1st peer: Case Scenario 1
Table 1
Classification and Symptoms of hypertensive Disorder of Pregnancy
Classification
Definition
Gestational Age in weeks
Maternal BP
Proteinuria
Seizures
example
>20 weeks
>120/80
Yes or No
Yes or No
Gestational HTN
Hypertension in pregnancy after 20 weeks of gestation without association of preeclampsia
> 20 weeks
>120/80
No
No
Mild Preeclampsia
Presences of high blood pressure and proteinuria.
> 20 weeks
Systolic >140 mmHg or Diastolic >90
Yes
No
Severe Preeclampsia
Presence of high blood pressure and proteinuria needing BP medication to stabilize
<30 weeks Systolic >160mmhg or Diastolic >110mmHG
Yes
No
Eclampsia
Onset of tonic clonic seizures and loss of consciousness in pregnancy or postpartum without previous Hx of seizure
>30 weeks
Systolic >160mmhg or Diastolic >110mmHG
Yes
Yes
Chronic HTN
HTN present prior to pregnancy
< 20 weeks Mild to moderate 140-150/90-109 mmHG No No Superimposed Preeclampsia Development of preeclampsia in a woman previously diagnosed with chronic HTN < 20 weeks >160mm Hg, 110mmHG
Yes
No
Table 2
Define and differentiate between the following PP disorders:
Definition
Signs and symptoms
Management of the Diagnosis
Postpartum Blues
Low mood and mild depressive symptoms
Crying, irritability, insomnia and appetite changes
It resolves on its own, no treatment other than validation, education and emotional support
Postpartum Depression
Depressive symptoms that last longer and affect womens ability to return to normal function.
Loss interest, loss of energy, fatigue, suicidal ideation, lack of concentration,
Psychotherapy and antidepressant medication
Postpartum Obsessive Compulsive Disorder
Recurrent intrusive thoughts and behavior towards the baby.
not feeding the baby out of fear, not changing diapers out of fear of sexually abusing the baby, obsessively checking the baby, fear that the baby will develop a serious disease
Combine medication and therapy to manage symptoms to help the person cope.
Postpartum Psychosis
Severe form of mental illness characterized by extreme confusion, loss of touch with reality, paranoia, delusion and hallucination
Confusion, disorganized reality, sleep disturbances, suicidal or homicidal ideation
Antidepressive medication, antipsychotic medication,
Electroconvulsive therapy
Definition
Presentation (include Signs and Symptoms)
Management of the Diagnosis
Puerperal Fever
Temperature of 100.4 or greater during post partum period
Abdominal pain with uterine tenderness, elevated temp, general malaise, lochia
Oral antibiotics. Moderate to severe cases, hospitalization for IV antbx.
Postpartum Hematoma
Hematoma formation is associated with episiotomy, instrumental birth or nullipartity
Reports severe perineal or rectal pain
Small hematomareabsorbed
Moderate to large hematomamay needs incision and drainage
Secondary (delayed) Postpartum Hemorrhage
Hemorrhage occurring after 24 and up to 12 weeks postpartum
Increased heart rate, pale or clammy skin, nausea or vomiting, worsening abdominal or pelvic pain, feeling faint
Uterotonic agents or curettage
Sore Nipples
Maternal challenges due to improper position and latch, flat or inverted nipple and ankyloglossia,
Sensitive to touching, aching, burning, red or swollen, throbbing
Apply warm compress, may use nipple shield, apply hydrogel dressing
Mastitis
Inflammation of the breast that may involve infection
Flu-like aching, increased heart rate, nausea, chills, pain or swelling at the site, red, tender
Mother continue to feed or pump on the affected side, rest, a full 10 to 14 day course of antibiotics
Breast Abscess
Complication of mastitis related to untreated treatment of mastitis. S. aureus the most common organism isolated in breast abscesses.
