Introduction
Mrs H is a 41 years old
housewife, G3P2 at 38 weeks of gestation admitted for diabetes
complicating pregnancy.
Menstrual History
She attained menarche 15 years old. Her cycle is irregular every 1-2
months lasted for not more than 4 days flow. The amount was about 2-3 pads
fully-soaked.
She does not experience dysmenorrhea, menorrhagia, intermenstrual
bleeding, dyspareunia or post coital bleeding.
Her first day of menstrual period is 12 or 10/03/2017 (she could not
remember).
Her revised expected delivery date (REDD) is 11/12/2017.
History of Present Pregnancy/Antenatal
History
This is unplanned pregnancy but welcomed.
She confirmed her pregnancy by doing urine pregnancy test (UPT) at
private clinic (Jalan Setapak Family Clinic) after 2 weeks of first day of
menstrual period.
She did booking at 24th weeks at KK Gombak Setia with green
coded book. The initial baseline was as below:
Weight : 78 kg
Height : 153 cm
BMI : 33.3 kg/m2
Blood pressure : Normal (Not sure of exact value)
Blood test was done and the result was as below:
Hb : Normal (Not sure
exact value)
Blood group : A
Rh : +
Infective screening :
Non reactive (HIV, VDRL and Hepatitis B)
ATT was given twice. She received one dose when she is in Iran (could
not remember when). Another one was given in Malaysia (KK Gombak Setia) because
all the antenatal document was left in Iran.
There was no problems in first trimester such as bleeding or anemia.
Quickening felt at 20th weeks.
Modified Glucose Tolerance Test (MGTT) was not done because she is
already diabetic.
She compliance to antenatal check up. Scan was done and the pregnancy
was viable and in good condition.
There was no problem in second trimester such as anemia, pre-eclampsia
or placenta previa.
There was no problem in third trimester such as breech presentation,
hypertension or transverse lie.
On 15/09/2017, she received referral letter for further management by
MO at KK Gombak Setia due to uncontrolled diabetes mellitus and defaulted check
up during antenatal check up.
On 16/09/2017, she warded in ward 2A Bed 5 due to macrosomic fetus.
There were no signs of labour like painful uterine contractions, leaking liquor
or show. Fetal movement was good and the CTG was reactive. A transabdominal
ultrasound was done at the PAC and the estimated fetal weight was 4.2 kg.
Past Obstetric History
Between 2012 to 2016, she has 2 pregnancies. There is no miscarriages.
Both of them are boys.
All of them were delivered in Hospital Kuala Lumpur (HKL) and delivered
by spontaneous vaginal delivery (SVD).
Both of them were breast fed up to 2 years and had completed
immunization. Both children are still alive and healthy. She does not practice
any contraception.
|
No
|
Year
|
Place
|
Mode of delivery
|
Sex
|
Weight
|
Breast fed
|
Comment
|
|
1
|
2012
|
HKL
|
SVD
|
Male
|
1.8 kg
|
2 years
|
-
|
|
2
|
2013
|
HKL
|
SVD
|
Male
|
1.4 kg
|
2 years
|
Warded 100 days due to lung infection
|
Past Gynaecology History
She has done pap smear once in Iran in 2015 and the result was normal.
Never undergo operation before such as myomectomy or D&C.
No previous gynaecology history such as fibroid, cyst, pelvic
inflammatory disease or endometrioma.
Past Medical History
She has never been warded before due to any medical illness.
She has diabetes mellitus. It was diagnosed accidentally during health
checkup in mall in 2010. She has symptoms of numbness at peripheral. She does
not take any medication and defaulted treatment and currently on diet control.
Otherwise, she does not have hypertension, renal disease,
cardiovascular disease, thyroid disease, epilepsy and asthma.
Past Surgical History
She does not have any surgery or operation before.
Drugs History
She is not on any medications before. She was only on obimin as prescribed
by the doctor during pregnancy.
Otherwise, no over the counter and herbal medication.
Allergic History
No allergic history.
Not having allergy to food or medication.
Family History
Her father died at age of more than 60 years old due to heart attack.
He had diabetes mellitus.
Her mother is still alive currently 68 years old. She has diabetes mellitus,
hypertension and heart problem.
The patient has 8 siblings. She is the 7th out of 8.
Her eldest brother passed away due to heart problem and pleural
effusion.
There are 3 girls in this family. All of them does not have gynaecology
problems such as fibroid or ovarian cysts.
There were no multiple pregnancies, fetal abnormalities or malignancy.
Otherwise, all siblings are healthy.
Social History
Patient currently work as housewife. Her husband’s job is businessman.
Total family income is about RM10k a month.
Patient is an ex-smoker. She started at age 18 years old. She smoked
about 1-2 sticks per day. She stopped in 2012 after knowing she was pregnant.
Patient also is an ex-alcoholic drinker. She drunk occasionally. She
started at age of 18 years old. She stopped in 2012 due to same reason.
She live at PPR Setapak with her family. It is flat house with good
accommodation utility such as water, electricity and sanitation.
She controls her diet by avoiding excessive food intake and
high-cholesterol diet to reduce her body weight as advised by the doctor.
