CASE PRESENTATION

Dereje S.
Jan. 2010
Identification
 Name - WS
 Age - 27 yrs
 Address - A.A
 Card no - 046571
 Date of 1st. ANC – 6 /4 / 02
 Date of admission – 22/ 4/ 02
 History revised
 Gravida VI, para III( 2 SB), abortion II
 LNMP unknown but stated to be 9 month
amenorrhic
 Is referred with a diagnosis of Type I DM + 3rd.
TM pregnancy from SPH( medical side) after
treated for DKA.
 Is a known DM( Type 1) patient for the last 6
yrs.
 On NPH=(46/ 8) & RI=(16/ 12)
 Has no early milestones
 No use of contraceptive
 No headache, blurring of vision or
epigastric pain
 No personal or family history of HTN
 Pregnancy is wanted, planned and supported
 Past obst. Performance:
- 1st & 2nd pregnancy= spont. Abortions
- 3rd pregnancy= term home delivery & alive
- 4th pregnancy= 1 yr after Dx of type 1 DM
- ANC at HC
- IUFD
- 5th pregnancy= D/Markos, DKA
- IUFD
- current preg. ANC at HC; DM at Ras Desta
Yek.12 – (DKA )- SPH
 Diabetic clinic:
 Hx (revised)
 P/E: BP=120/85 mmHg; PR= 80
 Funduscopy- not done
 28/52, longitudnal/ cephalic
ASS’t= 3rd trm. Pregnancy
- type 1 DM
plan: CBC,U/A,OFT,BG & Rh, U/S
P/E (at 1st visit to GOPD,6/4/02)
 V/S
BP=140/90mmHg PR= 88 RR= T=
 HEENT
pink conj.
 Chest
clear
 CVS
S1 and S2 , no murmur or gallop
 Abd.
32 wk. Sized gravid uterus
cephalic resentation
FHB +ve
 MS
no edema
 CNS
Concious & oriented
 ASS
3rd. TM pregnancy + pregestational DM

