I was very pleased to see Amelia (not real name) for management of her 3rd pregnancy. 
But there were concerns. Amelia has a history of pyelonephritis (kidney infection) in 2014 and chronic hypertension (elevated blood pressure). Her previous two pregnancies were complicated by increasing hypertension and preeclampsia. In first pregnancy in 2015 her labour was induced at 36 weeks 0 days because increased concern about her wellbeing due to her hypertension with preeclampsia. In second pregnancy in 2017 her labour was induced at 36 weeks 5 days because of increased concern about her wellbeing due to her hypertension with preeclampsia. In both pregnancies I consulted with a renal physician who has a special interest in preeclampsia for hypertension management support.
Amelia’s first visit with me for this pregnancy was when she was 7 weeks pregnant. She was taking the antihypertensive methyldopa at 750mg/day (in divided doses). I increased the methyldopa dose to 1gm/d (in divided doses). At 9 weeks pregnancy the renal physician increased methyldopa dose to 2gms/day (in divided doses) because of increasing hypertension. Amelia then developed a urinary tract infection which was treated with an appropriate antibiotic. At 21 weeks pregnancy she developed haematuria (blood in her urine) and was admitted to hospital by the renal physician with a suspected pyelonephritis. This was treated with intravenous antibiotics, and she recovered.
At 31 weeks Amelia was readmitted to hospital by the renal physician because her blood pressure was too elevated. As well, a renal ultrasound scan suggested she had a small intrarenal non-obstructive calculus (stone) in her left kidney. She also had a urinary tract infection. Her antihypertensive medications were increased to hydralazine 75mg/day (in divided doses), labetalol 600mg/day (in divided doses) and methyldopa 1.5gms/day (in divided doses). As well, an appropriate antibiotic was prescribed to treat her urinary tract infection.
At 32 weeks I readmitted Amelia to hospital as her blood pressure was 170 /105 and she had a frontal headache. Blood pressure considered elevated if 140/90 or above a severe headache can be due to severe preeclampsia. In hospital her labetalol dose was increased to 900mg/day (in divided doses). Her uric acid level was elevated at 0.47 mmol/L, but her platelets count was normal, her liver function tests were normal, her urea and creatinine were normal. I told Amelia she now had superimposed preeclampsia as well as hypertension. Her elevated uric acid level and had increased from earlier in her pregnancy.
After three days she discharged home on labetalol 900mg/day (in divided doses), nifedipine SR 60mg/day (in divided doses), methyldopa 1.5gms/day (in divided doses).
When she was 34 weeks Amelia was readmitted to hospital with increased blood pressure. Because she had unstable severe hypertension with superimposed preeclampsia, so she was kept in hospital until delivery. Her uric acid level was now 0.52 mmol/L.
Her blood became of increasing concern and so I decided to induce her labour when she was 35 weeks 3 days gestation. I made the decision with the support of the renal physician and agreement of Amelia. Despite her being on methyldopa 2gms/day, labetalol 1.6gms/day, nifedipine 120mg/day and now prazosin at the initial dose of 0.5mg and then 1 hr later another 1mg, her blood pressure remained at 180/110.
I deferred the induction until the next morning as it was safer to have such a high-risk patient labouring in the day rather than in the night. She commenced on the magnesium sulphate regime to reduce the risk of a seizure. When a seizure happens with preeclampsia the condition is called eclampsia rather than preeclampsia. Eclampsia is an extremely dangerous development. There was a reduction of her blood pressure to a safer level with the magnesium sulphate.
The next morning her labour was induced with an ARM and Syntocinon infusion She had an epidural for pain relief in labour The total duration of her labour was about 8 hrs. Amelia’s labour progressed to a spontaneous vaginal delivery, with her perineum remaining intact. Her daughter was born in good condition with a birth weight of 2760gms.
After delivery her antihypertensive needs reduced. Amelia was discharged home on labetalol 800mg/day (in divided doses) and methyldopa 1gm/day (in divided doses).
Amelia checked her blood pressure at home. After discharge there was elevation of her blood pressure at home and so I increased the methyldopa dose to 2gms/day (in divided doses) and a few days later the labetalol to 1.6gms/day (in divided doses).
When I saw Amelia for her postnatal visit, she advised me the renal physician had changed her antihypertensive regime. She was now on labetalol 1.6mg/day (in divided doses), nifedipine 40mg/day (in divided doses). Methyldopa had been ceased. Her blood pressure was 140/85 in my rooms. She felt well.
She remains under the care of the renal physician for her hypertension management.
We talked through the possibility of another pregnancy. I advised Amelia she can have another pregnancy but can expect her hypertension will be major issue and it would be most likely be like this pregnancy. This pregnancy I suspect this was her last.
Amelia had very severe hypertension with preeclampsia. The hospital staff contacted me frequently as they were worried about her, and they not used to managing a patient with hypertension of this severity. I told Amelia I was not personally stressed about her hypertension and would not let anything adverse happen to her or her baby. I wanted to continue her pregnancy if it was safe to do so. But when there was a lack of response to very high doses of antihypertensive medications, I suggested to Amelia we deliver her baby. More antihypertensive could have been introduced and/or the current medications could have been increased a little more but there was considerable risk to Amelia’s wellbeing. The risk outweighed the potential benefit. While I was the senior registrar in Oxford, I also worked with Prof Chris Redman in managing of patients with preeclampsia. Chris is considered a world authority on preeclampsia and so I am very grateful for this opportunity. I learned a lot about preeclampsia and its management from Chris. One thing Chris taught me is: “if you can’t get a week of pregnancy, there is no point trying for day”. With Amelia we were unlikely to get another week and so there was no point trying for an extra day when she was failing to respond to the antihypertensives. Chris also made me realise the importance of having the support of good renal physician who has a special interest in preeclampsia. I certainly had this in Amelia’s case, and I am very grateful.
Amelia and her husband Mark were incredibly strong during this pregnancy. Despite the very high-risk hypertension developments they remained calm. They trusted in my care and the care of the renal physician. I am so proud of them.