Summary
Mrs H, 41 years old admitted 2 days ago G3P2
(38 weeks) due to diabetes complicating pregnancy for further management.
General Examination
Patient is lying down comfortably with 1 pillow. She is not in distress
and well hydrated. She is friendly and cooperative.
Her vitals signs are as follows:
Blood Pressure –
110/70 mmHg
Pulse Rate – 72 beats
per minute
Respiratory Rate – 18
breaths per minute
Temperature – 37 ˚C
Hand : No clubbing, CRT<2 sec, warm and no palmar erythema
Eyes : No anemia and no jaundice
Mouth : Good oral hygiene, good hydration
status, no angular stomatitis
and central cyanosis.
Thyroid : Not swell and no
jaundice.
Breast : No nodules or
discharge(Patient refused)
Legs : No edema and
varicose vein.
Systemic review
- CVS : S1
S2 heart sound heard. No murmur.
- RESPI : air entry is
good, vesicular breath sound and no added sound.
Abdominal Examination
Inspection
Abdomen is distended with gravid uterus with evidence of lineanigra.
There was no striaegravidarum and no dilated vein.
Umbilicus is flat.
There is no surgical scar, no hernia orifices and skin lesion such as
scratches mark.
Palpation
Abdomen is soft and non-tender.
SFH = 33 cm , FH = 34 weeks
There is singleton fetus lying on longitudinal lie, in cephalic
presentation.
Estimate fetal weight is 2.5 – 3.0 kg.
Liquor is adequate.
The heart rate most likely is at the right iliac fossa.
Auscultation
The fetal heart sound heard.
Diagnosis
Provisional diagnosis
Diabetes complicating pregnancy
Differential Diagnosis
Gestational Diabetes Mellitus
Investigation
Investigations upon admission to HKL @
16/09/2017
1. Transabdominal
ultrasound scan on 16/09/2017
Estimated
birth weight – 4.0 – 4.2 kg
Amniotic
fluid index was 18
2. Blood sugar profile
3. Cardiotocograph
Reactive
(Fetal not in distress)
4. Full blood count
Management
1. Nil by mouth
2. Continue treatment for
GDM before the day before the procedure
3. Blood sugar profile
checked hourly
4. Plan for Caesarean section
Progress During Hospitalization
Day 1 post operation
The operation was uneventful. Baby born with birth weight of 4.88kg was
delivered at 1640H with Apgar score 9 in 1 min and 10 in 10 mins. Estimated
blood loss was 500ml. Liquor was clear.
After the operation, she has been keeping well.
BP – 108/70 mmHg
Pulse rate – 70 beats per minute, regular
She was pale but alert, complaining of nausea, no vomiting, no
shortness of breath or palpitation. She was strict on pad chart. Since the operation,
she has been using 3 pads full-soaked.
On abdomen examination, the uterus was not well-contracted at 22-week
size of a gravid uterus
She given IV oxytocin 40 units over 6 hours.
Day 3 post operation
Uterus was soft, non-tender, well-contracted at 20 weeks size of a
gravid uterus, no active bleeding at the site of operation. No longer has per
vaginal bleeding.
She was due for discharge and was told to repeat modified glucose
tolerance test 6 weeks later.
Discussion
This lady is a known case of diabetes mellitus should have been given
preconceptional counselling to achieve tight control of diabetes before the
onset of pregnancy. Since the patient defaulted treatment and follow up, her
blood sugar level was uncontrolled. If she compliance to diabetes follow up,
her HbA1c level should be measured to plan pregnancy, taught about self-glucose
monitoring and appropriate advice about diet and insulin is given. Aim for
HbA1C levels of 6.1 % or less.
During antenatal care, she should be advised about proper diet for
stabilization of blood glucose. If values are exceeded even on diet, insulin
therapy is suggested. Frequent blood sugar estimation is required as the urine
examination of sugar is not informative. Assessment of fetal well-being by
sonography is to be made from 28 weeks onwards to check for suspicion of
macrosomia.
When diabetes is first detected during pregnancy and cannot be
controlled by diet alone, it should be treated with insulin. A postprandial (2
hours) plasma glucose level of more than 140 mg% even on diet control is an
indication of insulin therapy. The aim is to maintain the blood sugar levels as
near to normal as possible without causing troublesome hypoglycaemia. Since the
patient defaulted treatment, her DM cannot be control.
Diabetic women controlled on insulin are considered for induction of
labor after 38 completed weeks. But in this patient, her DM is not control , so
Caesarean section is best choice of mode of delivery. During 38 weeks, the
doctor detected macrosomia by ultrasound in latest antenatal check up. So, she
was referred by MO to HKL for Caesarean section. Her estimated baby weight is 4
– 4.5kg (macrosomia) and it is indicated for Caesarean section.
During puerperium, antibiotics should be given prophylactically to
minimize infection. Insulin requirement falls dramatically following delivery.
She is to revert to the insulin regime. Breastfeeding is encouraged.
References
1. DC Dutta’s Textbook of
Obstetrics 8th edition
2. Clinical Protocols in
Obstetrics and Gynaecology for Malaysian Hospitals.
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