 Plan
FBS, 2hr.postprandial
CBC, BG & RH
Organ function tests
Follow up
 On 14 /4 /02
GA by P/E – 36 wk.
FHb +ve
BP – 120/90
plan - BPP, HBsAg, VDRL
- sent to DM clinic → continue same dose
of insulin & appointed after 1 wk.
 20/ 4/ 02
GA by P/E term, FHb +ve, Bp - 130/80
HCT – 23%
FBS - 93 mg/dl
2hr. Post prandial – 120 mg/dl
Plan – fefol, BPP
appointed after 1 wk.
( BUN=17, Creatnin= 0.7, LFT= WNL)
 On 22/4/02
- passage of liqour & pushing down pain
- has decrease fetal movment of 12 hrs.
- no vaginal bleeding
- no headach or blurring of vision
P/E
BP - 150/90 PR- 28
RR - 28 T – 37.4
HEENT- pink conj.
Abd. Term sized gravid uterus
cephalic presentation
long. Lie
FHB –ve
cont. 1-2/ 10 /30
PV – cervix 3cm, 80% effaced
membren ruptured, clear liqour
cephalic presentation
ASS
Multigravid
3rd. TM pregnancy
Bad obstetric history
Latent stage of labor
IUFD
 L/W
- put on sliding scale
- 5 IU RI in 1 bag of N/S
- D/W to run at 33 dpm
- RBS determined
- progress of labor followed
- Ampicillin 2gm. IV QID
- Augmented
 Delivery summery
- Mode of delivery, SVD
- Delivery complicated by sholder dystocia,
Mcrobert maneuver & suprapubic pressure
- Out come, grade I macerated, male
neaonate, wt. 4000gm., no gross conjenital
anomaly, no cord around the neck, foul
smelling liqor
- Placenta removed by CCT,no retroplacental
clot
 Postpartum
- sliding scale contiued
- 3rd. Postpartum day , she was put on
prepregnancy dose of insulin
- 5th. Postpartum day, RBS-304 mg/dl,
restarted on sliding scale
- postpartal glycemic control is not optimal
RBG level ( 55 mg/dl- 446mg/dl)
- Insulin dose revised (NPH= 40/ 20IU)
- RBS level Q 6hr & RI 5 IU if ≥ 250 mg/dl
 7th. Postpartum day, puerperal sepsis
- Ceftriaxon 1gm. IV BID
- Metrenidazole 500mg IV TID
 Changed to po
 In the ward
Discussion & comments
 Known type 1 DM on insulin
 Bad obstetric Hx
 Poor glycemic control
 DKA in pregnancy
 Unknown LMP
 Hypertension
 IUFD
 Macrosomia
 Puerperal sepsis
 Poor glycemic control postpartum
 Idealy , women with pregestational DM have received
both
- Preconceptional councelling,&
- Mg’t of DM to optimize their health status
 Key elements in mg’t of preg. Complicated by DM are:
- Achieving & maintaining excellent glycemic control,
- Screening, monitoring,& intervention for maternal
medical cxns;
- Monitoring, intervention for fetal 7 obstetric cxns.
Preconceptional care
 Maternal evaluation:
- Complete Hx & P/E
- Hx of acute cxns( infn.,DKA, severe hypoglyc.)
- Chronic cxns(retinopathy, nephropathy,..
- Useful to involve a diabetic educator
 Glycemic control:
- Plays an important role
- One goal of preconception care= evaluate glycemic
control- recommend adjustments
 ** Councelling
 Should emphasize the importance of
- strict adherence to diet, exercise, medication
- Meticulous monitoring of glucose
- Need for frequent ANC visits
 Glycemic control:
- Plays an important role in reducing the
frequency of fetal & neonatal cxns
- Frequent measurement of b/d glucose during
pregnancy advised
- Improves neonatal outcomes
- Atleast 5-7 times per day
 Target blood glucose:
 ACOG: - fasting glucose ≤ 95 mg/dl
- preprandial ≤ 100 mg/dl
- 1 hr pp glucose ≤ 140 mg/dl
- 2 hr pp glucose ≤ 120 mg/dl
- Mean capilary glucose 100 mg/dl
-glycosylated A1C ≤ 6%
ADA: - preprandial glucose 80- 110 mg/dl
- 2hr pp glucose ≤ 155 mg/dl
Testing (preconceptional/ 1st ANC visit)
- Routin investigations
- Assesment & Rx of asymptomatic bact.
- Glycosylated Hb conc.
- Baseline RFT
- Thyroid function
- ECG
- Comprehensive eye exam
 2nd Trm.
- Evaluated Q 2 wks
- More frequently if cxns arise or suboptimal glycemic
control
- screening for cong. anomalies
= detailed u/s exam. of fetal anatomy
- done at 18 wks
- including four-chamber view of the heart
3rd trmester
- The diabetic gravida are seen frequently
- The major concerns of the 3rd trm:
- Continue close monitoring of b/d glucose level
- Fetal testing & monitoring to minimize risk of IUFD
- Monitoring for obst. & medical cxns → preterm delivery
- Evaluation for excesive or insufficient growth
 DKA in pregnancy
- B/c of changes in the hormonal env’t, preg. predisposes to
worsening glycemic control.
- Occurs in only about 1-3% of diabetic preg woman
- Presentation = similar
- Hyperglycemia is severe in nonpreg. Woman
- DKA can occur at much lower b/d glucose levels during preg
- DKA alone is not an indication for delivery
- Fetal testing may be abnormal during acute DKA
- This improve as the mother is treated & improves
 Hypertension/ preeclampsia
- Incidences are increased in preg woman with DM & are related to
- Pregestational HPN,or
- Vascular or renal d/s
- Incidence: without vascular d/s= 8%
with = 17%
nondiabetics = 5-8%
- Dx & Mg’t are similar to that without D
- Exception :- woman with preexisting nephropathy
- Dificult & requires relying on deterioration of other markers
OUR Pt= - despite this increased incidence,
- several high BP measurements
→ NOT adressed at all
 Shoulder dystocia
- Occurs in 0.2- 3% of all births
- Represents an obst. Emergency
- Macrosomia & maternal DM are major risk factors
- Incidence increases progressively as BWt incresases
over 4 Kg
- Maternal DM incresaes the likelihood 2-6fold
Mg’t:- d/t maneuvers
- no single maneuver is clearly more effective than
the other
 IUFD(perinatal mortality)
- The 2 major causes -unexplained fetal death,&
- cong. Malformation
- Causes of unexplained fetal loss are not well understood
- Possible explanations
- Sustained hyperglycemia→
- Polycythemia & increased PLT aggregation→Intravascular
thrombosis
- 40% of loses can be attributed to congenital malformation
Timing of Delivery:- with good glycemic control..
- with cxns…
- with previous fetal loss
OUR pt:-
 comments
 Preconceptional care = NOT optimal
- Unlikely to receive health education
- Adhernce to medication
- Poor glycemic control
 Referal :
 1st ANC visit
- Thorough Hx & P/E
- Appropriate work up
- Admission= -poorly controlled DM,
- 2 previous fetal loss
 - unknown LMP & raised BP
 Intrapartum
- Mg’t of shoulder dystocia = appreciated
- Least invasive method is used
 Postpartum
- Glycemic control is suboptimal
 Will this mother come for ANC next time ????
 Refferences

- UpToDate 17.2
- DANFORTH’S Obstetrics & Gynecology, 10th ed.
- Steven G Gabbe Obstetrics: normal & problem pregnancy,5th ed.
- WILLIAMS OBSTETRICS, 22nd ed.
THANK YOU