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MRCOG PART 2 SBAs and EMQs

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Essay 307 - IDDM

Posted by geetha M.
Diabetes is a disease with multiorgan involvement. Careful assessment is necessary in pregnancy to minimise the complications.
The assessment involves history, investigations and examination and better done in a combined diabetic and antenatal clinic with the involvement of the diabetologist. History of any previous pregnancies, complications and mode of delivery is important as it can influence the present pregnancy. Symptoms related to the retinopathy, nephropathy,neuropathy, vascular and cardiac disease need to be elicited as these are the complications of longstanding diabetes. Blood sugar control needs to be assessed as uncontrolled diabetes can cause fetal congenital anomalies. history of medications like angiotensin converting enzyme inhibitors as there is a need to stop the medications which are not safe in pregnancy.
on examination the height, weight and blood pressure to be checked as with high BMI the pregnancy complications increase and difficulty achieving the target sugar levels. High blood pressure can be due to nephropathy and needs further investigations. Fundoscopy to be done to assess retinopathy. Detailed neurological examination to rule out neuropathy. Peripheries to be checked for vasculopathy. Auscultation of chest, electrocardiogram to check cardiac disease.
Investigatigations involve full blood count, HbA1c, infection screen, urine for microscopy, culture and sensitivity, protinuria, 24hr protein collection if proteinuria present, Protein creatinine ratio, serum creatinine to assess renal function. To know the fetal wellbeing, nuchal thickness as more prone for congenital anomalies, dating scan to know the exact gestation.
Regarding the monitoring of blood glucose concentration, the need for the target glucose levels to be informed as poor control is associated with congenital anomalies and risk of miscarriage and macrosomic baby.Blood glucose needs to be monitored 4 times a day and the premeal values to range between 3.5 - 5.9 mmol/L , post meal level less than 7.9mmol/L. Ketone strips to be given for self monitoring. The insulin requirement will be more as pregnancy progresses. Insulin dose can be adjusted according the blood sugar levels. Information regarding the hypoglycemia and hypoglycemia unawareness to be given. should be advised to carry sugar candies to prevent hypoglycemic attacks. Monthly check-up of HbA1c and it should be below 6.1. Information leaflet to be given, contact numbers of the diabetic nurse and hospital to be given.
Regarding the timing and mode of delivery - if pregancy progresses without any complications and blood glucose levels are well within control , IOL can be advised at 38-39 weeks. Vaginal delivery is advised if no other indication for caesarean section. Shoulder dystocia is more common. So experienced obstetrician need to be present at the time of birth especially if instumental delivery is anticipated. if fetal macrosomia is suspected and the estimated fetal weight is more than 4.5kg caesarean section should be advised. Post operative antibiotics and thromboprophylaxis if caeserean section is carried out.
If associated complications are present like preeclampsia, IUGR or polyhydromnios causing maternal discomfort IOL can be planned earlier once fetal maturity is obtained. Continuous fetal monitoring is needed during labour.
Posted by shipra K.
a)Patient with 15 years of diabetes mellitus on insulin needs to be assessed in detail because of increased chances of multiple organ involvement and pregnancy complications.The woman should be jointly assessed by a diabetic physician and obstetrician. The patient should be asked about the dose and type insulin she is on.Her last blood sugars values .The patient has completed her first trimester,her previous records need to reviewed regarding her periconception Hb A1c levels if done,any changes in type or dose of insulin in first trimester,any ultrasound done for dating pregnancy and for nuchal transluscency.First trimester down syndrome screening done.Her renal function test ie urea & electrolytes ,24 hr urinary protein.If her retinal assessment has been done.A detailed obstetrical history needs to be taken for any previous miscarriages,malformed fetuses,any stillbirths.If previous live births then whether normal delivery or caesarian section. Indication for ceasarian need to be noted .Birth weight of her previous children,any antenatal,intrapartum complication( like shoulder dystocia) should be asked for.patient should be asked for accompanying renal disease,hypertension,cardiovascular disease,nueropathy or ophthalmic problems and any medication/treatment(like ace inhibitors) is she taking for these problems.
A detailed examination done noting especially her BP and BMI. Cardiovascular status needs to be checked.Complete neurological examination done to look any neuropathy .retinoscopy done.
Investigations advised would be an FBC,Urea &Electrolytes,24 hr urinary protein,blood sugar fasting and 1hr preprandial and postprandial.Urine routine microscopy and for sugar and ketone bodies.
B)
.Patient would be detailed about the need for blood glucose regulation as hyper and hypo glycemia both are associated with maternal and fetal complications. In the fetus hyperglycaemia would lead to increased chances of macrosomia and its intended problems like caesarian,shoulder dystocia.there are increased rates of stillbirths due to hyperglycaemia In the mother it could lead to diabetic ketoacidosis,worsening of diabetic nephropathy,ischaemic heart disease. .Hypoglcaemia would again be dangerous and she could have ketoacidosis again high fetal mortalities.
Strict self blood glucose monitoring would be advised. It is advisable to keep fasting blood sugar in the range of 3.8-5.9mmol/l and postprandial below 7.8mmol/l.
If her blood sugar is uncontrolled it would be advisable that she gets admitted for adjusting her insulin requirements.
Once controlled she would need to do regular self monitoring of blood sugar which would include fasting 1 hour preprandial,2 hour postprandial,and at bedtime.
It is important that patient and her partner be told signs of hypoglycaemia like excessive sweating,palpitations,fainting.and that she should keep something sweet with her to have.The use of glucagon should be explained .
ketone strips provided to the patient.
Information leaflets should be provided
C)Factors which would influence timing and mode of delivery would be determined from her past obstetric history and her present pregnancy condition.
In case uncomplicated pregnancy IOL done at 38-39 weeks.
If in present pregnancy baby having macrosomia which could be seen by abdominal circumference above 90 percentile then patient should be induced around 38 weeks and if estimated baby weight more than 4.5kg caesarian section done.






Posted by SANCHU R.
sanchu
A 25 year old woman with a 15 year history of insulin-dependent diabetes mellitus is referred to the antenatal clinic at 12 weeks gestation. (a) Describe the assessment that you would undertake during this visit [10 marks].
She is assessed in the joint antenatal clinic by the multidisciplinary team consisting of the obstetrician, Diabetologist, specialist nurse and anaesthetist.
Her obstetric history is obtained. Any history of miscarriages or stillirths would point towards a poor blood sugar control. The birth weight of previous babies is noted. IUGR or macrosomia may be present. Her control of diabetes is enquired and her monitoring of blood sugars is checked. It should be noted whether she is on 5 mg folic acid. If she has not had her 1st trimester scan, it is arranged as early as possible.
She is enquired about her assessment of nephropathy and retinopathy and the notes are checked.
She is counselled about the fetal risks of miscarriage, congenital anamolies, hydramnios and macrosomia with poor blood sugar control and the risk of stillbirth near term . She is counselled about the maternal risks of pre-eclampsia, worsening of Retinopathy and nephropathy affecting pregnancy outcome. She is also made aware of the neonatal effects namely hypoglycemia, hyperbilirubinemia, hypercalcemia and hypermagnesemia.
Her HbA1c is checked. Her renal functions are checked -U&Es, 24 hour urine protein or Urine Protein-Creatinine ratio. She is referred to the Ophthalmologist for assessment of Retinopathy.

(b) Describe the advice that you would give her regarding the monitoring of blood glucose concentrations [6 marks].
She is advised to check her blood sugars 4 times everyday, fasting and 1hour after each meal. She should be advised to maintain fasting Blood sugar level at 3.5-5.9 mmol/l and 1 hour postprandial levels less than 7.8mmol/l. usually intermediate acting insulin is prescribed once a day and rapid acting Insulin at other times. She is also counselled about hypoglycemia unawareness, importance of seeking help if unwell, teaching to recognise ketoacidosis and hypoglycemia. The partner is taught to recognise and treat hypoglycemia.
She should also be made aware that good glycemic control can prevent macrosomia.

(c) Discuss the factors that will influence your decision on the timing and mode of delivery [4 marks].The factors would be development of complications like pre-eclampsia, worsening of Diabetic nephropathy which indicate early delivery.
Development of macrosomia and hydramnios coincide with poor glycemic control and delivery at 37 weeks. IUGR indicates early delivery. Because of risk of stillbirth, she needs delivery at 38 weeks even with good diabetic control .
The mode of delivery would depend upon the favourability of her cervix, the presence of macrosomia and her wishes.

