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MRCOG PART 2 SBAs and EMQs

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Essay 267 - GDM

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		Posted by H H. Wed Jul 9, 2008 05:22 pm
She is told that she is at high risk of gestational diabetes (GD)(diabetes occuring only during pregnancy),as she is 39 y old ,has BMI of 40 and is multipara.This can be controlled during pregnancy usually by diet but may need insulin.She will have a glucose tolerance test when she is around 24-26 wk to diagnose it.This would include giving ,while fast, 75 gram glucose then doing serial hourly bood glucose. She is told that GD is liable to recurre in subsequent pregnancies and she is at higher risk of developing non insulin dependant diabetes later in life. Control during pregnancy is important for fetal wellbing and to help prevent macrosomia and polyhydramnios. The mother will need control of her GD which if not controlled with diet will need insulin.She is at risk of hypoglycemic attacks if insulin dose not adjusted.She is also at risk of dibetic ketoacidosis if given drugs like corticosteroids for fetal lung maturity.If GD not controlled, fetal macrosomia can occur with its problems difficult labour ,with increased instrumental delivery and shoulder dystocia. Caecarean section would increase with associated increased risk of wound infection and use of antibiotics and more stay in hospital and increased cost implications on the NHS service.There would also be icreased risk of polyhydramnios with increased risk of malpresentations, preterm labour with associated preterm neonate with its problems, premature rupture of membranes with increased risk of cord prolapse and premature separation of placenta, and atonic post partum hemorrhage. The neonate is liable to to trauma during labour, hypoglycemia hypomagnesemia , jaundice and RDS. All these can be prevented by following local guide line and protocols which are always audited in a multidisciplinary care manner including dibeitologist, obstetrician ,GP ,midwife and social worker. Start control with the help of ditician , if no control within 2 weeks or if there evidence of macrosomia , patient should be controlled with insulin.Good glycemic control should be maintained with the help of diabeitologist. If control not achieved with insulin admit and control which might include , using insulin glucose sliding
		Posted by Manoj M. Wed Jul 9, 2008 08:42 pm
a. Explain to her the reason for referral is increased risk for gestational diabetes in her current pregnancy because she has risk factors which include her age 39yrs and her BMI 40. Also explain gestational diabetes mellitus (GDM) is a condition with carbohydrate intolerance that begins or is first recognised during pregnancy and in most cases resolve after pregnancy. If this condition is undiagnosed or poorly controlled this increases maternal morbidity and mortality (associated with obesity) and also perinatal morbidity and mortality. With early recognition and diagnosis we can significantly improve her risk with current pregnancy with adequate management and control of GDM. She will be offered a selective screening called oral glucose tolerance test(OGTT) and this should be performed between 28 and 32 weeks gestation, explain this is a simple test involving blood sugars tested with her fasting state and followed by oral intake of specified glucose and testing blood sugars and I will provide her with written information regarding GDM and OGTT. B. I will tell her the maternal implication of GDM is that she is at high risk for pre-eclampsia and pregnancy induced hypertension for this reason she should have her blood pressure and urine check atleast fortnightly and treat blood pressure if necessary. She is at risk for recurent vulvo vaginal infection and treating this may reduce her risk for preterm deliveries. There is increased possibility of obstructed labour mainly with big babies and increased incidence of operative deliveries (ventouse/ forceps/ Caesarean section)and also regarding possibility of long term development of diabetes mellitus. She should be explained regarding fetal and neonatal implications involved including macrosomia, polyhydramnios, preterm labour, traumatic delivery, unexplained intrauterine death and neonatal respiratory distress syndrome and neonatal complications like jaundice, polycythemia, hypoglycaemia, hypocalcaemia and hypomagnesaemia. Her survelliance in this pregnancy will be increased (twice weekly untill 32weeks and then weekly ANC or more if uncontrolled GDM) and under Concultant care preferably with special interest in Diabetes with multidisciplinary team involving diabetic specialist doctors and nurses. She will be closely monitored for optimum blood sugar control and implications for regular blood sugar monitoring for optimum outcome. Also regarding implication of testing blood sugars after delivery between 6weeks - 3 months to find occult type2 diabetes mellitus and long term implications of same. C. Her treatment options are to aim for normoglycaemia which is associated with good maternal and perinatal outcomes. Firstly diet control with nutritional intervention by dieticians and multidisiplinary team with obstetritian, diabetologist/physcian, diabetic nurse and midwives, if this does not control blood sugars in 1-2 weeks start Insulin therapy with short acting ones during daytime and long acting ones at night, newer insulins have better profile with usage and sugar control depending on availibility. Teach her regarding blood sugar monitoring and diary maintaing, also teach regarding administering insulin with use of different needles and devices and emphasis on safe sharp disposal. Her treatment in labour will involve sliding scale insulin and stop insulin after delivery. Also advice to monitor blood sugar postnatally if breast feeding due to risk of hypoglycaemia for mother.
