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7/18/2019 Case Presentation O&G

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CASE PRESENTATION 3

Low Xie Yee

Chandra Rubnee

Malvinder SinghCaroline

Aswini

Kalichandren



HISTORY TAKING

LOW XIE YEE

0!0!000"



• #ersonal $is%or&

• Chie' Co()lain

• $is%or& O' #resen% Illness

• $is%or& O' #resen% #regnanc&

• #as% Obs%e%rics $is%or&

• Mens%rual $is%or&

•*&necological $is%or&

• #as% Medical $is%or&

• #as% Surgical $is%or&

• +a(il& $is%or&

• ,ie% $is%or&• #ersonal $is%or&

• Social $is%or&

• ,rug $is%or&

O-.LI/E



• /AME WA/ RA+I,A$

• A*E 1"

• RACE MALAY

• RELI*IO/ ISLAM

• OCC-#A.IO/ $O-SEWI+E

•

*RA2I,I.Y 3• #ARI.Y 14

• LM# -/S-RE

• E,, !5 OC. !05 6,A.I/*

SCA/7• #OA 18w 5d

• ,OA 9 OC. !05

• ,OC ! OC. !05

#ERSO/AL

$IS.ORY



C$IE+ COM#LAI/

$er chie' co()lain was : Increase 're;uenc& o' urina%ion 'or ! (on%hs

!: Alwa&s 'eel hungr& and %hirs%& 'or a (on%h

1: +a%igue 'or a (on%h



$O#I

• 5 da&s ago have an%ena%al chec<u) on 18 w o'

ges%a%ion

• MO*.. abnor(al

• Re;uired ad(i%%ed 'or observa%ion

• Increase 're;uenc& o' urina%ion 'or )ass %wo(on%h

• -rine color is s%raw and no% concen%ra%ed

• Alwa&s 'eel %hirs%& and dr& (ou%h

• Alwa&s 'eel hungr&

• 'a%igue



•

According %o (ada( Wan Ra'idah= 5 da&s ago'ro( (& cler<ing da%e o' ! Oc%ober !05= she

wen% %o clinic 'or her A/C on 18 w o' ges%a%ion:

She %old %ha% she has been diagnosed as *,M

on 1! w o' ges%a%ion: She was as<ed %o run a%es% 'or her blood sugar level and also MO*..:

.he resul%s ob%ained were abnor(al=

sugges%ive o' *,M and no insulin is being

ad(inis%ered: .here'ore she was re;uired %o bead(i%%ed in $.AR 'or observa%ion )ur)oses un%il

%he end o' her )regnanc& as she was s%a&ing

'ar 'ro( $.AR: $er blood sugar level is

(oni%ored wi%h blood sugar )ro'ile:



• She clai( %ha% she had increase 're;uenc& o'

(ic%uri%ion 'or )ass %wo (on%h s%ar%ed since

1!w o' ges%a%ion: She wen% %o )ass urine (ore

%han 0 %i(e )er da&: $owever she doesn>%

have d&suria: She (en%ion %ha% her urine

colour a))ear %o be s%raw colour and no%

concen%ra%ed: She also denied -.I s&()%o(ssuch as 'ever= loin )ain and hae(a%uria: She

doesn>% had abdo(en )ain and u%erine

con%rac%ion:



• She clai( %ha% she was having e?cessive %hirs%

and dr& (ou%h: Ever&da& she need %o in%a<e a

lo% o' wa%er %o ease her %hirs%: She also increaseher ;uan%i%& o' 'oods due %o her hunger

es)eciall& during nigh% %i(e: She will %a<e ! slice

o' bread ever& nigh% be'ore slee)ing:

•She 'el% e?cessive 'a%igue un%il hardl& %o con%inueher dail& household wor< and need a long res%:

She denied %ha% she having shor%ness o' brea%h

and ches% )ain: She also %old %ha% she have no

s&()%o(s o' )ica such as craving 'or ice cube or'ingers nail and so on 'ound: She had no

vo(i%ing a'%er ! w o' her ges%a%ion: She can 'eel

her 'oe%us and %he 'oe%al <ic< was alwa&s (ore

%han 0 <ic< )er ! hours:



