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