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