$IS.ORY O+ #RESE/. #RE*/A/CY

1ST TRIMESTER

@ -n)lanned@ Miss ! (on%h o' (ens%rual@ ,a%ing scan on 9w ges%a%ion@ ,e%ec%ion o' single e(br&o@ lood grou) O4

@ -rine rou%ine B /@ +CB /@ $b level B /@ Screening %es%B 2E 'or $sAg= 2,RL D $I2@ #B /

@ Weigh%"0<g@ $eigh% 30c(@ MI !":" <g(F@ MO*.. G +AS.I/* B 5:0((olL

/O/+AS.I/* B ":9 ((olL@ +olic acid given



2ND TRIMESTER

@ Ano(al& scan on 5w B /uchal %hic<ness is !:9c(@ .e%anus inHec%ion

s% on !0w !nd on !5w

@ +C B /

@ $b level B /@ MO*.. G +AS.I/*B 3:0((olL

/O/+AS.I/*B :0((olL@ # B /@ -%erine siJe

@ Weigh% "3<g@ uic<ening on !0 w



3RD TRIMESTER

+e%us grow%h scan+C B /

$b level B /MO*.. +AS.I/*B 7.0mmol/L /O/+AS.I/* B 9.8 mmol/L,iagnose *,M on 1!w+e%us (ove(en%

#B /-%erine siJeWeigh% 0:3<gCo()lains o' #ol&uria

#ol&di)sia #ol&)hagiaIron su))le(en% given



#AS. OS.E.RIC $IS.ORY→ *3 #14

G YEAR PREGNANCY LABOR PEPERIM BABY REMARK

!000 +-LL .ERM /ORMALS#O/.A/EO-S2A*I/AL,ELI2ERY6S2,7

REAS.+EE,I/* -#.O ! YEARS

+EMALE1:K* ALI2E

! !000 AOR.IO/ A.9W #OA CO/S-MEOC# +OR1MO/.$

,DE ,O/E due %o)eriod be%ween !)regnancies were%oo close:

1 !00! +-LL .ERM /ORMAL S2, REAS.+EE,I/* -#.O ! YEARS

MALE5:0 K* ALI2E

5 !008 +-LL .ERM /ORMAL S2, REAS.+EE,I/* -#.O ! YEARS

MALE1:33K* ALI2E

3 !05 #RESE/.#RE*/A/CY



ME/S.R-AL $IS.ORY

Menarche ! &ears old

,ura%ion o' 'low 0 da&s

C&cle leng%h !910 da&sC&cle Regular



*&necological his%or&

Consu(e OC# A'%er s% )regnanc& in!000 'or 1 (on%hs

Sugges%ive S.I /O

*&necological)roble(

/O

#A# s(ear $is%or& /o% done



#AS. ME,ICAL $IS.ORY

.$YROI, ,ISEASE /O

$Y#ER.E/SIO/ /O

,IAE.-S MELLI.-S /O

RE/AL ,ISEASE /O



#AS. S-R*ICAL $IS.ORY A##E/,ICI.IS /O

S#LEE/O/A.OMY /OC$OLECYS.EC.OMY /O

LA#AROSCO#IC S-R*ERY +OR

I/+ER.ILI.Y

/O



+AMILY $IS.ORY

+a%her Alive= "5

$is%or& o' h&)er%ension 'or 1 &ears

Mo%her ,ied in !0! a% age 3! due %o hear%'ailure$is%or& o' h&)er%ension and %&)e II,M

Siblings 3 siblings= all alive

$is%or& o' %&)e II ,M on one siblingand o%hers were heal%h& and nohis%or& o' (alignanc&

*rand(o%her $is%or& o' (ul%i)le )regnanc& 6%wins7



,IE. $IS.ORY

•/O/ 2E*E.A.IA/

• /O +OO, ALLER*Y

• -/,ER*O ,IE. CO/.ROL ,-E .O *,M

• CO/S-ME C-# O+ LOW +A. MILK #ER ,AY

• #ERSO/AL $IS.ORYSMOKI/* /O

ALCO$OL ,RI/KI/* /O

,R-* A-SE /O



SOCIAL $IS.ORY

Married 'or 3 &ears since 888

$usband wor<ed as lorr& drive

Mon%hl& inco(e around RM1000

S%a&ing wi%h 'a%her in law

,R-* $IS.ORY

,o no% consu(e an& drug be'ore )regnanc&/o an& drug allerg&



P!"#$%&l E'&m$(&)$o(

Chandra rubnee a)

