Вы находитесь на странице: 1из 102

Case Presentation:

Gestational Diabetes
MACHITO L. GUARING

J.G
27

y.o
Single
November 15, 1987
Lives in Tugatog, Malabon City
Roman Catholic
Housewife

VAGINAL BLEEDING

Childhood illnesses: unrecalled


(-) Allergy
(+) Diabetes Mellitus diagnosed November
2014
( FBS: 5.29 mmol/dL; 96.7 mg/dL, Nov
29, 2014)
(-) Heart Disease
(-) HPN
(-) Cancer

Past Medical History

Previous hospitalizations: None


Previous surgery: None

(-)Diabetes
(-)Thyroid disease
(-)Hypertension
(-)Cancer
(-)Tuberculosis
(-)Psychiatric disorders
(-)Asthma

Menarche
Interval

Regular

Duration
Amount

14 years old

3-5 days

4 pads per day (mildly

soaked)
Symptoms

(-) dysmenorrhea

Menstrual History
LMP: September 24, 2014
AOG: 39 2/7 weeks AOG by LMP
EDC: July 01, 2015

Alcoholic beverage consumption: No


Smoker: No
Recreational drugs: None
Exercise: walking in the morning for 30
mins
Occupation: Housewife
Live-in with a seafarer for 7 years

Coitarche:

20 years old

Sexual

partners: 3

Sexual

activity: active

Post-coital
Last

bleeding: none

sexual contact: September 26,


2014

OB score: G1P0
Prenatal history
First trimester:
(+) Pregnancy Test
(+) Prenatal Checkup: 3x
(+) TVS
(+) Multivitamins
(+) Maternal Illnesses: Gestational Diabetes
Mellitus
Laboratories: HBa1C, Urine Ketones, FBS,
CBC, Pap Smear

Laboratories First
Trimester
CBC: ( Oct 31, 2014)
Hemoglobin: 13
Hematocrit: 0.40
Segmenters: 69%
Monocytes: 20%
Erythrocyes: 1%
Leukocytes: 4 %
WBC: 12.4

Platelets: Adequate

Laboratories: First
Trimester
TVS ( Nov 17, 2014)
7 1/7 weeks AOG, Placenta
Posterior, Grade 2, high lying)

Laboratories First
Trimester
RPR ( Oct. 31, 2014): Non Reactive

HBSAg (Oct 31, 2014): Non Reactive

Laboratories First
Trimester
Urinalysis ( Oct 31, 2014)
Color: Slight Yellow
Bacteria: Few
RBC: 1-2 hph
PMN: 0-1 hph
CHON: (-)
Sp Gr.: 1.015
Pus Cells: 0-1 hpf
Mucous Threads: Moderate

Laboratories: First
Trimester
FBS (Nov 29, 2014)
5.29 mmol/dL (Treshold: 5.1 mmol/dL)
96.7 mg/dL
( Treshold: 92 mg/dL )
HBA1C (Jan 09, 2015)
4.92%; (-) urine ketones

Pap

smear (Oct 31, 2014) , no


significant findings

Plan
1. DM Diet
2. Refer to IM
3. Congenital Anomalies Scan ( CAS)
4. Refer to Perinatology for Maternal
High Risk
Assessment

IM Recommendations
1. DM Diet
2. Insulin 4 units in the AM and PM
before meals
3. Capillary Blood Glucose (CBG)
Monitoring

Perinatology
Recommendations
1. DM Diet
2. Insulin as per IM recommendation
3. Schedule for CAS at 24th week

CAS ( March 16, 2014)


Pregnancy Uterine, 24 3/7 weeks AOG
by fetal biometry, Adequate AF
Volume; Posterior Placenta, High
Lying; No Gross Congenital
Anomalies

OB score: G1P0
Prenatal history
Second trimester:
(+) Prenatal Checkup ~ 4x
(+) TAS
(+) Multivitamins, Folic Acid , Calcium, Insulin
(+) Maternal Illnesses: Gestational Diabetes
Mellitus

Laboratories: Second
Trimester
HBA1c (March 11, 2015)
5.1% (-) urine ketones

OB

score: G1P0
Prenatal history
Third trimester:
(+) Prenatal Checkup
(+) Multivitamins, Folic Acid , Calcium, Insulin
TAS
(+) Maternal Illnesses: Gestational Diabetes

GENERAL:
No weight loss or weight gain
No fatigue

SKIN
No changes in skin color, nails, moles or

hair

HEAD

No head injury or any headache


No dizziness or lightheadedness

EYES

No pain, redness, blurring of vision

EARS

NOSE
No frequent colds, discharge, itching or

nose bleed

NECK
No neck pain or stiffness

MOUTH
No bleeding, sore tongue or dry mouth

CARDIAC
No edema or palpitations

RESPIRATORY

No
No
No
No

difficulty of breathing
chest pain
hemoptysis
cough

GASTROINTESTINAL
No dysphagia
No heart burn, no loss of appetite, no

abdominal pain, no nausea or vomiting,


no constipation, no diarrhea.

