You are on page 1of 21

CASE STUDIES

Gestational Diabetes Mellitus

1
Case study #1: Mrs. C

Mrs. C is a 22 year old primigravida coming for her first


antenatal checkup at 12 weeks of gestation.

On examination, she is 152 cm tall and weighs 69 kg.


BMI, 30 kg/m2

She does not have a family history of diabetes.

Does she need to be screened for diabetes?


If so, when?
What screening test is to be used?

2
Mrs. C.

Mrs. C had a fasting blood glucose done

Her results are as follows.


Time 0 hr (Fasting)

Glucose 4.7 (86)


mmol/L(mg/dL)

Does she have diabetes?


Does she have GDM?
Does she need to be tested again?
If so, when?

3
Mrs. C

Mrs. C undergoes repeat testing at 26 weeks gestation.

Her results on the 75 gm glucose load (fasting) are as


follows.
Time 0 hr (Fasting) 1 hour 2 hour
Glucose 4.8 (88) 10.3 (186) 8.9 (161)
mmol/L(mg/dL)

Does she have GDM?


If yes, what treatment is indicated?
When will you review her and using what tests?

4
Mrs. C

After 2 weeks, her results were as follows


Fasting blood glucose mmol/L 5.2 (93)
(mg/dL
2 hour postprandial blood 8.6 (156)
glucose mmolL (mg/dL)
breakfast

Is her glycemic control adequate?


What is the next line of treatment?
What other test can help assess level of glycemic control?

5
Mrs. C

Mrs. C is put on 4 units of rapid acting insulin before


breakfast and advised to monitor her blood glucose daily.
She does well.

After 2 weeks, her reports are as follows.


Fasting blood glucose mmol/L (mg/dl) 6.5 (118)
2 hour postprandial blood glucose 7 (126)
mmol/L(mg/dl) breakfast

Is her glycemic control adequate?


What is the next line of treatment?

6
Mrs. C

Mrs. C is now on 6 units of NPH insulin at bedtime in


addition to 4 units of rapid acting insulin before breakfast.
She starts complaining of excess hunger during the early
hours of the morning.

Her reports are as follows.


mmol/L (mg/dL)
Fasting BG 3.3 (61)
2 hour postprandial BG 5.6 (102)

Are these values acceptable?


What is the next line of treatment?

7
Mrs. C
Her insulin dose has stabilized
NPH 8 units at bedtime
rapid acting insulin 6 u before breakfast, 4 units before lunch
and 4 units before evening meal.
Mrs. C goes into labour at 39 weeks.
Should she have been induced earlier?
Should a C-Section be considered?

How should her insulin be managed during labour


and delivery?

8
Mrs. C
Following delivery, blood glucose levels normalised and
she was able to stop insulin.

After 6 weeks, she underwent an OGTT, the results of


which are as follows.
Time 0 hour (Fasting) 2 hours
Glucose mmol/L 4.5 (82) 7.0 (127)
(mg/dl)

What is the diagnosis?


What is her risk of developing diabetes in the future?
When should she be tested next?

9
Case study #2: Mrs. S
Mrs. S is a 35 year old nulliparous lady and has suffered
two miscarriages in the last three years.

After the last miscarriage she was diagnosed with PCOS


and has been on metformin since.

She did not test her blood glucose levels during either of
her previous pregnancies.

Her mother has diabetes.

She presents at 12 weeks gestation

What else do you need to know?


10
Mrs. S
Does she need to be screened for diabetes?
If so, when?
What screening test is to be used?

Should the metformin be continued?


What is the purpose of metformin?

11
Mrs. S
Mrs S has an OGTT at 13 weeks gestation

Fasting 2 hour
Glucose 6.0 (108) 9.0 (162)
mmol/L(mg/dl)

Are these results ok?


Should she be retested? When?
What management strategies should be
considered?
12
Case Study #3: Mrs M

Mrs. M, 30/F Primigravida

LMP: 13/10/12 EDC : 28/07/13 Regular cycles

Spontaneous conception 10 months after marriage

No family history of DM

13
Mrs M
Fasting BG at 6 weeks
Fasting
8.8 mmol/L (160 mg/dL)

What would you advise now?

Trial of MNT or medications right away?

Any other tests?

What risks to the pregnancy will you discuss with this lady?

14
Mrs M
Normal scan at 12 weeks with a low risk of Downs
19- 20 week scan plus fetal echo was normal
When will you advise next scan?

Glucose results as in next slide. Patient not very


regular with SMBG and not following the meal
plan

15
MRS M Blood glucose record
Gestational FBS mmol/L 1 h PPBS A1c Medication
age (mg/dL) mmol/L(mg/dL) %
15 5.9 (107) 6.9 (125) 8.1 Premix 70/30
18 - 0 - 18 +
Metformin
500 BD
18 7.1 (129) 10.1 (183) 7.2 22 - 0 - 22 +
Metformin BD
19 5.3 (97) 9.6 (173) 26 - 0 - 20 +
Metformin BD
5.8 (105) 8.7 (157) 6.5

16
Mrs M
29 week scan

Ask to comment

17
Mrs M

She comes in with c/o discomfort and


abdominal pain at 30 weeks
How will you manage her now?

Uterus is irritable with some tightening on and


off

18
Mrs M
Tocolytic which drug and dose
Steroids dose / concerns in GDM

19
Mrs M
Uterine contractions settle. UTI picked up and treated with
appropriate antibiotics
She is now 37 weeks
FBS 5.5mmol/L (100mg/dL) 1 hr PPBS 8.3 mmol/L (150
mg.dL) on
Regular (soluble) 26-10-14 + NPH 0-0-12
Comes in with decreased movements
What would your approach be?

20
Case Study #4
Mrs. C, a 32 year old primigravida
Reports for the first antenatal checkup.

She is obese with a body mass index of 35 kg/m2, both her parents
have diabetes.

Her OGTT results are as follows.


Time 0 hr (Fasting) 1 hour 2 hour
Glucose 10.6 (192) 16.0 (288) 14.6 (263)
mmol/L(mg/dL)

Her HbA1c is 9.2%.

What type of diabetes does this patient have?


What is the ideal line of treatment?
What is the prognosis for the pregnancy and for future resolution of
diabetes?
21