		Posted by Asma kamal K. Thu Jul 10, 2008 12:13 am
(a) I will inform her that she needs testing for gestational diabeties mellitus(GDM) in view of her BMI.i will give her information regarding GDM and the tests for it so that she can make informed choice and consent for the tests.GDM affects 2-5% of pregnancies.in 2/3 of cases GDM responds to exercise and simple adjustments in diet alone. 1/3 of the cases of GDM may need insulin or oral hypoglycemic drugs if diet and exercise are ineffective in controlling blood glucose concentration. diagnosis of GDM will make her undergo more frequent antenatal surveillance for her own and fetal benefit. If remain undiagnosed my lead to feto-maternal and neonatal complication like macrosomic baby with all its associated risk of induction of labour, assessed vaginal delivery and traumatic delivery both for the mother and the fetus. The test required for her is oral glucose tolerance test (OGTT).in which after 10-12 hours fast a 75g of glucose will be given to her and blood samples will be taken before and 2 hours after the glucose load. In view of her BMI OGTT will be offered to her at booking and at 24-28 weeks of gestation. if there is history of previous GDM in previous pregnancies than she should be offered OGTT at booking,at16-18 weeks and than at 24-28 weeks if previous results normal. I will provide her with written material to support my information and will document the discussion and her informed decision in the case record. (b)i will explain the diagnosis to the woman that it is the glucose imbalance that occur for the first time in pregnancey and usually disappears after it.i will tell her that GDM may effect her current pregnancy and is important regarding her future pregnancies and her life long risk of diabetes mellitus. I will inform her that usually the prognosis for mother, fetus and neonate are good. Diagnosis of GDM does not in general means greater risk for the fetus and neonate. perinatal mortality for GDM controlled on diet and exercise alone who do not require insulin is low.They usually don’t need any hypoglycemic drugs.she needs to seen by multi-disciplinary team comprising of obstetrician, dietician, diabetologist, diabetic nurse and mid wife. with good glycemic controll she does not need more frequent ante natal surveillance than is necessary for normal pregnancy.there is no increase risk of intrauterine demise hence no need to offer elective delivery around 37-38 weeks. Pregnancy can be extended up to 40-41weeks. good glycemic control during labour is very important because maternal hyperglycemia during labour will lead to neonatal hypoglycemia. she needs to be delivered in a hospital where her blood glucose can be monitored and postnatally the neonate may need admission in neonatal unit for monitoring. Postnatally there is usually no need for hypoglycemic agents (even if she needed them antenatally).there is at a very high risk for recurrence in future pregnancies (66%).there is high risk of developing non insulin dependent diabetes(NIDDM) mellitus in 70% of cases as compared to 10% risk in the normal population. there is also increase risk insulin dependent diabetes mellitus(IDDM) 5-10%.the child is more prone to adult life obesity and diabetes mellitus. (c)good glycemic control means blood glucose fasting less than 6mmol/l and 1 hour postprandial less than 8 mmol/l .in GDM this can be achieved with dietery adjustment in consultation with dietician.a diet with 40 -50% low glycemic index carbohydrate to prevent postprandial hyperglycemia.well balanced poly unsaturated and mono unsaturated fats and lean proteins like fish oils.according to her BMI 24Kcal/kg/day intake with aim of 25-35pounds weight gain. moderate exercise for 30 min can help to manage good glycemic control. If these measures fail to achieve desired glycemic control for 1-2 weeks or the fetus shows signs of macrosomia that is abdominal circumference at the 70 percentile(which may be difficult to estimate and may be un reliable in view of morbid obesity) hypoglycemic agents can be started in consultation with a diabetologist.oral hypoglycemic agents like metformin or glybenclamide or rapid acting insulin analogue like aspart and lispro can be sarted.
		Posted by g.b. D. Thu Jul 10, 2008 01:53 am
obesity and age of 39 are high risk factor for development of gestational diabetes.the woman should be counselled that she is at high risk of developing it and will need regular attendance to antenatal clinic.the visits may be frequent than for a normal woman. she will need a screening test for gestational diabetes. it is a blood test with 75 gms of glucose at 16-18 weeks. this test will be repeated again at 26-28 weeks even if the first test is normal. she will also need urine routine tests at every visit for sugar and proteins. In view of her age she is at high risk for aneuploidies and shall need a integrated test for the same.the risk is increased with abnormal glucose homeostasis during the first trimester. it should be emphasised that gestational diabetes if diagnosed early and welll controlled has very low risk of complications. the fetal complications include macrosomia, polyhydramnious, anmalies,malpresentations, prematurity. she should be told in layterminalogy that there is also a risk of leak amniotic fluid and cord accidents and increased perinatal morbidity and mortality. she should be told that the baby will gain more weight and will be difficult to deliver. the possibility of prolong labour, instrumental deliveries and delivery related trauma increases. after delivery the neonates are at risk of hypoglycemia , jaundice,hypoclacemia and feeding difficulties. the maternal complications include increased risk of preeclampsia, polyhyadramnious causing maternal discomfort, urinary and vaginal infections like candidiasis. this may lead to preterm rupture of membranes and preterm labour. traumatic or instrumental deliveries pose increased risk of anal and urinary incontinence after delivery. there are increased chances of operative delivery, need of anesthesia and post partum hemorrage due to overdistended uterus. the financial implications of frequent hospital visits for monitering,off from work,and insulins and investigations are also to be mentioned. a lot of cooperation will be needed from the partner in view of 4 previous children back at home during hospital stay and visits. good glycemic control can be achieved with diet, regular exercise, lifestyle modification and insulins if necessary. she should be advised to take sugar free, low fat and high fibre diet. a meeting with dietician should be arrranged for detail advised she will give a diet chart with calculated calorie intake of about 30 kcal/kg/day. regular light exercises like walking and antenatal exercises should be encouraged. she should be made aware that immobility increases her risk os venousthrombosis especially in view of obesity. regular monitering is essential to ensure good control. she should be called for 2-4 weekly visits to hospitals to moniter blood glucose levels. 6 readings with pre and post meal readings are more informative. if the sugars are not well controlled than she may need insulins. she should be educated on the topics of self insulin administration, self home blood glucose testing and compliance to treatment. information leaflets can be of very informative and educative to reenforce our advises. she should be told to mantain a glucose insulins and diet chart at least 2 times a week.her treatment should be in liason with diabetologist and dietician. proffesional support ,regular encouragements and counsellings are necessary for compliance to diet and treatments.
		Posted by Farina A. Thu Jul 10, 2008 07:16 am
a)I would like to inform about the possible risk she can have during this pregnancy due to her advanced age, multiparity and high BMI. The risk are both maternal and fetal. Around 17% of obese mothers develop GDM compared to 1-3% in people with normal BMI. The risk of PIH increases to 14-25% and the risk of preeclampsia doubles with each 5-7 kg/m2 increase in BMI. Patient is at risk of developing cardiovascular disease and metabolic syndrome in her future life. The rate of misscarages is also increase in obese elderly patients. The risk of NTD increases by 7%. Down syndrome screening can be affected because of obesity. This patient can be classified as at high risk for thromboembolism and wound infection. The fetus may suffer from macrosomia and requirement of CS for a microsomic baby. The midwife can face difficulty in monitoring her BP and a separate cuff may be needed. The clinician can face difficulty in assessing the fetal growth at clinical examination and transabdominal ultrasound so she may need a TVS for proper fetal assessment. Fetal presentation may need to be determined by ultrasound at term. During labour fetal scalp electrode monitoring may be required because of thick abdominal wall. Risk of prolong labour obstetric trauma and shoulder dystocia are increased. Weight loss is not advised during pregnancy however she can be reffered for a minimum weight gain to a dietician. b)Once she is diagnosed as gestational diabetic I would like to inform about the risk to mother and the fetus. The mother can have PIH, pre-eclampsia, diabetic ketoacidosis, hyperosmolar coma, treatment induce hypoglyscemia, preterm labour and infectious morbidity. Risk of delivery by CS is high in case of macrosomic babies and labour may need to be induced at around 38wks. As far as this patient is suffering from GDM, risk of fetal congenital anomalies is minimum. However parinatal mortality and morbidity due to IUGR macrosomia, and preterm labour is increased. The neonate can suffer from RDS, hypoglycemia, hypocalcemia and polycythemia. She will require frequent antenatal visits in a joint obstetrical and diabetic clinic. Patient should be provided with written information. c)A good glycemic control requires a good compliant patient and close liaison with the diabetologist. She should be provided with the diet chart and appointments with a dietician. Subcutaneous insulin is the treatment if only the diet control is not effective. There are various methods of calculating the dose of insulin, one of them is to start a sliding scale and calculating a total requirement and then divide the total requirement in fixed morning and evening regime. The other way is to calculate the requirement per kg body weight that is 0.8 u/kg in first trimester, 0.9 u/kg in second trimester and 1 u/kg in third trimester. Recent evidence with oral hypoglycemics ( metformin and glybenclamide) have not proven any drug induced fetal malformation but the drugs are still not licensed for the use in pregnancy informed consent should be taken before commencing oral hypoglycemic. Mode of delivery decided at 38 weeks with insulin glucose regime during labour and 2 hrs blood gloucose monitoring ( frequency of blood gloucose monitoring depends upon the level of control). Postnatal blood sugar levels and a follow up appointment after 6 weeks with GTT to rule out development of diabetes in future is required.
		Posted by Anna L. Thu Jul 10, 2008 07:49 am
A I will explain to her that she has a very high risk for GDM secondary to her obesity. I will point out the extra risk from undetected DM (poor glycaemic control/ketoacidosis, fetal macrosomia, IUD) and the benefits of testing and treatment (if needed)I will explain to her that she significantly reduces the risks for poor pregnancy outcome with a good control of her bloodsugar. I will offer her a OGTT with 75mg Glucose between 24-28/40, explain the test to her in detail (two blood tests within two hours, NBM for 6hrs prior test) and provide wrítten information. I will explain that a negative test may be repeated later but that it is less sensitive after 34/40 secondary to delayed gastric emptying. I will inform of the implications of a positive test with increased risk of intervention (treatment of GDM, fetal surveillance and increased risk for IOL/CS). I will give her general health advise regarding healthy diet, exercise and the need to minimise weight gain. As well as explaining possible technical difficulties in managing her pregnancy. B This morbidly obese grand multipara patient with severly Increased risk for maternal and fetal morbidity/ mortality should have consultant led care. I will explain to her that she needs intensive AN care,and advise on delivery in hospital. The pregnancy should be managed in a multidisciplinary team with special obstetric diabetic clinic/joined with endocrinologists/diabetic MW/GP . I will educate her regarding the need for compliance and strict personal glucose control to minimise risks for mother and baby. An individual plan to maintain stable blood glucose levels must be made and documented in the notes (Aim for HbA1c<6.1%, measure BMs pre and postprandial, need for diet/Metformin and or Insulin). I will warn her regarding hypoglycaemic episodes and provide glucometer/glucagon/family information leaflet /urine dipstix for ketones if on Insulin treatment. I will explain the need to monitor the baby with regurlar growth scans (28, 32, 36 weeks gestation) because of the risk of fetal macrosomia. I will exaplin her increased risk for intervention with IOL at 38 weeks and higher risk for CS secondary to AN fetal concerns, poor diabetic control or intrapartum problems. In labour he needs continous monitoring because of increased risk of fetal distress. There is an increased risk for shoulder dystocia. She may need a sliding scale in labour to prevent hypo or hyperglycaemic events. Insulin can usually be stopped after delivery. Regional anaesthesia is safe and an antenatal referral to anaesthestist is advised. I will point out the risk for neonatal hypoglycaemia and the need for early feeding. Mother and baby should be monitored at least 24hrs post delivery. I will explain the increased risk of VTE ante and postnatally and offer prohylactic Clexane antenatally with other risk factors ( immobility, Family history of DVT) and at least 3 days PN. I will explain her increased life time risk for DM and the need to ckeck nil by mouth glucose levels 6/52 post delivery. C A low sugar, low fat diet with products of low glycaemic index may control glucose levels in mild GDM. Regurlar Exercise increases Insulinsensitivity. Control may be achieved by Metformin which is safe to use on pregnacy, this may be used alone or in conjunction with Insulin. Insulin therapy is usually best with a basis-bolus regime of long and short acting Insulin. Pre prandial BMs should be between 3.9 and 5.9, post prandial levels <7.8. Insulin needs to be given sc and teaching is mandatory. With very poor control an Insulin pump may be considered.
		Posted by N K. Thu Jul 10, 2008 08:27 am
(a) What information would you give her prior to testing for gestational diabetes mellitus? [8 marks] First of all I will explain the condition i.e. condition arising in pregnancy and if detected and treated early (glycaemic control), risks associated such as macrosomia, ployhydramnios, shoulder dysticia, trauma to mother and fetus, still birth, neonatal problems and death could be reduced. She needs the test because she is at high risk of developing this condition because of her BMI and it is the national policy (NICE guidance) to screen women over the BMI of 30. Good glycaemic control can be achieved by diet and moderate exercise in most women. If this fails, she may require oral hypogyceamic (metformin, Glebenclamide) or insulin for control. If diagnosed of GDM there increased incidence of monitoring and interventions during pregnancy and labour (induction, caesarean section) She will also need explanation about the test – which is done from 24-28 weeks and it involves a fasting blood sugar followed by 75g sugary drink and a blood test in 2 hours. These results will be interpreted as per WHO criteria and she will be informed once the results become available. Written information on glucose tolerance test will be provided. (b) She is found to have gestational diabetes at 26 weeks gestation. What will you tell her about the implications of this diagnosis? [8 marks] I will advice her on the role of diet, body weight and exercise and the importance of glycaemic control in risk (macrosomia, increased intervention, and birth trauma and shoulder dystocia) reduction throughout pregnancy. I will also stress the importance of glycaemic control during labour and birth and the importance of early feeding to reduce the incidence of neonatal hypogycamia and the possibility of transient neonatal morbidity which may result in admission to neonatal unit. There is also a risk of the baby developing obesity and or diabetes later in life. She needs to be informed that she will require a fasting blood sugar 6 weeks post natal and annually thereafter to watch out for the possibility of developing diabetes and she will require early screening or self monitoring for Gestational diabetes in subsequent pregnancies. (c) What will you tell her about the treatment options to maintain good glycaemic control? [4 marks]. Initially she will be advised on diet (low carbohydrate low calorie diet – 25kkcal/kg/day) and moderate exercise. If this failed to control or macrosomia is suspected she will need to be initiated on hypoglycaemic medication which either be oral hypoglycaemics (metformin/glebenclamide) and or insulin (regular/rapid acting insulin analogues – aspart/lispro) tailored to her glycaemic profile and individual wish.
		Posted by J P. Thu Jul 10, 2008 09:00 am
a.I would tell her that in view of her age and BMI 40 kg/metre square she is at risk of develping gestational diabetes.2 hour oral glcose tolerance test is widely used for screening for gestational diabetes in UK.The cut off values are fasting blood glucose >5.5 mmol/l and 2 hour value >8 mmol/L for diagnosis of gestational diabetes.Urinary glycosuria or testing fasting and random blood glucose are of not value for the diagnosis or screening.If the values are normal ,the test will be repeated again in 24-28 weeks. I will also tell her that there are some maternal and fetal risks in gestational diabetes but also reassure her that it can be reduced by achieving optimum glycemic control.Optimum control of glucose can be attained by diet and exercise alone but in some cases where it could not be achieved in 1- 2 weeks insulin or metformin has to be added. b.I would tell her about the maternal and fetal risks in gestational diabetes like macrosomia,polyhydramnios,preterm delivery[iatrgenic and induced],PIH,recurrent maternal infections like boils and thrush,shoulder dystocia,increased rate of induction and caessarean delivery,perinatal mortality,transient neonatal morbidity like hypoglycemia,obesity ,diabetes risk in later life for mother and baby.I would reassure that these risks can be reduced by achieving optimum glucose level of 3.5-5.9 mmol/L fasting value and ihr post prandial value <7.8mmol/L.Targeted glycemic control can be attained by self monitoring 1 hour post prandial value.This can be usually attained by diet and exercise alone but in some case where control not achieved needs insulin.The diagnosis also mean she should have more frequent visits,USG monitoring for growtth and liquor every 4 weeks from 28 weeks.Tests of fetal being to be done only after 38 weeks if growth is normal.IF managed by diet alone she can be allowed to proceed till terrm if there are no other complications otherwise elective indution or c/s at 38 weeks.Delivry sholuld be managed in the hospital where 24 hour neonatal facilities are available because of neonatal morbidity.Information leaflets to be given c.Treatment must be a multidisciplinary approach consisting of obstetrician,dietician,midwife,physician.Diet and exercice should be tried first. Weight loss is not an ideal option in pregnancy.Diet should provide ideally 25 kcal/kg body weight for this woman which should comprise as 40-60% carbohydrate,20-30% protein and the rest fat. Insulin has to be added if adequate glycemic control not achieved in 1-2 weeks by diet and exercise alone or the USG done shows abdominal circumference more than 70 th percentile.Rapid acting insulins like aspart and Lispro or regular insulin or metformin can be used.Other oral hypoglycemics are contraindicated in pregnancy.Patient is to be informed of the side effects of insulin-hypoglycemia and of metformin like abdominal pain ,vomiting and diarrhoea if used.Moreover informed consent and documentation is to be done when rapid acting insulin or metformin is used since these are not licenced for use in pregnancy in UK.
		Posted by Priti T. Thu Jul 10, 2008 09:29 am
a]Gestational Diabetes mellitus[GDM] affects 2-5% of pregnancies.In poorly controlled GDM ,The perinatal mortality is 4 times that in uncomplicated pregnancies.Patient has a risk factor already of BMI 40kg/m2 . She should be asked in obstetric history about any previous stillbirth,history of macrosomic baby more than 4.5kg,previous gestational diabetes.Family historyof Diabetes mellitus in a first degree relative is important risk factor.Her ethnicity if she belongs to South Asian/Middle east/Carribean makes her more prone to GDM.Patient having any one of the above independent risk factor should be screened for GDM at the booking;in order to make the informed decision about the screening and testing the women should be informed that the most women respond to diet and exercise and have good pregnancy outcome with good glycaemic control. 10-20% of women will need oral hypoglycaemic/insulin therapy if diet and exercise are not effective in controlling GDM in 2 weeks time.Uncontrolled GDM has a risk of shoulder dystocia due to foetal macrosomia;it also leads to increased monitoring and intervention both during pregnancy and labour She should be given written information about the same.Patient shold have screening with OGTT 75 mg -2hours at booking ,followed by repeat ai 24-28 weeks if normal. b] Diagnosed GDM at 26 weeks,it carries increased complications for both mother and the foetus.The various implication of this diagnosis should be explained to the patient and the written information given.MATERNAL implications are the following:- due to GDM mother has increased risk of pre eclampsia and pregnancy induced hypertension;hence B.P. and Urine for proteinuria should be checked at each antenatal visit.There may be increased incidence of vulvovaginitis/boils or candidiasis;this should be treated promptly. There can be obstructed labour in mother due to foetal macrosomia and increased incidence of operative interventions in the form of ventose/forceps delivery or the caesarian section.In addition to these complication,the mother should also be informed of the long term implications of GDM.There is 66% recurrence of GDM in next pregnancyand 70% lifetime risk of Diabetes mellitus type 2.There may be 10% risk of IDDM also.She should change her lifestyle accordingly post delivery;try to reduce her weight and have OGTT 75mg 2hrs at 6 weeks postpartum. FOETAL implications:- Various foetal complications like foetal macrosomia,polyamnios can occur if the glycaemic control is in adequate in GDM.There is also danger of unexplained IUD ,preterm labour ,RDS and traumatic delivery.Neonatalogist should be informed at the time of delivery as the neonate may require admission for few days.Post delivery neonate may suffer from hypoglycaemia,jaundice,polycythemia,tetany,hypocalcaemia and hypomagnesaemia.All these problems can be managed by trained neonatal staff and the paediatrician with good outcome for the baby. c]Good glycaemic control is the key to decrease maternal and foetal morbidity.women should be instructed in self monitoring of glucose.Targets for the blood glucose control should be determined in the same way as for the women with pre existing diabetes i.e. 3.5-5.5mmol/L fasting and less than 7.8mmol/L one hour post prandial.They can be monitoted twice a day for mild GDM or increased upto 4 times if required. Treatment plan should include advice about diet/exercise and drug therapy.Dietician should be consulted and the written diet plan given to the patient in view of obesity.She should restrict her calories to 25kcal/kg/day and have moderate exercise of 30 minutes daily.the composition of diet should be 40-60% carbohydrates[200gm/day] and 20-30% of proteins;the remainig fats like poly or mono unsaturated fatty acids.During pregnancy there is accelerated starvation and hence 3 meals and 4 snacks,with the last snack at the bedtime is recommended to minimise starvation ketosis/hypoglycaemia. Hypoglycaemic drug therapy should be considered if diet and exercise fail to maintain blood glucose targets within 2 weeks or incipient foetal macrosomia[abdomonal circumference above 70 percentile ] at 29-32 weeks. Hypoglycaemic therapy includes regular insulin/rapid acting insulin analogues and oral hypoglycaemic agents like metformin,glibenclamide.Treatment should be tailored to the glycaemic profileand the acceptability of the individual women.
		Posted by hoping .. Thu Jul 10, 2008 09:56 am
A 39 year old woman is referred to the antenatal clinic at 12 weeks gestation in her fifth pregnancy. She has a BMI of 40 kg/m2 but no other significant medical history. (a) What information would you give her prior to testing for gestational diabetes mellitus? [8 marks] (b) She is found to have gestational diabetes at 26 weeks gestation. What will you tell her about the implications of this diagnosis? [8 marks] (c) What will you tell her about the treatment options to maintain good glycaemic control? [4 marks]. i would gather more history from her with regards to her previous pregnancies and family history of diabetes. prior to testing for gestational diabetes mellitus she should be informed that in view of her high BMI she is at increased risk of developing diabetes in pregnancy which is associated with increased risk to her and baby. early diagnosis and treatment improves pregnancy outcome. when well controlled most pregnancies have good outcomes. screening is advisable using oral glucose tolerance test at 26 weeks of gestation. she needs to be fasting overnight but can have water. two blood tests at begining and 2 hours after sugar drink would be obtained and evaluated against set criteria.if test is normal on this occasion, it shall be repeated at 32 weeks as late onset is common. she should be advised to eat healthy balanced diet and maintain usual activity levels. weight loss is not advisable in pregnancy. increased BMI also increases risk of preeclampsia and thrombosis. baby is at increased risk of congenital anamolies and chromosomal anamolies due to her age. serum anamoly screening is less accurate for high BMI, nuchal translucency has better sensitivity but may require trans vaginal scanning. information should be reinforced with written material. gestational diabetes diagnosed means that she would need close surveillance. her blood glucose levels should be maintained between 4-8 mmol ideally as near normalglycaemia improves outcome of pregnancy. she may need insulin to acheive this. dietician and diabetic team input is of utmost importance. she is at increased risk of developing preeclampsia. baby is at risk of macrosomia which inturn increases risk of shoulder dystocia and operative delivery. polyhydramnios increases risk of preterm labour and cord prolapse. after delivery there are increased risks of baby being admitted to neonatal unit. baby is at risk of hypoglycaemia and hypocalcaemia . baby is also more likely to develop jaundice and hypothermia. respiratory distress syndrome is more common in babies born to diabetic mothers. she is at increased risk of developing type 2 diabetes in later life. good glycaemic controll is most important step in her management. this should be done in conjunction with diabetologist, specialist nurse and dietician. first option is eating healthy balanced diet . if diet control is not sufficient insulin should be considered. this should be spread over four times a day with short and intermidiate acting. she should record her blood glucose levels atleast four times a day . she should be given contact numbers to call if levels start to creep up or she gets frequent hypos. patient declining insulin could be given metformin to optimise blood glucose.
		Posted by Iffat ara M. Thu Jul 10, 2008 09:11 pm
a):First of all I will take detail history regarding previous H/O GDM, any previous macrocosmic baby, any previous stillbirth, family H/O DM. Then in view of her increase BMI >30+ increase age>35y I will explain her you are coming in high risk gp for GDM, so I will reasure her this is a condition which is carbohydrate intolerance that begin or recognize in pregnancy and most cases recover after delivery, so it is associated with increase perinatal mortality and morbidity. which are related to congenital abnormalities, still birth, prematurely obstructed labor,birth trauma, neonatal hypoglycemia, jaundice- so early diagnosis & early treatment is associated withd out come. So you need to have a OGTT in which you will have to be fasting 12hrs then FBS will be taken for & then you will be given 75gm of glucose ….& your 2hr PP BS will be checked. If GDM will be diagnosed then you have to attend antenatal clinic regularly and your cooperation is must. As good glyceamic control can easily achieved by controlling weight, by proper diet, e.g you need 25K cal/kg per day and moderate exercise , so you need serum screening, anomaly scan at 2o wk, OGTT at 28wk, growth scan form 28wk on wards, Biophysycal profile and we will given her written information. b): Regarding implication of diagnose, I will explain her the early implication( on offspring congenital abnormalities, macrosomia, RDS, polycythemia hypocalcaemia jaundice & later in adult life obesity DM, HT. on mother there are early & late implication. So in early implication she will have anxiety about disease & baby. increase wt gain, PET, operative delivery, high chances of C.section. In later implication she is prone to have type 2 DM, hypertension & cardiac Disease. c): regarding treatment I will tell her importance & involvement of MDT which involve diabetist, endocrinologist, diabetic specialist nurse & clinician. So she should be determent to attend all these appointments for good glycemic control.so I will explain about 2/3 of GDM respond to simple diet control & moderate exercise & she should take 25K cal/kg daily & should take three meals & in between 3 snacks to avoid ketoacidosis which is more frequent in diabetes. I will explain the S/S of hypoglycemia. if Even after diet control, still there is uncontrol diabetes & EFWt more then 70centile so she will be offered insulin which may be rapidly acting like lispro & aspart or may be long acting . other options like glibenclamide and metformin can be consider if no response to insulin.
		Posted by Sam M. Fri Jul 11, 2008 05:37 am
Part a. I will explained to her that because of her age and weight and any of the following important riskfactors in her past history like in previous pregnancies baby weighing more than 4.5 kg ,or gestataional diabetes in previouse preganancies,diabetes in first degree relative ,her ethnic origin ,(south asian ,afrocarrabian middle east ) are significant because any of these risk factor makes her a candidate for screening for gestational diabetes. gestational diabetes is disease which is associated with pregnanacy and complete recovery occur after pregnancy. ,if its not controlled it can lead to problems in pregnancy ,labour and purpeurium to mother and fetus /newborn .in most of the cases simple exercise and diet can control the condition but 10% may need hypoglycaemic agents for better control .she will be explained about 75 oral glucose tolerance test as best in diagnosis of diabetes. Even in absence of other risk factors keeping her weight in mind she should have OGTT between 24 and 28 weeks.tto exclude established diabetes mellitus which might not be diagnosed prior to pregnancy ,she will need a further OGTT 6 weeks post partum. Part b .i will informed her there is risk of congenital she is also at risk of recurrent urogenital infections,uncontrolled diabetes increases risk for miscarriages, sudden fetal death ,macrosomia ,polyhaydramniose and its complications as (preterm labour ,malpresentations ,sudden rupture of membranes resulting in cord prolapse and abruption ,overdistended uterus can cause pph),with fetal macrosomia (,prolonged labour and difficult delivery especially risk of shoulder dystocia .she must be told. There is increase risk of preterm delivery which can cause respiratory distress syndrome ,necrotising enterocolitis, intracerebral haemorrhages ,hypothermia in new born ,. there is risk of caesarean section for fetal macrosomia for estimated weight more than 4.5 kg.new born could be at risk of hypoglycaemia ,hypocalcemia ,hyperbilirubinemia ,polycythemia, risk of hyper or hypoglycaemia which in their sever forms need hospital admission and inpatient treatment as hypoglycaemic coma and diabetic ketoacidosis respectively,.she can have diabetes mellitus later in life,cardiac disease.newborn can also have diabetes and obesity in life.she should be informed about self glucose monitoring .frequncy of her visits ,importance of congenital anomaly and cardiac scanes.she will be explained about the labour ,induction or caesarean section according to individual circumstances. Part c. Her management will be done in collaboration with dietician ,endocrinologist ,diabetic specialist nurse and her GP.she will be started with exercise and diet control . as her bmi is 30 kg/m2 so she needs no more than 25 kcal /kg/day.carbohydrates with low glycemic index ,more fish and poly unsaturated fats preferable.and if no improvement in 1-2 weeks then hypoglycaemic agents ,insuline /oral hypoglycaemic agents will be started ,she requires every 2 week visit till 32 weeks and then weekly , blood sugar monitoring at home by her ,how and when to be done will be explained.
		Posted by H P. Fri Jul 11, 2008 06:20 am
(a) I would inform her that in view of her BMI of 40 kg/m2, she comes under the high risk group for development of gestational diabetes mellitus (GDM). I would tell her that GDM is a condition of carbohydrate intolerance first recognized during pregnancy, however, most resolve after pregnancy. I would offer her to be screened for GDM in the form of oral glucose tolerance test (OGTT) at 24-28 weeks. It would be repeated after 4 weeks, if it is normal. I would inform her that there is a small risk of birth complications if GDM is not detected and controlled. GDM will respond to change in diet and exercise in most women. Oral hypoglycemic agents or insulin may be needed in about 10-20% women. Extra monitoring and care may be needed during pregnancy and labour. To help her make informed decision regarding the test, I would give her information leaflets. I would also inform her that the screening test will involve checking her blood sugars while she is fasting and then twice hourly after drinking 75gm of specified glucose solution. In view of her weight, she may want to start controlling her diet and doing some exercises. An appointment with dietician should be arranged to guide her to restrict her caloric intake to <25 kcal/kg/day. (b) Her management will require a multidisciplinary approach involving senior obstetrician, diabetologist, dietician and specialist midwife. She should have an immediate referral to a joint diabetic and antenatal clinic and should be followed up every 1-2 weeks to assess glycaemic control. An appointment for scan should be arranged at 26-28 weeks and then serial fetal growth scan every 4 weekly to detect fetal effects (macrosomia) and liquor volume. I would inform her that GDM has risk to her and her baby in the form of fetal macrosomia, birth trauma( to her and the baby), induction of labour, caesarean section, transient neonatal morbidity requiring admission of intensive unit, neonatal hypoglycemia and perinatal death. The child may develop obesity and diabetes later in life. She should be counseled to start dietary measures and exercises if not already started. The diagnosis of GDM implies that she would need further monitoring and intervention in the form of frequent appointments, daily blood glucose monitoring and more frequent scans. Most (80-90%) of the women will achieve target blood glucose levels by diet and exercise alone. She will need to deliver in hospital based set-up with advanced neonatal skills available 24 hours a day. After delivery, the child should be started on breastfeeding early and baby may need some monitoring to detect hypoglycemia or hyperbilirubinaemia. She will need continuous support and education during each appointment. Her partner should be involved and she may need social support to help with her other children. She should be made aware about the financial implications of her frequent visits, off from work and transport to hospital (c) She should be counseled that the primary goal is to maintain near normal glycaemic control. A carbohydrate rich diet with low glycaemic index will improve overall glucose control and reduce postprandial glucose excursions. As she is obese, moderate caloric restriction (<25 kcal/kg/day) will help without resulting in ketonaemia. With the help of dietician a proper diet plan should be charted to suit her needs. Moderate exercise (walking 30minutes/ day) in conjunction with diet will improve blood glucose control further and may reduce the need for insulin. She should be informed about self glucose monitoring which should be done fasting and I hour after eating. Targets for blood glucose should be invidualised. She should be advised to aim for a fasting blood glucose level of 3.5-5.9 mmol/l and I hour post prandial blood glucose of less than 7.8mmol/l.. Hypoglycemic therapy should be considered if lifestyle changes do not maintain blood glucose targets over a period of 1-2 weeks or if ultrasound shows incipient fetal macrosomia in the form of abdominal circumference more than 70th percentile. Hypoglycemic therapy should be tailored to glycaemic profile and acceptability of the individual woman. Regular insulin or rapid acting analogues and/ or oral hypoglycemics like metformin and glibenclamide can be started. She should be informed about the usage of these drugs in pregnancy, leaflets given and documented. When on insulin, she should be counseled regarding hypoglycemia and asked to check her glucose before sleeping. Her partner/ family member could also be informed about hypoglemia and treatment with oral glucose.
		Posted by R M. Fri Jul 11, 2008 03:40 pm
a)I’d tell her she is more likely to develop gestational diabetes mellitus or GDM (which is diabetes developing during pregnancy) considering her risk factors of high BMI of 40 , advanced maternal age &high parity. The risk is higher if she had a macrosomic baby of more than 4.5kg previously or if she had previous history of GDM; if her ethnicity is south Asian, black Caribbean or middle Eastern. I’ll offer her 2h 75g oral glucose tolerance test (OGTT) at 16 – 18 weeks if she has previous history of GDM and if the test is normal it has to be repeated at 24 – 28 weeks. I’d tell her screening of gestational diabetes using other tests like fasting blood glucose, random blood glucose, urinalysis and glucose challenge test has only poor sensitivity (around 40%). I’d also tell her that there is a small risk of birth complications and increased incidence of induction of labour and caesarean section if GDM is not controlled. GDM will respond to diet and exercise in most women. Oral hypoglycemic agents or insulin injection may be needed if diet and exercise do not control blood glucose levels. Extra monitoring of blood glucose and care of foetus may be needed during pregnancy and labour-need to be managed in a joint diabetic antenatal clinic .I’ll also tell the implications on her serum screening results if she has GDM(due to low MSAFP,hCG&estriol)and need for nuchal translucency measurement. I’ll provide her with written information. b)I’ll tell her GDM is associated with increased risks to mother and baby. Foetal risk include macrosomia, birth trauma, transient neonatal morbidity,respiratory distress syndrome, neonatal hypoglycemia, hypocalcaemia, hypomagnesaemia, perinatal death and obesity and diabetes developing later in babies life. Maternal risks include increased risk of pre-eclampsia & PIH,infections(UTI,Candidiasis etc),ischaemic heart disease, increased need for induction of labour and caesarean section, 66% recurrence risk, 70% life time risk of developing type2 DM, 5% life time risk of type1 DM (which is unmasked by pregnancy). I’ll stress on the need for extra monitoring of blood sugar and foetal surveillance-need to be managed in a joint diabetic antenatal clinic . Need for self monitoring of blood glucose and individualized targets. With good glycemic control incidence of complications can be reduced but not eliminated. I’ll reassure her that GDM is not associated with an increased risk of foetal anomaly. I’ll provide her with written information. c)I’d explain to her the role of diet, body weight and exercise in maintaining good glycemic control- restrict calories, moderate exercise and arrange consultation with dietician. Hypoglycemic therapy should be considered if diet and exercise fail to maintain blood glucose control after a period of 1-2 weeks or if ultrasound suggests incipient foetal macrosomia. Hypoglycemic therapy include regular insulin, rapid acting insulin analogues (aspart and lispro) and / or oral hypoglycemic agents (metformin and glibenclamide). Women with GDM do not require insulin after delivery. I’ll provide her with written information and support group address (Diabetes UK)
		Posted by Farkhanda A. Fri Jul 11, 2008 07:52 pm
I will check the reason of referral to antenatal clinic. She is with significant risks which can make her vulnerable to develop gestational diabetes mellitus, pregnancy induced hypertension, venous thrmboemblism and some other complications. I will do counselling and tell her risk of developing gestational diabetes mellitus (GDM) and definition of GDM. I will discuss with her dipstick urin testing in every visit to antenatal clinic but explain her that only 40 % women shows glycosuria who are diabetic or their 2 hours blood sugar level is more than 11 mmol per litre. I will offer her oral glucose tolerance test (OGTT) and explain about it. If she is agreed then I will book this test at 26 -28 weeks of pregnancy. I will also arrange anomaly scan for her and inform her that there is no risk of congenital abnormality in GDM, but at the same time I will discuss that this risk of congenital abnormality may be due to her advanced age such as Down syndrome or molar pregnancy. I will also discuss that 10 -20% women with GDM may have good control by diet and if she is with GDM then she will be looked after in combine clinic under obstetrician and physician (special interest in diabetes) care where she will be seen by dietician. B On diagnosis of GDM, she will be discussed about effect of diabetes on pregnancy and vice versa. Due to DM, there is a risk of hyperinsulinaemia in baby which can cause macrocosmia and ultimately birth trauma, increased chance of induction of labour and caesarean section. There is a risk of polyhydramnios and so preterm delivery. To check these complications, there is a need of more monitoring of baby by performing ultra sound scans to check growth at least 2 weekly and to do biophysical profile. There is a risk of developing hypertension so need to do more close eye on blood pressure. