1. Summary of medical history:
Chen **, female, 24 years old. Main complaint: Menopause for 40 weeks, blood pressure increased for one month and worse for one day.
The patient was pregnant for the first time, now 40 weeks of menopause, regular menstruation, 4~5/35 days, last menstruation on April 1, 2010, expected date of delivery on January 8, 2011. Early pregnancy reaction and urinary HCG(+) occurred after 40 days of menopause, and fetal movement was felt after 4 months after menopause, so far, there is no history of exposure to harmful substances during menopause, no history of viral infection, no history of medication, no history of abdominal pain, vaginal bleeding . After 12 weeks of menopause, a perinatal health card was established for prenatal examination, and no other abnormalities were found in 6 inspections. There was no obvious cause for edema of both lower limbs one month ago. At that time, the blood pressure in the prenatal examination was 145/90rnmHg, the urine routine examination was normal, and the medication was not prescribed by the doctor. The day before admission, the patient felt dizzy and uncomfortable, no vertigo, nausea, vomiting, chest tightness and palpitation. He went to the outside hospital with a blood pressure of 160/110mmHg and was transferred to this hospital for emergency. The patient has no chest tightness, palpitation, wheezing, and other discomforts, no abdominal pain, and no signs of labor.
Past history: past physical fitness, denying "hepatitis, tuberculosis, epilepsy" and other medical history. Deny the history of drug allergy. Denies the history of surgical trauma. Marriage and childbirth history: married at 23 years old, loves human health, birth history 0-0-0-0, menarche 13 years old. Family history; deny family history of hypertension, diabetes, epilepsy, malignant tumors, etc. The parents are alive.
2. Medical history analysis:
(1) The patients are women in the third trimester of pregnancy, primiparous, and elevated blood pressure and lower extremity edema appear in the third trimester, which is in line with the onset characteristics of hypertensive disease during pregnancy; and the patient has a history of physical fitness and no history of primary hypertension and kidney disease. Therefore, it should be considered that the increase in blood pressure is caused by pregnancy.
(2) The characteristics of the medical history: ① Menopause for 40 weeks, and it was found that the blood pressure increased by one day a month. ②The blood pressure was 145/90rnmHg in the prenatal check, and the medication was not followed by the doctor. ③The day before admission, he felt dizzy and uncomfortable, and his blood pressure was 160/110mmHg. ④Past physical fitness.
T 37℃, P 90 times/minute, R 20 times/minute, BPI60/110mmHg.
Normal condition, normal development, good nutrition, clear mind, physical examination cooperation; no yellowing of skin and mucous membranes, no rashes and bleeding spots; no palpable swelling of superficial lymph nodes; normal head and facial features, no yellowing of sclera; no thyroid enlargement No abnormality of the thorax, full breasts on both sides; no abnormality in cardiopulmonary examination; pregnancy abdominal type, liver, spleen, and ribs not reached; normal limbs movement, lower extremities swelling (++); no scar ulcers on the vulva, no varicose veins, no hemorrhoids in the anus .
Specialist examination: Uterus height 36cm, abdominal circumference 96cm, fetal position left anterior occiput, fetal heart rate 140 beats/min, first appearance, connected, unbroken fetal membranes, no contractions, cervical canal length of about 2cm, medium quality, ranking Later, the uterine orifice was not opened; external measurements of the pelvis: the diameter of the iliac spine was 25cm, the diameter of the anterior superior iliac crest was 27cm, the diameter of the sacral pubis was 19cm, and the ischial tuberosity was 9cm.
2. Physical examination analysis:
(1) The patient is generally in good condition, full-term pregnancy, abdominal type, fetal heart rate 140 beats/min, fetal orientation left anterior to the occiput, consistent with the signs of late pregnancy; no uterine contractions, fetal membranes are not broken, and the uterine orifice is not open to meet the expectation of delivery; Blood pressure 160/110mmHg, lower limb edema (++).
(2) Positive signs: Mainly manifested as increased blood pressure of 160/110mmHg, lower extremity edema (++); the patient is generally in good condition, full-term pregnancy abdominal type, fetal heart rate 140 beats/min, fetal position left anterior occiput; no contractions , Fetal membranes are not broken, and the uterine mouth is not opened. Meet the signs of hypertension in pregnancy.
(1) Blood routine: WBC 7.4×109/L, Hb 133g/L, HCT 37.1%, PLT 170×109/L.
(2) Blood PT and KPTT are normal.
