Patient’s data

• Name - Mrs.S.D.Karunanayake• Age - 28 years • From Awissawella • House wife

In her 2nd pregnancy with a 4 year old daughter presented at 36weeks and 6days of POA

Previous obstetric history • The first born in 2010 by a c-section at 38weeks

of POA • It was complicated with GDM• Diagnosed at 24th week POA by OGTT• On dietary control for 1 month, later changed

into insulin 8 units three times per day • Birth weight 3.525kg• NICU-for 2days• After 6 weeks post partum FBS was normal

HISTORY OF CURRENT PREGNANCY

1st Trimester(0-12weeks) • This is an unplanned pregnancy. • Pregnancy was confirmed by urine hCG after missing her

periods for 2 weeks.• Booking visit at Awissawella clinic (8th week of POA) • Folic acid was started • Basic Investigations done- normalHbUFRGrouping and Rh - A+ VDRLPPBS

• LMP on the 8th of November 2013- irregular menstural cycle - According to ultra sound scan the EDD is

2nd september 2014

1st Trimester(0-12weeks)

• At 8th week of POA, OGTT was done at Awissawella clinic• OGTT- 310mg/dl (2hr value)• Then was admitted at Castle Hospital at 8th week of POA

for 5days • Insulin was started Morning 20unit Day 18unit Night 18unit Night 10pm 14unit• 8th week of POA HbA1c-11.6

1st Trimester(0-12weeks)

• Dating scan at 12th week and fetal viability was confirmed.

• General Health –tiredness, non specific symptoms such as headache ,increased appetite

• No complications of 1st trimester-hyperemesis, bleeding PV, vaginal discharge or fever with papular rash

2nd trimester (12-28 weeks)

• Tetanus toxoid given • Perception of 1st fetal movement on 18th

week of POA• Fetal anomaly scan-20th week and it was

normal. • Iron & Calcium given after 12th week • Worm treatment not given. • No other complications detected.

3rd trimester(28-40weeks)

• Regular clinic visits every 2 weeks. • USS scan-33weeks (fetal weight-2.4kg) • BSS done every two weeks and was normal.

• Past medical history – migraine • Past surgical history – past c section in 2010• Drug history – Soluble insulin s/c, lente at night. • Allergic history – no known allergies • Family history – mother has DM for 5 years.• Social history – husband is a businessman. He is a

non alcoholic and a non smoker. She has adequate family support from her parents and in laws.she has the capability to store insulin at home,she is knowledgeable on different sites on insulin administration.and she is aware of hypoglycemic symptoms and the actions to take on such event.

ExaminationGeneral examination• Maternal weight- 100.23 kg Height-162cm (BMI-38.18)• Afebrile• No pallor• Good oral hygiene• No thyroid enlargement• bilateral ankle oedema

Cardiovascular examination

• Pulse-70per min regular rhythm, normal volume• No collapsing pulse, Peripheral pulses were felt • BP - 130/80mmHg• On inspection - No scars or deformities No parasternal heaves. Apex beat was felt at 5th ICS in MCL 1st & 2nd heart sound were normal No murmers heard

Respiratory system examination

• RR-24per minute • On inspection- no scars or deformities• Normal symmetrical chest expansion• Trachea central• Percussion - vocal fremitus normal • Auscultation - vesicular breathing

Abdominal examination

• On inspection Symmetrically enlarged abdomen Striae gravidarum Linea nigra Supra pubic transverse scar Hernial orifices intact

On palpation

Symphysio fundal height- 40cm which was not compatible with gestational age.

Lower pole- Single hard round ballotable mass,3 fifth palpable. Suggestive of fetal head Upper pole- Smooth less harder broader mass Suggestive of breech

Single fetus Longitudinal lie in cephalic presentation, left occipito anterior position.

approximate fetal weight 3.200 kg & high liqour volume

• Auscultation Fetal heart beat was present

Summary

• 29year old house wife in her 2nd pregnancy was admitted for confinement,at 36 weeks & 6days of POA.(later developed SROM) OGTT was done at 8th week and the 2hr value is 310 mg/dl. Her HbA1c was 11.6 at 8th week. She was on insulin.

• On Ex- CVS ,RS,CNS were unremarkable. Abdominal examination

symphysio fundal height is 40cm which was higher than POA. • Single fetus longitudinal lie left occipito anterior cephalic

presentation, high liqua volume. Estimated fetal size is 3.200kg.

Problem list

• Gestational diabetes mellitus• Previous c-section• Large for gestational age

Investigations Assess fetal well being• CTG• Ultra sound –polyhydramniose,fetal weightPre – op assessment• FBC• Clotting time and bleeding time

ManagemetDiabetic Diet• Break fast-2 slices of bread, one boiled egg

cup of tea/non -fat milk with small amount of sugar and a sour plantain

• Lunch/Dinner brown(unpolished ) rice, plenty

of vegetables,fish/meat and slice of papaw • 10am/4pm -2 bran crackers and a cup of tea

with low sugar

Pharmacological Management

• Soluble Insulin -20 units,18 units,18units• Betamethasone 12mg IM 1dose (2nd dose was

not given )

Surgical management• ELCS

Risk factors

• -Age more than 35years• -Previous child with birth weight >3.5 kg• -Previous unexplained still birth• -Recurrent abortions• -Recurrent vaginal candidas or urinary tract

infection• -Obesity and polycystic ovarian disease• -Previous baby with spina bifida or sacral agenesis

Diabetes in Pregnancy• Pregnancy is a diabetogenic state. Therefore in pre-

diabetic women diabetes mellitus can develop for the first time in pregnancy. This is known as gestational diabetes mellitus .

• In pregnancy around 24-28th weeks of POA secretion of human placental lactogen by the placenta , it increases the cortisol level

• These are the diabetogenic hormones which increases the blood sugar level.

Effects of diabetes to the fetus

• 1st trimester- Fetal abnormalities such as congenital heart

diseases & neural tube defects are common in uncontrolled diabetes.

Recurrent spontaneous abortions • 2nd trimester- Polyhydramnios Large for days babies(fetal macrosomia) Fetal growth restriction

• Neonate Hypoglycemia Respiratory distress syndrome Jaundice Electrolyte imbalances

• Effects on the mother Pregnancy induced hypertension Recurrent urinary tract infections Vulvo-vaginal candidiasis Puerperal endometritis Lactation failure

Thank you !!!