Shan(uga(0!0!030339



*eneral E?a(ina%ion

•#a%ien% l&ing down in a su)ine )osi%ionco('or%abl& :

• #a%ien% is conscious and coo)era%ive:

• #a%ien% is aler% and is average buil% and well

nourished :• /o cannula or I2 dri):

• I, %ag is )resen%:



•

.e()era%ure 1": degree Celsius• #ulse ra%e 80 )er (inu%e :

• lood )ressure 1090 (($g

• #ressure is %a<en while )a%ien% is

in %il%ed )osi%ion : Wh&

Vital parameters



*eneral E?a(ina%ion

•/O ic%erus e&es= no )allor seen in conHunc%iva:

• Chloas(a is observed:

• Oral h&giene is good :

• /O angular s%o(a%i%is or glossi%is sugges%ing

absence o' ane(ia or vi%a(in ! de'icienc& :• /O %h&roid enlarge(en% or l&()hadeno)a%h&:

• /O 2# rise :

•

/O clubbing nails= ca)illar& 'illing %i(e N!sec=)al( was war(= )in<ish and (ois%:

• /O varicose veins :

• /O )i%%ing ede(a :



S&s%e(ic E?a(ina%ion

Cardiovascular

s&s%e( :



Cardiovascular e?a(ina%ionIns)ec%ion

• Ches% wall (ove s&((e%ricall& wi%h

res)ira%ion:

#al)a%ion

• A)e? bea% was loca%ed a% 3%h in%ercos%al

s)ace le'% (idclavicular line: /o heave and

%hrill: Auscul%a%ion

• S and S! heard and no (ur(urs



Res)ira%or& S&s%e(

Ins)ec%ion• Ches% wall (ove s&((e%ricall& wi%h

res)ira%ion and no% in res)ira%or& dis%ress

#al)a%ion

• .rachea was cen%rall& loca%ed:

• /or(al ches% e?)ansion and %ac%ile vocal

're(i%us:

• #ercussion

• Resonance



Con%inua%ion :::

Auscul%a%ion• Air en%r& is e;uall& bila%eral and nor(al

vesicular brea%h sound heard: .here were

no rhonchi heard:



Obs%e%ric E?a(ina%ion

•#a%ien% co()lain% o' no )ain a% %he 8 regionso' abdo(en:

• Abdo(en is dis%ended b& a gravid u%erus

su))or%ed b& %he )resence o' lines nigra

and s%riae gravidaru( and s%riae albicans• Abdo(en is so'% :

• /O scar )resen% :

• -(bilicus is cen%rall& loca%ed and 'la%%ened:



•+lan< is 'ull :

• S&()h&sis 'undal heigh% is 1"c(

• Clinical 'undal heigh% is a% 50wee<s o'

)eriod o' ges%a%ion



Local E?a(ina%ion

LEO#OL,>s MA/E-E2ER

• +undal gri) %here is a broad so'% irregular

(ass sugges%ive o' 'e%al breech

• Righ% la%eral gri) %here are s(all <nob li<e

s%ruc%ure sugges%ive o' 'e%al li(bs



• Le'% la%eral gri) %here is s(oo%h curved

resis%ance sugges%ive o' 'e%al bac<

• s% )elvic gri) .here is ballo%able s(oo%h

hard globular (ass sugges%ive o' 'e%al head

• !nd )elvic gri) Con'ir(s %he s% )elvic gri)



• .he head o' 'e%us is engaged:

• %his is single%on 'oe%us in longi%udinal lie wi%h

ce)halic )resen%a%ion = )lacen%a an%erioru))er seg(en% :

• Li;uor a(oun% is ade;ua%e

• Es%i(a%ed 'oe%al weigh% wi%h ohnsons

'or(ula 61"7? 33B193gra(s• +oe%al hear% ra%e is !9bea%s )er (inu%e

heard along %he s)inou(bilical line:



