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Low Xie Yee

Chandra Rubnee
Malvinder Singh
Caroline
Aswini
Kalichandren

CASE PRESENTATION 3

HISTORY TAKING

LOW XIE YEE


012012100016

OUTLINE

Personal History
Chief Complain
History Of Present Illness
History Of Present Pregnancy
Past Obstetrics History
Menstrual History
Gynecological History
Past Medical History
Past Surgical History
Family History
Diet History
Personal History
Social History
Drug History

PERSONAL
HISTORY

NAME : WAN RAFIDAH


AGE : 36
RACE : MALAY
RELIGION : ISLAM
OCCUPATION : HOUSEWIFE
GRAVIDITY : 5
PARITY : 3+1
LMP : UNSURE
EDD : 24 OCT 2014 (DATING
SCAN)
POA : 39w 4d
DOA : 18 OCT 2014
DOC : 21 OCT 2014

CHIEF COMPLAIN
Her chief complain was :
1. Increase frequency of urination for 2 months
2. Always feel hungry and thirsty for a month
3. Fatigue for a month

HOPI
4 days ago have antenatal checkup on 39 w of
gestation
MOGTT abnormal
Required admitted for observation
Increase frequency of urination for pass two
month
Urine color is straw and not concentrated
Always feel thirsty and dry mouth
Always feel hungry
fatigue

According to madam Wan Rafidah, 4 days ago


from my clerking date of 21 October 2014, she
went to clinic for her ANC on 39 w of gestation.
She told that she has been diagnosed as GDM
on 32 w of gestation. She was asked to run a
test for her blood sugar level and also MOGTT.
The results obtained were abnormal,
suggestive of GDM and no insulin is being
administered. Therefore she was required to be
admitted in HTAR for observation purposes until
the end of her pregnancy as she was staying
far from HTAR. Her blood sugar level is
monitored with blood sugar profile.

She claim that she had increase frequency of


micturition for pass two month started since
32w of gestation. She went to pass urine more
than 10 time per day. However she doesn't
have dysuria. She mention that her urine
colour appear to be straw colour and not
concentrated. She also denied UTI symptoms
such as fever, loin pain and haematuria. She
doesn't had abdomen pain and uterine
contraction.

She claim that she was having excessive thirst


and dry mouth. Everyday she need to intake a
lot of water to ease her thirst. She also increase
her quantity of foods due to her hunger
especially during night time. She will take 2 slice
of bread every night before sleeping.
She felt excessive fatigue until hardly to continue
her daily household work and need a long rest.
She denied that she having shortness of breath
and chest pain. She also told that she have no
symptoms of pica such as craving for ice cube or
fingers nail and so on found. She had no
vomiting after 12 w of her gestation. She can feel
her foetus and the foetal kick was always more
than 10 kick per 12 hours.

HISTORY OF PRESENT PREGNANCY


1ST TRIMESTER

Unplanned
Miss 2 month of menstrual
Dating scan on 8w gestation
Detection of single embryo
Blood group : O+
Urine routine = N
FBC= N
Hb level = N
Screening test= -VE for HBsAg, VDRL & HIV
BP= N
Weight:60kg
Height : 150cm
BMI : 26.6 kg/m
MOGTT FASTING = 4.0mmol/L
NONFASTING = 6.8 mmol/L
Folic acid given

2ND TRIMESTER
Anomaly scan on 14w = Nuchal thickness is 2.8cm
Tetanus injection
1st on 20w
2nd on 24w
FBC = N
Hb level = N
MOGTT FASTING= 5.0mmol/L
NONFASTING= 7.0mmol/L
BP = N
Uterine size
Weight : 65kg
Quickening on 20 w

3RD TRIMESTER
Fetus growth scan
FBC = N
Hb level = N
MOGTT- FASTING= 7.0mmol/L
NONFASTING = 9.8 mmol/L
Diagnose GDM on 32w
Fetus movement
BP= N
Uterine size
Weight : 70.5kg
Complains of
Polyuria
Polydipsia
Polyphagia
Iron supplement given

PAST OBSTETRIC HISTORY


G5 P3+1

YEAR

PREGNANCY

LABOUR

PUEPERIUM

BABY

2000

FULL TERM

NORMAL
SPONTANEOUS
VAGINAL
DELIVERY
(SVD)

BREAST
FEEDING UP
TO 2 YEARS

FEMALE
3.1KG
ALIVE

2000

ABORTION AT
8W POA

2002

FULL TERM

NORMAL SVD

BREAST
FEEDING UP
TO 2 YEARS

MALE
4.0 KG
ALIVE

2009

FULL TERM

NORMAL SVD

BREAST
FEEDING UP
TO 2 YEARS

MALE
3.55KG
ALIVE

2014

PRESENT
PREGNANCY

CONSUME
OCP FOR
3MONTH

REMARK

D&E DONE due to


period between 2
pregnancies were
too close.

