Posted: April 7th, 2015

Hypertension in pregnancy:

3- Hypertension in pregnancy:
Location: obstetrics ward 1                                                  Date: 24/2/2014
Case summary:
Mrs. IS is a 33 year old female, prima gravida, who presented with a high blood pressure (180/90) at an antenatal visit, during 36 weeks gestation.
History of Present Pregnancy:
Mrs. IS had her last menstrual period on 18th June 2013 her cycles were previously normal and regular every 28 days. She has no history of any menstrual problems. Mrs. IS said the pregnancy was planned and she was taking folic acid from 3 months prior to the pregnancy and throughout the first trimester. Ultrasound scan was done at 18 weeks gestation; no abnormality reported
History of Presenting Complaint: Mrs. IS was noted to have a blood pressure of 180/90 during her last antenatal visit (2 days previously). Patient was asymptomatic other than feeling slightly lethargic and a slight headache on date of admission. She did not have any of the following symptoms: nausea, vomiting, blurred vision, or pain.
Past Obstetric History:
There is no obstetric history or any history of miscarriages
Past Medical and Surgical History:
Patient was reported to have borderline hypertension prior to pregnancy, however was not on any form of medication.
She had a D&C in 2012; no problems with anesthesia were reported.

Past Gynecological History:
The patient reached menarche at the age of 14. Her cycles, prior to pregnancy were previously normal and regular occurring every 28 days. Patient had a dilatation and curettage 2 years ago due to menorrhagia. Last smear test was done in January 2013, and this was normal. She has never used any form of contraceptive method
Drug History:
Patient is not on any regular medication No known drug allergies
Social History:
Patient lives with husband in Birzebbugia. She does not smoke nor drink alcohol
She is employed as an accounts executive
Family History:
Father: hypertension
Mother: Diabetes mellitus type 2; mother suffered from hypertension during her pregnancy

On examination:
The patient was examined at 36 weeks pregnancy, she was an inpatient in obstetric ward 1, and did not suffer from any acute symptoms.
On inspection the patient seemed to be in good general health, with no visible signs of anemia, distress, or malnutrition. Cardiovascular examination was normal, with a blood pressure of 125/80 and pulse rate of 67; she did not show any peripheral signs of heart failure and no ankle swelling. Respiratory system examination was also normal, with normal air entry in both lungs and no added sounds. On visualization of the abdomen, it appeared to be distended which conformed to pregnancy; she had a linea nigra and straie gravidum.  The fundus was at the level of the xiphisternum and symphysis-fundal height measured 36 cm. the fetal lie appeared to be longitudinal with a cephalic presentation.
Case discussion:
Differential diagnosis:
Pre-existing hypertension: this could be a cause; since it would show up on previous antenatal visits to outpatients.
Pre-eclampsia: this is the most likely diagnosis since the patient was borderline hypertensive prior to pregnancy, especially since it presenting at this stage of gestation, and it is important to check for proteinuria.
Renal disease: is a rare cause of hypertension, and would be excluded during early stages of pregnancy.

Management:
Management of pregnant patient with hypertension depends on what stage of pregnancy the patient is in, and if she is symptomatic from the hypertension.
In the case of this patient, she requires hospitalization due to the fact that she is in late stage pregnancy and is therefore at risk of developing pre-eclampsia and therefore requires close monitoring.
Blood pressure should be aimed at less than 160 systolic and less than 100 diastolic, and in the case that it is sustained higher than that, IVmagnesium sulfate can be given to prevent eclamptic seizures. To lower blood pressure, labetalol (beta blocker) can be given orally or IV as it has a rapid onset of action and is considered firs line treatment. Nifedapine (calcium channel blocker) is mostly used to treat chronic hypertension as it has a slow onset of action but is long acting. Both ACE inhibitors and Angiotensin receptor antagonists should be avoided in pregnancy as they are associated with fetal renal dysgenesis and death.

5- Ovarian Dermoid cyst
Location:  Gynecological ward                                                                      date: 28/3/2014
Case summary: Mrs. MC is a 20 year old female who was admitted to the gynecological ward following the scheduled removal of a left ovarian cyst.
History of Presenting Complaint: in 2012, Mrs. MC presented to the causality department after having severe pain in her left iliac fossa, it was noted that this pain was mid-cycle. She was then referred to her gynecologist, who after investigations (most importantly Ultrasound) discovered that she had ‘water cysts’ and also a small dermoid cyst in her left ovary. She was then kept on conservative management, and was prescribed analgesia for the pain. The patient describe that the pain remained and never went away, and in January 2014, the pain become very severe; and the patient scored it as 10/10. She described it as a pressure sensation which was intermittent. She did not experience any nausea/vomiting, but she note that her cycles were longer during these past few months and she was attributing this to the dermoid cyst .She tried taking Panadol, voltaren and catafast for the pain, however they had minimal effect. Investigations showed that the dermoid cyst had increased in size. After a couple of days in hospital, she was discharged and an operation date (27/3/2014) was set for removal of the cyst.
Past Obstetric History:
The patient does not have an obstetric history or any history of miscarriges.
Past Medical and Surgical History:
She has reported that during her childhood she would have recurrent urinary tract infections.
She suffers from Allergic rhinitis

Past Gynecological History:
The patient had her first period at the age of 15 years. Her last menstrual period was on the 22nd March 2014. Prior to these past few months, her Cycles would vary from 28 to 35 days, with normal flow, and each menses lasting about five days. She states that she sometimes experiences normal discharge, with no intermenstrual bleeding or postcoital bleeding. She has minimal pain associated with menstruation, but she does not usually take any analgesics for it. She has never used any form of contraception. She had her last Smear test done in January 2014, which was normal.
Drug History:
Neoclaritine 5mg daily between March and May
No known drug allergies
Family History:
None relevant
Social History:
Patient is a smoker, and smokes about 8 cigarettes a day for the past 4 years. She is a social drinker and mostly consumes alcohol on the weekends. She Lives at home with her parents in Luqa. Mrs.MC works at a call Centre.
On examination:
The patient was viewed in the gynecological ward where she was an inpatient.
On inspection, the patient was in good general health. Cardiovascular examination was normal, with no murmurs heard and no peripheral signs of heart failure noted. Her blood pressure was 125/75mmhg and her pulse was 82bpm. Respiratory exam was normal, with no signs of decreased air entry in both lungs and no added sounds.  Abdominal examination was normal, with no signs of distention, rigidity, or tenderness. The patient did not consent for a gynecological examination and it was therefore was not performed.
Case discussion:
Differential diagnosis:
Chocolate ovarian cyst: this an important differential as it is often confused with dermoid cysts, however the patient would most likely report symptoms of endometriosis like heavy periods and intermenstrual pain.
Ovarian cancer: it is a potential diagnosis; however given the patient age it less likely to occur.
Ectopic pregnancy: this should be ruled out with proper investigations.
Management:
The management of this type of cyst depends on the size. Small cyst can be treated conservatively with pain management and continuous follow up at outpatients to observe size. Larger cysts require removal, as they make the patient susceptible to ovarian torsion which is a medical emergency, and it is traditionally done under laparoscopic surgery depending on the facilities and experience of the surgical team.