PUSHPAGIRI INSTITUTE OF MEDICAL SCIENCE AND RESEARCH CENTRE,THIRUVALLA Department of Community MedicinePREGNANCY INDUCED HYPERTENSION-HOSPITAL INCIDENCE & RISK FACTORS

CONDUCTED BY Arun Raphael Antony

Arya sasi T.K

Ashitha A.S

SUPERVISED BY:Dr ELSHEBA MATHEW Assistant ProfessorDepartment of community Medicine 2015 CERTIFICATEPUSHPAGIRI INSTITUTE OF MEDICAL SCIENCE AND RESEARCH CENTRE, THIRUVALLADepartment of Community Medicine

Certified that the Research Project entitled, Pregnancy Induced Hypertension Its Hospital Incidence and Risk Factors was conducted under the guidance of the faculty of the Department of Community Medicine, in partial fulfilment for the Kerala University of Health Sciences MBBS Practical Examination in Community Medicine. It is certified that this is an original research work done by the following students under the supervision of Dr.Elsheba Mathew Assistant Professor

1.Arun Raphael Antony

2.Arya Sasi T.K 3.Ashitha A.S

Date: Dr.E.R.Indira Devi

ACKNOWLEDGEMENT

We are grateful to our principal Dr. T.P Thankappan for his approval, Professor Dr. E.R.Indira Devi, Head of Department of Community Medicine for her support and guidance. We are also grateful to Dr. Elishiba Mathew and all other faculty members of community medicine department for their support and assistance. We thank the participants for their willingness and cooperation.We praise and thank God Almighty for his blessings and for being with us throughout the entire work

1.Arun Raphael Antony2.Arya Sasi T.K 3.Ashitha A.S

CONTENTSSl.noChapterPage number

1Introduction6

2Objectives8

3Review literature9

4Materials and methods12

5Ethical issues15

6Observation and results15

7Discussion29

8Summary31

9Conclusion32

10Recommendation32

11References33

LIST OF TABLESNumberTablePage number

1Frequency distribution of study participants with PIH

2Mean and standard deviation for age of study participants

3Association of PIH with duration

4Association of PIH with place of residence

5Association of PIH with gravidity

6Association of PIH with gestational age at delivery

7Association of PIH with GDM

8Association of PIH with Previous foetal loss

9Treatment taken for PIH

10Association of PIH with Previous gestational hypertension

11Association of PIH with family history of PIH

12Association of PIH with PCOD

13Association of PIH with twin pregnancy

14Association of PIH with hypothyroidism

LIST OF FIGURESNumberFigurePage number

1Pie diagram showing distribution of study participants with PIH

2Bar diagram showing distribution of study participants having GDM

3Bar diagram showing distribution of study participants having previous gestational hypertension

4Bar diagram showing distribution of study participants having family history of PIH

5Bar diagram showing distribution of study participants having PCOD

6Bar diagram showing distribution of study participants having twin pregnancy

LIST OF ABBREVIATIONSPIH-Pregnancy Induced HypertensionPCOD- Polycystic Ovarian DiseaseTSH-Thyroid Stimulating HormoneWHO - World Health OrganizationGDM - Gestational Diabetes MellitusOGTT- Oral Glucose Tolerance TestBMI Body Mass Index

INTRODUCTION

Hypertension is a common medical disorder in pregnancy. Hypertensive disorders are seen in 5-10% of all pregnancies(1).It is also the second most common cause of maternal mortality and morbidity in India. Primary concerns about elevated blood pressure relates to potential harmful effects in both mother and foetus. These potential adverse reactions ranging from trivial life threatening(2).According to International Society for the study of Hypertension in Pregnancy (ISSHP) Hypertension is defined as a systolic blood pressure >140 mmHg or a diastolic blood pressure >90 mmHG on at least two occasions taken 6 hours apart(1).

