Answer
Provisional diagnosis
Pre eclampsia
- Occur at 24w of gestation.
- Primigravida
- Twin pregnancy
- Symptoms of impending pre eclampsia (frothy urine suggestive of proteinuria and headache.)
Twin to twin transfusion syndrome
- Intrauterine blood transfusion from donor twin to another recipient twin
- Donor twin has smaller size and anemic
- Recipient twin will be plethoric
- Only occur in monozygotic twin with monochorionic placenta
Factors contributes to preterm delivery
- Lower and upper genital tract infection
- Uterine over distension
- Cervical incompetence
- Maternal medical complications, maternal stress
- Fetal, placental or uterine abnormalities
Management to this patient
1) Evaluation on severity of the pre eclampsia
- Close monitoring of blood pressure (15 minutes interval until BP stable)
- Repeat Dipstick testing within 6H
- 24 hour urinary protein
- PE Profile (platelet count, uric acid level, sr Creatinine level, liver enxyme)
- Clotting study if platelet < 100 x 106/l
2) Management of hypertension
Mild PE
T. Methyldopa 250mg tds, max 3g/day or
T. Labetolol 100 mg tds, max 300mg tds
Or, Tab. Nifedipine 10 mg tds stat dose
Severe PE
IV hydrallazine start 5mg, double if no effect until 35mg. change drug if fails or
IV Labetolol start 10 mg, double if no effect until max 300mg/day)
** MgSo4 slow infusion 4g 10-15 minutes. Maintenance dose IV
3) Fetal surveillance
- CTG for fetal well being.
- Biophysical profile (Ultrasound monitoring of fetal movement, fetal tone and fetal breathing, ultrasound assesment of liquor volume with or without assesment of fetal heart rate)
4) Anticipating in preterm delivery by giving IM Dexamethasone, 12 MG, and 12 hours apart.
5) Others
- Bed rest
- Reduce physical activity
- Reduce high cholesterol and salty diet.