Case Study 8 Activity
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Medicine
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Apr 3, 2024
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Part I – Something is wrong
Jenny sat up and wiped her mouth. She had thought that her morning sickness had passed, but maybe
not. She flushed the toilet and headed back to her birthing class at the hospital. She slipped into the
room and took her seat.
A few minutes later, Jenny felt something warm on her face. She wiped it with her hand and realized her
nose was bleeding. Jenny stood up to get some tissues and suddenly felt the onset of a severe
headache; she clutched her head.
“Jenny?! Are you okay?!” the birthing instructor asked as she grabbed some tissue and handed it to
Jenny.
“Yeah, just feeling pretty crappy today with this nosebleed and headache. I also thought the morning
sickness was supposed to be totally gone when you were this far into pregnancy.” Jenny shrugged and
tried to play it cool, her head still aching.
“Perhaps you should go home and rest but call your partner because you shouldn’t risk driving yourself,”
the instructor replied. “You should also go see your obstetrician to make sure there is nothing wrong.
Headaches, severe nausea, and nose bleeds in pregnancy can often signal an underlying problem.”
“Oh no, I’m okay. I think I’m just a little dehydrated. I’ve had a headache and been feeling pretty tired
this week. You know how it is being pregnant and all,” Jenny replied, feeling embarrassed about the
episode.
The instructor insisted on calling Jenny’s partner, Brie, who worked as an EMT. About ten minutes later,
Brie arrived frantically worried, and insisted Jenny be rushed to the doctor. Jenny stubbornly refused but
compromised by letting Brie check her vital signs with her equipment at home.
“Jenny, your blood pressure is 160/110 mmHg,” Brie exclaimed. “Your feet are swollen four times the
normal size. Why haven’t you said anything?!”
Jenny looked puzzled. “I’m sorry Brie, I had no idea. I thought that was just because of the pregnancy.
I’m 28 weeks along you know. Besides, I’ve never had high blood pressure before. Don’t worry, I have an
appointment tomorrow, I’ll have Dr. Ramchandani check into it.”
Brie sighed. “Okay dear, just take it easy tonight and please avoid doing anything that could worsen this
condition until you have it checked out. Hypertension can be really dangerous, especially during
pregnancy.”
Brie was still worried as they lay in bed that night. She was concerned about her wife and unborn child.
Jenny was thinking about how she had been feeling lately and whether it was typical for pregnancy.
Jenny whispered, “Brie, are you still up?”
“Yes,” she replied. “I can’t sleep; I’m worried about you.”
“I’m a bit worried too, Brie. Could you explain blood pressure to me and why having high blood pressure
is a problem?” “Of course,” said Brie.
Questions
1.
What signs and symptoms have Jenny been experiencing?
High blood pressure, severe headache, nose bleed, swollen feet
2.
Define blood pressure. What is the difference between systolic and diastolic pressure measures?
You can use a website from a reputable source (e.g., American Heart Association or MedlinePlus).
Blood pressure: the pressure that blood exerts on the walls of the blood vessels Systolic pressure measure: the pressure against the walls of the arteries during ventricular systole Diastolic pressure measure: the pressure against the walls of the arteries during ventricular diastole 3.
According to the American Heart Association, what are the normal, healthy ranges for systolic
and diastolic blood pressure in a typical adult?
Systolic pressure is best under 120 and diastolic is best under 80. 4.
According to the American Heart Association or the Mayo Clinic (both have websites), define
hypotension and hypertension. Provide the definition and include the systolic and diastolic values
associated with these definitions, and then fill out the below chart (make sure you are using a chart that
was made in or after 2017).
Hypotension: Low blood pressure – below 90/60
Hypertension: High blood pressure – stage 1 is 130/80+ and stage 2 is 140/90+
Blood Pressure Category
Systolic mmHg
And/Or
Diastolic mmHg
Hypotension
90>
OR
60>
Normal
120>
AND
80>
Elevated
120-129
AND
80>
High blood pressure
(hypertension) stage 1
130--139
OR
80-89
High blood pressure
(hypertension) stage 2
140<
OR
90<
Hypertensive crisis (consult
doctor immediately)
180<
AND/OR
120<
5.
Chronic hypertension is associated with multiple health conditions. Please use information
provided by the American Heart Association or the Mayo Clinic to list seven different complications
associated with hypertension.