Posted by Manoj M.
M
(a) A history of end organ diseases with long standing diabetes like retinopathy, nephropathy, cardiac disease, peripheral vascular disease, as this will alter her pregnancy care. Her current Insulin requirement and other oral hypoglycaemic agents used, so as to advice accordingly as only insulin and(or)metformin recommended in pregnancy. Previous pregnancy details including outcomes, complications and modes of delivery. Current medications history as ACE inhibitors may cause fetal growth restrictions and need to change to safer antihypertensives and if on statins advice to stop as not recommended in pregnancy.
Examination including BP and urine dipstick for proteinuria as baseline to exclude underlying hypertension and also as increased risk of preeclapmsia later in pregnancy. Consider 24hr proteinuria if significant on dipstick (or protein creatine spot test)and if proteinuria quantified above 5g/l then need for thromboprophylaxis as increased risk of thrombosis with nephrotic proteinuria. Renal function test and if serum creatine above 120micromol/l then need to refer to nephrologist. BMI as associated obesity will significantly increase pregnancy risks and complicatons. Oranise a dating scan if not already done as increased risk of miscarriage. Organise retinal assessment if not done within last 6 months especially if associated with retinopathy. Organise 4 chamber cardiac scan at 18-20 weeks to exclude fetal cardiac abnormality along with detailed anomaly scans.

(b) Advice on tight control of blood glucose to optimise the outcome of her pregnancy and to minimise complications, ideally with a HbA1C maintained <6.1%. Her fasting blood sugar maintained between 3.5 and 5.9 and her 1hr post prandial maintained <7.8mmols after every meal and these targets should be individualised for self monitoring. Offer ketone testing strips to detect ketoacidosis if feeling unwell or with hyperglycaemia.
Educate patient and family members regarding hypoglycaemia and awareness and teach patient, partner and family member on use of sugar substances and glucagon in event of hypoglycaemia.
Advice on testing blood sugars prior to bed to avoid risks of hypoglycaemia and complications in sleep.

(c) If she has uncomplicated antenatal period and good glycaemic control with no fetal compromise and no contraindications for vaginal delivery then aim for induction of labour at 38-39weeks gestation.
If suspected macrosomia or estimated fetal weight above 4.5 kg then offer caesarean section at 38-39 weeks gestation to reduce the risk of shoulder dystocia and birth related injuries. Her previous pregnancy and deliveries especially caesarean deliveries or any previous uterine surgeries may warrant caesarean section at 38-39weeks gestation.
If patient wishes spontaneous onset of labour or refuses induction at 38 weeks then offer monitoring for fetal well being on weekly basis with understanding none of the monitoring test will predict impending fetal death.
Any current complications like preeclampsia may warrant early induction or early delivery. Her wishes should be considered.
Posted by H H.
I would follow unit protocols for assessment of pregnant with insulin dependant diabetes(IDDM).I should have communication with her physician who controls her diabetes. I would ask her of her diabetic control and how much insulin given and see if she knows how to take insulin and monitor her blood glucose before and after meals at home.I would ask of any complications of diabetes,like visual disturbances, renal problems or leg ulcers.I would ask if she experienced hypoglycemic attacks and how dealt and if she had previous hospital admission to control her diabetes or diabetic ketoacidosis. Would ask of obstetric history , parity, previous pre eclampsia, mode of delivery,macrosomic babies, shoulder dystocia or post partum hemorrhage.
I would ask if she had previous urinary tract infection and treatments or prvious candidal infections. Would ask of family history of diabetes.Would ask of smoking,alcohol and illicit drugs habits.Would ask of other medications given.
On examination, pule, BP (associated hypertension), temp (infection),do fundus examination (retinopathy –need ophthalmic exam and may be photocoagulation), see if leg ulcers due to peripheral neuropathy.
Investigations include, FBC and CRP (infection), hemoglobin A1c to assess control of her diabetes ,should be <6.5 some say <7. Urea and electrolytes,serum creatinine for renal function and liver function tests. Urine dip stix for protein,nitrites(infection),glucose and ketones.Will ask for visual field . Will screen for rubella antibodies, opt out HIV testing, hep B ,C and VDRL.
Will ask for datind scan and nuchal scan for nuchal thickness as serum screening tests for chromosomal abnormalities are not valid for this patient.
B) Would advise her that monitoring of her blood glucose should be done before and after meals at home. It should be <5.5mol/l before meal and <7 mol/l one hour after meal,or according to the protocol she was given by her physician.
Injection of insulin is given subcutaneously.Dose adjusted by diabetologist.
Patient and relatives should be advised regarding detection of hypoglycemia and what to do in such situation. Glucagon intramuscular should be available and given if patient develop hypoglycemic coma. Patient advised to have a card showing she is diabetic and to keep sweet with her in case she feels hypoglycemic.

C)In a patient who is adequately controlled and who has no other maternal( pre eclampsia hydramnios)or fetal (macrosomia) complications , I will induce her labour at 38-39 wk to avoid increased risk of intrauterine fetal death in last 4 wk.
Patients who has fetal macrosomia ,I will deliver by elective lower segment c/s(LSCS) at 39wk.
Patient who had previous shoulder dystocia ,I will counsel and advise LSCS at term.
Patient who has polyhydramnios, might have preterm labour, will manage according to unit protocol, steroids for lung maturity , control diabetes, manage polyhydramnios .Might be faced with unstable lie at term ,and LSCS might be a safer option.
Presence of intrauterine growth restriction in fetus with fetal compromise , might prompt early delivery ,usually by LSCS.
Presence of associated malpresentation eg breech or transverse lie. Timing and decision will depend on experience of obstetrician ,maternal wishes and presence of other associated complications.

Posted by C P.
C
(a)
I will find out from the patient about her diabetic control. Adequate control brings good out come. This can be estimated from her HbA1c level. Ideally it should be below 6.1%. I will find out from her about the whether she had any pre conception counselling and her renal assessment and retinal assessment. Her history of taking folic acid and the dosage would be helpful to asses the risk of neural tube defect. If not done already done in last six months her Nephropathy and retinopathy need evaluation,
Multi disciplinary involving diabetic nurse, diabetic physician, dietrecian, and specialist midwife who is trained in diabetic brings the optimum out come of pregnancy.
I will organise a dating scan. This is important because most of the parameters we asses and investigate depends upon the gestational age. Because she is diabetic her serum screening for Downs will not be accurate thus, I will organise NT scan for her to know the Downs risk. Further arrange detail anatomy scan at 18 to 20 weeks, further high resolution cardiac scan at 22 weeks if indicated.
If she is on any medication which are teratogenic to the foetus, it would have been stopped at the pre conception. If it is not don with the advice of her physician I will change the medication the safest option. By 12 weeks organ genesis will be completed. However, medication like ACE inhibitor would cause renal impairment to the foetus.
She should be managed in the consultant let care with combined diabetic clinic. I will document clear management plan in the antenatal notes this will help in uniform plan.

(b)
I will tell her during pregnancy she need more frequent monitoring of her blood sugar. This will help stable serum sugar levels which is mandatory for good out come of the pregnancy. She needs home monitoring. Pre and post parential blood sugar and pre bed level should be monitored. These reading should be documented in a given diary. Optimum serum blood sugar level should be between 3.9 to 5.1pre meal and up to 6.9 mmol/L post meal. She should be advice to contact the diabetic nurse in the events of poor control. She should be taught what to do when she gets hypoglycaemic attack or ketoacidosis.
(c)
Control of serum glucose level, foetal macrosomia, IUGR , abnormal Doppler, and congenital anomaly will influence the mode, time and place of delivery. Well controlled diabetic and adequate size foetus can be induced at term. Macrocomic foetus more than 97 the centile will be planned for elective caesarean section at 38 to 39 weeks to avoid dystocia and perinatal morbidity . IUGR foetus depends upon the Doppler studies may need emergency caesarean section or early induction. The mother should be well communicated and explained about the management plans.
Posted by Sophia Y.
(a) Describe the assessment that you would undertake during this visit [10 marks].

Poorly controlled insulin-dependent diabetes mellitus (IDDM) is associated with poor maternal & perinatal morbidity & mortality. Pre-conceptual counselling in women with IDDM can improve outcome. Therefore on initial assessment i will ask her if this pregnancy is planned or not & whether she has been on high dose folate acid 5mg pre-conceptually. I will also ask if her diabetes has been well or poorly controlled. This can be reflected by presence of complications including retinopathy, nephropathy, hypertension & peripheral neuropathy. I will also ask if she has any hospital admissions due to poorly controlled diabetes eg diabetic ketoacidosis. Her capillary blood glucose monitoring daily record may also reflect her glycemic control. I will also ask her how much insulin she has been on, consumption of any medications, including ACE inhibitor which is teratogenic. I will also ask her previous obstetric history and outcome, birth weight and mode of delivery as women with poorly IDDM are prone to fetal anomaly, miscarriages, stillbirth, macrosomia and caesarean sections. I will also ask her any complications developed in previous pregnancies - pre-eclampsia, poor glycemic control and shoulder dystocia.

On examination i will check her body mass index and blood pressure. She will need retinal assessment with digital imaging Mydriasis is achieved by applying topicamide.

I will check her HbA1c to assess her glycemic control. I will request baseline renal function. If dipstix urine shows 2+ proteinuria, 24 urinary protein collection is needed so that we can assess the extent of nephropathy. Referral to nephrologist will be needed if serum creatinine if over 120 mmol/L or 24 hour protein collection shows more than 2g. Midstream urine will be sent for microscopy, culture & sensitivity if dipstix urine shows leukocytes, nitrites, blood or protein.