Pain, redness, swelling, warm skin, nipple drainage
Surgical drain, needle aspiration or percutaneous catheter drainage. Continue breastfeeding on the affected side to help promote drainage/
Hannah is 38 years old, G1P0, 32 weeks EGA and comes to you for her routine prenatal appointment. Her BP is 156/96 and her urine has 2+ protein. She complains of having a headache that will not go away and just not feeling right for the past 7 days.
SOAP NOTE
Demographic Data
38 year old female, G1P0
Subjective
Chief Complaint (CC): heading that wont go away and I havent felt right for the past 7 days.
History of Present Illness (HPI):
Patient is a 38 year old female G1P0, presented to the clinic with an elevated blood pressure of 156/96. She complains of headache despite taking Tylenol and verbalized not feeling “right” for the past 7 days. She has positive urine protein in the urine +2.
What other relevant questions should you ask regarding the HPI?
O- When did you first notice your symptoms? 7 days ago
L- Where does it hurt? Head
D- Does the pain come and go? Or is it consistent? It has been consistent for the past few days.
C- Can you describe the pain? Mainly headache and sometimes eye pain
A- What helps relieve the pain? I take Tylenol almost daily
R-Do you experience any pain or discomfort elsewhere? No
T-When does your headache usually occur? Whenever I am doing chores at home or when I feel hot.
What other medical history questions should you ask?
Medical Hx: Any history of hypertension or diabetes? No
Allergies: Any allergies to medication? I dont have any allergies
Current Medication: Are you currently taking any medications? my prenatal vitamins
What other OB history questions should you ask?
Any vaginal bleeding? No. Any abnormal leak of fluid? No. Any uterine contractions? No.
Do you feel the need to drink more water? I try to drink plenty of water to keep me hydrated but I dont feel dry. Do you feel tired or fatigued even early in the day? I feel tired and sometimes I try to rest and close my eyes whenever I feel my headache is about to start.
Any visual changes? No changes in my vision
Psychosocial/ Sexual HX
Do you smoke cigarettes or tobacco? No
Do you drink alcohol? No. How many alcoholic beverages per day/week? No
Any usage of recreational drugs? No
Sexual HX
Are you currently sexually active? Yes, with my husband
How many partners have you had within the last 12 months? Only my husband
Do you use any form of contraception? No.
REVIEW OF SYSTEMS:
General: Reports fatigue and occasional weakness. Denies any changes in weight, no recent weight loss.
Cardiovascular: Denies any fast heart beat. Denies any skip beats. Denies chest pain or chest pressure.
Respiratory: Denies any shortness of breath.
Genitourinary: Denies any vaginal bleeding. Denies any leak of fluid. Denies any abnormal contractions. Reports fetal movement. Reports 10 kicks within 2 hours.
Psychiatric: Denies any episode of confusion or changes in memory.
Objective:
Describe the appropriate physical assessment that needs to be included in this visit.
Vital signs: BP 156/96, HR 72, 50, 152 lbs, BMI 29
Physical Exam:
General: Alert, well nourished and well developed
Head/Neck: Facial edema noted.
Eyes: Extraocular movements were intact. PERRLA
Neck: Supple.
Lungs: Lung sounds clear. Chest rise is equal and symmetric.
Heart: No murmur; regular rate and rhythm.
Breast/Skin: Skin is intact. Normal darkened nipples and areolas. No redness or lesions on skin.
OB: Good fetal movement. Fundal Ht: 32cm. FHR 140 bpm.
Psych: Alert, oriented x4. Answer questions appropriately. Mood and affect appropriate.
Neuro: Cranial nerves are intact grossly II-XII. DTRs intact, +2 symmetric response. Sensation intact to light and touch. No motor or sensory deficits.
Explain what test(s) you will order and perform, and discuss your rationale for ordering and performing each test.
CBC with platelets
Rationale: Thrombocytopenia. Platelet less than 150,000/ microL occurs in about 20% of patients with preeclampsia (August et al., 2023).
Serum Creatinine level
Rationale: It is a marker of how well the kidneys are able to filter otherwise called glomerular filtration rate (GFR) and renal dysfunction. In preeclampsia, GFR and renal plasma decreases to 30 to 40% in comparison to normal pregnancy. Prolonged renal hypoperfusion can cause acute tubular necrosis which can occur in severe preeclampsia (August et al., 2023).
