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You are an FY1 working in the antenatal clinic. Your next patient is 36-year-old Amy O’Derone. She is 32 weeks pregnant, and has been referred to the antenatal clinic by her midwife.

Her drug history includes:

Folic Acid 400micrograms OD Labetalol OD

Please take a history, focusing on her presenting complaint and current pregnancy.

You are Amy O’Derone, a 36-year-old school teacher who is 32 weeks pregnant with a single baby boy. This is your first pregnancy and you are very excited! our midwife has referred you to the antenatal clinic, as you’ve also been feeling a bit off the last few weeks- feeling a bit more nauseous than usual, and you’ve even vomited a few times. There isn’t any pattern to this, and you passed it off as morning sickness although you’re aware that it’s a bit late on in the pregnancy for that. You haven’t really suffered with sickness until now. You’ve been getting a little bit of tummy pain just under your ribs, it’s not too severe, just a bit of a dull ache and you just thought it was just the baby pressing on things inside. It’s not worse with food, and again there’s no pattern to it.

You’ve also been getting a few headaches that have started over the last week. It was these that worried your midwife. The headaches are usually right at the front of your head, around your forehead. You’ve had no problems with your vision, and you’ve not had any dizziness or hot spells. You’ve not noticed any swelling of your hands, feet or face

So far your pregnancy has been going well. You’ve been quite lucky, with no morning sickness. Your back and hips are starting to hurt a bit but you were expecting this. You’ve been peeing a lot more recently, and sometimes you leak a bit, but you were expecting this too; after all there’s a baby plonked on your bladder! You’re feeling kicks quite a lot- you think he is going to be a footballer! All your scans and tests so far have been normal, but your blood pressure has been up at your last few appointments, though you can’t remember what it was. You saw a doctor when it was first measured as high who started you on tablets. Your midwife says your baby is head down at the moment, and there’s been no problems with the size of your bump.

Your periods have always been irregular, and you were diagnosed with Polycystic Ovaries when you were 17. You found it quite difficult to conceive, and this baby is an IVF baby. Your smear tests have always been normal.

ICE You’re a bit worried about being referred to see a doctor, as your midwife was quite concerned but didn’t really tell you why, so you’re hoping for some explanations at the clinic. As it is your first pregnancy you weren’t really sure if these symptoms were just normal pregnancy things. As your baby was conceived by IVF you’re really terrified of something happening to harm the baby, and of losing the baby as it’s been such a stressful process to get this far.

PMH Asthma in childhood, rarely affects you now

DH Folic Acid 500 micrograms od Labetalol od Allergic to penicillin

FH Your mum had both you and your sister a bit early, though you can’t remember why

SH You live with your husband Alan in a semi-detached four bedroom house with a nice garden, with lots of space for the baby. You don’t have any pets. You’ve never touched a cigarette in your life, and you haven’t drank any alcohol since finding out you were pregnant. You work as a primary school teacher, and have planned your maternity leave from week 37 of your pregnancy. Alan works in a bank and will also be taking time off. Your parents live close by and are very supportive and excited about the baby.

The student should take a good history of Amy’s symptoms, and also of her current pregnancy, eliciting ideas, concerns and expectations. An obstetric examination would be appropriate.

Differential Diagnosis

My differential diagnoses would include hypertensive disease of pregnancy, as Amy takes Labetalol to control blood pressure. I would be concerned about pre-eclampsia, as Amy has experienced frontal headaches and upper abdominal pain. I would thus consider blood pressure measurements and urinalysis. Urinary tract infection could also be considered due to Amy’s urinary frequency.

Discussion Points What is the definition of pre-eclampsia? What is the pathophysiology behind pre-eclampsia? What are the risk factors that predispose a mother to pre-eclampsia? What investigations would you consider in Amy? What is HELLP syndrome? How would you manage pre-eclampsia? When would you consider admission to hospital?