Week 4 DB Response

Table 1: Hypertensive Disorders of Pregnancy

Table 2: Postpartum Mental Health and Physical Disorders

Mental Health Disorders

Classificat ion Definition

Gestatio nal Age

in Weeks

Maternal BP Proteinuria

S ei z ur e s

Gestation al HTN

New-onset HTN without proteinuria or end-organ dysfunction

>20 weeks

≥140/90 on 2 occasion s

No N o

Mild Preeclam psia

HTN with proteinuria or signs of mild end-organ dysfunction

>20 weeks

≥140/90 but <160/110

Yes (≥300 mg/24h or ≥1+ dipstick)

N o

Severe Preeclam psia

Preeclampsia with severe features (e.g., high BP, thrombocytopenia, elevated LFTs)

>20 weeks ≥160/110 Yes

N o

Eclampsia Preeclampsia with seizures not attributable to other causes

>20 weeks

≥140/90 (may vary)

Yes Y es

Chronic HTN

HTN diagnosed before 20 weeks or persists >12 weeks postpartum

<20 weeks or pre- existing

≥140/90 No (unless superimpos ed)

N o

Superimp osed Preeclam psia

Chronic HTN with new-onset proteinuria or worsening BP/ organ dysfunction

Any, usually >20 weeks

≥140/90 (worseni ng trend)

Yes N o

Conditi on Definition Signs and Symptoms Management

Postpar tum Blues

Transient mood disturbance in first few days after delivery

Crying, mood swings, irritability, anxiety, sleep disturbance; resolves <2 weeks

Reassurance, support, monitoring

Postpar tum Depres sion

Major depressive episode within 12 months postpartum

Sadness, hopelessness, loss of interest, sleep/appetite changes, suicidal ideation

Psychotherapy, SSRIs (e.g., sertraline), screening

Postpar tum OCD

Obsessions and/or compulsions related to infant safety

Intrusive thoughts (e.g., harm to infant), compulsive behaviors, intense distress

CBT, SSRIs, psychiatric referral

Postpar tum Psycho sis

Rare, severe psychiatric emergency postpartum

Delusions, hallucinations, mood swings, confusion, disorganized thinking

Hospitalization, antipsychotics, safety precautions

Postpartum Physical Conditions

SOAP Note – Prenatal Visit

Patient: Hannah (female) 
 Age: 38
 Gravida/Para: G1P0
 Gestational Age: 32 weeks EGA

Subjective

Chief Complaint:
 "I’ve had a headache that won’t go away and I just don’t feel right."

Condition Definition Presentation (Signs and Symptoms) Management

Puerperal Fever

Fever ≥100.4°F on ≥2 days postpartum (excluding day 1)

Uterine tenderness, foul lochia, chills, tachycardia, elevated WBC

Broad-spectrum antibiotics (e.g., clindamycin + gentamicin)

Postpartum Hematoma

Collection of blood in vulva/vagina/ pelvis after delivery

Severe perineal pain, swelling, visible mass, hypotension (if large)

Small: Ice, analgesia; Large: surgical evacuation

Secondary Postpartum Hemorrhage

Excessive bleeding >24h to 6 weeks postpartum

Persistent bright red bleeding, passage of clots, uterine subinvolution

Uterotonics, D&C for retained products, antibiotics if infected

Sore Nipples

Common during early breastfeeding

Nipple pain, cracking, bleeding, latch pain

Improve latch, lanolin, breast shields, lactation consult

Mastitis Inflammation of breast tissue (often due to infection)

Unilateral breast pain, redness, fever, flu-like symptoms

Continue breastfeeding, antibiotics (e.g., dicloxacillin)

Breast Abscess

Localized pus collection in breast

Painful, fluctuant mass, erythema, fever

Drainage (needle aspiration or I&D), antibiotics

HPI: 
 Hannah is a 38-year-old primigravida at 32 weeks gestation presenting for a routine prenatal visit. She reports experiencing a persistent, dull headache for the past 7 days that has not responded to acetaminophen. She also describes a general sense of malaise and “not feeling right.” She denies visual disturbances, nausea, vomiting, epigastric pain, chest pain, shortness of breath, or recent illness. Fetal movements are present and normal.

Obstetric History:

• G1P0

• No complications reported until this visit

Medical History:

• No known chronic conditions

• No history of chronic hypertension or preeclampsia

Medications:

• Prenatal vitamins

• Acetaminophen PRN (for headache)

Allergies:

• NKDA

Social History:

• Non-smoker, no alcohol or drug use

• Supportive home environment

ROS:

• Neuro: Persistent headache

• GU: No dysuria, vaginal bleeding, or leakage

• Cardio/Resp: No chest pain, dyspnea

• GI: No nausea, vomiting, or RUQ pain

• Vision: No changes or disturbances reported

• MSK: No swelling noted by patient

O – Objective

Vitals:

• BP: 156/96 mmHg (repeated and confirmed)

• HR: 86 bpm

• RR: 16

• Temp: 98.6°F

• Weight: [Insert]

• Fundal height: 32 cm

• Fetal heart rate: 140 bpm (normal)

• Fetal movement: Present by maternal report

Physical Exam:

• General: Alert, mildly anxious

• HEENT: Normocephalic, no sinus tenderness

• CV: Regular rhythm, no murmurs

• Lungs: Clear to auscultation bilaterally

• Abdomen: Non-tender, fundal height appropriate

• Extremities: No significant edema noted

• Neuro: No focal deficits, reflexes slightly brisk (3+)

• Urine dip: 2+ proteinuria

A – Assessment

Primary Diagnosis:

• Preeclampsia with severe features

o ICD-10: O14.13 – Severe preeclampsia, third trimester

Rationale: 
 BP >140/90 with proteinuria and symptoms (persistent headache, not relieved by medication) indicates preeclampsia with severe features per ACOG criteria.