She needs to have a dating scan to confirm viability, number of fetus and expected date of delivery. She should also be offered nuchal transluency scan as part of Downs syndrome screening test.

(b) Describe the advice that you would give her regarding the monitoring of blood glucose concentrations [6 marks].

She is advised to check her fasting blood glucose before every meal, aiming between 3.5 - 5.9 mmol/L. She also needs to check 1 hour post-prandial blood glucose after every meal, aiming below 7.8mmol/L. She should also check her blood glucose before going to bed every night during pregnancy.

She should also be given ketone testing strip and to test for ketonuria or ketonaemia when she becomes unwell or hyperglycemic. She should be counselled about symptoms of hypoglycaemic unawareness as symptoms of pregnancy can mimick hypoglycemia. She and family needs to give her some oral fluids rich in glucose or glucagon in case of hypoglycemia. She needs to be reviewed by dietician

(c) Discuss the factors that will influence your decision on the timing and mode of delivery [4 marks].

All women with IDDM should be delivered around 37-38 weeks gestation to reduce risk of stillbirth. However she may need to deliver early if her glycemic control is poor. This can be reflected by fetus having abdominal circumference of being or over 97th centile persistently at third trimester. Delivery will also be needed if there is any concern with fetus eg abnormal doppler. She might also need early delivery due to maternal disease complications - worsening pre-eclampsia, hypertension or nephropathy.

Mode of delivery is determined by size of baby. If the baby is expected to be big, there is a high risk of shoulder dystocia and birth trauma to baby & woman so caesarean section may be a better option. If the mother has previous caesarean section & baby needs to be induced early due to fetal or maternal complications, elective caesarean section will be more appropriate. If baby is average size & mother has previous successful vaginal births, induction of labour will be more appropriate. Maternal wish is also important as she might prefer to try for vaginal birth. If her cervix is favourable, vaginal birth will be more appropriate. Gestation at delivery is important as preterm baby may not tolerate vaginal birth very well.
Posted by Johnson  O.
A/
This is high risk pregnancy. I will take a detailed history about her health any complication of diabetic that may affect her care. I will ask her about the amount of insulin and the frequency of injection everyday to know if it is well controlled or not. I will ask about history of visual problem, including any laser treatment to exclude retinopathy. History of chronic leg ulcer to exclude neuropathy. History of high blood pressure to exclude nephropathy and medication like Angiotensin converting enzyme inhibitor which needs to be changed because it is teratogenic. I will ask her if it is a planned pregnancy and if she has been taking folic acid 5mg before pregnancy.
If multiparous, her obstetric history including number of children and mode of delivery. I will ask about any previous obstetric complication including shoulder dystocia, Pre-eclampsia, intrauterine growth restriction.
I will check her height, weight and calculate her BMI. Blood pressure and Urinalysis for protein. Abdominal palpation for fundal height. Examination of the leg for any chronic leg ulcer.
Fundoscopy to exclude any retinopathy.
Investigation will include HBA1c to determine state of glycemic control. Renal function test will include blood for urea and electrolyte. Baseline routine investigation which include full blood count. I will offer viral screening including Hepatitis B, HIV and Rubella status. Mid stream urine for culturea and sensitivity because of risk of urinary tract infection.
B/
The advise should involve multidisciplinary team involving obstetrician with special interest in Diabetic, endocrinologist, Dietecian and midwive.
I will inform her that optimal control of blood sugar will reduce both the fetal and maternal risk associated with diabetic. The maternal risk include worsening retinopathy, neoropathy and nephropathy, pre-eclampsia, recurrent urinary tract infection. The fetal risk include miscarriage, congenita anomalies, macrosomia, intrauterine growth restriciton, intrauterine death, still birth and shoulder dystocia.
Insulin is safe in pregnancy and not teratogenic. I will tell her to take her insulin according to the advice of endocrinologist. The insulin requirement may increase during pregnancy and fall after delivery. The aim is to maintain blood sugar between 4 and 7mmol/L.
I will inform her about the risk and symptoms of hypoglycemia which may include sweating and dizzyness. It is important to have glucose drink or glycogen to drink in case of hypoglycemia. I will inform her about ketone strips to check her urine for ketosis and the need to report to the hospital if any of thes symptoms and signs developed.
Information leaflet about diabetic in pregnancy will be provided. The contact details of the hospital will be given to her.
C/
If all is well with no maternal or fetal complication, aim for vaginal delivery by induction of labour at 38-39weeks gestation to reduce the risk of unexplained intrauterine death.
She may go into spontaneous labour by herself and hve normal vaginal delivery without any complication.
Previous mode of delivery and the indication will affect her delivery in this pregnancy. Two previous caesarean section[C/S] will be delivered by C/S.
Previous shoulder dystocia will be an indication to offer elective caesarean section.
Suspected macrosomia will be a factor to consider caesarean section. Maternal complication like poor glycemic control or severe pre-eclampsia will be a factor for early delivery. Severe Intrauterine growth restricition will be an indication for early delivery. Maternal wishes is also an important factor.

Posted by SA M.
a) This is a high risk Pregnancy which requires assessment to detect maternal and fetal complications associated with Diabetes in pregnancy and enable to take measures to prevent them and treat them. To achieve this, complete history, examination and investigation should be done.Multi disciplinary Team should look after this patient including Diabetilogist,consultant Obstetrician with interest in Diabetes, Diabetic Mid Wife ,Neonatologist.Her Parity with previous pregnancy outcome ,complications in pregnancy,delivery (Should Dystocia, C/S) .Live Births need to be asked to manage current pregnancy accordingly.In current pregnancy her symptoms of retinopathy,nephtopathy,peripheral neuropathy should be asked.Her recent retinopathy & Nephropathy Dates should be asked.Type of Insulin she is using,Dosage of insulin,as it may need to increase in pregnancy.Recent Hypo glycarmic attacks & treatment,any recent Diabetic Keto Acidosis which indicate poor control in this pregnancy.

Examination include her B.P to exclude Hypertension common in Diabetes,BMI,Cardiovascular system to exclude Cardiac disease.Peripheral Nerve Sensation to exclude peripheral neuropathy. Urine Dipstick if protein, Leucocytes ,nitrite indicate UTI.
I would like to investigate for Diabetic Retino & Nephropathy if not done in last 12 months. MSU, 24 hours urine for proteins .Baseline Renal profile,uric acid urea electrolites.Liver function test as baseline.HBA 1C for recent 3 months Blood sugar control.
Ultra sound Scan for fetal assessment viability,Dating,Nunchal translucency as Serum Screeing for down Syndrome not reliable in diabetes.
b) I will tell her the normal blood sugar levels which she should aim during pregnancy,her FBS between 3.5-5.9 mmol/L ,post prandial one hour after meal should be less than 7.8 mmol/L.She should do self monitoring with four points BSS including fasting and after one hour of each meal.she should check her blood sugar before going to bed.If sugar are not control ,7 points BSS with pre & post prandial .Urine ketone strips should be provided for monitoring if feels unwell..I will give her Hospital Contact Numbers, Diabetic Midwife contact number if her sugars are not controlled.
c) If her blood sugars are controlled and no maternal or fetal indications of early delivery,no pregnancy complications,I will offer her Induction of Labour at 38-39 weeks, aim for vaginal delivery,with full protocol of prevention of shoulder Dystocia.If Fetal Macrosomia with weight of 4.5 kg C/S at 39 weeks to prevent Maternal & fetal Morbidity.Severe polyhydramnios as a complication of uncontrolled Diabetes with non cephalic presentation LSCS at 38-39 weeks.


Posted by Ron C.
RnRn

A.
If she has been very well controlled around time of conception, risk for fetal anomalies is close to back-ground population risk. Pre-conceptional use of folic acid 5 mg od at least 3 months prior to conception may reduce risk for neural tube defect. Record of glucose-monitoring and recent insulin levels give insight in control. Presence of diabetic nephropathy & retinopathy reflect disease severity and together with hypertension if present can cause extra problems in pregnancy (pre-eclampsia) and often show further deterioration, though retinopathy and nephropathy return to pre-pregnancy level after delivery in most women. Obstetric history including delivery is noted and may affect management, for example in previous caesarean.
Blood pressure measurement is done with adequate sized cuff. Weight & height are noted to calculate BMI. Funduscopy can identify presence of retinopathy. Booking bloods for blood group, full blood count to identify anemia and serology for rubella, hepatitis B & Syphillis are taken as part of normal screen, and additional renal function tests to identify severity of any renal impairment if present. HbA1c is taken too and reflects how well the diabetes was controlled over the last 2-3 months. And should ideally be <6.1%. Urine is checked for proteinuria, and if present this is quantified wit sample for protein-creatinine ratio. Transvaginal; scan is done to obtain accurate dating, which is important when taking screening bloods for chromosomal anomalies.