SMMARY

Mada( Wan Ra'idah is a% 18%h wee<

5da&s o' )eriod o' ges%a%ion wi%h 'undal

heigh% o' 50 wee<s=s&()h&sio 'undalheigh% o' 1"c( wi%h a single%on 'ea%us

wi%h a longi%udinal lie and ce)halic

)resen%a%ion= head is engaged:



PRO*ISIONAL DIAGNOSIS

MAL2I/,ER SI/*$ AL AC$I.ARA

SI/*$

0!0!0009!*RO-# C

OS.E.RICS D *Y/AECOLO*Y



#RO2ISIO/AL ,IA*/OSIS

Mada( Wan Ra'idah a 1" &ears oldMusli( housewi'e wi%h *3#14 a% 18

wee<s and 5 da&s o' )eriod o' ges%a%ion

wi%h single%on 'e%us in longi%udinal liewi%h ce)halic )resen%a%ion associa%ed

wi%h *es%a%ional ,iabe%es Melli%us and

no% in labour:



,I++ERE/.IAL ,IA*/OSIS

: *es%a%ional ,iabe%es Melli%us

Su))or%ing )oin%s #oin%s agains%

: /o de%ec%ed )resence o',iabe%es Melli%us6%&)e or!7 be'ore !0 wee<s o' )eriod

o' ges%a%ion!: +a(il& his%or& o' ,M1: ,e%ec%ions occurs in wee<

18 o' ges%a%ion5: Overweigh%

3: Age above 13 &ears old": #ol&uria: #ol&di)sia9: #ol&)hagia8: #revious big bab& P 5:0 <g



!: .&)e ,iabe%es Melli%usSu))or%ing )oin%s #oin%s agains%

: #ol&uria!: #ol&di)sia

1: )ol&)hagia

: /o% lean!: /o )as% his%or&

1: /o 'a(il& his%or&5: #a%ien%s age is 1&ears old

3: Weigh% no% decreasing



1: .&)e ! ,iabe%es Melli%usSu))or%ing )oin%s #oin%s agains%

: #ol&uria!: #ol&di)sia

1: #ol&)hagia5: Overweigh%3: +a(il& his%or&": Age

: /o )as% his%or& recorded!: Albu(inuria no% de%ec%ed

1: Regular (ens%rual c&cle #ol&c&s%ic ovar& s&ndro(echarac%eriJed b& irregular (ens%rual)eriods= e?cess hair grow%h and obesi%&

5: /o% s(o<ing



5: -rinar& .rac< In'ec%ionSu))or%ing )oin%s #oin%s agains%

: #ol&uria : /o 'ever or high grade'ever

!: /o )ain or a burning'eeling duringurina%ion:

1: /o blood in urine



5: $&)er%h&roidis(

E?cessive %h&roid hor(ones causes increased

glucose )roduc%ion in %he liver= ra)id absor)%ion o'

glucose %hrough %he in%es%ines and increased insulin

resis%ance:

Su))or%ing )oin%s #oin%s agains%

: Increase a))e%i%e : Enlarge(en% o' %h&roidis no% de%ec%ed:

!: /o weigh% loss:1: /or(al .S$ in blood%es%:



I(+,#)$-&)$o( &( #%,,($(- o-,#)&)$o(&l $&,),#

Caroline Sundralinga(

0! 0! 00 0

Ri < ' %



Ris< 'ac%ors

• Age over 2 ",&#

• MI 24-/m5• Increased weigh% gain during )regnanc&

• #revious h? o' large'orges%a%ionalage in'an%s

•

$? o' ges%a%ional diabe%es in )revious )regnanc&• Eleva%ed 'as%ingrando( blood glucose levels

during )regnanc&

• 6&m$l" !' o' diabe%es in 'irs%degree rela%ive6s7

• $? o' (e%abolic X s&ndro(e• $? o' %&)e or %&)e ! diabe%es

• #revious h? o' m&%o#om$&4-= s%illbir%h= I-,=

recurren% (iscarriage



Screening

•

ALL )a%ien%s visi%ing an%ena%al clinic 6Mala&sia7screened using rando( blood sugar)os% )randial

blood sugar

• Diagnostic of DM in pregnant and non pregnant

Bloo Gl:%o#, l,+,l Nom&l A(om&l

Rando( : ((olL Q:((olL

+as%ing :0 ((olL Q:0 ((olL



MO*..

: #revious ges%a%ional diabe%es

MO*.. done "9 wee<s o' ges%a%ion

I' nega%ive= re)ea% %es% !5 wee<s o' ges%a%ion

2. O)!, $#4 &%)o

MO*.. done !!!" wee<s

I' nega%ive= re)ea% %es% 15 wee<s o' ges%a%ion



MO*.. #rocedure3g oral glucose %olerance %es%

: 1 da&s )rior %o %es% consu(e (ini(u( 30gcarboh&dra%e

!: +as% !hr

1: Morning +as%ing blood glucose level

(easured= drawn 'ro( (a%ernal venous blood5: ,rin< glucose )re)ara%ion wi%hin 0(ins

3: .a<e !$## reading



Resul%s indica%ing abnor(ali%&

+as%ing ! $##

#las(a

venous

Q": ((olL Q:9 ((olL

Ca)illar&whole blood

Q3:"((olL Q:9 ((olL

6&#)$(- 2HPP

P:0 ((olL P:9((olL

W$O cri%eria

$.AR



,iagnosed *,M

1. Gl"%o#"l&), !,mo-lo$( HA1%@: Seru( blood sa()le %a<en

@: Re'lec% gl&ce(ic con%rol over )revious !

1(on%hs

@: /or(al range 5:":1 6non)regnan%7

5:33: 6earl& )regnanc&7

5:53:" 6la%e)regnanc&7



+e%al well being

• l)&#o:( A(nio%ic 'luid inde? 6oligo#ol&h&dra(nios7

Macroso(ic 'e%us 6abdo(en circu('erence7

Congeni%al ano(alies 69!0w7



6:)!, I'

1. $(, 6EME@: I' ni%ri%es )osi%ive= indica%ive o' -.I

@: +ur%her %es% T-rine cul%ure D sensi%ivi%&

2. T6T

@: Measure .S$= . D .₃ ₄



MANAGEMENT

– Aswini A# /alla Mu%%hu

Krishna *andi –0!01030!3



An%ena%al Manage(en%•

+irs% %ri(es%er

: Receive die%ar& ins%ruc%ion

and nu%ri%ion counseling:

!: Modera%e e?ercise )rogra(:

1: Moni%oring o' blood glucose

5: Screening 'or (icrovascular

co()lica%ions




Second %ri(es%er : Moni%oring o' blood glucose

!: Ano(al& scan a% 9!0 wee<s=

'e%al echocardiogra( a% !!!5

wee<s:

1: Serial grow%h scans 'or

A(nio%ic +luid Inde? and

abdo(inal circu('erence:

5: Surveillance 'or (a%ernal

co()lica%ions:




.hird %ri(es%er : Moni%oring o' blood glucose

!: Assess 'e%al weigh%

1: ,iscuss %i(ing and (ode o'deliver&

D$,)



D$,)

Ea% (eals on a regular schedule%hroughou% %he da&

Ea% s(aller a(oun%s o'carboh&dra%es a% each (eal

Add a nigh%%i(e snac< %o (eal)lan

E(,-" ,;:$,m,()



E(,-" ,;:$,m,()

Female 60 kg

Carbohydrate (65% !50Prote"# ($0% 0Fat (&5% $'0

Carbohydrate

$00 gmProte"# ($0% $5gmFat (&5% $gm

"et Carbohy) Prote"# Fat *Arab"a# bread 30 gm +++ +++Chee,e 5 gm $0 gm $0 gm-o#ey 50 gm & gm 3 gm.la,, o/ m"lk $0 gm 5 gm 5 gm*Total 5 gm $ gm $' gm

