162/90 mmHg on presentation and increased to 166/88 mmHg upon arrival at the emergency room, with manual cuff confirmations. Her pulse is 82 bpm, respirations are 16 bpm and unlabored, temperature is 98.2 orally. She reports slight swelling and has gained 17 lbs with a current BMI of 25.1. Fetal movement is reported as normal. No other symptoms are reported, and she appears in no apparent distress.
A: Differential Diagnosis:
- Gestational Hypertension
- Chronic Hypertension with Superimposed Preeclampsia
The most important diagnosis is Preeclampsia. This is due to the presence of hypertension after 20 weeks of gestation in a woman with previously normal blood pressure. In addition, Kita reports slight swelling, weight gain, and her repeat blood pressure is elevated. As such, Preeclampsia is the most important diagnosis as it is associated with maternal and fetal morbidity and mortality.
Diagnostic Tests and Treatment: Diagnostic tests:
- Urine dipstick to evaluate for proteinuria
- CBC with platelets to assess for hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome
- Serum creatinine and liver function tests to assess for renal and hepatic dysfunction.
- Hospitalization for fetal and maternal monitoring and treatment initiation with magnesium sulfate for seizure prophylaxis.
- Immediate delivery if there is evidence of severe preeclampsia, eclampsia, or fetal compromise.
- If delivery is not indicated, the patient can be managed with antihypertensive medications such as labetalol, hydralazine, or nifedipine.
Rationale: Urine dipstick evaluation is the first step in diagnosing preeclampsia. CBC with platelets, serum creatinine, and liver function tests are necessary to evaluate for hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome and assess for renal and hepatic dysfunction. Hospitalization is necessary for close fetal and maternal monitoring, as well as initiation of magnesium sulfate for seizure prophylaxis. Immediate delivery may be indicated if there is severe preeclampsia, eclampsia, or fetal compromise. If delivery is not indicated, the patient can be managed with antihypertensive medications such as labetalol, hydralazine, or nifedipine.