MENSTRUAL HISTORY
Menarche
Duration of flow
Cycle length
Cycle

12 years old
7-10 days
28-30 days
Regular

Gynecological history
Consume OCP

After 1st pregnancy in


2000 for 3 months

Suggestive STI
Gynecological
problem

NO
NO

PAP smear History

Not done

PAST MEDICAL HISTORY


THYROID DISEASE
HYPERTENSION
DIABETUS MELLITUS
RENAL DISEASE

NO
NO
NO
NO

PAST SURGICAL HISTORY


APPENDICITIS
SPLEENONATOMY
CHOLECYSTECTOMY
LAPAROSCOPIC SURGERY FOR
INFERTILITY

NO
NO
NO
NO

FAMILY HISTORY
Father

Alive, 64
History of hypertension for 3 years

Mother

Died in 2012 at age 52 due to heart


failure
History of hypertension and type II
DM

Siblings

5 siblings, all alive


History of type II DM on one sibling
and others were healthy and no
history of malignancy

Grandmother History of multiple pregnancy (twins)

DIET HISTORY

NON- VEGETATIAN
NO FOOD ALLERGY
UNDERGO DIET CONTROL DUE TO GDM
CONSUME 1 CUP OF LOW FAT MILK PER DAY

PERSONAL HISTORY
SMOKING
ALCOHOL DRINKING
DRUG ABUSE

NO
NO
NO

SOCIAL HISTORY
Married for 15 years since 1999
Husband worked as lorry drive
Monthly income around RM3000
Staying with father in law

DRUG HISTORY
Do not consume any drug before pregnancy
No any drug allergy

Physical Examination

Chandra rubnee a/p


Shanmugam
012012050558

General Examination
Patient lying down in a supine position
comfortably .
Patient is conscious and cooperative.
Patient is alert and is average built and well
nourished .
No cannula or IV drip.
ID tag is present.

Vital parameters

Temperature : 36.7 degree Celsius


Pulse rate : 90 per minute .
Blood pressure : 130/80 mmHg
Pressure is taken while patient is
in tilted position . Why ?

General Examination

NO icterus eyes, no pallor seen in conjunctiva.


Chloasma is observed.
Oral hygiene is good .
NO angular stomatitis or glossitis : suggesting
absence of anemia or vitamin B12 deficiency .
NO thyroid enlargement or lymphadenopathy.
NO JVP rise .
NO clubbing nails, capillary filling time <2sec,
palm was warm, pinkish and moist.
NO varicose veins .
NO pitting edema .

Systemic Examination

Cardiovascular
system .

Cardiovascular examination
Inspection
Chest wall move symmetrically with
respiration.
Palpation
Apex beat was located at 5th intercostal
space left midclavicular line. No heave and
thrill.
Auscultation
S1 and S2 heard and no murmurs

Respiratory System
Inspection
Chest wall move symmetrically with
respiration and not in respiratory distress
Palpation
Trachea was centrally located.
Normal chest expansion and tactile vocal
fremitus.
Percussion
Resonance

Continuation ...
Auscultation
Air entry is equally bilateral and normal
vesicular breath sound heard. There were
no rhonchi heard.

Obstetric Examination
Patient complaint of no pain at the 9 regions
of abdomen.
Abdomen is distended by a gravid uterus
supported by the presence of lines nigra
and striae gravidarum and striae albicans
Abdomen is soft .
NO scar present .
Umbilicus is centrally located and flattened.

Flank is full .
Symphysis fundal height is 36cm
Clinical fundal height is at 40weeks of
period of gestation

Local Examination
LEOPOLD's MANEUEVER
Fundal grip- there is a broad soft irregular
mass suggestive of fetal breech
Right lateral grip - there are small knob like
structure suggestive of fetal limbs

Left lateral grip - there is smooth curved


resistance suggestive of fetal back
1st pelvic grip - There is ballotable smooth
hard globular mass suggestive of fetal head
2nd pelvic grip - Confirms the 1st pelvic grip

The head of fetus is engaged.


this is singleton foetus in longitudinal lie with
cephalic presentation , placenta anterior
upper segment .
Liquor amount is adequate
Estimated foetal weight with Johnsons
formula : (36-11)x 155=3875grams
Foetal heart rate is 128beats per minute
heard along the spino-umbilical line.

Madam Wan Rafidah is at 39th week


4days of period of gestation with fundal
height of 40 weeks,symphysio fundal
height of 36cm with a singleton featus
with a longitudinal lie and cephalic
presentation, head is engaged.