Stroke, heart attack, kidney failure, vision loss, dementia, metabolic syndrome, aneurysm
Part II – But what is blood pressure?
“Thanks, Brie,” said Jenny. “That helped me understand blood pressure and hypertension, but why is
blood pressure important? What does it do for the body?
“Great question,” Brie replied. “But before we get too deep into this, let’s make sure you understand
some basic principles of cardiac function and blood pressure measurement.”
Questions
6.
Why is blood pressure important for physiological function and survival?
Blood pressure must be maintained in order to supply the body’s tissues with oxygen, nutrients, and to
remove wastes. Without adequate blood pressure, blood flow will not reach certain areas of the body. 7.
How is blood pressure generated? Make sure to include the source of pressure generation and
resistance in your answer.
Blood pressure is generated by the heart pumping blood into the arteries. The walls and length of the
arteries and the viscosity of the blood contribute to resistance. 8.
Fill in the chart below by matching the term to its definition. Select from the following: pulse
pressure; mean arterial pressure (MAP); cardiac output; flow rate; flow velocity; vessel compliance;
resistance; vasoconstriction; vasodilation
Word
Definition
MAP
This is the average blood pressure in a single cardiac cycle. This is useful because atrial
pressure is pulsatile (increases with cardiac systole) and this number gives a
representative measure of driving pressure through the arteries. Calculated as diastolic
pressure + 1/3 (systolic − diastolic pressure). Example: 120/80 BP = 93 mm Hg. Also
written as: diastolic + (pulse pressure/3).
Cardia output This is the pumping power or efficiency of the heart; it is measured in ml/min and is
the heart rate (beats per min) × the stroke volume (ml/beat).
Vessel compliance A measure of the blood vessel ability to change diameter. This can be measured as
change in volume/change in pressure.
Vasoconstriction A decrease in blood vessel diameter, which decreases the volume of blood that can
flow through it; can be caused by many different cues, such as vasopressin and
angiotensin II.
Flow rate The volume of blood that travels past a certain point per time unit. This is constant
throughout the vasculature. It is directly proportional to change in pressure and
inversely proportional to resistance or is inversely proportional to 1/resistance.
Vasodilation An increase in blood vessel diameter which allows a greater volume of blood to flow
through. Can be caused by many different cues, such as epinephrine, histamine, and
nitric oxide.
Pulse pressure The systolic minus diastolic pressure. This is a measure of the pressure wave created
with cardiac systole.
Flow velocity The speed at which blood flows past a certain point. This is not the same in all vessels (in
the body, blood flows faster in vessels with lower total diameter (large veins and
arteries) and slower in vessels with higher total diameter (capillaries)). Flow rate/cross-
sectional area
Resistance The tendency of the cardiovascular system to oppose blood flow and is abbreviated as R.
This varies with vessel length, blood viscosity, and vessel diameter.
Brie explained that the heart and the blood vessels make a closed system of fluid (blood)-filled tubes in
the body. Therefore, the volume of blood, diameter of the vessels, and pressure are directly related. If
blood volume increases, or vessel diameter decreases, pressure on the walls of the vessels increases.
Likewise, if fluid volume decreases, or vessel diameter increases, pressure in the system decreases.
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“Think of it like a water balloon,” said Brie. “If I have a balloon and let out water, the balloon is less
stretched, there is less pressure; but if I add more water to the balloon, the pressure on the balloon
walls increases.”
“Got it,” said Jenny. “So, if a person were to decrease their blood volume, say if they had a major cut
and were bleeding, their blood pressure would drop?”
“Exactly! Additionally, the length of the vessel and the viscosity, or thickness, of the blood matters. Think
about drinking out of a straw; which one is easier to use? One that is of typical length or one that is five
feet long? The shorter straw is easier to use because there is less resistance. Likewise, what is easier to
suck up through a straw, a thick milkshake or orange juice?”
“Orange juice, for sure!” said Jenny. “Sometimes you really have to suck to get a thick milkshake to
move in the straw.”
“That’s right. The cardiovascular system works much the same way; longer tubes and thicker blood
increase resistance, which means the heart must generate more force to move the blood, which
increases blood pressure.”
“Wow, that’s amazing; I hadn’t realized how important blood pressure is for our health. Are there
additional issues I should be aware of because I’m pregnant?”