B.
Most patients will be experienced using the glucose-sticks and adjusting their insulin doses accordingly. The diabetic nurse may check whether her technique is right though. She is instructed to take a mixture of fasted, pre-meal and 1 hour post-prandial blood samples, on different days, reflecting her overall control, and she should note all values down. She is advised to strive for fasted glucose 3.5-6, pre-meals 4-6 and post-meal/ pre-night values of 4-7. Nevertheless target values are individual, and she must be aware that she may be less able to note hypoglycaemic episodes. If in doubt she must be given a contact number of the diabetic nurse for advice.

C.
Time of delivery would normally be at 38 weeks, provided no problems arise during pregnancy. If diabetic control is very difficult and poor, or if complications do arise, such as fetal growth restriction/compromise, or pre-eclampsia, iatrogenic premature delivery may be necessary. Mode of delivery depends on fetal condition & presentation; in malpresentation or fetal distress, a caesarean is done. Only if scan shows estimated fetal weight above 4500 gram, she can be counseled on elective caesarean, though she must be aware actual fetal weight can differ significantly. If she previously had a caesarean, she must be counseled regarding vaginal birth after caesarean. If there are no complicating factors she can attempt a vaginal delivery. Whether induction will be depends on parity and Bishop’s score of cervix. If very preterm, successful induction
Posted by robina K.
(A) Poorly controlled insulin dependent D.M is associated with maternal complications and like retinopathy, nephropathy, nuropathy and vasculopathy, and fetal complications like miscarriage, congenital malformations , prematurity, macrosomia, shoulder dystocia and birth trauma .
Women should be seen in a joint diabetic and antenatal clinic .All her blood sugar levels in the last 12 weeks should be reviewed including HBAIC , The type and dosage of insulin is reviewed and any other medications she is receiving should be asked about metformin or ACE inhibitors .Metformin can be continued but ACE inhibitors are teratogenic and should be discontinued , though teratogenicity at 10 weeks is not going to be influenced .I will ask about the complications of D.M like deteriotation in vision which indicates worsening retinopathy ,in that case she should be referred for opthalmological assesment .I will take history about weakness in limbs, numbness and tingling sensations to exclude neuropathy . A previous obstetric history is taken regarding parity, misscarriages ,mode of deliveries and perinatal complications . Menstrual history , cycle, length, regularity is asked , LMP is confirmed
I will check her B.P , BMI ,Retinal assesment with mydriasis and fundoscopy, and renal assesment if not performed in the last 12 months. I will examine her limbs for sensations and check reflexes.
A FBC, RFT , U&E, serum creatinine and creatinine clearance , and LFT is advised .HBAIC is advised , it indicates glycemic control in the last 12 weeks .
A scan is offered for dating ,viability, number of fetuses and nuchal translucency . HepB, C and HIV testing is offered if not done before pregnancy .
(B) Her care should be in a multidisciplinary context involving diabetic physician, consultant obstetrician, dietician and diabetic specialist nurse . She is advised about regular antenatal attendence fortnightly in second trimester and weekly in third trimester. She is provided with glucometers and advised to check her capillary blood sugar levels , one fasting which should be 3.5-5.9mmol, one postprandial one hour which should be <7.8 mmol and one reading before going to bed . Blood sugar levels are agreed with the women and documented , if there is poor control she may need admission and treatment in the hospital . Rapid acting insulin is preferred , she is taught self injection and needle disposal .Dietry advise is provided with the help of dietician .
She is also taught symptoms of hypoglycemia and provided with concentrated glucose and glucagon .Family and partner are advised about her care . She is provided with urine ketone testing strips and taught about symptoms of diabetic ketoacidosis in that case she is advised to attend hospital immediately for level 2 critical care where a combine medical and obstetric care is provided .
(C) Gestational age is the most important determining factor , after 37 completed weeks delivery should be considered .Hospital delivery is advised ,IOL is offered depending on the bishops score ,and a vaginal delivery is anicipated with caserean section for obstetric indications .
Fetal macrosomia is an indication for caserean section because of risk of shoulder dystocia and increased risk of perinatal morbidiry and mortality .
Maternal and fetal complications may indicate early delivery ,like HTN, pre eclampsia, or fetal distress . In severe cases vaginal delivery may not be possible and casearen section is indicated .
Spontanous preterm labour and delivery is a recognised complication of poorly controlled diabetes mellitus . A vaginal delivery is anticipated with continous electronic fetal monitoring and insulin glucose regime .
Rarely iatrogenic preterm delivery is needed if there are lethal fetal congenital abnormalities, IUFD or worsening maternal complications. Maternal views should be taken into account .
Posted by SUNDAY A.
sos answer

a) I would ask about her blod sugar control and insulin requirement in this pregnancy. I would ask her to stop taking folic acid since she is now 12 weeks. Any history ofabdominal pain, pv bleeding, pv discharge would be enquired. Her general wellbeing including history of weakness, headaches, sweatiness, visual disturbance would be asked which might correlate with tight glycaemic contol or relative unawareness of hypoglycaemia in pregnancy. i would check her dating scans and EDD if available and i would advice her to stop smoking, adopt healthy lifestyle if appropriate. I would check her BP, BMI. Cardiovascular examination to check for any abnormal heart sounds. Auscultating the Fetal heart can be deferred in view of gestation and a previous normal dating scan to avoid unnecessary maternal anxiety if FH is not picked up. I would check her baseline booking blood including FBC, Group/Rh factor. Baseline liver and renal function including creatinine clearance would be requested to rule any underlying nephropathy. Urine dipstick for proteinuria would also be relevant. I would ensure HbA1c is within target of less than 6% and pre-prandial BM of 5-6mmo/l and post meal(1hr) of less than 7mmol/l is maintained. She would be referred for Retinal screening if not recently done in the last 6 months and referral made to the Diabetologist for joint care in pregancy( if not already in place) , and dietician for review.
b) Blood sugar should be checked with the glucometer at the appropriate time with the targets in view and diabetic midwive should be alerted if any recurrent deviation from target or insulin adjusted according to plan. She should be warned about the symptoms of hypoglycaemia including headaches, sweatiness, and relatives taught on how to administer glucagon. She can also carry sweets or glucose drink in her bag. Very high hyperglycaemia episode with evidence of her been unwell should necessitate review in the hospital as this could be a serious complication ( Diabetic ketoacidosis).

c) A poor blood sugar control despite insulin adjustment or a high requirement might necesitate early delivery. Assocciated complication such as pre-eclampsia, fetal macrosomia with AC grater than 95th centile, severe polyhydramnios or estimated fetal weight( EFW) greater than 4.5 kg might necessitate early delivery. History of reduced fetal movement would also influence the timing of deivery.If delivery is necessary before 34 weeks , she should be offerred IM Betametasone 12mg 24 hours apart under insulin sliding scale cover. In the abscence of any major complication IOL at 38 weeks should be offerred with the aim of vaginal delivery with caesarean section planned for obstetrics reasons- ie Breech presentation, or if EFW is greater that 5kg.
Posted by Mohamed A.
a)
Woman better to be assessed jointly with a diabetologist. Clinical history to establish the extent of diabetes related complications, enquire if she is being treated for diabetic retinopathy, neuropathy or nephropathy which is associated with high risk of pre-eclampsia, pre-term delivery and poor perinatal outcome . Any previous acute complications as hypoglycemia or ketoacidosis which indicate poor diabetic control. Ask about insulin dose, type and frequency and other drugs taken for example anti-hypertensive drugs which may need to be changed or modified. ACE inhibitors and angiotensin-II receptor antagonists should be discontinued and suitable alternative given. Ask about recent blood glucose tests and review reults. Ask about social history and availability of support. Obstetric history should be sought including number and outcome of pregnancies, any antenatal complications like miscarriages, anomalies, IUGR, macrosomia or IUFD and intrapartum complications like shoulder dystocia and mode of deliveries.

General examination for BMI, blood pressure and pulse. Check for leg ulcers associated with peripheral neuropathy and refer for fundoscopy.

Dating scan should be performed to confirm viability and gestational age and measure nuchal translucency.

Initial investigations should include FBC, renal functions, Liver function tests HbA1C, 24 hours urine protein and visual field examination.

b)
I will tell her that the aim of monitoring is to adjust insulin requirements to reduce the incidence of adverse outcomes of pregnancy for example macrosomia, and neonatal hypoglycemia.

I will tell her that she need to measure fasting blood glucose level and 1 hour after every meal during pregnancy.

I will tell her that the target range is 3.5 – 5.9 mmol/l for fasting blood glucose and < 7.8 mmol/l for 1 hour postprandial blood glucose.

I will advise her together with her partner if any about the risks of hypoglycemia and provide a concentrated glucose solution and glucagons kits and teach them how to use.

I will advise her how to use ketone strips test for ketonemia or ketonuria and to test for it if she becomes hyperglycemic or unwell. If suspected of having ketoacidosis she should be admitted immediately.

I will tell her that HbA1C should be measured during the 2nd and 3rd trimester.

c)
Elective induction of labour at 38-39 weeks if growth within normal limits and there is no fetal or maternal complications Or elective c.section if indicated for example for repeated c.sections.