PERIPHERAL VASCULAR
No leg cramps, no blood clots, no
swelling.
GENITO-URINARY
No frequency, urgency, dysuria,
hematuria, hesitancy, incontinence,
dribbling or nocturia
No swelling of genitals, soreness or

MUSCULOSKELETAL
No joint or muscle pain, no stiffness. No
limitation of movements.
NEUROLOGIC
No changes in attention, no fainting
episodes, black outs, seizures or
paralysis.
No numbness, no paresthesias

HEMATOLOGIC
No easy bruising or bleeding
No anemia or any history of past blood
transfusion

GENERAL

SURVEY

Awake
Oriented x 3
Alert
Conscious
Coherent
Not in cardiorespiratory distress

Blood

pressure: 110/70 mmHg

Heart

rate: 97 bpm

Respiratory

rate: 21 cpm

Temperature:
Pain

area

37.1C

scale: 7/10 pain to lower lumbar

Pre-pregnancy weight: 53.5 kg


Height: 165.1 cm
BMI: 20.1 kg/cm2
Weight at time of Admission: 65.5 kg

Warm

to touch, moist, good skin

turgor
No

masses, no lesions, no bruises, no


hematomas

CRT

<2 seconds

Symmetrical
No

facial edema

Hair

is course, dry, black, and well


distributed

Scalp

is intact, without scales,


plaques or other lesions.

Auricles

are symmetrical with no


lesions or deformities

No

cerumen or any discharge

Tympanic

membranes intact, smooth


and non-hyperemic

Hearing

intact bilaterally

Eyebrows

are symmetrical with well


distributed hair

Eyelids

are smooth, symmetrical without


ptosis or lesions

Pinkish

palpebral and bulbar conjunctivae


Anicteric sclerae
Clear cornea and lens clear
Both

pupils are symmetric at 3cm, briskly


reactive to light

Symmetrical
Septum

at the midline

No

swelling or obstruction

No

bleeding or exudates

Oral

mucosa and gingiva pink and intact


No mucosal bleeding
Tongue at midline
Lingual frenulum at midline
No swelling, bleeding or ulcers
Tonsils are non-hyperemic and noncongested
Uvula at the midline
Pharynx without exudates

Trachea

at the midline, no deviation

Symmetric
No

cervical lymphadenopathy

No

masses, no lesions

Clear

breath sounds

Symmetrical
No

chest expansion

retractions

Adynamic

precordium, regular rate


and rhythm

Apex

beat at the level of the 5th ICS


Left Midclavicular Line

No

thrills, no heaves

No

murmurs or carotid bruits

Soft,

Globular

FH:

37cm
FHT: 130s-140s (via CTG)
EFW:

4,030 gms
LM1= breech
LM2= fetal back at the right
LM3= breech
LM4= unengaged

Both

UE and LE symmetrical in size

No

edema

No

cyanosis

No

palpable inguinal nodes

No

atrophy

Equal
No

muscle bulk

swelling, no masses

Full

range of motion towards all


planes of movement

Internal exam:
4 cm,
50% effaced,
station (-)3,
cephalic,
(+) bag of water

Cervical

dilatation: 4 cm = 2pts
Cervical Effacement: 50% = 1 pt
Station of baby: (-)3 = 1pt
Cervical Position: posterior = 0 pt
Cervical consistency: moderately
firm = 1 pt
TOTAL: 5 pts

Grossly normal, full and equal


pulses,
(-) edema;
No lesions
Intact sensation as to light touch and
pain

27 years old
G1P0 primigravid
Filipino

G1P0, pregnancy uterine,


39 weeks AOG by UTZ,
cephalic, in labor, GDM
on insulin

Trial

of labor

Assisted

vaginal delivery
under epidural anesthesia

Nothing per orem (NPO)


Hooked to IV fluids D5LR 1L to run
for 8 hours
Request for CBC with APC, Urinalysis,
PT and PTT
Refer and co-manage with IM
Progress of labor monitored

First Hospital Day


Plan:
1.Hyosine N-Butyl bromide 2 cc/IV,
ANST; then 2 cc/hour for 3 doses
1.Give Anesthesia Omeprazole 40 mg
IV psuh once on NPO