“Unfortunately, yes,” said Brie. “A woman’s body goes through all sorts of physiological changes during
pregnancy. In some cases, pregnant women develop high blood pressure and if that happens there can
be risks to both the mother and the baby. I don’t know as much about specifics, though. We should
consult Google Scholar and the American College of Obstetrics and Gynecologists webpage for
information so that you’re prepared for your appointment in the morning. Sounds okay?”
“Yes, that sounds great.”
Brie and Jenny grabbed the computer and found helpful peer-reviewed publications that discussed the
physiology of pregnancy. Brie was currently enrolled in a Master of Science program, so she had
experience with credible scientific articles and helped interpret some of the complicated information for
Jenny. They read about the maternal-placental (uteroplacental) and fetal-placental (fetoplacental) blood
circulation. The mother and the fetus each have their own blood supply and that blood does not mix (at
least typically). The placenta is the organ of gas, nutrient, and waste transfer. The fetus is connected to
the placenta via the umbilical cord (houses the umbilical artery and vein) and the placenta is implanted
into the mother’s uterus. As pregnancy progresses, the placenta becomes more developed and the
mother’s vascular network within the placenta grows; there are new spiral arteries, intervillous spaces
(funnel-shaped areas that aid in exchange with fetal blood), and veins. The remodeling of the utero-
placental vasculature is typically complete by weeks 20–22 of pregnancy.
They also found typical cardiovascular changes that occur in the mother during pregnancy include:
•
A 40–50% increase in plasma volume.
•
A 25% increase in red blood cells (RBC), but a decrease in overall hematocrit and hemoglobin
concentration.
•
A decrease in vascular resistance driven by fetoplacental developmental changes, a decreased
sensitivity of the mother to angiotensin, and increased production of nitric oxide and relaxin.
•
An increase in arterial compliance.
•
A 30–50% increase in cardiac output, driven by an increase in both stroke volume (about a 30%
increase) and heart rate (about a 15% increase).
After their web browsing session, Brie and Jenny felt that they had looked up enough information for
one night and were finally able to fall asleep.
Questions
9.
Based on what Brie and Jenny found, make a prediction (increase, decrease or no effect) about
how each of the listed physiological changes would impact blood pressure.
Measure
Predicted Impact on Blood Pressure
New arteries and veins develop in utero-placental unit
Decrease Increase in plasma volume
Increase
Decrease in blood viscosity
Decrease
Decrease in vascular resistance
Decrease Increase in arterial compliance
Decrease Increase in cardiac output
Increase 10.
Based on your table, do you think a pregnant woman typically has blood pressure that is higher
or lower compared to her pre-pregnancy reading?
Pregnant women have lower blood pressure compared to pre-pregnancy readings. Part III – Medical Tests
The next day Jenny went to her doctor’s appointment. When she arrived, a nurse took her vital signs
and asked Jenny to provide a urine sample for further analysis. Jenny complied and was escorted to the
exam room.
When Dr. Ramchandani entered the room, Jenny reported her vomiting, headaches, and nosebleed she
experienced the day before. She also mentioned the discussion she had had with Brie about blood
pressure, and their conclusion that pregnant women should generally have lower rather than higher
blood pressure.
Dr. Ramchandani was impressed that Jenny had done so much background research and reading.
However, he was still very concerned about her symptoms. He looked at her chart to find the blood
pressure value that the nurse had taken when she arrived; it was 148/90 mmHg.
Throughout his assessment of Jenny, he asked a variety of questions regarding her diet, exercise, familial
history, and home medications, all of which are factors that can attribute to hypertension. After
considering Jenny’s background information, Dr. Ramchandani recognized that none of these risk factors
for hypertension were applicable to Jenny.
“Jenny, based on the new symptoms you told me about and today’s blood pressure reading, I’d like to
do some more tests to find out what’s going on. High blood pressure can be especially dangerous in
pregnancy because it can be associated with a diagnosis of preeclampsia.”
Jenny was now really worried. She didn’t understand what preeclampsia was; she couldn’t believe that
all of this was happening to her. “Dr. Ramchandani, I’m very concerned for my baby’s health, as well as
my own. Could you please explain to me what exactly preeclampsia is?”
“Absolutely.” He went over to the white board in his office and explained.
