Upload
kyo-jie-ming
View
120
Download
0
Tags:
Embed Size (px)
Citation preview
Integrated Medical SeminarMATERNAL DISORDERS IN PREGNANCY
Gestational Diabetes Mellitus
Definition• Gestational diabetes mellitus is defined as
glucose intolerance of variable degree with onset or first recognition during pregnancy.
Reference: T Karagiannis, E Bekiari et al; Gestational diabetes mellitus: why screen and how to diagnose. Hippokratia. 2010 Jul-Sep; 14(3): 151–154.Available from: URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2943351/
Epidemiology • A study by N Idris, CH Che Hatikah et al in 2009
recorded a prevalence of 18.3% for gestational diabetes mellitus in Malaysian population.
• Higher compared to Western population (3.3%-6.1%) and other Asian countries:• Filipino (8.6%)• India (16%)
Reference: Idris N, Che Hatikah CH, Murizah MZ, Rushdan MN. Universal versus selective screening for detection of gestational diabetes mellitus in a Malaysian population. Malaysian Family Physician. 2009;4(2&3):83-87. Available from: URL: http://www.e-mfp.org/2009v4n2_3/gestational_diabetes_mellitus.html
Ethnicity vs percentage of mothers with GDM (%)
Malay Chinese Indian Other0
10
20
30
40
50
60
70
80
90
100
85.1
10.43 1.5
Age (years) vs percentage of mothers with GDM(%)
Less than 25 25-34 35 and above0
10
20
30
40
50
60
70
80
90
100
3
46.350.7
Parity vs Percentage of mothers with GDM (%)
Nulliparous Parity 1-4 Parity 5 and above0
10
20
30
40
50
60
70
80
90
100
19.4
76.1
4.5
Pathophysiology of GDM
Pregnant women develop marked insulin resistance particularly during second half of pregnancy
Insufficient insulin secretion by pancreas to compensate for insulin resistance
Increased plasma glucose in blood
Reference: RC Nicki, RW Brian, HR Stuart. Davidson’s Principles and Practice of Medicine. 21st Ed. Churchill Livingstone; 2010. Ch 23; p 815-16
30-65% of women develop T2DM from GDM within 10 years
Gestational Diabetes Mellitus
Type 2 Diabetes Mellitus
Reference: Meztger BE, Buchanan TA, Coustan DR, et al. Summary and recommendations of the Fifth International Workshop- Conference on Gestational Diabetes Mellitus. Diabetes Care. 2007;30(Suppl 2):S251-60
Screening for GDMPregnant women should be screened if they have any of the following risk factors:
BMI >27kg/m2 (Obesity)
Bad obstetric history (Unexplained stillbirth,
prior infant with congenital
malformation)
Previous gestational diabetes mellitus (GDM)
Age above 25 years old
Current obstetric problems (essential
hypertension, pregnancy induced hypertension, polyhydramnios and
current use of steroids)
Glycosuria at the first prenatal visit (>2++)
First-degree relative with diabetes
Reference: Clinical Practice Guidelines Management of Type 2 Diabetes Mellitus (4th Edition)
Effects on motherDM in pregnancy Normal pregnancy
High Likelihood of preeclampsia-
eclampsia
Low
More common Infections Less commonDifficult Delivery Normal
Complications:
Effects on babyDM in pregnancy Normal pregnancy
Macrosomia (>4.0kg) Size of baby Normal (< 3.0kg)Cardiac and neural tube
defectCongenital
abnormalitiesNone
Hypoglycemia Blood glucose Normal
References:1) TM Goodwin, MN Montoro, L Muderspach et al; Management of common problems in obstetrics and gynaecology. 5th Ed. Wiley-Blackwell; 2010.2) Gupta, Sadhana. A comprehensive textbook of obstetrics and gynecology. Jaypee Brothers Medical Pub; 2011.
Index Patient
• INITIALS: Madam J• AGE: 37 years old• RACE: Malay• GENDER: Female• MARITAL STATUS: Married (For 18 years)• OCCUPATION: Housewife (Ex-factory worker)
• LAST MENSTRUAL PERIOD: 3-9-2011• GRAVIDA:8• PARA: 3+4 (abortion)• EDD: 21-5-2012 (Naegele’s rule)• GESTATION PERIOD: 35 weeks• DATE OF ADMISSION: 6-5-2012
CHIEF COMPLAINT
• Elective admitted to HTJ for observation in view of 3 previous LSCS on 6-5-2012
• Planned for elective LSCS and bilateral tubal ligation on 21-5-2012
History of Presenting Complaint
1) At 9 weeks period of gestation during her booking(8/11/11), her modified glucose tolerance test was 12.2/12.5 mmol/L(high)
• Her HbA1C on 21-11-11 was 11.2% and on 23-4-12 was 8.4%
• Blood sugar profile(3-5-2012): 5.1/5.3/5.6/5.4mmol/L
• She was given S/C Actrapid (10/16/18 units tds) and Insulatard (20 units ON)
2) 3 histories of LSCS• 2005-transverse lie• 2007- late onset of pregnant induced
hypertension• 2010- 2 previous LSCS
3) History of Goitre since 1st pregnancy• Not on treatment• TFT(9/11/11): T4-15.5 pmol/L
TSH-0.24 mU/L
4) On admission, there were no signs of labour like painful uterine contractions, leaking liquor, or ‘show’. Fetal movement was good and the Cardiotocography was reactive.