Women who have an ultrasound-diagnosed macrosomic fetus should be informed of the risks and benefits of vaginal birth, induction of labour and caesarean section. Mostly elective c.section is advised for the fear of shoulder dystocia but maternal wishes should be respected after proper counseling.

When the estimated fetal weight is between 4000 -4500 gm, additional factors such as the past obstetric history should be taken in consideration. ie vaginal delivery of a fetus with EFW 4200 may be allowed if she had safely delivered a 5000 gm baby.

Worsening maternal retinopathy and/or nephropathy or pre-eclampsia or severe IUGR may warrant earlier delivery.
Posted by Shalini  M.
PART A {sh)
a) It is essential to assess this lady in a multidisciplinary setting involving diabetologist, diabetic nurse and experienced midwife.
I would begin by taking a detailed history of symptoms of pregnancy in first trimester- nausea, vomiting and fainting attacks, any pain or burning during micturition to rule out urinary tract infection as women with IDDM are predisposed to develop frequent infections.Also, her drug intake should be enquired into-whether she is taking insulin,in what doses and which ones.Any history of hypertension and any medications for the same.Her BMI should be assessed as also her blood pressure.Glycaemic control should be checked by fasting and 2 hour post prandial blood sugar estimation as also HbAic which will predict glycaemic control 6-8 wks prior,i.e , around period of organogenesis, and would predict her risk of congenital malformations in the fetus if HbAic is > 6.6%.Retinal assessment by mydriasis is essential as retinopathy needs monitoring for worsening and predicts disease severity.Renal function needs to be assessed by serum creatinine estimation and GFR. Serum creatinine > 120 mmol/L and GFR < 45ml/minute / 1.73m2 needs assessment by nephrologist.Ultrasound pelvis should be done for fetal viability and assessment of nuchal translucency as a lady with IDDM is at increased risk of developing congenital malformations in her fetus.
b) She should be explained that strict glycaemic control avoids most problems of an IDDM pregnancy like miscarriage, congenital malformations, macrosomia, traumatic births , shoulder dystocia, instrumental deliveries. Indivisualised blood glucose monitoring targets should be decided upon and she should be taught self monitoring of fasting and post prandial 2 hour values by glucometer. She should be explained to report if fasting blood glucose is > 5.8mmol/l and post prandial > 8 mmol/L. Also , she should be explained that she is at an increased risk of developing hypoglycaeia and thus use of glucagon/ glucose solution should be explained.
c) Adequately controlled blood glucose levels and no systemic complications of diabetes like superimposed hypertension/ pre eclampsis, nephropathy or retinopathy can allow planning of delivery after 38 weeks. Also, clinical and ultrasound evidence of macrosomia( Birth weight > 4.5 kg) are an indication of cesarean section. Any evidence of growth- retardation needs assessment of placental vascular flows by doppler and delivery desicions accordingly. There are only obstetric indications for cesaerean section and no contraindications to vaginal delivery due to diabetes.
Posted by R S.
a/ As the patient is IDDM, so she should be seen in joint multidiscipilinary clinic. multidisciplilinary team which include, obstetrician, diabetic phsycian, senior midwives. i would like to assess the patient throuh history. past medical illness because she has history of IDDM ,inquire about, eye problem for exclusion of severity of retinopathy,referr her opthlamologis.Hypertension, can causes maternal preeclampsia so asked about her medication if shes taking.if shes on ACEinhibotors she has to stop this medication becauses it has terratogenic effct on fetus, so referr her cardiologist for change of medication.further more shen can develop nephropathy, controll of blood pressure is important. during her assessment her urine analysis should be done, to identify protien uria, or sign of infection. if she has albuminuria chances of having deterioration of existing hypertion or leads to preeclampsia, which is leading cause of maternal mortality.I would also do the full blood count to assessment of any aneamia or thrombocytopenia and also ask for abourt family history of any heamatological disease, LFT for any liver involement.The most important assessment is blood glucos measurement and glycoslation of heamoglobin.i would assess her because increase level of glycosylation leads to congenital abnormalities. i will arrange for ultra sound to assess nuchal transluency and any congenital malformation and assessment for any aneuploidy. Inaddition i will also send blood for HBV, rubella and HIV testing.
b/ Tight glyceamic control is very important in IDDM. i would advice her that she should do daily blood glusoce check through home bloog gluco meter. she has to check for at leat 4 time.fasting level up to 4-5.5mmol/l and postpardinal level should be less than 7.
i would also tell her about hypglyceamia awareness, if she found that she has hypoglycamia , level below 4,she should take candies or use of glucagone. if shes having gluocose level more than 11, she has contact hospital soon because she can develop diabetic ketoacidosis.
i would advice her tight glyceamic control causes control level of glycosylated heamoglobin which should be less than 6%. if it is more than 6% it leads to fetal congenital mal formation, macrosomia which can cause shulder dystocia in normal delivery.so adviseed her to measuer HbAc1 every 4-6 weeks.
c/ the most important factor is pregnancy going safely to term. if blood glucose levels are control and there is no obstetric indication for ceesarean section then normal delivery can be carried. if there is polyhydrominous or there is any preterm labour or preeclampsia or abruptio, the delivery should be considered accordibgly wether nornal or cessarean section.
Posted by M E.
a) DEscribe the assessment you would indertake at this visit (10)

Assessment should be made in conjunction with the diabetologist. History of her current insulin requirements and her blood sugar levels should be assessed. Whether she is still having symptoms of hyperemesis, since this would make her blood sugar more difficult to control and increase her risk of ketoacidosis. Check for symptoms of UTI or candida infections. Medical history of diseases that may be associated with long standing diabetes such as HTN, nephropathy, retinopathy, since these conditions may worsen during preganancy. Enquire about drugs being used for these conditions since these have teratogenic effects. Even though the first trimester has been completes these drugs should still be switched.Check whether she commenced Folic acid 5mg pre pregnancy.
Enquire whether she had complications with her previous pregnancies, such as miscarriages, still births, previous babies with anomalies, since these may be assocaited with poorly contolled diabetes. History of macrosomia and shoulder dystocia. Mode of previous deliveries, whether c/s performed.
On examination check BP, since there is a higher risk of HTN. Calculate BMI. Fundoscopy should be performed, since this may deteriorate with pregnancy.
Urine analysis should be performed to check for ketones and glucose, albumin. 24 hr urine collection maybe indicated in the presence of proteinurea, nephropathy or HTN. FBC and U&E for baseline functioning. Creatinine >120mmol/L would require intervention by the neprhologist. HbA1c to assess control in the last 8 weeks during the period of organogenesis.. Pelvic ultrasound for viablity,dating and measurement of NT.

b) Describe the advice you would give her regarding the monitoring of her blood glucose (6)

Patient should be advised to perform blood glucose monitoring at home home with the aid of a glucometer. FAsting blood sugar should be kept between 3.5 - 5.9 mmol/L. 1 Hr post prandial blood should be done after each meal and this should be <7.8 mmol/L. These values should be documented or glucometer brought to clinic for review. If blood sugar poorly control, this may require admission to hospital for stabalisation. She should be advised to check blood glucose prior to going to bed, to avoid hypoglycemia episodes.
She should be counselled that poorly controlled diabetes is associated with macrosomia, shoulder dystocia and stillbirths.
Patient should be advised that she and a family member need to be aware of the symptoms of hypoglycemia and taught how to administer glucagon in that event.
She should be advised that hyperglycemia may cause ketoacidosis and ketone strips should be used for detection. If present she requires urgent hospital review.
Patient should be offered review by the dietician to avoid foods that would cause wide variation in the glycemic index. Written information about glycemic control should be provided for the patient and contact information for further questions.