*****
Watch the following video:
•
Preeclampsia and Eclampsia: Causes, Symptoms, Diagnosis, Treatment, Pathology. Produced by
Osmosis.org, 2017. <https://youtu.be/RB5s85xDshA>
*****
This new information made Jenny even more anxious because she had never had high blood pressure
before and had always lived a healthy lifestyle. The doctor advised her to stay calm and explained that
they were going to run some further tests. First, they needed to get at least one more blood pressure
reading and a measure of the protein in her urine over a 24-hour period. Jenny was instructed to take
the provided containers home and, starting the next morning, collect all urine produced in the next 24
hours. She was to note the time of first urination and discard that sample. She was then to collect all
urine for 24 hours and keep it cool, either in the refrigerator or on ice in a cooler and then return the
samples. The technicians would look for protein in her urine. Protein in the urine can be a sign of
multiple physiological conditions. Elevated blood pressure can cause issues with several physiological
systems, one of which is the renal system. Prolonged increase in blood pressure can damage the
glomeruli of the nephrons, leading to protein leaking into the filtrate and ultimately into the urine.
Dr. Ramchandani said he would provide a laboratory analysis of her urine immediately and call her as
soon as the results were available. Jenny was also instructed to have Brie take her blood pressure that
evening before going to bed, and then again in the morning before getting out of bed. Dr.
Ramchandani’s office would take it again when she returned with the urine. Jenny nodded in
agreement. Dr. Ramchandani handed Jenny two reference sheets on preeclampsia and a flyer explaining
how to properly take one’s blood pressure. Even though he knew Brie was an EMT, he emphasized the
importance of following the proper protocol for collecting a blood pressure reading. Jenny hurried home
to read her resources and talk with Brie.
Questions
11.
List five things that Brie should do when taking Jenny’s blood pressure in order to get an
accurate reading with the sphygmomanometer. You may use credible sources such as the American
Medical Association or the American Heart Association.
As soon as Jenny had completed her sample collection, she returned to Dr. Ramchandani’s office to drop
it off and to get her blood pressure taken again. She also brought her blood pressure readings from
home. A nurse took Jenny’s blood
pressure and collected the samples. The nurse assured Jenny that Dr. Ramchandani would call as soon
as the results came in.
12.
Using the chart you completed in Question 4 of Part I above, provide the blood pressure
classification for each of Jenny’s readings.
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Blood Pressure Results
Jenny’s Values
Classification According to AHA Chart
Initial blood pressure at home
160/110 mmHg
Hypertension stage 2
Blood pressure in office (initial reading)
148/90 mmHg
Hypertension stage 2
Blood pressure before bed at home
142/89 mmHg
Hypertension stage 2
Blood pressure upon waking at home
135/89mmHg
Hypertension stage 1
Blood pressure in office (follow-up)
160/95 mmHg
Hypertension stage 2
Urinary results
Hypertension 24 hr urinary protein (typical < 229 mg)
355 mg
13.
Why do you think Jenny was asked to take her blood pressure several times?
Hypertension is usually based on the average of two or more blood pressure readings. A patient may
have high blood pressure one day but not have hypertension. To ensure a diagnosis, patients can have
their blood pressure read on different occasions to accurately diagnose a patient with hypertension and
guide treatment
Early the next day, Dr. Ramchandani received Jenny’s results and called her in to discuss the data. Jenny
was now 29 weeks pregnant and Dr. Ramchandani was concerned. He did some quick calculations to
determine Jenny’s mean arterial pressure (MAP). Based on medical studies (Cnossen et al., 2008), MAP
is a better predictor of preeclampsia risk than solely systolic or diastolic blood pressure readings and
thus he wanted to consider those values.
14.
Calculate Jenny’s pulse pressure and MAP for each of her blood pressure readings.
Measure
Jenny’s values
Pulse Pressure
MAP
Initial blood pressure at home
160/110 mmHg
50
127
Blood pressure in office (initial reading) 148/90 mmHg
58
109
Blood pressure before bed at home
142/89 mmHg
53
107
Blood pressure upon waking at home
135/89mmHg
46
104
Blood pressure in office (follow-up)
160/95 mmHg
65
117
15.
Calculate Jenny’s average MAP. Then, using the below figure as a reference, determine if Jenny’s
average MAP falls within the average range for her stage of pregnancy.