SUMMARY

PROVISIONAL DIAGNOSIS

MALVINDER SINGH A/L BACHITARA


SINGH
012012100082
GROUP C
OBSTETRICS & GYNAECOLOGY

PROVISIONAL DIAGNOSIS
Madam Wan Rafidah a 36 years old
Muslim housewife with G5P3+1 at 39
weeks and 4 days of period of gestation
with singleton fetus in longitudinal lie
with cephalic presentation associated
with Gestational Diabetes Mellitus and
not in labour.

DIFFERENTIAL DIAGNOSIS
1. Gestational Diabetes Mellitus
Supporting points
1. No detected presence of
Diabetes Mellitus(type 1 or
2) before 20 weeks of period
of gestation
2. Family history of DM
3. Detections occurs in week
39 of gestation
4. Overweight
5. Age above 35 years old
6. Polyuria
7. Polydipsia
8. Polyphagia
9. Previous big baby > 4.0 kg

Points against

2. Type 1 Diabetes Mellitus


Supporting points

Points against

1. Polyuria
2. Polydipsia
3. polyphagia

1.
2.
3.
4.

Not lean
No past history
No family history
Patients age is 37
years old
5. Weight not decreasing

3. Type 2 Diabetes Mellitus


Supporting points

Points against

1. Polyuria
2. Polydipsia
3. Polyphagia
4. Overweight
5. Family history
6. Age

1. No past history recorded


2. Albuminuria not detected
3. Regular menstrual cycle Polycystic ovary syndrome
characterized by irregular menstrual
periods, excess hair growth and obesity

4. Not smoking

4. Urinary Track Infection


Supporting points

Points against

1. Polyuria

1. No fever or high grade


fever
2. No pain or a burning
feeling during
urination.
3. No blood in urine

4. Hyperthyroidism
Supporting points

Points against

1. Increase appetite

1. Enlargement of thyroid
is not detected.
2. No weight loss.
3. Normal TSH in blood
test.

Excessive thyroid hormones causes increased


glucose production in the liver, rapid absorption of
glucose through the intestines and increased insulin
resistance.

Investigation and screening of


gestational diabetes

Caroline Sundralingam
012 012 100 017

Risk factors

Age over >25 years


BMI >25kg/m
Increased weight gain during pregnancy
Previous hx of large-for-gestational-age infants
Hx of gestational diabetes in previous pregnancy
Elevated fasting/random blood glucose levels
during pregnancy
Family hx of diabetes in first-degree relative(s)
Hx of metabolic X syndrome
Hx of type 1 or type 2 diabetes
Previous hx of macrosomia(>4kg), stillbirth, IUD,
recurrent miscarriage

Screening

ALL patients visiting antenatal clinic (Malaysia)


screened using random blood sugar/post prandial
blood sugar
Blood Glucose level

Normal

Abnormal

Random

11.1 mmol/L

Fasting

7.0 mmol/L

11.1
mmol/L
7.0 mmol/L

Diagnostic of DM in pregnant and non pregnant

MOGTT
1. Previous gestational diabetes
MOGTT done @ 16-18 weeks of gestation
If negative, repeat test @24 weeks of gestation
2. Other risk factor
MOGTT done @22-26 weeks
If negative, repeat test @34 weeks of gestation

MOGTT- Procedure
75g oral glucose tolerance test
1. 3 days prior to test consume minimum 150g
carbohydrate
2. Fast 12hr
3. Morning: Fasting blood glucose level
measured, drawn from maternal venous blood
4. Drink glucose preparation within 10mins
5. Take 2HPP reading

Results indicating abnormality


WHO criteria
Fasting
2HPP
>7.0 mmol/L
>7.8mmol/L
HTAR

Plasma
venous
Capillary
whole blood

Fasting
6.1 mmol/L

2 HPP
7.8 mmol/L

5.6mmol/L

7.8 mmol/L

Diagnosed GDM
1. Glycosylated hemoglobin (HbA1c)
. Serum blood sample taken
. Reflect glycemic control over previous 23months
. Normal range: 4.7-6.3% (non-pregnant)
4.5-5.7% (early pregnancy)
4.4-5.6% (late-pregnancy)

Fetal well being


Ultrasound
-Amniotic fluid index (oligo-/Polyhydramnios)

-Macrosomic fetus (abdomen circumference)


-Congenital anomalies (@18-20w)

Further Ix
1. Urine FEME
. If nitrites positive, indicative of UTI
. Further test Urine culture & sensitivity
2. TFT

. Measure TSH, T & T

MANAGEMENT
Aswini A/P Nalla Mutthu
Krishna Gandi

012013050215

Antenatal Management
First trimester
1. Receive dietary instruction
and nutrition counseling.
2. Moderate exercise program.
3. Monitoring of blood glucose
4. Screening for microvascular
complications

Antenatal Management
Second trimester
1. Monitoring of blood glucose
2. Anomaly scan at 18-20 weeks,
fetal echocardiogram at 22-24
weeks.
3. Serial growth scans for
Amniotic Fluid Index and
abdominal circumference.
4. Surveillance for maternal
complications.