Second Hospital Day


Plan:
1.Evening Primrose 2 capsules per
vagina every 6 hours
2.Give IV fluids D5LR 1 L to run for 8
hours
3.Start Oxycontin Drip to run for 10-15
ug/tts/min to titrate with uterine
contractions

4. Ampicillin 2 gm/IV ANST loading


dose then 2 mg IV every 6 hours
5. NPO

Third Hospital Day


(+) Variable Contractions
1.Hold Oxycontin
2.Hydrate 200 cc
3.For emergency Caesarian Section
and get consent
4.Inform Anesthesia resident on Duty
5.Cefuroxime Cefixime 1.5 g/IV

Partograph

Friedmans Curve

Nothing per orem

Monitored vital signs every 15minutes and


recorded

Oxygen support was given via nasal


cannula

Regulate current IV fluid

Post- Operative

Medications given:

Medications given:
Ampicillin 1 g every 6 hours
Omeprazole 40mg/IV once a day
while on NPO
Tramadol drip: 300mg + Plain NSS
494ml to run at 20ml/hour
Ketorolac 30mg/IV every 8 hours for 4
doses
Paracetamol + Tramadol tablet 1
tablet every 8 hours for pain once
started on diet

Ampicillin

1 g every 6 hours
Omeprazole 40mg/IV once a day
while on NPO
Tramadol drip: 300mg + Plain NSS
494ml to run at 20ml/hour
Ketorolac 30mg/IV every 8 hours for 4
doses
Paracetamol + Tramadol tablet 1
tablet every 8 hours for pain once
started on diet

Course in the ward: Day


1
S

No subjective
complaints
reported

BP 11/70
mmHg
CAR 84 bpm
RR 21 cpm
T 38.3 C

G1P1
(1001) , PU,
39 3/7 weeks
AOG,
delivered by
primary
caesarian
section sec to
arrest in
cervical
dilatation, to
a live, term
baby girl, BW
3500 g, AS
9,9,9 BS 39
weeks, GDM

1. Increase
fluid intake
2. Give
Paracetam
ol 500 mg
tablet fro T
>= 37.5 C
3. Start
Metronidaz
ole 500
mg tablet
every 8
hours
4. May turn
to side

(-) BM
(-) Flatus
UO 50-180 cc
Clear Breath
Sounds
(-) phlebitis

P
5. Moderate
Back Rest
6. Apply
Abdominal
Binder
7. May have
clear liquids;
soft diet if with
flatus; full diet if
with BM
8. Discontinue
CBG
(CBG= 108
mg/dL

P
9. Medications
a.Cefuroxime
500 mg
capsule; 1
capsule
every12 hours
b.Paracetamol
+ Tramadol 1
tablet every 8
hours
c.Ferrous
Fumarate 1 tab
once a day
d.Ascorbic Acid
500 mg tablet,
1 tablet

Course in the Ward: Day


2
S

BP 110/70
mmHg
CAR 85 bpm
RR 18 cpm
T 39 C

G1P1 (1001) ,
PU, 39 3/7
weeks AOG,
delivered by
primary
caesarian
section sec to
arrest in
cervical
dilatation, to a
live, term baby
girl, BW 3500 g,
AS 9,9,9 BS 39
weeks, GDM on
insulin

1. Increase Oral
Fluid Intake
2. Progressive
Ambulation
with cane
3. Insert
Bisacodyl
suppository;
1
suppository
par anus
4. Continue
present paln
and
management
5. CBC
monitoring

(-) BM
(-) Flatus
(+) NABS
(+) Urge to BM
(-) abdominal
pain
(-) Vaginal
bleeding
(-) s/sx of
infection to

Course in the Ward: Day


3
S

Cough

BP 110/70
mmHg
PR 79 bpm
RR 18 cpm
T 39 C

G1P1 (1001) ,
PU, 39 3/7
weeks AOG,
delivered by
primary
caesarian
section sec to
arrest in
cervical
dilatation, to a
live, term baby
girl, BW 3500 g,
AS 9,9,9 BS 39
weeks, GDM on
insulin

1. Request
Chest X Ray
2. Paracetamol
500 mg tab,
1 tab every 4
hours for T
>=37.5
3. Request for
CBC with
APC
4. Hook to Plain
LR 1 L to run
for 8 hours
5. Hook to O2
via nasal
cannula

(+) crackles to
L lower lung
field
(+) BM
(+) Flatus
(+) freely
voiding

Course in the Ward: Day


4
S

BP 100/70
mmHg
CAR 90 bpm
RR 20 cpm
T 36.2 C

G1P1 (1001) ,
PU, 39 3/7
weeks AOG,
delivered by
primary
caesarian
section sec to
arrest in
cervical
dilatation, to a
live, term baby
girl, BW 3500 g,
AS 9,9,9 BS 39
weeks, GDM on
insulin

