Question

CASE STUDY –HYPERTENSION

Mrs. Abu, a Primigravida was admitted with severe pre-eclampsia of 29 weeks’ gestation and complained of a headache. A Junior house officer prescribed co-proxamol over the telephone, failing to appreciate the significance of a rise in Blood pressure. The Blood pressure was checked later to be 150/100mm Hg

A. What is the common forms of hypertension during pregnancy ?

B. What are the shortfalls with the way the Junior house officer managed Mrs. Abu?

C. Outline in a stepwise manner the pharmacological management of severe pre-eclamsia according to the Standard Treatment Guideline (STG).

QUESTION TWO (2)

A. Outline the protocol for the management of diabetes in pregnancy. ( 10 marks) B. Outline the protocol for the management of TB in Pregnancy. (10

Answer 1

A. Here are the common forms of hypertension during pregnancy :

1. Gestational Hypertension : Women who develop high blood pressure after 20 weeks of gestation are known to have Gestational Hypertension. There are no other signs of organ damage.

2. Chronic Hypertension : If there is high blood pressure before 20 weeks of pregnancy or before pregnancy is called chronic hypertension. Sometimes it is diffcult to identify because it doesn't have symptoms usually.

3. Chronic Hypertension with superimposed preeclampsia : When women have chronic hypertension with protein in urine or other blood pressure related problem during pregnancy.

4. Pre-eclampsia : When hypertension develops after 20 weeks of pregnancy with other signs of organ damage including kidney,liver,brain. Pre eclampsia if not managed properly can lead to complications during pregnancy.

5. Eclampsia: Generalized convulsions occuring after 20th week of pregnancy in a patient with underlying pre eclampsia.

2. Shortfalls with the way junior house officer managed Mrs. Abu : Co-proxamol should be prescribed with caution to the pregnant women. There are two active ingredients in co proxamol :  dextropropoxyphene and paracetamol. Dextropropoxyphene is an opiod and can have serious effects on the baby. Also  As a side effect of this drug blood pressure may fall or increase. So it should be avoided.

3. Management of severe pre eclampsia : a) Diagnosis : BP- If it is more than 160/110 mm/hg at the gap of six hours

Proteinurea: If it is more than 2 -5 grams/24 hours.

Oliguria : Output of urine less than 400ml/24 hours

Platelets count is greater than 100,000 per cubic mm

Elevated liver enzymes

Increased level of serum creatinine.

If blood pressure is greater than 160/100 mm hg patient is advised for immediate hospitaliztion and is kept under close supervision.

Blood tests are done to monitor kidney functions.

Adequate preoteins are advised in the diet.

Medication Therapy : Tab. Methydopa 250-500mg/day 3 to 4 times/day

Tab. labetalol : 100-200mg 2 to 3 times/day

Labetolol IV regime: 20 mg stat. If diastolic blood pressure is greater than 110 after 20 minutes give 40 mg and increase the dose to 80 mg and again 80 mg to a total of 220 mg

Nitroglycerine drip can also be used for hypertension. 50 mg in 500ml dextrose,start at 10ml/hour followed by 5 ml till systolic blood pressure comes to 140 mm hg.

Ans 2 . Protocol for management of diabetes in pregnancy : Medical Management : Pregnant women with diabetes in pregnancy are first put on Medical nutrition therapy for 2 weeks. After 2 weeks if the sugar levels are greater than 120 mg/dl, insulin therapy is started along with Medical nutrition therapy

Oral tablets for diabetes treatment are not given during pregnancy as they are not safe.

Any pregnant women on insulin therapy should be guided to keep the sugar/jaggery/glucose powder handy to treat hypoglycemia if it occurs.

When the sugar levels are greater than 120 mg/dl Start with human insulin premix 30:70

subcutaneous injection, 30 mins before breakfast, once a day

Dose of insulin is calculated by blood glucose levels.

Blood sugar Between 120-160 -----4 unit insulin

between 160-200--------6 units insulin

More than 200 --------8 units insulin

Check for Fasting blood sugar and 2 hour PPPg every 3rd day till the dose of insulin is adjusted.