(3) Blood electrolytes: K+ 4.62μmol/L, Na+137.9μmol/L, C1 -106.5mmol/L.
(4) Blood biochemical function: there is no abnormality in liver, kidney function and blood sugar.
(5) Fetal heart rate monitoring NST: good response, 10 points.
(6) B-ultrasound: fetal double parietal diameter (BPD) 9.4cm; fetal heart rate 140 beats/min; placenta II+, located at the bottom of the uterus, thickness 43mm; amniotic fluid index (AFI) 101mm, cord blood flow (S/D) 2.2 .
(7) ECG: Sinus heart rate, 90 beats per minute, normal ECG.
(8) Fundus examination: Fundus A:V=1:3, no edema, no exudation and bleeding in the retina.
(9) Urine routine: protein (++), the rest is normal.
(10) Urinary estriol/creatinine (E/C) value: 15.
2. Auxiliary inspection analysis
(1) The patient's NST response is good, indicating that the fetus is currently in good condition in the uterus, and the blood test reports and ECG are not abnormal, indicating that the patient's general condition and important organ function are good.
(2) B-ultrasound indicates that the fetus is mature.
(3) Fundus examination revealed retinal arteriole spasm, reflecting the severity of hypertension.
(4) The amount of urine protein also marks the severity of hypertension during pregnancy. The patient's protein (++) indicates that the protein loss is serious and has reached the standard for severe preeclampsia.
(5) The urinary estriol/creatinine (E/C) value reflects the status of placenta function. The patient's result is 15, indicating that the status of placental function is not very good and the fetal living environment in utero is not very favorable.
Diagnosis and differential diagnosis
(1) Zero birth of the first child is expected to be delivered at 40 weeks of pregnancy, LOA
(2) Preeclampsia: severe
2. Diagnose based on:
(1) A 24-year-old married female, her first pregnancy.
(2) Chief complaint: Menopause was stopped for 40 weeks, and blood pressure was found to be elevated for one month and worse for one day.
(3) Features of the medical history: The patient was a 24-year-old married primiparous woman who had been post-menopausal for 40 weeks. She was found to have increased her blood pressure for one month and was admitted to the hospital for one day, accompanied by edema and dizziness. No previous history of hypertension.
(4) Physical examination features: blood pressure 160/110mmHg, lower extremity edema (++), full-term pregnancy abdominal type, fetal heart rate 140 beats/min.
(5) Auxiliary examination: urine routine: urine protein (++).
(6) Special examination: fundus examination: fundus A:V=1:3, no edema, no exudation and bleeding in the retina; urinary estriol/creatinine (E/C) value: 15. B-ultrasound indicates that the fetus has become feverish.
3. Differential diagnosis:
(1) Essential hypertension combined with pregnancy: refers to the first diagnosis of hypertension before pregnancy or 20 weeks of gestation, and the patient has been physically healthy, and no increase in blood pressure was found in the early pregnancy examination.
(2) Chronic nephritis with pregnancy: Refers to a previous history of chronic nephritis, persistent proteinuria or with tubular urine, edema, anemia, hypertension and renal insufficiency before pregnancy or 20 weeks of pregnancy. Combined with the patient's medical history, there was no history of nephritis in the previous physical fitness, and proteinuria appeared in the third trimester of pregnancy, accompanied by increased blood pressure.
1. Treatment principle: Sedation, antispasmodic, lowering blood pressure, and timely termination of pregnancy.
2. treatment plan:
(1) Monitor blood pressure, pulse, breathing and other vital signs.
(2) Under normal conditions such as urine output, breathing, tendon reflexes and other vital signs, 25% magnesium sulfate can be considered for spasmolytic therapy, and nifedipine orally taken.
(3) The patient's blood pressure fluctuated at 145/100mmHg within 24 hours of admission, pulse, breathing were stable, urine protein (++), lower extremity swelling (++), vaginal examination was performed, indicating no obvious abnormality in the bone-soft birth canal; cervical canal length is about 2cm , Mid-quality, second, head first, 2cm above spine, no membrane rupture, considering that the patient has been menopausal for 38+4 weeks, B-ultrasound indicates that the fetus is mature, placenta Ⅱ+ grade, urine E/c value 15 has reached the warning line , Blood pressure control is not very satisfactory, the vaginal delivery cannot be performed in a short time, and the pregnancy is planned to be terminated by surgery. Therefore, after explaining the condition of the patient and family members, prepare for the lower uterine cesarean section.
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