Liver ChemistriesAST, ALT, and bilirubin
Rationale: Liver chemistries are increased which can cause decreased hepatic blood flow which can potentially cause ischemia, necrosis and periportal hemorrhage. Elevated bilirubin can suggest hemolysis. (August et al., 2023)
Quantitative urine proteinProtein to creatinine ratio in a random specimen or 24 hours urine collection for total protein
Rationale: Proteins are normally confined in the blood and are filtered by the kidneys, however with preeclampsia protein starts to leak out in the urine. As the protein in the urine increases so does the blood pressure which makes it a good indicator of the severity of preeclampsia (August et al., 2023).
Assessment/ Diagnosis:
What is your diagnosis?
O14.03 Mild to moderate pre-eclampsia, third trimester
Include any appropriate differential diagnosis
O13.3 gestational hypertension without significant proteinuria, third trimester
Plan:
Do you feel that this can be managed via outpatient? Why? How will you manage this?
I would advise Hannah to proceed to labor and delivery for close monitoring. However, if she chooses not to proceed to labor and delivery, I would educate her about the s/s of preeclampsia such as nausea or vomiting, shortness of breath and severe headache. If she experiences any of these symptoms, she must go to the nearest labor and delivery.
Do you feel that should be managed inpatient? Why? What do you think will be done in the patient?
The patient should be managed inpatient as the mother is at risk of severe preeclampsia. Since the fetus is viable at 32 weeks, Hannah should be advised to be sent to the hospital for close monitoring. Hannahs blood pressure is 156/96 with +2 proteinuria and symptomatic, these alone can progress to eclampsia if not closely supervised which can be dangerous for both mother and baby. Hannah will be started on medication to help prevent seizure as well as to lower blood pressure.
If you chose to manage outpatient- explain the medication regimen, testing, and follow up that needs to be done.
I would advise the patient to proceed to labor and delivery.
If you chose to manage inpatient- explain what medication and testing will be done inpatient, and how will you continue management once the patient is discharged. What medication and testing do you need to continue for this patient?
24 hour Urine collection
Hannah at 32 weeks of gestation will receive steroid injections to help speed up the development of the babys lungs.
Magnesium Sulfate will be started to help prevent seizures.
Magnesium levels will be checked every 4 to 6 hours
Check deep tendon reflexes as MagSulfate can cause magnesium toxicity which results in muscle weakness and flaccid paralysis.
Labetalol to help lower blood pressure
Induction
(August et al., 2023)
What patient education is important to include for this patient?
Advise the patient that the only concrete treatment for preeclampsia is the actual delivery of the fetus and placenta (Norwitz, 2023).
Patient should also be educated that continuous monitoring will be needed during and after delivery as the patient will continue to be monitored for any episodes of elevated blood pressure and be provided scheduled blood pressure medication (Norwitz, 2023).
Provide education that patients’ hypertension may persist for weeks postpartum.
The patient should also be provided education that upon discharge will need to continue monitoring blood pressure as well as symptoms associated with hypertension, including headache, nausea, vomiting, fatigue, lightheadedness, and dizziness (Norwitz, 2023).
Explain complications that can occur if a patient does not comply with treatment regimen.
If a patient does not comply with the treatment regimen of preeclampsia, it can result in coma, brain damage and possible death of both mother and baby.
2nd peer: Case Scenario 2
Table 1
1-hour Oral Glucose Tolerance Test (OGTT) After a 50-g oral glucose load in pregnant women
Normal Range (Negative)
Abnormal range (Positive)
1 hr
< 140 mg/dl > 140 mg/dL
Table 2
Criteria for Abnormal Result on 100-g, 3-Hour Oral Glucose Tolerance Test in Pregnant Women
Blood Sample
National Diabetes Data Group Criteria
Carpenter and Coustan Criteria
Fasting
Equal to or > 105 mg/dL
Equal to or > 95 mg/dL
1 hr
Equal to or > 190 mg/dL
Equal to or > 180 mg/dL
2 hr
Equal to or > 165 mg/dL
Equal to or > 155 mg/dL
3 hr
Equal to or > 145 mg/dL
Equal to or > 140 mg/dL
What defines a positive 3 hr gtt result (failed result)? A positive result, indicating a failed 3-hour Oral Glucose Tolerance Test (OGTT), typically implies that the woman has impaired glucose tolerance or gestational diabetes.
Table 3
Define and differentiate between the following Postpartum disorders:
Definition
Signs and symptoms
Management of the Diagnosis
Postpartum Blues
also known as “baby blues,” refers to a mild and temporary emotional disturbance that commonly occurs in the first few days to weeks after childbirth. It is considered a normal and common experience.
Mood swings, tearfulness, irritability, anxiety, and difficulty sleeping are common symptoms. The symptoms are usually self-limiting and resolve without specific intervention.
Supportive measures, such as reassurance, rest, and emotional support from family and friends, are often sufficient. Education about the transient nature of postpartum blues is important.
Postpartum Depression
a more severe and prolonged form of mood disturbance that occurs after childbirth. It can manifest within the first few weeks to months postpartum.
Persistent feelings of sadness, hopelessness, fatigue, changes in appetite, sleep disturbances, and difficulty bonding with the baby. It can significantly impact daily functioning
Treatment may involve psychotherapy, support groups, and in some cases, medication. It is essential to involve healthcare professionals, and a comprehensive treatment plan may include counseling and, if necessary, antidepressant medications.
Postpartum Obsessive Compulsive Disorder
intrusive and unwanted thoughts (obsessions) and repetitive behaviors or mental acts (compulsions). It can occur after childbirth and may center around concerns about the baby’s safety or well-being.
Intrusive thoughts, anxiety, and compulsive behaviors such as checking, counting, or cleaning. Mothers with postpartum OCD are usually distressed by these thoughts and rituals.
Cognitive-behavioral therapy (CBT) is often the primary treatment for postpartum OCD. Medications may be considered in more severe cases, and involving mental health professionals is crucial.
Postpartum Psychosis
a rare but severe mental health condition that usually emerges within the first few weeks postpartum. It is considered a psychiatric emergency
hallucinations, delusions, severe mood disturbances, disorganized thinking, and impaired reality testing. Mothers may be at risk of harm to themselves or their infants.
Hospitalization is typically necessary for safety reasons. Treatment may involve antipsychotic medications, mood stabilizers, and intensive psychiatric care. A multidisciplinary approach involving mental health professionals and obstetricians is crucial.
Table 4
Definition
Presentation (include Signs and Symptoms)
Management of the Diagnosis
Puerperal Fever
an infection that occurs in the postpartum period, typically within the first ten days after childbirth.
Fever, uterine tenderness, abdominal pain, foul-smelling vaginal discharge (lochia), and general signs of infection such as chills and malaise
Treatment involves antibiotics to target the causative bacteria. In severe cases, hospitalization may be necessary. Prompt diagnosis and treatment are crucial to prevent complications.
Postpartum Hematoma
accumulation of blood in the perineal or vaginal area after childbirth, often associated with trauma to blood vessels during delivery.
Swelling, severe perineal or vaginal pain, and possible signs of shock if there is significant bleeding internally.
Treatment may involve drainage of the hematoma, pain management, and monitoring for signs of ongoing bleeding. In some cases, surgical intervention may be necessary.
Secondary (delayed) Postpartum Hemorrhage
excessive bleeding that occurs after the initial 24 hours and up to six weeks postpartum.
Increased bleeding, persistent or new-onset abdominal pain, and signs of anemia (e.g., weakness, lightheadedness).
Identifying the source of bleeding and addressing the underlying cause is crucial. Treatment may involve medications to contract the uterus, manual removal of retained placental tissue, or, in severe cases, surgical intervention
Sore Nipples
discomfort, pain, or tenderness in the nipples often experienced by breastfeeding mothers
Pain or tenderness in the nipples, redness, cracking, or blistering.
Improving breastfeeding technique, ensuring a good latch, using lanolin or other nipple creams, and providing education and support to the mother on proper nipple care and breastfeeding practices.
Mastitis
inflammation of the breast tissue, often associated with infection, and commonly occurs in breastfeeding women.
Breast pain, redness, swelling, warmth, fever, and flu-like symptoms
Antibiotics to treat the infection, pain management, frequent breastfeeding or pumping to maintain milk flow, and supportive measures such as rest and hydration
Breast Abscess
collection of pus within the breast tissue, usually a complication of untreated mastitis.
Localized breast pain, swelling, redness, and the presence of a fluctuant mass.
Drainage of the abscess, antibiotics, and supportive measures. In some cases, surgical intervention may be needed for drainage.
Jennifer is a G2P1, 31-year-old pregnant female at 24 weeks EGA who has come to the clinic for her 24-week prenatal visit and recommended screening tests. Jennifers one hour glucose test result is 156 mg/DL. Her BP is 118/78 T 98.7 F, P 68, RR 18, fundal height is 25 cm, no urine/protein in urine, weight is 145 lbs at 5 lbs increased from last visit 4 weeks ago, her height is 5 5.
Write a brief SOAP note regarding this patient. Make sure to include your answers to these questions in your SOAP note.
Subjective:
What other relevant questions should you ask regarding the HPI?
How has this pregnancy been progressing for you so far?
Have you experienced any bleeding, spotting, or abnormal discharge during this pregnancy?
Can you describe the frequency and intensity of fetal movements?
Have you noticed any changes in your weight, appetite, or sleeping patterns?
Were you screened for gestational diabetes? If so, what were the results?
Have you noticed any excessive thirst, increased urination, or unusual fatigue?
Are you currently following any specific dietary or lifestyle recommendations related to gestational diabetes?
Have you experienced any headaches, visual disturbances, or upper abdominal pain recently?
Do you have a history of chronic hypertension or high blood pressure before or during pregnancy?
Have you been consistently monitoring your blood pressure at home?
What other medical history questions should you ask?
Are you currently taking any medications or supplements? If so, please provide details.
Do you have any chronic medical conditions such as thyroid disorders, asthma, or autoimmune diseases?
Have you experienced any significant illnesses or hospitalizations since your last visit?
What other OB history questions should you ask?
Can you tell me about your previous pregnancy, including the outcome and any complications?
How did labor and delivery go in your last pregnancy? Were there any complications?
Did you experience any preterm births, gestational diabetes, or hypertensive disorders in previous pregnancies?
How have you been feeling during this pregnancy in terms of physical and emotional well-being?
Have you attended any childbirth or parenting classes during this pregnancy?
Are you considering a specific birth plan or have any specific preferences for labor and delivery?
Are you currently taking any over-the-counter medications or herbal supplements?
Have there been any changes to your medication regimen since the start of your pregnancy?
How have your prenatal appointments been going? Any concerns or questions you’d like to discuss?
Have you been experiencing any difficulties with accessing prenatal care or understanding the information provided during visits?
Objective:
Describe the appropriate physical assessment that needs to be included in this visit.
Physical Assessment:
Vital Signs:
Blood Pressure: 118/78 mmHg
Temperature: 98.7°F
Pulse: 68 bpm
Respiratory Rate: 18 breaths per minute
Weight: 145 lbs
Height: 65 inches
BMI 24.13
General: vital signs stable, in no acute distress. alert, well developed, well nourished.
HEENT: Eyes: no conjunctival pallor. Mouth: no signs of dehydration, moist mucous membranes. No oral lesions or infections.
Respiratory/chest: unlabored. chest rise is equal and symmetric. lungs are cta bilaterally with no adventitious breath sounds.
Cardiovascular: s1, s2 without murmurs, rubs or gallops appreciated. No edema in lower extremities.