Carbohydrate (65% 50Prote"# ($0% 0Fat (&5% &&0

Carbohydrate

$30 gmProte"# ($0% &0gmFat (&5% &&gm

"et Carbohy) Prote"# Fat *R"1e '0 gm +++ 6 gm1h"1ke# 5 gm $5 gm $& gmSalad 30 gm ! gm ! gmOra#ge $0 gm +++ +++***Total $&5 gm $ gm && gm

Carbohydrate (65% 330Prote"# ($0% 50Fat (&5% $&0

Carbohydrate

65 gmProte"# ($0% $0gmFat (&5% $$gm

"et Carbohy) Prote"# Fat *T2#a ,a#d"1h !5 gm $& gm $0 gmA44le $5 gm +++ +++Tea +++ +++ +++ *Total 5 gm $ gm $' gm

60 g 30 k1al 7 $'00k1al "th 30% e8tra7 &$00

1al9reak/a,t 00

k1al:2#1h 00

k1al"##er 500

k1al

Sel'(oni%oring o' lood



Sel' (oni%oring o' lood*lucose

.ES.*L-COSE

LE2ELS 6M* #ER,L UMMOL #ER LV7

+as%ing N 8" 63:"7

Onehour

)os%)randialN 50 6:!7

.wohours)os%)randial

N !0 %o ! 6":7

I li I di %i



Insulin Indica%ions• lood glucose no% (ain%ained b& die%:

• Insulin dose is individualiJed andadHus%ed according %o %he )a%ien%sblood glucose levels:

Adverse e''ec%s

$&)ogl&ce(ia

Symptoms of



Symptoms ofHypoglycemia

• Very hungry• Very tired

• Shaky or trembling

• Sweating or clamminess

• Nervous

• Confused• Like you’re going to pass out or faint

• Blurred vision

I M



In%ra)ar%u( Manage(en%

• ,eliver& b& cesarean sec%ion usuall& is'avored when 'e%al dis%ress has been

iden%i'ied:

• ,eliver& )lanned a% 19 wee<s or 18wee<s ges%a%ion:

• *,M on die% can be delivered a% 50

wee<s:• Main%ain nor(ogl&ce(ia:

#os% #ar%u(



#os% #ar%u(

Manage(en%• Reassess blood glucose level:

• Counsel regarding die%= weigh% loss

and e?ercise:

• reas% 'eeding:

DISCSSION



DISCSSION

KALIC$A/,RE/ AL AR-M-*AM

0!01030!!



.Y#E

.&)e ! diabe%es6/on Insulin

,e)enden%

,iabe%es7:

.&)e diabe%es6Insulin ,e)enden%

,iabe%es Melli%us7



,E+I/I.IO/

Carboh&dra%e in%olerance resul%ing inh&)ergl&ce(ia o' variable severi%& wi%h onse%

or 'irs% recogni%ion during )regnanc&

SYM#.OM



SYM#.OM

•+eeling %hirs%& (ore o'%en %han usual

• -rina%e (ore o'%en

RISK +AC.OR



RISK +AC.OR

#A.$O#$YSIOLO*Y



#A.$O#$YSIOLO*Y

@ Earl& in )regnanc&= (a%ernal oes%rogen

and )roges%erone increase and )ro(o%e

)ancrea%ic cell h&)er)lasia andincreased insulin release

@ As )regnanc& )rogresses= increased

levels o' hu(an )lacen%al lac%ogen=cor%isol= )rolac%in= )roges%erone= and

es%rogen lead %o insulin resis%ance in

)eri)heral %issues:

COM#LICA.IO/



COM#LICA.IO/

#reecla()sia#re%er( labor

#ol&h&dra(nios $&)ergl&ce(ia

E++EC. O/ #RE*/A/. WOME/

COM#LICA.IO/



COM#LICA.IO/

COM#LICA.IO/



COM#LICA.IO/



COM#LICA.IO/

C l i



Conclusion

• Gestational diabetes is a common problem .

• Risk stratification and screening is essentialin almost all pregnant women

• Tight glycemic targets are required for

optimal maternal and fetal outcome• Patient education is essential to meet these

targets

•Long term follow up of the mother and baby is essential



RE+ERE/CE

,C ,u%%a .e?%boo< o' Obs%e%rics

case presentation o&g

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