Among hypertensive disorders, Preeclampsia that is , Proteinuria Gestational Hypertension is the most common cause of pregnancy loss and foetal abnormalities. Preeclampsia is a protein disorder affecting virtually every system in the body. Preeclampsia is associated with more risk when it occur before 34 weeks. The risk of small for gestational age infants is Prematurity among women who present before 34 weeks(3).if seizures occur in a women with preeclampsia that cannot be attributed to any other cause, it is called eclampsia (1) it may lead to foetal depressive disorders and has significant effects on mother also. The latest classification by the working group of the National High Blood Pressure Programme (NHBPEP 2000) is simple and recognizes four types of hypertensive disease in pregnancy Gestational hypertension Preeclampsia and eclampsia Chronic hypertension Chronic hypertension with superimposed preeclampsiaGestational Hypertension is hypertension arising for the first time after 20 weeks of gestation in the absence of proteinuria.The blood pressure returns to normal within 2 weeks postpartum. Indeed gestational hypertension is followed by signs and symptoms of preeclampsia in 50% cases. Gestational hypertension can be reclassified as transient hypertension, if evidence for preeclampsia does not develop and blood pressure returns to normal by 12 weeks postpartum.Preeclampsia is gestational hypertension in association with significant proteinuria.Eclampsia is defined as seizures that cannot be attributed to any other cause in a woman with preeclampsia.The incidence of eclampsia has decreased over the years due to good prenatal care.Chronic hypertension is hypertension antedating pregnancy or hypertension diagnosed before 20 week of gestation but not attributable to gestational trophoblastic disease. Hypertension first diagnosed after 20 weeks and persisting 12 weeks postpartum is also considered chronic hypertension.Superimposed Hypertension is an exacerbation of hypertension with new onset of proteinuria or laboratory abnormalities such as elevated liver enzymes or a platelet count below 10,000/L in a woman with chronic hypertension. Many risk factors are preposed for the development of gestational hypertension. They are Genetic factors, Obstetric factors like primiparity, extreme maternal age, previous history of preeclampsia, multiple pregnancy. Medical factors like diabetes, obesity, renal disease, chronic infections, connective tissue disorders like systemic lupus erythematosis(1). With high blood pressure, there is increase in resistance of blood vessels. This may hinder blood flow in many different organ system in the expected mother including the liver,kidney,brain,uterus and placenta. There are other problems that may develop as a result of PIH. Placental abruption (premature detachment of the Placenta from uterus) may occur in some pregnancies. PIH can also lead to foetal problems including intrauterine growth restriction and stillbirth. If untreated severe PIH may cause dangerous seizures and even death of mother and foetus. Because of this risk it may be necessary for the baby to be delivered early before 37 weeks of gestation. Test for PIH include1. Blood pressure measurement2. Urine test 3. Assessment of oedema4. Frequent weight measurement5. Eye examination to check for retinal changes6. Liver and Kidney function test7. Blood clotting testHypertension is preventable if detected early in pregnancy otherwise it may lead to toxaemia of pregnancy. So it is essential to conduct a study to find out the prevalence & risk factors of PIH for its early management & for reduction of complications

OBJECTIVES1)To estimate the relative frequency of pregnancy induced hypertension among antenatal women (32 weeks and above) getting admitted for delivery in the OBG Department of the Pushpagiri Medical College during the period January 1 2013 to December 31 20132)To determine the risk factors for hypertension in pregnancy

REVIEW OF LITERATURE

Theoretical Overview According to International Society for the study of Hypertension in Pregnancy (ISSHP) Hypertension is defined as a systolic blood pressure >140 mmHg or a diastolic blood pressure >90 mmHG on at least two occasions taken 6 hours apart(1). The latest classification by the working group of the National High Blood Pressure Programme (NHBPEP 2000) is simple and recognizes four types of hypertensive disease in pregnancy Gestational hypertension Preeclampsia and eclampsia Chronic hypertension Chronic hypertension with superimposed preeclampsiaGestational Hypertension is hypertension arising for the first time after 20 weeks of gestation in the absence of proteinuria.The blood pressure returns to normal within 2 weeks postpartum. Indeed gestational hypertension is followed by signs and symptoms of preeclampsia in 50% cases. Gestational hypertension can be reclassified as transient hypertension, if evidence for preeclampsia does not develop and blood pressure returns to normal by 12 weeks postpartum.Preeclampsia is gestational hypertension in association with significant proteinuria.Eclampsia is defined as seizures that cannot be attributed to any other cause in a woman with preeclampsia.The incidence of eclampsia has decreased over the years due to good prenatal care.Chronic hypertension is hypertension antedating pregnancy or hypertension diagnosed before 20 week of gestation but not attributable to gestational trophoblastic disease. Hypertension first diagnosed after 20 weeks and persisting 12 weeks postpartum is also considered chronic hypertension.Superimposed Hypertension is an exacerbation of hypertension with new onset of proteinuria or laboratory abnormalities such as elevated liver enzymes or a platelet count below 10,000/L in a woman with chronic hypertension.