Breasts: skin intact without lesions, masses, or rashes. no nipple discharge. breasts with slight asymmetry, no dimpling, retractions or peau dorange appearance.
Genitourinary: no suprapubic tenderness or bladder bulges. No lesions, rashes, masses or swelling.
Abdomen: no TTP, masses or abnormalities.
Explain what test(s) you will order and perform, and discuss your rationale for ordering and performing each test.
3-Hour Glucose Tolerance Test (OGTT):
Rationale: Jennifer’s one-hour glucose test result is elevated at 156 mg/DL. Ordering a 3-hour OGTT is essential to confirm or rule out gestational diabetes, a condition that could impact both maternal and fetal health.
CBC (Complete Blood Count):
Rationale: Order a CBC to assess Jennifer’s hemoglobin and hematocrit levels, ensuring there is no anemia, a common concern during pregnancy.
Blood Type and Rh Factor:
Rationale: Confirm Jennifer’s blood type and Rh factor to identify any potential issues that may require intervention, such as Rh incompatibility.
Rubella Immunity Test:
Rationale: Verify Jennifer’s immunity to rubella to assess the risk of congenital rubella syndrome and plan appropriate interventions if necessary.
Assessment/ Diagnosis:
What is your diagnosis?
O24.419 – Gestational Diabetes
According to clinical practice guidelines, gestational diabetes mellitus (GDM) develops in pregnant people whose pancreatic beta-cell function is insufficient to overcome the insulin resistance associated with the pregnant state (Durnwald, 2023).
Plan:
If the patient fails her 3 hr gtt, what is the next course of action?
The patient will be diagnosed with gestational diabetes.
Explain what medication regimen this patient could be on?
Insulin dose adjusted based on glucose level
What education can you include with this patient?
Patients should self-monitor their glucose concentrations.
Intermittent self-monitoring of blood glucose
Before breakfast (ie, fasting glucose level) and
At one or at two hours after the beginning of each meal
A typical meal plan for patients with GDM includes three small- to moderate-sized meals and two to four snacks. Ongoing adjustment of the meal plan is based upon results of self-glucose monitoring, appetite, and weight-gain patterns, as well as consideration for maternal dietary preferences and work, leisure, and exercise schedules (Durnwald, 2023).
Adults with diabetes are encouraged to perform 30 to 60 minutes of moderate-intensity aerobic activity (40 to 60 percent maximal oxygen uptake [VO2max]) on most days of the week (at least 150 minutes of moderate-intensity aerobic exercise per week). A program of moderate exercise is recommended as part of the treatment plan for patients with diabetes as long as they have no medical or obstetric contraindications to this level of physical activity (Durnwald, 2023).
For insulin therapy:
At least four daily glucose measurements are required (fasting and one or two hours postprandial with the addition of pre-lunch and pre-dinner measurements as needed) to optimize therapy and ensure timely dose increases as insulin requirements increase with pregnancy progression (Durnwald, 2023).
Explain complications that can occur if patient does not comply with treatment regimen.
Failure to adhere to the treatment regimen for gestational diabetes can lead to various complications, including:
Macrosomia:
Uncontrolled gestational diabetes increases the risk of macrosomia, which can complicate delivery and increase the likelihood of birth injuries.
Birth Complications:
Increased risk of cesarean section due to fetal size.
Higher likelihood of neonatal hypoglycemia.
Preeclampsia:
Greater susceptibility to developing preeclampsia.
Type 2 Diabetes Risk:
Elevated risk of developing type 2 diabetes later in life for both the mother and the child.
If the patient passes her 3 hr gtt, what is the next course of action? Would you diagnose her as GDM?
If Jennifer passes her 3-hour GTT, she would not be diagnosed with gestational diabetes mellitus (GDM). The next course of action would involve:
Routine Prenatal Care:
Continue with routine prenatal care, including regular monitoring of blood pressure, weight, and fundal height.
Ongoing Monitoring:
Keep an eye on blood glucose levels during subsequent prenatal visits, as gestational diabetes can still develop later in pregnancy.
