Pregnancy some times can lead to diabetes and hypertension. Although its treatable if neglected can lead to serious consequences

1. CASE PRESENTATION ON
PREGNANCY INDUCED
HYPERTENSION AND
DIABETES MELLITUS
PRESENTED BY:
Dr. MOHAMMED HAMZA BAIG

2. Gestational hypertension
■ Gestational hypertension, also referred to as pregnancy
induced hypertension (PIH) is a condition characterized
by high blood pressure during pregnancy.
■ Gestational hypertension can lead to a serious condition
called preeclampsia, also referred to as toxemia.
■ Hypertension during pregnancy affects about 6-8% of
pregnant women.

3. TYPES
■ Chronic Hypertension– Women who have high blood pressure
(over 140/90) before pregnancy, early in pregnancy (before 20
weeks), or continue to have it after delivery.
■ Gestational Hypertension– High blood pressure that
develops after week 20 in pregnancy and goes away after
delivery.
■ Preeclampsia – Both chronic hypertension and gestational
hypertension can lead to this severe condition after week 20
of pregnancy.

4. ETIOLOGY
■ Being overweight or obese
■ Failing to stay active
■ Smoking
■ Drinking alcohol
■ First time pregnancy
■ A family history of kidney disease, preeclampsia, or chronic hypertension
■ Carrying more than one child
■ Age (over 40)

5. SIGNS & SYMPTOMS
■ High blood pressure
■ Protein in the urine
■ This can lead to serious complications for both mother and baby if not treated quickly
■ Abdominal pain
■ Severe headaches
■ A change in reflexes
■ Reduced output of urine or no urine, blood in the urine
■ Dizziness, or excessive vomiting and nausea.

6. RISK FOR GESTATIONAL HYPERTENSION
■ First-time moms
■ Women whose sisters and mothers had PIH
■ Women carrying multiples
■ Women younger than age 20 or older than age 40
■ Women who had high blood pressure or kidney
disease prior to pregnancy

7. DIAGNOSTIC CRITERIA
Blood pressure
• Greater than or equal to 140 mm Hg systolic or greater than or equal to 90
mm Hg diastolic on two occasions at least 4 hours apart after 20 weeks of
gestation in a woman with a previously normal blood pressure
• Greater than or equal to 160 mm Hg systolic or greater than or equal to
110 mm Hg diastolic, hypertension can be confirmed within a short
interval (minutes) to facilitate timely antihypertensive therapy
and
Proteinuria
Greater than or equal to 300 mg per 24-hour urine collection (or this
amount extrapolated from a timed collection)
Or
Protein/creatinine ratio greater than or equal to 0.3*
Dipstick reading of 1+ (used only if other quantitative methods not
available)

8. DIAGNOSTIC CRITERIA
Or in the absence of proteinuria, new-onset hypertension with the new onset of
any of the following:
Thrombocytopenia Platelet count less than 100,000/microliter
Renal insufficiency
Serum creatinine concentrations greater than 1.1
mg/dL or a doubling of the serum creatinine
concentration in the absence of other renal
disease
Impaired liver function Elevated blood concentrations of liver
transaminases to twice normal concentration
Pulmonary edema
Cerebral or visual symptoms
Each measured as mg/dL

9. GESTATIONAL HYPERTENSION AFFECT
BABY
■ Hypertension can prevent the placenta from getting enough blood.
■ If the placenta doesn’t get enough blood, your baby gets less oxygen
and food.
■ This can result in low birth weight.
■ Most women still can deliver a healthy baby if hypertension is detected
and treated early.
■ If hypertension is severe, it can lead to pre-eclampsia, which can have
much more serious affects on both mother and baby.

10. TREATMENT
Mild to moderate hypertension:
FIRST LINE AGENT
■ Methyldopa:
 Centrally acting agent
 Randomised trials and has the longest safety track record
 Long term use has not been associated with fetal or neonatal
problems
 Women-sedative action
 Elevation of liver transaminases (in up to 5% of women) or a
positive Coomb’s test (although haemolytic anaemia is
uncommon).
 Methyldopa should be avoided in women with a prior history of
depression, because of the increased risk of postnatal depression.

11. SECOND LINE AGENTS
■ These agents should be used when monotherapy with methyldopa
is insufficient or when women are unable to tolerate methyldopa.
■ Nifedipine:
 Most popular and widely used in pregnancy
 It is safe at any gestation
 Sublingual nifedipine - avoided to minimise the risk of sudden
maternal hypotension and fetal distress, caused by placental
hypoperfusion.