Related Studies A retrospective cohort study (2) identified 638 women, 312 had subsequent pregnancy, hypertensive disorders recurred in 120 of which 15 delivered pre terms. Women undergoing recurrence were more at risks to develop chronic hypertension after pregnancy. BMI, chronic hypertension, maximum diastolic pressure, no use of anti convulsive medicines and inter pregnancy interval were predictors for recurrence.

In a study (3) finds that pre eclampsia is allocated with greatest risk, when it is resent before 34. The risk of small for gestational age infants is primarily among women who present before 34 weeks. According to the study on the topic Management of hypertension before during & after Pregnancy (4) finds no antihypertensive has been shown to be teratogenic but angiotensin receptor blockers and angiotensin converting enzyme inhibitors are foetotoxic. Pregnancy induced hypertension increases the risk of cerebrovascular diseases and ischemic heart disease in later life.

In the study on the topic Prediction of pregnancy induced Hypertension using coherence analysis (5) presents a novel method to predict hypertensive disorders in pregnancy using coherence analysis the results presented using maternal and foetal blood flow velocity curve forms indicate that in complicative hypertensive pregnancy TSH value is in lower than in normal hypertensive cases. In CHIPS Trials ( Control of Hypertension in Pregnancy study) (6) showed that pregnant women with non severe non proteinuric maternal hypertension at 14-33 weeks will increase the likely board pregnancy loss f neonatal intensity care unit for > 48 hours or severe maternal complications measured upto 6 weeks post partum like adverse neurological complications and organ failure etc. In the study on he topic Role of obesity in Pregnancy (7) shows obesity increases the risk of pre edampsia about three folds and address the hypothesis that assymmetric dimethyl arginine an endogenous inhibitor of NO synthase may be convergence point for the mechanism by which obesity increases risk of pre eclampsia. In a cross sectional study (8) among all mothers who gave birth in the labor room of JimmahospitAL from April 1 2009 to March 31 2010 found a prevalence of 8.5% of Pregnancy Induced Hypertension.

In a case control study on the topic Role Of TSH and OGTT screening in PIH (9) among 200 antenatal women found a prevalence of 7 %.In a prospective study conducted by MaijushaSajith,VandhanaNinbargietal on the topic Incidence of Pregnancy Induced Hypertension and Prescription pattern of Antihypertensive, over a period of one year in IN patients of OBG Department of Bharathy Hospital Pune found prevalence of 7.5%.In the study on the topic diagnosis,evaluation and management of hypertensive disorders and pregnancy (10) found a greatest risk of preterm delivery associated with preeclampsia. A cohort study (11) found that GDM was found to be present in 13% women with PIH .In a population based cohort study on the topic, comparison of risk factors for the pre eclampsia And gestational hypertension (12) among 10666 women found that GDM has a significant association with PIH.

