A 32-year-old multigravida (G3P2L2) at 24 weeks of gestation attends her third antenatal visit. She has a history of gestational diabetes in her previous pregnancy. On examination, BP is 138/88 mmHg (previously normal). Urine dipstick shows 1+ proteinuria. Fasting blood glucose is 105 mg/dL. Which of the following is the MOST appropriate next step in her management?

Explanation

## Management of Hypertension, Proteinuria, and Hyperglycemia at 24 Weeks ### Clinical Assessment: Red Flags for Preeclampsia and Gestational Diabetes **Key Point:** This patient presents with a triad of concerning findings at 24 weeks: 1. **New-onset hypertension** (138/88 mmHg, previously normal) — threshold for gestational hypertension 2. **Proteinuria** (1+) — suggests possible preeclampsia 3. **Elevated fasting glucose** (105 mg/dL) — recurrent gestational diabetes risk These findings mandate urgent investigation to exclude preeclampsia and confirm gestational diabetes. ### Diagnostic Workup for Suspected Preeclampsia at 24 Weeks | Finding | Investigation | Rationale | | --- | --- | --- | | **BP ≥140/90 mmHg (new-onset)** | Serum creatinine, 24-hour urine protein | Assess renal function and proteinuria severity | | **Proteinuria 1+** | 24-hour urine protein (>300 mg/24 hr = significant) | Confirm proteinuria; rule out contamination | | **Fasting glucose 105 mg/dL** | 75 g OGTT | Diagnose gestational diabetes (fasting ≥92 mg/dL is abnormal) | | **Symptoms absent** | Platelet count, LDH, liver enzymes | Screen for HELLP if available | **High-Yield:** The diagnosis of preeclampsia requires **hypertension + proteinuria** (or hypertension + end-organ dysfunction). At 24 weeks, this patient meets criteria for suspected preeclampsia and requires urgent confirmation. ### Why 75 g OGTT Is Essential NOW 1. **Recurrent gestational diabetes risk:** History of GDM increases recurrence to ~50%. 2. **Fasting glucose 105 mg/dL is abnormal:** Normal fasting is <92 mg/dL in pregnancy; this patient is already elevated. 3. **Timing:** 24 weeks is the standard screening window; delay increases fetal risk. 4. **Compound risk:** Gestational diabetes + gestational hypertension/preeclampsia = highest maternal and fetal morbidity. **Clinical Pearl:** A fasting glucose ≥92 mg/dL at any time in pregnancy warrants immediate OGTT, even if not at the scheduled 24–28 week window. ### Correct Management Algorithm ```mermaid flowchart TD A["24 weeks: BP 138/88, 1+ proteinuria, FBS 105"]:::outcome --> B{"Preeclampsia suspected?"}:::decision B -->|Yes| C["Perform 75g OGTT<br/>Serum creatinine<br/>24-hour urine protein<br/>Platelet count"]:::action C --> D{"Results?"}:::decision D -->|Preeclampsia + GDM| E["Intensive monitoring<br/>Antihypertensive if BP ≥160/110<br/>Corticosteroids if <34 weeks"]:::action D -->|Preeclampsia only| F["Antihypertensive if indicated<br/>Weekly monitoring"]:::action D -->|GDM only| G["Diet + exercise<br/>Glucose monitoring"]:::action E --> H["Plan delivery at 37 weeks<br/>or earlier if deterioration"]:::outcome ``` **Warning:** Do NOT reassure or delay investigations. New-onset hypertension + proteinuria at 24 weeks is preeclampsia until proven otherwise. Early detection and management reduce maternal mortality and severe morbidity by ~50%.