Source: Hall, M.E., E.M. George, and J.P. Granger. 2011. The heart during pregnancy. Revista Española de
Cardiología (English Edition), 64(11), 1045–50. Part IV- The diagnosis
Typically, preeclampsia is diagnosed by hypertension and increased proteinuria (elevated protein in the
urine). There are other factors that influence preeclampsia, including thrombocytopenia, renal
insufficiency, impaired liver function, and systematic erythematosus lupus (SLE). However, Jenny met
criteria for both traditional markers and thus likely had preeclampsia. Dr. Ramchandani called Jenny
back to his office to share the news.
“Jenny, based on your diagnostic results, such as the proteinuria and consistent hypertension, I am
concluding that you have developed preeclampsia.”
Jenny started to cry. “I know this is scary news,” said Dr. Ramchandani. “We’ll take good care of you. I’m
going to put you in the hospital on bed rest so that we can keep a close eye on you and help to track and
monitor your symptoms. With proper care, babies that are delivered at 29 weeks can grow up to be
happy and healthy children. I’d like to see if we can get you to 32 weeks, as odds of complications
decrease with every additional week of intrauterine fetal development.”
Jenny called Brie to come to the office and explained the situation. Jenny was admitted to the hospital.
They were both incredibly concerned and continued to do additional research on preeclampsia. They
found some useful information on a website hosted by the American College of Obstetricians and
Gynecologists (ACOG) <https://www.acog.org/ Patients/FAQs/Preeclampsia-and-High-Blood-Pressure-
During-Pregnancy>.
Questions
16.
What causes preeclampsia?
Preeclampsia is believed to start in the placenta, which is responsible for noursing the fetus during
pregnancy. In women with preeclampsia, the blood vessels in the placenta do not develop or function
correctly. These abnormal blood vessels are narrower than usual and respond differently to hormonal
signals, leading to constricted blood flow. 17.
What are the risks to the baby if preeclampsia occurs?
Preeclampsia affects the arteries carrying blood to the placenta. If the placenta doesn’t get enough
blood, the baby will receive inadequate blood and oxygen and fewer nutrients. This can lead to slow
growth known as fetal growth restriction, low birth weight pre-term birth. 18.
What are the risks to the mother if preeclampsia occurs?
In the cases of severe preeclampsia, early delivery may be necessary to safeguard the mother and baby.
Preeclampsia raises the chance of placental abruption, where the placenta detaches from the uterine
wall before birth. This detachment can lead to significant bleeding which poses a risk to he lives of both
the mother and baby. Part V- Conclusion
Dr. Ramchandani continued to monitor Jenny and her developing fetus following the Gestational
Hypertension and Preeclampsia Practice Bulletin published by the American College of Obstetricians and
Gynecologists (ACOG). Dr. Ramchandani and his team were careful to look for any changes or worsening
in Jenny’s condition, including consistent blood pressure of over 160 mmHg (systolic) or 110 mmHg
(diastolic) even with antihypertensives; persistent head- aches that cannot be alleviated; epigastric pain;
visual disturbances, motor deficit or altered sensorium; stroke; myocardial infarction; HELLP syndrome;
renal dysfunction; pulmonary edema; eclampsia; or placental abruption. Jenny was borderline for being
diagnosed with severe preeclampsia, but Dr. Ramchandani prescribed some antihypertensive drugs and
Jenny’s blood pressure lowered. Dr. Ramchandani did weekly monitoring of the fetus using ultrasound
and routinely checked Penney’s blood count, serum creatinine, LDH, AST, ALT, and urinary proteins.
Jenny’s condition was maintained until week 34 of gestation, but then her symptoms worsened. A baby
was vaginally delivered early via induction. The baby was sent to the neonatal intensive care unit but
was doing well and progressing as expected. It was possible that the baby would encounter some
complications as it grew; long-term health issues, including learning disorders, cerebral palsy, epilepsy,
deafness, and blindness, have been noted in babies born to mothers with preeclampsia. Jenny was also
being monitored and was expected to make a full recovery. Jenny was lucky that Dr. Ramchandani and
his team were up to date on literature and made sure to monitor her condition. Unfortunately, many
women in the United States are not as lucky as maternal mortality is currently at an all-time high (see
the CDC for more information).
Adapted from content created by M.E.Sistrunk, C.M.Cherrington and B.N.Harris (Texas Tech University)
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