MATERIALS AND METHODSType of study : record based Case Control StudyStudy Population: Antenatal women getting admitted for delivery in the OBG department in Pushpagiri Medical college (32 weeks and above) during the period January 1 2013 to December 31 2013Exclusion criteria: In the antenatal women in whom hypertension is detected before the onset of pregnancy.TOOLS FOR DATA COLLECTIONDetails regarding the following variables are included Age Place Duration of PIH Treatment of PIH Gestational age at delivery Gravidity Gestational diabetes mellitus Previous foetal loss Previous PIH Family history of PIH Other significant conditions like PCOD, twin pregnancy, hypothyroidism

METHODOLOGY Permissions were obtained from college authorities for conduct of the study, and hospital authorities to access the files of the study population.We collected the IP numbers of antenatal women(32 weeks and above) getting admitted for delivery in the OBG department of Pushpagiri Medical College during the period January 1 2013 to December 31 2013.IP numbers of the patients were collected from labour room to attain IP files from the Medical records. Essential datas was extracted from IP files.COLLECTION OF DATA Data was collected from medical records of antenatal women admitted for delivery in OBG department of Pushpagiri Medical college during the period January 1 2013 to December 31 2013.Study duration of research was 1 year.DATA MANAGEMENTAfter collecting the data it was entered into Microsoft Excel and analysed using Epi info and presented according to the objectives. Using the data collected we determined the frequency of PIH and the associated risk factors among antenatal women attending the ante-natal clinic of Pushpagiri Institute of Medical Sciences and Research Centre. Tests used are chi-square test and paired t-test.

ETHICAL ISSUES . The information was kept confidential and was used only for group statistics. Anonymity of the subject has been ensured.

OBSERVATIONS AND RESULTSStudy was conducted among 748 antenatal women admitted on OBG department of Pushpagiri medical college during the period January 1 2013 to December 31 2013. Among 748 antenatal women 55 were diagnosed to have PIH.Hospital incidence of PIH is found to be 7.352%. From the rest 693 normotensive antenatal women we randomly choose 57 as controls. Analysis of information was done regarding the following

Table 1 Frequency Distribution of Study Participants with Pregnancy Induced Hypertension (PIH)

PIHNumberPercentage

Yes5549.1

No5750.9

Total112100

Among the study groups 49.1 % are having PIH and 50.9% are controls.

Figure 1. Pie diagram showing distribution of study participants with PIH

Table 2 Mean and standard deviation for age of study participants

VariablePIHNMeanSD

AgePresent5526.643.407

Absent5726.653.383

Mean age group of study participants having PIH is 26.64.

Table 3- Association of PIH with DurationDuration of PIHFrequencyPercentage

Detected in second trimester2219.6

Detected in third trimester3430.4

Total5650

In 19.6% of the participants the PIH was detected in the second trimester and in 30.4 % of participants PIH was detected in third trimester.

Table 4-Association of PIH with place of residence

Place of residencePIHTotal

PresentAbsent

NumberPercentageNumberPercentage

Urban2749.13256.159

Rural2850.92543.953

Total5510057100112

2 = 0.558 p value = 0.45549.1% of study participants having PIH and 56.1 % of controls belong to Urban area. & The relation is statistically insignificant

.

Table 5 Association of PIH with Gravidity

Gravida PIHTotal

Present Absent

NumberPercentageNumberPercentage

primi3767.33866.775

second1425.51628.30

third47.235.37

Total5510057100112

. 2=2.461 p value=.11767.3%of the PIH subjects and 66.7% of controls are primigravidas.The relation is statistically insignificant. Table 6 Association of PIH with Gestational age at DeliveryGestational age at delivery (weeks)PIHTotal

PresentAbsent

NumberPercentageNumberPercentage

32-371323.6712.320

Above 37

4276.45087.792

Total5510057100112

2 =0.322 p value=0.90523.6% of study subjects having PIH and 12.3 % of controls delivered preterm.Cases having more preterm delivery compared with that of controls and the relation is statistically insignificant .

Table 7-Association of PIH with Gestational Diabetes Mellitus

Gestational diabetes mellitus PIHTotal

Present Absent

NumberPercentageNumberPercentage

Yes2545.51322.838

No3054.54477.274

Total5510057100112

2 =6.404 p value=0.011 (significant)45.5% of the study subjects having PIH also had GDM when compared to 22.8% of controls and there is a statistically significant association between the same.

Figure 2. Bar diagram showing distribution of study participants having GDM.