P – Plan

Immediate Management:

• Hospital admission for further evaluation and management

• Labs ordered:

o CBC with platelets

o CMP (AST/ALT, creatinine)

o LDH

o Coagulation profile

o 24-hour urine collection or protein/creatinine ratio

• Fetal monitoring:

o Non-stress test (NST)

o Biophysical profile (BPP)

o Ultrasound for fetal growth and amniotic fluid index

Medications/Interventions:

• Labetalol or hydralazine IV as needed to control BP per hospital protocol

• Magnesium sulfate for seizure prophylaxis

• Corticosteroids (e.g., betamethasone 12 mg IM q24h × 2) if delivery anticipated <34 weeks

Education:

• Explained signs of worsening preeclampsia (severe headache, visual changes, RUQ pain, reduced fetal movement)

• Importance of hospital monitoring for maternal and fetal safety

• Possible need for early delivery if condition worsens

Follow-up:

• Inpatient monitoring and coordination with OB/MFM team

• Continued prenatal care per high-risk protocol

1. Subjective

a. Relevant HPI Questions:

• When did the headache start? Describe its location, intensity, and whether it's continuous or intermittent.

• Does the headache worsen with light, noise, or activity?

• Are there any visual symptoms (blurred vision, flashing lights, scotomata)?

• Do you have any upper abdominal (RUQ) pain?

• Any nausea, vomiting, or swelling in your hands, face, or feet?

• Fetal movement – has it changed?

• Any recent illness, infections, or trauma?

b. Medical History Questions:

• Do you have a history of high blood pressure or kidney disease?

• Any autoimmune disorders (e.g., lupus, antiphospholipid syndrome)?

• Are you currently taking any medications, including over-the-counter or herbal supplements?

• Any allergies or history of migraines?

c. OB History Questions:

• Have you had any complications so far in this pregnancy?

• Any prior pregnancies, losses, or fertility treatments?

• Results of prior ultrasounds or labs during this pregnancy?

• Have you had any bleeding, cramping, or leaking fluid?

2. Objective

a. Physical Assessment:

• Vitals: Blood pressure (repeat in both arms, after 5 mins of rest), pulse, temperature, respiratory rate, weight.

• General appearance: Distress, alertness, signs of pain or swelling.

• Neurological: Mental status, deep tendon reflexes (DTRs), clonus.

• Cardiovascular: Heart sounds, edema in extremities.

• Pulmonary: Breath sounds (rales/crackles may suggest pulmonary edema).

• Abdomen: Fundal height, fetal movement, tenderness, RUQ or epigastric pain.

• OB exam: Fetal heart tones (FHT), Leopold's maneuvers.

b. Tests to Order and Rationale:

• CBC with platelets: Check for thrombocytopenia (part of severe features).

• CMP (LFTs, creatinine): Evaluate liver enzymes and renal function.

• LDH: Marker of hemolysis.

• Urine protein/creatinine ratio or 24-hour urine protein: Quantify proteinuria.

• Non-stress test (NST): Assess fetal well-being.

• Ultrasound: Assess fetal growth, amniotic fluid, and Dopplers if growth-restriction suspected.

• Magnesium sulfate eligibility screen: For seizure prophylaxis.

3. Assessment/Diagnosis

a. Primary Diagnosis:

• Preeclampsia with severe features

o ICD-10: O14.13 – Severe preeclampsia, third trimester

b. Differential Diagnoses:

• Chronic hypertension with proteinuria (unlikely given gestational timing)

• Migraine headache (no visual aura or typical features)

• Gestational hypertension (but proteinuria and symptoms point beyond this)

• HELLP syndrome (if labs show hemolysis, elevated LFTs, low platelets)

• 4. Plan

a. Outpatient Management?

• No. This cannot be safely managed outpatient due to:

o Severe range BP (≥160 systolic or ≥110 diastolic)

o Persistent headache (a severe feature)

o Proteinuria + systemic symptoms

o Risk of rapid decompensation for mother and fetus

b. Inpatient Management? Why?

• Yes, inpatient is required for:

o Close BP and neurological monitoring

o Lab surveillance for HELLP or eclampsia

o Seizure prophylaxis (magnesium sulfate)

o Fetal monitoring for distress

o Potential delivery if maternal or fetal conditions worsen

c. Outpatient Plan (if symptoms were milder): 
 N/A in this case due to severe features.

d. Inpatient Plan:

• Medications:

o Magnesium sulfate IV for seizure prophylaxis

o Labetalol or hydralazine IV for BP control

o Corticosteroids (betamethasone 12 mg IM x 2 doses) if <34 weeks for fetal lung maturity

• Tests:

o Serial BP and neuro checks (q4h or more frequent)

o Daily labs (CBC, CMP, LDH)

o Continuous fetal monitoring

o Ultrasound with Dopplers and amniotic fluid index

• Discharge Planning:

o If stabilized and not delivered: home on oral antihypertensives, twice-weekly NSTs, weekly labs, and BP checks

o If delivered: follow up in 1–2 weeks post-discharge with BP monitoring and depression screening

e. Patient Education:

• Warning signs of worsening: severe headache, vision changes, RUQ pain, decreased fetal movement

• Importance of medication compliance and follow-up visits

• Rest and avoid high-sodium foods

• Possible need for early delivery

• Educate on signs of postpartum preeclampsia and eclampsia

f. Complications if Untreated:

• Maternal risks: Eclampsia (seizures), stroke, pulmonary edema, liver rupture, renal failure, HELLP syndrome, death

• Fetal risks: IUGR, placental abruption, hypoxia, preterm delivery, stillbirth