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Gestational Diabetes
MACHITO L. GUARING
J.G
27
y.o
Single
November 15, 1987
Lives in Tugatog, Malabon City
Roman Catholic
Housewife
VAGINAL BLEEDING
(-)Diabetes
(-)Thyroid disease
(-)Hypertension
(-)Cancer
(-)Tuberculosis
(-)Psychiatric disorders
(-)Asthma
Menarche
Interval
Regular
Duration
Amount
14 years old
3-5 days
soaked)
Symptoms
(-) dysmenorrhea
Menstrual History
LMP: September 24, 2014
AOG: 39 2/7 weeks AOG by LMP
EDC: July 01, 2015
Coitarche:
20 years old
Sexual
partners: 3
Sexual
activity: active
Post-coital
Last
bleeding: none
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
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
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
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
EYES
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
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
Heart
rate: 97 bpm
Respiratory
rate: 21 cpm
Temperature:
Pain
area
37.1C
Warm
turgor
No
CRT
<2 seconds
Symmetrical
No
facial edema
Hair
Scalp
Auricles
No
Tympanic
Hearing
intact bilaterally
Eyebrows
Eyelids
Pinkish
Symmetrical
Septum
at the midline
No
swelling or obstruction
No
bleeding or exudates
Oral
Trachea
Symmetric
No
cervical lymphadenopathy
No
masses, no lesions
Clear
breath sounds
Symmetrical
No
chest expansion
retractions
Adynamic
Apex
No
thrills, no heaves
No
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
No
edema
No
cyanosis
No
No
atrophy
Equal
No
muscle bulk
swelling, no masses
Full
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
27 years old
G1P0 primigravid
Filipino
Trial
of labor
Assisted
vaginal delivery
under epidural anesthesia
Partograph
Friedmans Curve
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
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
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
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
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
Segmenters = 0.72
Eosinophiles =0.01
Lymphocytes = 0.22
Monocytes = 0.05
Thrombocytes = 331
MCV = 83.3
MCH = 28
MCHC = 0.33
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
Culture
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
It
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
CLASS
DESCRIPTION
C
D
D1
D2
Duration of over 20
D3
D4
CLASS
DESCRIPTION
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
natal visit
Average Risk
Perform blood glucose testing at 24-28
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
Maternal Effects
American
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.
THANK YOU!!!