Table 8-Association of PIH with Previous Foetal Loss

Previous foetal loss PIHTotal

Present Absent

NumberPercentageNumberPercentage

Yes814.5712.315

No4785.55087.797

Total5510057100112

2 =0.124 p value=0.725

Only 14.5% of the PIH subjects and 12.3% of controls had previous fetal loss and the relation is statistically insignificant.

Table 9- Treatment taken for PIH

Treatment of PIHFrequencyPercentage

Tablet Aldomet4842.9

Tablet Nicardia87.1

Total5650

42.9% of the PIH subjects are prescribed with tablet Aldomet and only 7.1% are prescribed with tablet Nicardia

T able 10-Association of PIH with previous history of Gestational Hypertension

Previous pregnancy induced hypertension PIHTotal

Present Absent

NumberPercentageNumberPercentage

Yes1221.80012

No4378.257100100

Total5510057100112

2=13.929, P=0.001 ODDS RATIO =2.326(Significant)

In 21.8% of PIH subjects had a positive history of previous gestational hypertension and none of the controls had a positive history of previous gestational hypertension relation is statistically significant with an Odds ratio of 2.326.

Figure 3.Bar diagram showing distribution of study participants having previous history of Gestational Hypertension.

Table 11- Association of PIH with Family History of PIH

Family history of PIH PIHTotal

PresentAbsent

NumberpercentageNumberPercentage

Yes3258.235.335

No2341.85494.777

Total5510057100112

2 =36.484 p value=0.001 (significant)

58.2% of the subjects having PIH and 5.3 % of controls had a positive family history of PIH and the relation is significant between the same .

Figure 4.Bar diagram showing distribution of study participants having Family History of PIH

Table 12- Association of PIH with PCODPCOD PIHTotal

PresentAbsent

NumberPercentageNumberPercentage

Present916.3623.50811

Absent4683.635596.49101

Total5510057100112

2 =5.22, P value=.022(significant)

16.36% of the PIH subjects and 3.508 % of controls had PCOD and the relation is significant.

Figure 5-.Bar diagram showing distribution of study participants having PCOD.

Table 13-Association of PIH with Twin pregnancyTwin Pregnancy PIHTotal

PresentAbsent

NumberPercentageNumberPercentage

Present610.9011.757

Absent4989.095698.24105

Total5510057100112

2 =4.004, p value=.045 (Significant)10.9 % of the PIH subjects and 1.75% of controls had a twin delivery and the relation is statistically significant.

Figure 6-.Bar diagram showing distribution of study participants having Twin pregnancy.

Table 14-Association of PIH with Hypothyroidism

Hypothyroidism PIHTotal

PresentAbsent

NumberPercentageNumberPercentage

Present35.76911.754

Absent5294.545698.24108

Total5510057100112

. 2 =2.89 p value=.061Only 5.769% of PIH subjects and 1.75% of controls had hypothyroidism and the relation is statistically insignificant.

DISCUSSION

The present record based study conducted on antenatal women getting admitted for delivery in the OBG Department of Pushpagiri Medical college (32 weeks and above) during the period January 1 2013 to December 31 2013 is done to estimate relative frequency of pregnancy induced hypertension and to determine the risk factors of PIH

55 cases and 57 controls were studied. Most of the participants belong to the age group 20 to 40 years. Prevalence of PIH is found to be 7.352% . In a cross sectional study (8) on the topic Hypertensive disorders of pregnancy in Jimma University Specialised Hospital , among all mothers who gave birth iin the labor room of Jimmahospital from April 1 2009 to March 31 2010 found a prevalence of 8.5% of Pregnancy Induced Hypertension.

IN a case control study (9) on the topic Role Of TSH and OGTT screening in PIH among 200 antenatal women found a prevalence of 7 %.

In a prospective study (10) on the topic Incidence of Pregnancy Induced Hypertension and Prescription pattern of Antihypertensive, over a period of one year in IP patients of OBG Department of Bharathy Hospital Pune found prevalence of 7.5%.

Prevalence is comparable with other studies. Most of the women with PIH having the mean age group of 26.64 and those without having mean age group of 26.65 that is there is no significant differences in mean age groups of the cases and controls.39.2% of the cases was detected with PIH in the second trimester and 60.8% were detected in third trimester.

Of the cases 39.1% came from urban area and 50.9% came from rural area. Among controls 56.1% belongs to urban population and 43.9% belongs to rural populations. In a cross sectional study (8) on the topic Hypertensive disorders of pregnancy in Jimma University Specialised Hospital , among all mothers who gave birth in the labor room of JimmahospitAL from April 1 2009 to March 31 2010 found that proportion of mothers from rural area was 56.9% and there was statistically significant association between place of residence and severity of hypertensive disorders.Even though most of the PIH subjects belongs to rural area there were no statistically significant association is found between place of residence and PIH.

Among the cases 63.7% were primigravida ,25.5% belongs to second and 7.2% belongs to third gravida.In case of controls 66.7% are primigravidas and 28% and 5.3% are second and third gravida respectively. In a cross sectional study (8) on the topic Hypertensive disorders of pregnancy in Jimma University Specialised Hospital , among all mothers who gave birth iin the labor room of JimmahospitAL from April 1 2009 to March 31 2010 found that majority (66.5%) of mothers affected by the disorder were primigravidas.More severe forms of hypertensive disorders were found to be more common in Primigravidas but there was no statistically significant association between Parity and Severity of hypertensive disorders.

Results are comparable with the above study. 23.6% of the women having PIH had preterm delivery (below 37 weeks) and 76.4% had term delivery In the study on the (3) topic diagnosis,evaluation and management of hypertensive disorders and pregnancy found a greatest risk of preterm delivery associated with preeclampsia.

Here the results are not similar to the above study. There were no risk of preterm delivery, it may be due to better hospital facilities.

Mainly 2 drugs are precribed for treatment of PIH. They are Aldomet and Nicardia.85.8% women taken Aldomet and 14.2% Nicardia.Gestational diabetes melitus has found to be significant association with PIH( 6.404,p value .011,). Among cases 45.5% where found to having gestational diabetes melitus. But only 22.8% has GDM among control group. In a cohort study on the topic Association between GDM and PIH (11) found that GDM was found to be present in 13% women with PIH . In a population based cohort study on the topic, comparison of risk factors for the pre eclampsia And gestational hypertension (12) among 10666 women found that GDM has a significant association with PIHAll though study population and method of study is different. Results are comparable.

Among the cases 14.5% of the women experienced previous foetal loss and 12.3% among the controls. That is there is no significant differences of previous foetal loss among case and control.12.8% of the cases had PIH in their previous pregnancy. That is It is found to be significant association with previous history of gestational hypertension and PIH.( 13.929, P value.001, odds ratio 2.3216)

A retrospective cohort study on the topic prediction of recurrence of hypertensive disorders of pregnancy in term period (2) . Identified 638 women with PIH.312 Had subsequent pregnancy, and hypertensive disorders recurred in 120 of them (38.2%).

Here also results are similar to the above study.

Among cases 58.5% had family history of PIH (First degree relative) but only 5.3% of the controls had positive family history of PIH.There found to be a significant association with PIH and family history of PIH( 2=36.484, p value=0.001).

A cross sectional study conducted by (13) among Ghanian 100 pregnant women shows family history of PIH increased the risk of development of PIH (50%)

Above study also shows a positive correlation between PIH and family history of PIH. 16.36% of cases are found to be having Poly Cysytic Ovarian Disease but only 3.508% of controls had Poly Cysytic Ovarian Disease. There found to be a significant association between PCOD and PIH ( 2=5.22, P value=0.022, Oddss Ratio=5.3804) In a study (14) .Among 220 pregnant PCOS. And women with 594 healthy womens found that incidence of PIH was was higher among all PCOS. Lean women with PCOS had higher incidence of GDM.(51.1% versus 14.5%)and PIH.(8.9% Versus 3.2%) and concluded that PCOS is an independent risk factor for development of both GDM and PIH.Above stydy also shows a significant relation between PCOS and PIH.

Among controls 10.90% of the women had twin delivery. But only 1.754% of controls had twin delivery . A significant association was found between twin delivery and PIH.