12. ■ Oral hydralazine
 safe throughout pregnancy, although the occurrence of
maternal and neonatal lupus-like syndromes have
been reported.
 Hydralazine is more frequently used as an infusion for
the treatment of acute severe hypertension

13. THIRD LINE AGENTS
■ α and β Adrenergic blockers:
 β adrenergic blockers have been highlighted as a class of antihypertensives
associated with an increased risk of IUGR.
 Recent meta-analysis of published data from randomised trials - IUGR appeared
not to be related to the antihypertensive used.
 β adrenergic blockers are still avoided in the first half of pregnancy
 Blockers are safe throughout pregnancy and there is wide experience with
oxprenolol and labetalol.
 The safety and efficacy of prazosin in pregnancy has been demonstrated.
 Doxazosin appears to be safe, although data are limited.

14. ■ Thiazide diuretics:
 Used infrequently in pregnancy
 Plasma volume expansion associated with normal
pregnancy, this has not been proven to impair fetal growth.
 Chronic hypertension - withdrawn if pre-eclampsia
develops.

15. Drug treatment of severe hypertension:
■ Adequate blood pressure control
■ Often using parenteral agents, and ‘‘expectant’’ management by
trying to prolong the pregnancy without unduly risking the mother
or fetus.
■ Different units have their preferences for either parenteral
hydralazine or labetalol, and some use oral nifedipine.
■ Hydralazine should be given after a colloid challenge to reduce the
reflex tachycardia, and abrupt hypotension, precipitated by
vasodilatation of a volume contracted circulation.

16. ANTIHYPERTENSIVE DRUGS TO AVOID IN
PREGNANCY
A variety of malformations and adverse events have been reported for both
ACE inhibitors and ARBs including:
■ Oligohydramnious
■ IUGR
■ Joint contractures
■ Pulmonary hypoplasia
■ Hypocalvaria (incomplete ossification of the fetal skull)
■ Fetal renal tubular dysplasia and neonatal renal failure.

17. DEMOGRAPHIC DATA
■ NAME: AAA
■ AGE: 30 Years
■ SEX: Female
■ IP No: 4422/17
■ DOA: 24/10/17
■ DOD: -
■ WARD: Gynaecology
■ CONSULTANT:
Dr. Annapurna, MD GDEO (Gynaecologist)

18. SUBJECTIVE
CHIEF COMPLAINTS:
■ C/O: increased thrist, increase output, increased appetite
■ Vomitings 5 months back
■ Dizziness, head ache
PAST MEDICAL HISTORY:
■ Gestational diabetes 5 months
PAST MEDICATION HISTORY:
■ I. EGEUSENT INSULIN 7 U BBF
■ I. INSUGEN INSULIN 6U BD

19. PERSONAL HISTORYAND HABITS:
■ No relevant infomation found
FAMILY HISTORY:
■ Father and mother had hypertension

20. OBJECTIVE
24/10/17
Temperature (ºF) 98.6
Blood pressure (mm of hg) 140/100
Pulse rate (beats/min) 84
RR /min 22
PHYSICAL EXAMINATION:

21. LABORATORY DATA
VALUE NORMAL VALUE UNITS
Hemoglobin 10 13-17 Gm/dl
PPBS 108 110-160 Mg/dl
URINE TEST
ALBUMIN 2+
SUGAR Nil
PUS CELLS 10-12 Cells/HPF
EPITHELIAL CELLS 6-8 Cells/HPF

22. ASSESSMENT
■ Based on subjective and objective evidence the patient
was known case of gestational diabetes and now newly
diagnosed to have PRIMI 36 WEEKS OF
GESTATIONAL AGE WITH PREGNANCY
INDUCED HYPERTENSION

23. PLANNING
DAY 1 & 2 (17/10/2017 - 18/10/2017)
BRAND NAME GENERIC NAME DOSE FREQ ROUTE
T.LOBET LABETALOL 100mg BD PO
I.EGEUSENT INSULIN 7U OD SC
I.INSUGEN INSULIN 6U OD SC

24. PHARMACIST
INTERVENTION
DRUG INETRACTIONS:
■ No specific drug interactions were clinically reported
ADVERSE DRUG REACTIONS:
■ No adverse effects found

25. PATIENT COUNSELLING
■ Use salt as needed for taste.
■ Drink at least 8 glasses of water a day.
■ Increase the amount of protein intake and decrease the amount of fried foods and junk food
you eat.
■ Get enough rest. Rest, lying on left side to take baby weight off the major blood vessels.
■ Exercise regularly.
■ Elevate the feet several times during the day.
■ Avoid beverages containing caffeine.

26. REFERENCE
■ Agnes. Clinical treatment guidelines - gynecology and
obstetrics. Pg 45-50; Sep 2013