Case Summary Structure for Multiparous Patient with Hypertension and Post-Dates Pregnancy After Failed Tubal Ligation
Patient Presentation Summary
Write a concise opening statement that includes: multiparity status, advanced maternal age (if ≥35 years), gestational age beyond 40 weeks, current blood pressure readings with severity classification, and the unique circumstance of pregnancy following failed bilateral tubal ligation 1.
Hypertension Classification and Risk Stratification
Classify the hypertension immediately using the following framework 2:
- Pre-existing hypertension: BP ≥140/90 mmHg documented before 20 weeks gestation or known prior to pregnancy 2
- Gestational hypertension: New-onset BP ≥140/90 mmHg after 20 weeks without proteinuria 2
- Preeclampsia: Gestational hypertension with proteinuria ≥0.3 g/24h or ≥30 mg/mmol urinary creatinine 2
- Severe hypertension: BP ≥160/110 mmHg requiring immediate intervention 2, 3
Document severity features including: headache, visual disturbances, right upper quadrant pain, elevated liver enzymes, thrombocytopenia, or renal dysfunction 4.
Post-Dates Pregnancy Management Context
State the gestational age precisely (e.g., 40+5 weeks) and document fetal surveillance results including non-stress test reactivity, biophysical profile score, and amniotic fluid index 3.
The combination of hypertension and post-dates pregnancy necessitates delivery planning, as expectant management beyond 40 weeks with hypertensive disorders increases maternal and fetal risk 2.
Failed Tubal Ligation Documentation
Document the sterilization details: date of procedure, method (modified Pomeroy, clips, rings), and any prior documentation of successful sterilization 1.
This represents a sterilization failure requiring documentation for medicolegal purposes and future contraceptive counseling 1.
Current Management Plan
Immediate Blood Pressure Management
For severe hypertension (≥160/110 mmHg lasting >15 minutes), initiate acute treatment within 30-60 minutes 5, 3:
- First-line IV options: Labetalol 20 mg IV bolus (repeat 40-80 mg every 10 minutes, max 300 mg cumulative) OR immediate-release nifedipine 10-20 mg PO 5
- Alternative: Hydralazine 5 mg IV initially, then 5-10 mg every 30 minutes 5
- Target BP: Systolic 140-150 mmHg and diastolic 90-100 mmHg 5
For non-severe hypertension (140-159/90-109 mmHg), continue or initiate oral antihypertensives 2:
- Preferred agents: Labetalol, methyldopa (antepartum only), or nifedipine extended-release 2
- Avoid: ACE inhibitors, ARBs, and direct renin inhibitors due to fetotoxicity 2
Delivery Planning
Recommend delivery at 40 weeks or upon diagnosis if severe features present, as the only definitive treatment for gestational hypertension/preeclampsia is delivery 2, 4.
Mode of delivery should be determined by standard obstetric indications, though note that cesarean delivery increases risk of postpartum preeclampsia 4.
Laboratory and Fetal Surveillance
Order baseline labs: Complete blood count, comprehensive metabolic panel, liver function tests, 24-hour urine protein or spot protein/creatinine ratio 2, 4.
Continuous fetal monitoring during acute hypertensive episodes to assess for fetal compromise from uteroplacental hypoperfusion 3.
Postpartum Considerations
Critical Monitoring Period
Blood pressure peaks 3-6 days postpartum, requiring close monitoring for minimum 3 days, as this is when most hypertension-related maternal deaths occur 5, 6.
Avoid NSAIDs for postpartum analgesia in women with preeclampsia, especially with renal involvement, as they worsen hypertension 5, 6.
Postpartum Antihypertensive Management
Transition to breastfeeding-compatible agents 5:
- First-line: Nifedipine extended-release 30-60 mg daily OR amlodipine 5-10 mg daily
- Alternative: Labetalol 200-800 mg twice daily OR enalapril 5-20 mg daily (with documented contraception plan)
- Discontinue methyldopa immediately postpartum due to increased risk of postpartum depression 5, 7
Contraception Counseling
Address the failed tubal ligation and discuss highly effective contraceptive options for future pregnancy prevention 5.
If prescribing ACE inhibitors or ARBs postpartum, document contraception plan due to teratogenicity risk 5.
Long-Term Follow-Up
Schedule 6-week postpartum visit to assess for persistent hypertension requiring further workup for secondary causes, especially in women <40 years 5.
Counsel regarding increased lifetime cardiovascular risk: Women with hypertensive disorders of pregnancy have significantly elevated risk of chronic hypertension, stroke, and ischemic heart disease 5, 4.
Key Documentation Elements
Include in case summary: admission vital signs with BP trends, gestational age, parity, maternal age, failed sterilization history, laboratory values, fetal surveillance results, antihypertensive medications with doses and timing, delivery plan with indication, and postpartum monitoring plan 2, 5, 4.