Ina population based cohort study on the topic Comparison of risk factors for preeclampsia, gestational hypertension (12). Among 10666 women found that twin gestation had an increased risk for developmental PIH. (odds ratio 4.17) Here also a positive correlation between PIH and Twin pregnancy can be seen.5.45% Of cases were found to be hypothyroids but only 1.75 % controls have hypothyroidism.SUMMARY AND CONCLUSIONSThe hospital records of all the patients admitted for delivery in OBG Department of Pushpagiri Medical College during the period January 1 2013 to December 31 2013 were examined for the hospital incidence of PIH. A record based case control study was conducted among them for risk factors associated with PIH. All 55 patients with PIH and 57 randomly chosen controls were recruited into the case control study. Hospital incidence of PIH is found to be 7.352%. Cases and controls were similar with respect to age and place of residence. Most of the patients with PIH were treated with Tablet Aldomet. Most of the women having PIH had full term delivery and most of them are primigravida.There is a significant association between PIH and Gestational Diabetes Mellitus previous Gestational Hypertension and Positive Family History of PIH. Majority of the subjects did not have a history of previous foetal loss. Twin pregnancy and PCOD also show a statistically significant association with PIH.

RECOMENDATIONS Screening of PIH should be made mandatory for all antenatal women attending the clinical. More attention should be given for those antenatal women having family history of PIH, previous gestational hypertension, GDM and twin pregnancy Awareness regarding normal blood pressure, risk associated with PIH, delivery and postpartum care should be provided to antenatal women and especially those at risk of PIH.Public health workers should be trained on the importance and the care for antenatals with PIH

REFERENCES1. Sheela Balakrishnan-Text book of obstetrics 2nd edition.2. Miriam F Van evstwaard, Joosje langenveld,Ewnnd seheet etal.-Prediction of recurrence of hypertensive disorders of pregnancy in term periode, available at www.hindwai.com,accepted 6 april 2010.3. Laurece A Magii,Anank pel etal- diagnosis ,evaluation and management of hypertensive disorders of pregnancy.4. P.Rachel James,Cathenere Nelson prey et al-Management of hypertension before during and after pregnancy.5. Fernado kumarol,v.john etal.- Prediction of pregnancy induced hypertension using coherence analysis.6. University of british Columntitris,department of OBG and data coordinating centre.-CHIPS trail and control of hypertension in pregnancy.7. Robert M Bodnaslm,Pantac TP etal.-role of obesity in pre eclampsia.8. Zensevewolde,Hailemariamsegmi etal- hypertensive disorders of pregnancy.9. Aruna varmma ,Monika kashyath etal-Role of TSH and OGTT Screening in PIH.10. Magusha sajith ,Vandana Ninbarji etal-Hypertension and prescription pattern of antihypertensive.11.Chris Brysm George ,Laumae etal.-association between GDM and PIH.12.Salonen rose ,Synech ettingue etal.-Comparison of risk factors for pre eclampsia and gestational hypertension. 13. WKBA Owireclue,LAwenkorahetal-Putative risk factors of PIH 14. Yuhuvivong , Xiaomiazhaoettal-Risk for GDM and PIH

ANNEXURE

PREGNANCY INDUCED HYPERTENSION AND RISK FACTORS

A. Code:B. Age:C. Place Of Residence:-3 / 4D. Occupation: 20 / 21 / 22 / 23 / 24 / 25 /26E. Education:-30 / 31 / 32/ 33 / 34 / 35 / 36F. Gestational Age:H. Hypertension : 1 / 2 J. Treatment:K. Diabetes Mellitus : 1 / 2L. Renal Disease: 1 /2 If Yes Specify:M. Any Other Significant Med. ConditionN. GravidaO. ParaP. Foetal Loss 1 / 2 .Cause:Q. Pregnancy Induced Hypertension In Prev. Pregnancy - 1 / 2R. Any Foetal Abnormality: 1 / 2 If Yes Specify:S. Any Family History Of Pregnancy Induced Hypertension: 1 / 2 If Yes Specify : 1 / 2

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