Menstrual History
• She attained menarche at the age of 10 years old with regular cycle of 28-30 days interval lasting for 5-7 days of bleeding.
• The amount was about 3-4 pads fully-soaked.
• No clots.• No dysmenorrhea.
PAST OBSTETRICS HISTORYYear
of birth
Type and place of delivery
Gestational
weeks
Type of Delivery
Gender Weight(KG)
Complications
Mother Baby
Baby’s condition currently
2005 Hospital Kajang
38 LSCS Girl 2.5 HyperThyroidism
Transverse lie
Healthy
2007 HTJ 36 LSCS Girl 2.1 GDM, PIH None Healthy
2010 HTJ 36 LSCS Boy 3.1 Amniotic fluid
leakage, GDM
None Healthy
• She has 4 previous abortion (deliveries prior to 22 weeks):
1. 1994- 12weeks2. 1995- 8 weeks3. 2004- 8weeks4. 2009- 8weeks
• Dilation and curettage not done for each abortion
• According to her, all her miscarriage was due to vigorous sports as she is a state netball player.
PAST GYNAE HISTORY
• Pap smear and mammogram done one month after the third delivery in 2010 at HTJ.(No abnormal findings)
PAST MEDICAL & SURGICAL HISTORY
• Denied to be T2DM even though HbA1C on (21/11/11) was 11.2% thus she is not on any medication
• In first pregnancy(2004) she was diagnosed with goitre secondary to hyperthyroidism.
Took medication during first pregnancy only. Swelling became progressive bigger during
current pregnancy.No signs of hyperthyroidism. Advised to follow up at SOPD.
DRUG HISTORY
• 6/5/2012-S/C Actrapid (10/16/18 units tds) and Insulatard (20 units ON)
• 9/5/2012-T. Propylthiouracil 300mg stat T. Propylthiouracil 100mg(2/7) T. Propylthiouracil 50mg
TDS(cont)
FAMILY HISTORY
• Dad- deceased at 76 due to stroke. He had DM & HPT.
• Mom- 65, DM, HPT, breast Ca.• No siblings.
SOCIAL HISTORY
• Non smoker non alcoholic.• Husband work as editor in RTM. income is
around RM700 to 800 a month• Husband smokes 5 cigarettes per day
outside the house.• She does not control her and continue to
take high-cholesterol diet like nasi lemak and etc
PHYSICAL EXAMINATION
• Height-159cm• BMI-34• Miss J was lying flat in supine position, supported with
one pillow. She was conscious, alert, cooperative, and responsive to time, place and person.
• There was no puffiness in her face. • Goiter seen on neck-size 10x4cm, no bruit, non tender,
soft• Her palm was warm, no pallor, no excessive sweating, no
clubbing, no fungal infection between the fingers. • No pedal edema. No fungal infection in the toes
Vital Signs
• BP-126/80 mmHg• Pulse Rate-80 beats per min• Temperature-37°C• Respiratory Rate- 18 breaths / min
Abdominal Examination
• Inspection: On examination, the abdomen was distended by gravid uterus. There was striae gravidarum and linea nigra seen. The umbilicus was centrally located and inverted. There was a transverse surgical scar of around 10cm on the suprapubic region on the abdomen. There were superficial dilated veins. Fetal movement was seen.
• Light palpation : The abdomen was soft and non-tender. There was singleton mass. Liver, spleen and kidney were not palpable.
• Leopold Maneuver: Symphysio-fundal height was 36 weeks size. The fetus was in longitudinal lie, not engaged. The fetal back lies on maternal right side .Cephalic presentation which is 5/5th palpable.
• Auscultation: Fetal heart rate 142 beats per minute
• Estimated Fetal Weight: 2.0-2.2kg
Laboratory InvestigationsQ 7/5/2012 20/5/12 NORMAL VALUESWBC 8.1 x 10^9 /L 9.0 x 10^9 /L 4.0 – 10.0 X 10 RBC 3.85 x 10^12/L 3.89 x 10^12/L 3.8 – 4.8 X 10Hb 111 g/L 111 g/L 120 – 150 g/LHematocrit 0.335 L/L 0.339 L/L 0.36 – 0.46 L/LMCV 86.9 fl 87 fl 83 – 101 flMCH 28.8 pg 28.5pg 27 – 32 pgMCHC 331 g/L 327 g/L 315 – 345 g/LPlatelets 274 x 10^9 /L 271 x10^9 /L 150 – 400 x 10Neutrophils 5.18 6.30 2 – 7Lymphocytes 2.15 2.12 1.0 – 3.0Monocytes 0.67 0.50 0.2 – 1.0Eosinophils 0.06 0.10 0.02 – 0.5Basophils 0.02 0.02 0.02 – 0.1
Renal Profile
9/5/2012 20/5/2012 NORMAL VALUES
Urea 3.2 3.4 2.8 – 7.2 mmol/l
Sodium 137 131 136 - 145 mmol/l
Potassium 4.3 4.2 3.5 - 5.1 mmol/l
Chloride 103 100 98 – 107 mmol/l
Creatinine 59 30 58 – 96 umol/l
Thyroid Function Test
7/5/2012 9/5/2012 Normal Values
Free T4 17.7 15.5 11.5 – 22.7 pmol/l
TSH 0.011 0.24 0.35-5.50mU/l
Free T3 4.9 3.5 – 6.5 pmol/l