Case Discussi on A 35-year-old pregnant woman (gravida 2 胎次,para 1) was admitted to this hospital at 19 weeks and 6 days of gestatio n 怀孕期 because of the recent on set of hyperte nsion and diabetes.

Three weeks before admission, at a routine prenatal visit, her blood pressure was 150/100(150 over 100) mm Hg(millimeters hydragyrim). On the same day she saw her primary care physicia n, who recorded a blood pressure of 172/102 mm Hg. The results of a physical exam in ati on were normal. Urinalysis showed glucose (4+). The results of other laboratory tests are shown in Table 1. The n ext day, the blood pressure was 180/100 mm Hg. The blood glucose level 1 hour after the oral adm ini strati on of glucose (50 g) was 346 mg per deciliter [?desili:t?]分升(19.2 mmol per liter). Treatment with labetalol 拉贝洛尔，glyburide 格列本脲(优降糖) ，and potassium

[p???si?m]乍钾 suppleme nts was in itiated. The results of fetal ultraso und exam in ati on were normal for the gestational age of the fetus [?fit? s]. Three weeks later, despite increasing doses of labetalol, the patient's blood pressure remained in the range of 180/110 mm Hg and her fasting blood glucose level ran ged betwee n 140 and 180 mg per deciliter (7.8 and 10.0 mmol per liter); the patie nt was admitted to the hospital.

The patient had gained 6.8 kg in weight during the pregnancy. She had recently had polyuria and polydipsia and in creased facial puffin ess 虚胖;her complexi on 面色 was chroni cally ruddy 红润. She did not have headaches, proximal muscle weakness, bruising 挤压伤,flushing 激动脸红, abdominal pain, edema, palpitations 心悸 , diaphoresis [,dai?f?ri:sis]发汗(sweat), edema, or cha nges in visi on. Her men ses had bee n regular before preg nancy, and she had had no difficulty conceiving 怀胎 with either this pregnancy or a pregnancy 3 years earlier, during which she had mild, diet-c on trolled gestati onal diabetes. She had bee n mildly overweight, with a body-mass index ( BMI) (the weight in kilograms divided by the square of the height in meters) of approximately 25 for several years. She did not smoke, drink alcohol, or use illicit [ ?l?s?t]非法的 drugs. She was married, with a 2-year-old daughter. Her mother and maternal [m ??:?:nl]母亲方面 的 grandmother had type 2 diabetes mellitus, and many family members had hypertension.

Q1: What' sthe possible cause of the patient? Give 3 or more diseases for hypertension duri ng preg nan cy. 1. preeclampsia or eclampsia 2. chr onic hyperte nsion probable diag no sis 3. preeclampsia or eclampsia superimposed on chronic hyperte nsion 4. gestati onal hyperte nsion When I saw this patient during her first admission, she had marked hypertension, poorly controlled diabetes mellitus, and hypokalemia. The four hypertensive disorders that are recognized during pregnancy are preeclampsia [?pri?Kl?mpsi ?]先兆子痫 or eclampsia [ek?l?mpsi?] 子痫惊厥,chronic hypertension (including "essential" hypertension and secondary hypertension), preeclampsia or eclampsia superimposed [?sju:p?rim?p/&zd] on chronic hypertension , and gestational hypertension . Although this patient had proteinuria, it was not severe enough to warrant 正当理由 a diagnosis of preeclampsia; in addition, the onset of preeclampsia would be unlikely this early in the pregnancy. Gestational hypertension WOukLe unlikely this early in pregnancy. Thus, I was left with a probable diagnosis of chronic hypertension. In a patient with newly diagnosed chronic hypertension, the major question is whether it is essential hypertension or associated with another condition . A pregnant patient with chronic hypertension is at increased risk for superimposed preeclampsia, intrauterine子宫 内的 growth restriction(grow slowly), abruption 分裂 placentae [pl?会ent?]胎盘(胎盘早剥 正常 20week to birth), premature birth, and perinatal [?peri?neitl]围产期 death. Efforts to control blood pressure with labetalol or methyldopa 甲基多巴 to reduce the incidence of preeclampsia and its associated

perinatal morbidity 发病率 have been disappointing; thus, a search for a secondary cause in a case such as this is mandatory 必要的强制的 .In this patient, the presence of hypokalemia increased my suspicion that the problem was secondary hypertension. Q2: Did the patie nt have preexist ing, un diag no sed diabetes? Why? Yes The glycated hemoglob in value of 8.2% at 16 weeks and 6 days' gestatio n led me to suspect that she had had hyperglycemia for some time before her preg nancy bega n. The broad definition of gestational diabetes includes the coincidental development of type 1 during pregnancy as well as the presence of preexisting, undiagnosed type 2. Diabetes in Pregnancy This patient also had carbohydrate intolerance, with glycosuria at 16 weeks and 6 days' gestation, as well as gestational diabetes (defined as carbohydrate intolerance of any degree of severity, with an onset or first recognition during pregnancy). The glycated hemoglobin value of 8.2% at 16 weeks and 6 days' gestation led me to suspect that she had had hyperglycemia for some time before her pregnancy began. The broad definition of gestational diabetes includes the coincidental 巧合的 development of type 1 during pregnancy as well as the presence of preexisting, undiagnosed type 2. The vast majority of patients who receive a diagnosis of gestational diabetes have a relatively mild degree of carbohydrate intolerance that develops late in pregnancy and is associated with the insulin resistance of pregnancy. It seemed fairly clear to me that this woman had preexisting, undiagnosed type 2 diabetes.The results of additional laboratory tests (Table 2) led me to suspect that she had Cushing's syndrome and to request a consultation with an endocrinologist. Q3: What is keypo int in the n ext physical exam in ati on? BMI and weight gain blood pressure and pulse edema (face orbital peripheral) extraocular moveme nts and visual fields thyroid supraclavicular or dorsal adipose tissue, hirsutism, bruising 痤疮 abdome n striae Proximal muscle stre ngth and reflexes Cushing's Syndrome in Pregnancy In a case that is suggestive of Cushing's syndrome, the goals are to confirm the presence of a pathologic excess of endogenous cortisol, to determine its source, and to remove the source to prevent illness and death. Both the diagnosis and management in this case were further complicated by the patient's pregnancy. The diagnosis of Cushing's syndrome in pregnancy is confounded by the normal hormonal and biochemical changes of pregnancy the management is confounded by the profoundly 极度的 leterious effect of hypercortisolemia on both mother and fetus, the side effects of medications, and the technical problems involved in undertaking surgical resection. The complications of pregnancy for women with Cushing's syndrome include hypertension, diabetes, preeclampsia, and infection. Fetal complications include prematurity and intrauterine growth retardation 延迟. This patient had no signs or symptoms of Cushing's syndrome before pregnancy. Consideration of the diagnosis of Cushing's syndrome is typically based on clinical features. However, many features of this disease are similar to those of normal pregnancy, including weight gain, amenorrhea [ei?men??:?]无月经,striae 条纹,fatigue [f??i q劳累,back pain, mood changes, and plethora [?ple r??过量过剩.In this patient, clinically significant hypertension