1. Paracetamol
500 mg
tablet; 1 tab
as needed
for T >=
37.5 C
2. Plain LR 1 L
to run for 8
hours
3. Continue VS
monitoring
4. Continue
present
management
5. Follow up
Chest X Ray
result

(+) crackles to
L lower lung
field
(-) cough
(-) dyspnea
(-) pain to
abdominal
incision site
(+) BM
(+) Flatus

Chest X- Ray Result (0629-2017)


Follow up examination when compared
to the study on 04-17-2015 shows
partial clearing of pneumonic
infiltrates in both lower lobes.
Left costophrenic sulcus is minimally
blunted suggestive of minimal pleural
effusion and/or thickening.

CBC with Platelets (06-29-215


Hemoglobin = 11.40
Hematocrit = 0.35
Leukocytes = 11.3

Segmenters = 0.72
Eosinophiles =0.01
Lymphocytes = 0.22
Monocytes = 0.05

Thrombocytes = 331
MCV = 83.3
MCH = 28
MCHC = 0.33

Course in the Ward: Day


5
S

No subjective
complaints
reported

BP 110/70
mmHg
CAR 81 bpm
RR 20 cpm
T 36.5

G1P1 (1001) ,
1. For discharge
PU, 39 3/7
home
weeks AOG,
delivered by
primary
caesarian
(+) clear breath section sec to
sounds
arrest in
(-) fever for 24
cervical
hours
dilatation, to a
live, term baby
girl, BW 3500 g,
AS 9,9,9 BS 39
weeks, GDM on
insulin

Home Medications
Home Medications:
1.Cefuroxime 500 mg tab, 1 tab every 12
hours for 5 more days
2.Ferrous Fumarate tablet, 1 tablet once a
day
3.Ascorbic Acid 500 mg tablet, 1 tablet
once a day
4.Paracetamol + tramadol, 1 tablet 3x/day
for pain

PT,

PTT (24-June-2014)

Prothrombin Time
PT = 12.4
Control = 13.9
% Activity = >100
INR = 0.88
Partial Thrombin Time
PTT = 26.2
Control = 31.5

Urinalysis (25-June-2015)

Volume: 35cc
Character: turbid
Specific Gravity: 1.025
Reaction: Acidic
Albumin (+)2
Glucose (-)
PMN: 15-18/hpf
RBC: 8-10/hpf
Hyaline Cast: (-)
Amorphous urates: few
Bacteria: many

Haemoglucotest
DATE

RESULTS

24-June-2015 mcc

89 mg/dL

25-June-2015 rlg

170 mg/dL

25-June-2015

83mg/dL

25-June-2015

117mg/dL

26-June-2015 mcc

88 mg/dL

26-June-2015 adm

76mg/dL

26-June-2015 save

86mg/dL

Haemoglucotest

DATE

RESULTS

25-June-2015 vhcc

112mg/dL

25-June-2015

76mg/dL

27-June-2015 shas

50mg/dL

27-June-2015 tnc

67mg/dL

27-June-2015 save

107mg/dL

27-June-2015 sars

68mg/dL

27-June-2015 sars

153mg/dL

Culture

and Sensitivity (28-June-2015)

Specimen: Urine (26-June-2015; 10:30am)


RESULTS: No growth after 2 days of incubation

Culture

and Sensitivity (27-June-2015)

Specimen: Urine (25-June-2015; 10:30am)


RESULTS: No growth after 2 days of incubation

G1P1(1001)

Pregnancy Uterine,
39 3/7 weeks AOG, delivered by
primary caesrean section
secondary to arrest of cervical
dilatation to a live term baby
girl Birth weight: 3500 grams
AS:999 BS:39 weeks
gestational DM on insulin

WHAT

IS GDM?

Diabetes

with onset or first


recognition during pregnancy that is
not clearly overt (type 1 or 2)
diabetes.

It

is the most common medical


complication of pregnancy

Oral Glucose Load


Time

100g Glucose

75g Glucose

mg/dL

mmol/L

mg/dL

mmol/L

Fasting

95

5.3

95

5.3

1-h

180

10.0

180

10.0

2-h

155

8.6

155

8.6

3-h

140

7.8

Etiology of GDM
Human Placental
Hormone

Increases
mobilization of
glucose

Strong antiinsulin effect

Places mother at high


risk for developing
diabetes during

CLASS

DESCRIPTION

Abnormal GTT at any age or of any duration treated by


diet only

Onset at age 20 or older and duration of less than 10


years

C
D
D1

Onset at age 10-19 years or duration of 1-19 years


Onset before age 10, duration of over 20 years, BDR or
HTN
Onset before age 10

D2

Duration of over 20

D3

Calcification of vessels of leg (macrovascular disease)

D4

Benign retinopathy (microvascular disease)

CLASS

DESCRIPTION

Evidence of arteriosclerotic heart disease

Prior renal transplantation

A1

Diet-controlled GDM

A2

Insulin-treated GDM

BMI >30
Previous

kg/m2
macrosomic baby weighing
(4.5 kg and up)
Previous gestational diabetes
Family history of diabetes ( first degree
relatives with diabetes)
Family origin with a high prevalence of
diabetes:
Asian (specifically women whose country of

family origin is India, Pakistan or


Bangladesh)

Recommended Screening Strategy


Based On Risk Assessment for
Detecting GDM

GDM Risk Assessment: Should


be ascertained at the first pre

natal visit

Recommended Screening Strategy


Based On Risk Assessment for
Detecting GDM

Low Risk: Blood Glucose testing not


routinely required if all the following are
present:
1.Member of an ethnic group with a low
prevalance of GDM
2.No known diabetes in the first degree
relatives
3.Weight normal before pregnancy
4.Weight normal at birth

5. No history of abnormal glucose


metabolism
6. No history of poor obstetrical
outcome

Average Risk
Perform blood glucose testing at 24-28

weeks using either


Two step procedure:

50g oral glucose challenge test (OGCT), followed by a


diagnostic 75/100g oral glucose tolerance test (OGTT)
for those meeting the threshold value in the GCT

One step procedure:


Diagnostic 75/100g oral glucose tolerance test
performed on all subjects

High risk
Perform blood glucose testing
(One/Two steps) as soon as feasible
Severe obesity
Strong family history of type 2
diabetes
Previous history of:
GDM, impaired glucose
metabolism or glucosuria

If GDM is not diagnosed, blood


glucose testing should be repeated
at 24-28 weeks or at any time
If If GDM is not diagnosed, blood
there areglucose
symptoms
orbe signs
testing should
repeated at
24-28 weeks or at any time there are
suggestive
of hyperglycemia
symptoms
or signs suggestive of
hyperglycemiGDM is not diagnosed,
blood glucose testing should be
repeated at 24-28 weeks or at any
time there are symptoms or signs
suggestive of hyperglycemia

Maternal Effects
American

Diabetes Association (1999)


has concluded that
Fasting hyperglycemia>105 mg/dL may

be associated with an increased risk of


embryonic death during the last 4-8
weeks of gestation
Adverse maternal effects include an
increased frequency of hypertension and
caesarean delivery secondary to
macrosomia

Fetal Effects
Macrosomia
Macrosomic infants are those whose
birthweight exceeds 4500g
Except for the brain, fetal organs
are affected by macrosomia

Hyperinsulinemia
Maternal hyperglycemia prompts
fetal hyperinsulinemia particularly
during the second half of gestation
stimulates excessive somatic growth
Neonatal hyperinsulinemia may
provoke hypoglycaemia within
minutes of birth

Diet
Exercise
Insulin
Oral

hypoglycaemic agents

Diet
Should be individualized based on
weight and height
Daily caloric intake of 30-35 kcal/kg/day
ACOG (2013) recommends carbohydrate
intake limited to <40% of total calories

Exercise
Resistance exercise reduce the need
for insulin therapy
ACOG (2013) recommends a moderate
exercise program for at least 30
mins, 3-5x/week

Glucose Monitoring
Women using daily blood-glucose selfmonitoring had significantly fewer
macrosomic infants and gained less
weight after diagnosis.
Post-prandial monitoring has been
shown to be superior to preprandial
monitoring.

Insulin Therapy
Insulin therapy should be initiated if fasting
levels exceed 95 mg/dL
ACOG (2013) also recommends insulin
therapy be initiated in women with:
1 hour post prandial level exceed 140 mg/dL
2 hour post prandial level exceeds 120
mg/dL

Oral Hypoglycemic
Agents
Glyburide and Metformin both
safe and effective in management of
gestational diabetes.
No adverse neonatal and maternal
outcomes.

Advice and Prevention


1. Take all medications as per MD order
2. DM diet; measured caloric intake
3. Moderate exercise at least 30 mins 35x/week
4. Post partum evaluation
75 g OGTT at 6 to 12 weeks post partum

Advice and Prevention


5. ACOG (2013) and ADA (2009)
recommend testing at least every 3
years in women with history of GDM
but normal post partum glucose
screening.

THANK YOU!!!