Antenatal Management
Third trimester
1. Monitoring of blood glucose
2. Assess fetal weight
3. Discuss timing and mode of
delivery

Diet
Eat meals on a regular schedule
throughout the day

Eat smaller amounts of


carbohydrates at each meal
Add a nighttime snack to meal
plan

Energy requirement
Female 60 kg
60 Kg X 30 kcal = 1800
kcal with 30% extra= 2100
Kcal
Breakfast
kcal

700

Carbohydrate (65%)
Protein (10%)
70
Fat (25%)
180
Carbohydrate
100 gm
Protein (10%)
gm
DietFat (25%)
Carbohy.
gm bread
Arabian
30 gm
Cheese
Honey
Glass of milk
Total

5 gm
50 gm
10 gm
95 gm

450

15

Lunch

900
kcal

Carbohydrate (65%)
Protein (10%)
90
Fat (25%)
220
Carbohydrate
130 gm
Protein (10%)
gm
_DietFat (25%)
Ricegm

Protein 17
Fat
----10 gm 10 gm chicken
2 gm
3 gm Salad
5 gm
5 gm_ Orange
17 gm 18 gm Total

Carbohy.
80 gm
5 gm
30 gm
10 gm
125 gm

590

Dinner

500
kcal

Carbohydrate (65%)
Protein (10%)
50
Fat (25%)
120

Carbohydrate
65 gm
20
Protein (10%)
gm
22
Fat (25%)
Fat _Diet
Carbohy.
gm
6 gm Tuna
sandwich
45 gm

Protein
--15 gm 12 gm Apple
4 gm
4 gm Tea
-----___ Total
19 gm 22 gm

15 gm
--95 gm

330

10
11

Protein Fat _
12 gm
10 gm
--------_
17 gm 18 gm

Self-monitoring of Blood
Glucose
TEST

GLUCOSE
LEVELS (MG PER
DL [MMOL PER L])

Fasting

< 96 (5.6)

One-hour
postprandial

< 140 (7.2)

Two-hours
postprandial

< 120 to 127 (6.7)

Insulin Indications
Blood glucose not maintained by diet.
Insulin dose is individualized and
adjusted according to the patients
blood glucose levels.
Adverse effects :
Hypoglycemia

Symptoms of
Hypoglycemia

Very hungry
Very tired
Shaky or trembling
Sweating or clamminess
Nervous
Confused
Like youre going to pass out or faint
Blurred vision

Intrapartum Management
Delivery by cesarean section usually is
favored when fetal distress has been
identified.
Delivery planned at 38 weeks or 39
weeks gestation.
GDM on diet can be delivered at 40
weeks.
Maintain normoglycemia.

Post Partum
Management

Reassess blood glucose level.


Counsel regarding diet, weight loss
and exercise.
Breast feeding.

DISCUSSION
KALICHANDREN A/L ARUMUGAM
012013050221

TYPE

Type 1 diabetes
(Insulin Dependent
Diabetes Mellitus)
Type 2 diabetes
(Non Insulin
Dependent
Diabetes).

DEFINITION
Carbohydrate intolerance resulting in
hyperglycemia of variable severity with onset
or first recognition during pregnancy

SYMPTOM
Feeling thirsty more often than usual
Urinate more often

RISK FACTOR

PATHOPHYSIOLOGY
Early in pregnancy, maternal oestrogen
and progesterone increase and promote
pancreatic
-cell
hyperplasia
and
increased insulin release
As pregnancy progresses, increased
levels of human placental lactogen,
cortisol, prolactin, progesterone, and
estrogen lead to insulin resistance in
peripheral tissues.

COMPLICATION
EFFECT ON PREGNANT WOMEN

Preterm labor

Polyhydramnios

Pre-eclampsia

Hyperglycemia

COMPLICATION

COMPLICATION

COMPLICATION

Conclusion
Gestational diabetes is a common problem .
Risk stratification and screening is essential
in almost all pregnant women
Tight glycemic targets are required for
optimal maternal and fetal outcome
Patient education is essential to meet these
targets
Long term follow up of the mother and
baby is essential

REFERENCE
DC Dutta Textbook of Obstetrics