c) Discuss the factors that would influence the time and mode of delivery (4)
If blood sugars are well controlled and there are no maternal and fetal complications and fetus is of normal size, induction of labour can be offered after 38 weeks, to prevent RDS and reduce risk of SB. Caesarean section can be offered instead if there are indications, such as macrosomia>5kg, breech presentation.
If there is evidence of macrosomia. VBAC can also be offered to diabetic patients, once there are no contraindications. Patients desire would also influence the mode of delivery. Fetal complications such as IUGR or worsening of maternal complications such as preeclampsia or nephropathy may promt earlier delivery.
Posted by A A.
I will ask the woman whether pregnancy was planned or unplanned to assess whether her health condition was optimized before conception.Has she used folic acid before conception and until now.There is a need to assess severity and current status of disease like any complications. Regarding complications of disease like diabetic retinopathy,nephropathypathy and peripheral neuropathy, I will ask her about any visual loss, weight change, decrease sensations in her extremities andhigh blood pressure.I will ask about any acute complications like hypoglycemmia and ketoacidosis.I will review her drug history specially the dose of insulin and if she is using any other drug like for hypertension to make sure it is not teratogenic.I will ask about a previous obstetric history regarding any complications in antenatal period, during delivery (birth trauma/shoulder dystocia) mode of delivery and outcome (weight of the baby,any neonatal complications). I will ask her about social life like alcohol intake,smoking and drug abuse.I will ask her about family support. I will check her recent glycemic control.I will also involve a diabetologist in her assessment. In examination I will check her pulse, blood pressure, BMI and I will do fundoscopy to check retina.In case of diabetic retinopathy there is need for assessment by ophthalmologist. I will check sensations in her lower limbs and extremities for neuropathy and also any leg ulcer. I will send FBC, Urine diplsticks for proteinuria , nitrites and leucocytes.To check renal functions creatinine urea and 24hours urinary excretion of proteins will be send.If serum creatinine is abnormal (>=120umole/l) and if total protein excretion is >2gm/day referral to nephrologist will be considered.Hb A1C to check glycemic control in the first trimester. I will offer screening for Hep B, Rubella, HIV and syphilis .
Part B) I will offer her a glucometer for monitoring of blood glucose and will instruct her about its usage. I will instruct her to keep her BSF between 3.5 to 5.9 mmol and 1 hour postprandial < 7.8mmol/l during pregnancy. I will tell her that she should test her BSF and Blood Glucose after every meal and once before going to bed at night.I will tell her that good glycemic control is necessary throughout pregnancy and labour to reduce maternal and fetal complications. I will also offer her ketone testing strips to test for ketonuria if they become hyperglycemic or unwell.I will also advise her about the risk of hypoglycaemia and its unawareness during pregnancy.I will make sure that she has been provided injection glucagon and her partner or family members have been instructed in its use. In addition to this, she needs to attend Diabetic Obstetric clinic for assessment of glycemic control every 1-2 weeks throughout the pregnancy. I will also tell her that in case of poor glycemic control she needs admission in the hospital for insulin dose adjustment until glycemic control is optimized. I will also advise her about the role of diet, weight control and exercise in blood sugar control. I will provide her written information, hospital contact numbers and further appointments.
PART C ) These are maternal complications, fetal complications, gestational age, state of the cervix and maternal wishes or preferences. If the woman is having complications like diabetic nephropathy with worsening renal functions and proteinuria or if patient is having hypertension or super added preeclampsia /eclampsia then early delivery will be required. Similarly polyhydramnias either due to poor glycemic control or fetal anomalies causing maternal discomfort may require earlier delivery. In the presence of sever fetal compromise, IURGR, earlier delivery might be required. Mode of delivery will depend upon the urgency of the condition and state of the cervix. In case of fetal macrosomia with weight > 4.5 kg delivery by caesarean section will be required. Similarly presence of fetal complications like congenital abnormalities, NTD, Sacral agensis and cardiac defects will also influence the timing and mode of delivery.If the glycemic control is good and there is well grown baby with no complications delivery via induction of labour can be offered after 38 weeks of gestation. All these information should be discussed in detail with the woman so that she can make the informed choices regarding delivery and her wishes should be respected.
Posted by SN  K.
SN

A 25 year old woman with a 15 year history of insulin-dependent diabetes mellitus is referred to the antenatal clinic at 12 weeks gestation.

(a)Describe the assessment that you would undertake during this visit [10 marks].
History regarding diabetic control should be taken. This includes the doses of Insulin that she’s on, whether IDDM is well controlled on the dosage that she’s on. Any additional oral hypoglycaemics should be reviewed as may not be suitable in pregnancy (E.g. glibenclamide).
Consequences of long standing IDDM should be looked into (E.g. Retinal damage, Renal damage) as these may worsen during pregnancy and additional measures should be taken to prevent further damage. I will also take a medical history as patient may also have chronic renal failure secondary to IDDM (due to renal damage) and may have secondary hypertension.
Past Obstetric history is important as may have undergone Caesarean sections or had adverse effects of uncontrolled IDDM (such as sudden fetal deaths or baby with cerebral palsy following shoulder dystocia) which may assist in decision making on mode of delivery. Social history is important to assess and advice on life style modifications (Cessation of smoking). If she is not on Folic acid, I will prescribe 5mg of Folic acid/day throughout pregnancy.
It is important to manage her in a multidisciplinary clinic which includes an Obstetrician with a special interest on DM in pregnancy, Diabetic physician, Diabetic nurse who will review her diabetic control and advice, change medication accordingly.
Examination of the eye is important to exclude diabetic retinopathy, therefore I will refer her for ophthalmic examination. Booking BP is important as already may have hypertension. Also pre-eclampsia or pregnancy induced hypertension can occur during the pregnancy. Assessment of urine dipstix (needs to be done in each medical visit) as this may indicate UTI or renal damage and necessitate further investigations (mid stream urine for culture sensitivity as there can be asymptomatic bacteriuria). Baseline investigations include FBC, Renal profile, Liver profile and other booking bloods (E.g. Hep. B, HIV, Rubella Antibodies). I will also send glycosilated Hb levels as this indicates patient’s long-term DM control. Her blood sugar diary (which includes fasting, pre-prandial and post-prandial blood sugar monitoring) should be assessed and Insulin dosages introduced or changed accordingly. A dating scan is important as this will assist in subsequent assessments on fetal growth (as macrosomia is common in uncontrolled DM) and planning of delivery. Serum screening for aneuploidy is not reliable in DM, therefore a nuchal translucency measurement upto 14 weeks should be offered.
If abnormal results, necessary referrals (may need renal physician’s involvement if abnormal renal functions).

(b) Describe the advice that you would give her regarding the monitoring of blood glucose concentrations [6 marks].
I will explain to her that starving in pregnancy is not recommended but a tight control of Blood sugars are important as uncontrolled DM can give rise to adverse maternal and fetal outcome. For the fetus, good control of DM is important to minimise congenital abnormalities (such as cardiac abnormalities, sacral agenesis) and also that fetal macrosomia can result if DM is not well controlled which may result in operative deliveries and adverse outcomes such as shoulder dystocia and increased risk of having Caesraean sections (with it’s consequences) and even fetal death.
Risks for her are, hypoglycaemia, hyperglycaemia, worsening of renal functions and retinopathy if Blood sugar levels (BMs) not well controlled. Symptoms of hypo and hyperglycaemia should be explained and Intra Muscular glucose should be provided to take if symptomatic. Random BMs should be maintained between 3.5-8mmol/l. Capillary blood suagr should be measured pre-prandial and post-prandial (6 measurements per day). Fasting blood sugar should be between 3.5- 6mmol and 2 hour post-prandial should be below 8mmol/l. Home BMs monitoring kit should be provided and her partner should be explained how to measure blood sugar in an emergency and appropriate measures to take.
She should have the direct contact numbers for the diabetic nurse and the hospital.
She should be advised to take a low sugar, high fibre diet.
I will refer her to the dietician and advice her to have exercise in moderation (e.g. aerobics, walking) for better control of BMs.


(c)Discuss the factors that will influence your decision on the timing and mode of delivery [4 marks].
The current recommendation (NICE) is to induce labour at 38 completed weeks in uncomplicated DM but this may vary according to Blood sugar control, patient’s medical condition (if worsening renal functions or retinopathy), previous obstetric history (CS recommended if classical CS previously), current obstetric condition (If major placenta previa or the lower edge of the placenta is within 2cm from internal cervical os, needs a Caesarean section). Also if abnormal fetal parameters such as absent or reversed end diastolic flow, IUGR requiring early delivery. Patient’s wishes are also taken into account.
Posted by Sahithi T.
A))))
In this visit priority would be baseline assessment of disease condition. I will ask history of any presenting complaints in this pregnancy. I will enquire about overall glycaemic control before and during this pregnancy, any visual complaints, any symptoms suggestive of neuropathy such as bowel, bladder symptoms. I will ask her about previous pregnancies, mode of deliveries, any complications and previous baby weights. I will offer her retinal examination by specialist if it was not done in last 12 months to rule out retinopathy. I will check her fasting and postprandial blood sugar levels. Glycoselated Hb levels correlates with past glycemic contol but not reliable in pregnancy. I will do her full blood count, renal function tests, and urine tests. Presence of 4 + proteinuria is indication to start thrombo prophylaxis. Renal function tests provide information about nephropathy. Presence of nephropathy and hypertension adversely affects pregnancy. I would advise scan at booking. I will also advise her antenatal screening tests. Presence of IDDM should be considered in Downs screening. I will advise her follow up appointment at 20th week for detailed anomaly scan.

B))))
Good glycemic control during pregnancy is essential for good peri-natal outcome.
I will advise her to control her fasting capillary blood sugar level 3.8 to 5.5 mmmol/l
And post prandial sugar less than 7.8mmol/l. I will advise her to check blood sugar levels before going to bed. Post pradial sugar levels correlates with risk of large baby hence I will advise her more frequent diets to prevent post pradial hyperglycemia. I will advice her low glycemic diet and offer her dietician advice. Fasting hypoglycaemia and post meal hyper glycemia is common in pregnancy. I will advice her on symptoms of hypoglycaemia and immediate treatment with sugar solution. Her insulin requirement will be increased with advancement of pregnancy hence I will make sure that she understands this and requirement will fall down with delivery.
I will supply her keto sticks to monitor any ketone bodies in urine. Ketoacidosis is a known complication of IDDM which requires immediate attention.

c))))
Most important factor influence the time of delivery is any maternal of foetal risk. If there is any foetal risk like growth retarded baby with placental insufficiency needs to be delivered immediately. If there is development of any maternal complication like severe preeclampsia may require decision to deliver baby. If there is any previous history of intra uterine death, baby should be delivered before 40 weeks. Baby weight above 97th centile should be delivered after completing 37 weeks. Mode of delivery depends mainly on estimated baby weight. Most of the times baby weight more than 5 kg is advised to have planned caesarean section. Previous history of shoulder dystocia influences decision to delivery by planned caesarean section. Maternal wishes should be respected after impartial counselling about mode and time of delivery.
Posted by Nur Sakina K.
NSK

A.
Diabetes has significant implication to mum and baby during pregnancy. Key to a good outcome is optimizing diabetic control in pregnancy. History re diabetes is important. Specifically age onset, previous and current diabetic control is important to elicit. Her blood glucose monitoring book/diary should be reviewed to assess degree of diabetes control. Her compliance to treatment and monitoring of blood sugar should also be addressed. The type of insulin taken and dosage must be asked as this may need to be altered as the pregnancy progresses. Complications developed in association with diabetes is queried – episodes of hypo/hyperglycemia, long term diabetic complications – retinopathy, neuropathy, nephropathy. Family history of diabetes/hypertension is important to elicit as may identity risk of developing these problems in future. Aim is to assess degree of diabetic control so that modification can be made to optimize pregnancy outcome.
Other medical problems such as hypertension, renal problems, previous venous thromboembolic disease(VTED) should be queried as this complicates pregnancy further and requires more frequent surveillance.
Symptoms suggestive of urinary tract infection – dysuria and frequency should be asked for early detection treatment.
Previous obstetric history is asked – specifically parity, birth weights, previous mode of delivery and whether any complications occurred during the pregnancy – such as shoulder dystocia, PET should be asked. There is a risk of these recurring in the current pregnancy. Current medication taken should be asked - specifically whether folic acid prophylaxis had been used.
Examination involves obtaining observation for blood pressure, pulse, temperature, respiration rate for baseline level. This is important as she is at high risk of future hypertensive disease developing later in pregnancy. Her weight and height are measured to calculate BMI. Presence of any long term diabetic complication retinopathy, neuropathy should be examined – funduscopy, neuro examination to assess progress of symptoms. The abdomen is palpated for fundal height and fetal heart heard using a sonicaid. The lower limbs should be examined for varicose veins and ulcerations as increases risk for VTED.
Urine sample taken for urinalysis (exclude glycosuria, nitrites) and MSU sent to exclude UTI. Fasting blood glucose level should be taken to assess blood glucose control along with HbA1C (diabetes control). Ultrasound scan is arranged for nuchal translucency and dating scan. Opportunistic screening for UTI, HIV, Hepatitis, Rubella should be offered as well as serum screening for Down Syndrome.

B.
She needs to monitor blood glucose levels pre and post meals and at bedtime. The aim is to maintain glucose levels = 5.5 – 7.5 mmol/L. Method of monitoring should be explained including safe disposal of sharps. All readings should be recorded on a blood glucose diary. I’d explain symptoms of hypo and hyperglycemia that can occur and actions to be taken – drinking sugary drinks/glucose tablets if hypo and glucagon injections (hyper). Conditions which can cause her blood glucose to fluctuate should also be explained – infections or illness where she should seek medical help.

C.
This is affected by her diabetic control and development of complications associated with diabetes – hyperglycemia/hypoglycemia episodes, fetal macrosomia which increases the risk of shoulder dystocia. The gestational age fetus must be taken into consideration. It should be explained that there is a risk of sudden IUD in late 3rd trimester, hence delivery usually aimed at ~ 38/40. C/S is for obstetric indications only. Size of fetus based on ultrasound scan estimation -macrosomia or IUGR will affect decision on delivery timing. Presence of other pregnancy complications – PET, IUGR will also be a factor. Mode of delivery will depend on presentation fetus, previous mode of delivery, size and maternal wishes.
Posted by Leen K.
LEEN
A 25 year old woman with a 15 year history of insulin-dependent diabetes mellitus is referred to the antenatal clinic at 12 weeks gestation.
(a) Describe the assessment that you would undertake during this visit [10 marks].

Liason with an endocrinologist and specialist diabetic nurse (preferably in a combined diabetic antenatal clinic is ideal) as well as her GP, is important in the management of this patient. I would ask whether her diabetes has been well controlled so far, and find out what insulin dosage and regimen she is on. I would also enquire about any other associated problems such as retinopathy, nephropathy, neuropathy or vascular diseases, all of which may worsen in pregnancy and can also affect the prognosis of the pregnancy (eg. increased hypertensive disorders of pregnancy if nephropathy present). Any medications should also be reviewed (eg. ACE inhibitors and statins are contraindicated in pregnancy) and changed if appropriate with input form the endocrinologist.

I would also measure her BMI (body mass index) - increased BMI is associated with increased risk of congenital abnormality independent of maternal diabetes (as a separate risk factor), and also increases the risk of complications in pregnancy, such as hypertension. Her blood pressure and blood sugar level should be checked. I would also take blood for HBA1C (to check the control of her diabetes and compliance with insulin therapy), and urea and electrolyte (to check for signs of nephropathy). If nephropathy is present, her creatinine clearance must be check, as the level would give an indication of the prognosis for the pregnancy. I would perform a fundoscopy and neurological examination to look for signs of diabetic retinopathy and neuropathy. Presence of these would prompt me to liase with an ophthalmologist, neurologist and nephrologist, as appropriate.

I would arrange for a scan to check viability ( there is an increased risk of miscarriages in diabetics), exclude multiple pregnancy,and for dating of the pregnancy (accurate dating is important to improve the accuracy of screening tests for Down Syndrome and neural tube defects). Diabetic mothers are more at risk of having a baby with congenital abnormality, especially if her blood sugar levels are poorly controlled.



(b) Describe the advice that you would give her regarding the monitoring of blood glucose concentrations [6 marks].

I would advice her to measure her blood sugar levels (using a portable glucometer, measuring her capillary blood from her fingertips) before and after each meal; and document them in a diary, so that the pattern of her sugar levels may be monitored. Her drug/insulin regime and dosage can be changed according to these results. She should also check her blood sugar levels more frequently if she experiences any hypoglycaemic episodes or if her sugar levels are poorly controlled. Serum HBA1C should be check every trimester, and more frequently if there is suspicion of poor drug compliance.



(c) Discuss the factors that will influence your decision on the timing and mode of delivery [4 marks].

The risk of late stillbirths are increased in women with diabetes, therefore I would aim to deliver her before her due date. The presence of maternal (eg hypertension, nephropathy, vascular diseases that are worsening) or fetal (eg. intrauterine growth restriction or macrosomia/polyhydramnios) problems would indicate earlier delivery, and should be balanced against the risks associated with prematurity. The presence of congenital abnormality would also affect the timing and mode of delivery - especially if severe. In the presence of severe polyhydramnios and/or macrosomia (>4.5kg), I would consider elective caesarean section between 37-39 weeks depending on the severity, to reduce the risk of labour dystocia and shoulder dystocia secondary to fetal macrosomia, or cord prolapse in the presence of malpresentation with polyhydramnios.
Posted by Maayka ..
maayka

a) She should be seen in a joint clinic with endocrinologist at booking to assess her level of glycaemic control. A medical history with respect to her insulin – dependent diabetes mellitus (IDDM) will determine if she has had prior assessment in the last 12 months for retinopathy and nephropathy as long standing IDDM patients are likely to have such complications. Her present use of insulin, dosage and her compliance will determine the likely periconception control and risk of abnormalities – likely high if she was poorly controlled. Any use of drugs like ACE inhibitors, statins may need to be altered or stopped to prevent adverse fetal effects. Any previous recent episodes of diabetic ketoacidosis will imply that she was not controlled.
Her obstetric history will determine if she had previous miscarriages or live births and in the latter, the development of pre- eclampsia (PET), polyhydramnios, intrauterine growth restriction (IUGR) and subsequent complications should be noted, as it is likely to recur in the current pregnancy. If there were any stillbirths, the gestational age at delivery is to be noted. The birth weights of her children, if any > 4.5kg will suggest there was poor glycaemic control in the pregnancy. The mode of delivery of her pregnancies – if any Caesarean section (CS) or shoulder dystocia encountered should be noted. Her plans for future pregnancies should be noted also.
Examination will include the routine antenatal assessment, specifically looking out for BP, urinalysis at each visit because of need to be vigilant for PET. An ophthalmic assessment should be done if not undertaken in the last 6 months.
Beside the screening investigations otherwise done, she would have a 24hr urine collection requested, a mid stream urine to rule out urinary tract infection. A HbA1C will give an idea of her last prior glycaemic control .In addition her diascan reading will determine if she needs admission for blood glucose stabilization or it can be done at home. An ultrasound will be requested for dating and nuchal translucency measurement. Serum markers for aneuploidy in IDDM are less reliable.

b) She will be advised on the importance of avoiding hyperglycaemia during the pregnancy, as this will lead to the development of antenatal problems like IUGR, polyhydramnios and suspected macrosomia. It will also have effects on the neonate like jaundice, hypoglycaemia, hypocalcaemia and hypomagnesia.
The blood glucose monitor provided is to record her fasting and a combination of pre- and postprandial glucose levels. The target levels should be for fasting < 3.5 – 5.9 mmol/l and 1hr postprandial < 7.8mmol/l. She would be in contact with the diabetic specialist nurse and adjustments can be made accordingly. If hypoglycaemia occurs, she and her family members should be able to administer a glucose drink or glucagons. There is no adverse effect on the fetus from hypoglycaemic episodes. Night time monitoring before going to bed should also be done.

c) Delivery should be at a tertiary institution where there is 24hr neonatal services available. The timing will be determined by the presence/ absence of other complications like PET, IUGR, nephropathy or suspected fetal macrosomia. If any of these develop she may need to be delivered by 37- 38 weeks gestation or earlier .If there is no suspected macrosomia or contraindication to vaginal delivery, induction of labour should be performed by 38 weeks .The mode of delivery will be determined by the presence of any previous CS scars, the outcome of previous deliveries, the gestational age at delivery and the patient wishes. To avoid shoulder dystocia if suspected fetal macrosomia, it may be best to consider CS.

Posted by A H.
AH
This patient will be assessed by a multidisciplinary team which will include the obstetrician and diabetologist and diabetic nurse.
She will be asked about any persistent vomiting in pregnancy and consequent difficulty in maintaining her target blood glucose. Her insulin regime as well as her record of blood glucose levels will be reviewed.
Pre-existing complications of pregnancy likely to affect pregnancy outcome or to deteriorate in pregnancy include diabetic nephropathy, retinopathy,macro-and microvascular disease, and autonomic neuropathy. I would ask she developed any of these. I would also find out about the time since her last retinal and renal assessment. A review of her medications, especially anti-hypertnsives will be reviewed. I would enquire if she used periconceptual folic acid.
She will be asked about symptoms of urinary tract infections and abnormal vaginal discharge.
her past obstetric history will be reviewed to determine pregnancy outcome, complications experienced then as well as time and mode of delivery.
On examination, I will check her mucus membranes for pallor and dehydration.
The cardiovascular system will be examined. Blood pressure will be measured and peripheral pulses will be palpated.
I will examine the injection sites for signs of infection, and lipoatrophy/hypertrophy
A vaginal examination will be done if indicated
Bloods will be sent for full blood count, renal function tests( urea, creatinine, electrolytes), Hb A1c and random blood sugar.
Urine will be tested for proteins and ketones. If there is proteinuria, a 24 hour urine collection will be advised to quantify proteinuria and to determine the protein:creatinine ratio. A midstream specimen of urine will be sent for microscopy and culture to detect asymptomatic bacteriuria.
Ultrasound will be done as soon as possible for dating the pregnancy and for nuchal translucency.

b)I will advise that good glycaemic control will increase her chances of a good pregnancy outcome. There will be a reduced risk of both fetal complications( for example fetal macrosomia and stillbirth), and maternal complications like pre-eclampsia.
The target blood glucose recommended is a fasting value of 3.5 to 5.9 millimol/l and a one hour post-prandial of less than 7.8 millimol/l This will be decided in consultation with her, taking into account her risk of hypoglycaemia.
She will be advised to test her blood glucose everyday for a fasting value, a one hour postprandial level as well as.that before going to bed.
She would be advised that HbA1c will not be used for monitoring glcaemic control during the pregnancy as there is a physiological fall in the HbA1c and a normal reading will not necessarily mean good control.
If she is vomiting or feels unwell she will be advised the check her blood glucose and contact diabetic nurse to determine if her insulin dose has to be adjusted.

c) Both maternal and fetal considerations will be taken into account to determine the time and mode of delivery necessary for the best pregnancy outcome.. Usually it is a combination of factors that are important.
Good control of diabetes is one factor. If there good control, there are no maternal complications, fetal wellbeing has been confirmed and there is no evidence of fetal macrosomia, induction of labour at 38-39 weeks is appropriate.
Complications in pregnancy leading to deteriorating maternal condition is another factor.
Evidence of fetal compromise will also prompt delivery sooner than term.
If an maternal or fetal complications occur at around 36 weeks, the mode of delivery will depend on the clinical condition of mom and/or baby. The safest route of delivery will be used.
Caesarean section will be recommended if there is fetal or maternal compromise prior to 34 weeks.
One previous caesarean section is not an indication for repeat caesarean section but risks and benefits of each will be discussed.
The patient\' s wishes is an important factor in deciding the time and mode of delivery.
Posted by AFSHEEN M.
A 25 year old woman with a 15 year history of insulin-dependent diabetes mellitus is referred to the antenatal clinic at 12 weeks gestation. (a) Describe the assessment that you would undertake during this visit [10 marks]. (b) Describe the advice that you would give her regarding the monitoring of blood glucose concentrations [6 marks]. (c) Discuss the factors that will influence your decision on the timing and mode of delivery [4 marks


A- Initial assessment should include detailed history,examination of relevant body systems nad conducting necessary investigations and planning antenatal care.
History should include whether blood glucose control has been optimal in the past few months;also whether she has encountered any episodes of hypo or hyperglycemia or been admiited to the hospital with any adverse features.I would also ask specific questions about multi system involvement including renal,ophtlamic ,sensory and peripheral vascular symptoms.
Examination should include measurement of height,weight and calclulation of body BMI.BP should be checked, urine dipstick recorded for evidence of proteinuia.Presence of any proteinuria necessiates further renal function investigations.If any sensory or peripheral vascular symptoms present, full neurologiacl assessment should be conducted.Ophthalmic examination to exclude retinopathy should be arranged.Bloods including FBC to check for anemia, U&Es, LFTs as baseline should be organised.
Mutidisciplinary team involvement with diabetic team should be arranged throughout the pregnancy.


B-She should be made aware of the importance of optimal blood glucose control during pregnancy.I would make sure that she is aware of self injecting insulin at home.Also, I would check whether she and her partner is aware of the symptoms of hypo and hyper glycemia and their appropriate treatment.Symptoms of hypoglycemia include dizziness, headache,feeling faint and tremors. She must have a biscuit or fruit if such symptoms occur.She should be provided with blood glucose strips to check her pre and post meal levels.She should also have ketone strips at home to check her urine for ketones.She should be aware that insulin requirements increase during concurrent illnessor infection.

C- Factors influencing include general health of the woman pre pregnancy, any concurrent morbidities such as renal or retinal involvement,blood glucose control during the pregnancy,BP control throughout the pregnancy,size and estimated fetal weight.
If the blood glucose control is good, no co morbidities and baby is growing well, she should be induced electively between 38 and 39 weeks.However,if the estimated fetal weight is more than 4.5 kg, caesarean section should be offered.
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Posted by Seham S.
(a)DM is one of the common medical problems that affect pregnancy outcome and maternal health as well.pregnancy can affect the course of DM also. As she came at 12 w full history regarding other medical problems,previous preg. insulin dose ,any recent renal or retinal assessment done in last 12 m.examination of BP,pulse,tem.,eye exam,chest and heart ,abdominal exam. then investigation should include routine one which are FBC,U&E,urin for protein and glucose,ketone.also serological tests,kidney functions,liver functions.HBA1C for glycaemic control in last 3 m.then U/S for gestational age,fetal viability,chorionicity.referal to endocrinologist for insulin dose adjustment and follow up.follow up with diatition for diat regulation.this patient should be counselled regarding effect of preg. on the disease and effect of disease on course of preg. regarding maternal and fetal complications as increase incidince of 1st trimester miscarriage,cong. anomalies,IUGR, Preterm labour.stillbirth,macrosomia,instrumental deliveries and CS.

(b)regarding monitoring of glucose level;after adjustment of insulin dose in 1st trimester follow up in close antenatal visits every 2 w in high risk preg clinic for FBS and 2 h PP. patient at home should follow her self by checking blood glucose level before and after meal and before bed time.if patient feel unwell she should check her keton level for ketoacidosis and her partener or family should be aware about managment of these complication.glucagon should be given in such case.

(c)timing of delivery depend on glycaemic control throughout preg.in case of good glycaemic control induction of labour after 38 completed weeks could be done .if there is macrosomia ( f.wt >4.5) or there is any other obstetric indications CS can be done.
in case of preterm labour,corticosteroids could be given with increasing insulin dose. after delivery insulin dose should be decreased to before preg.
baby of diabitic mother is liable to hypoglycaemia,hypocalcaemia,jaundice,polycythaemia and neonatologist should be informed to attend delivery . contraception can be discussed before discharge and follow up visit at 2w and 6w could be arranged.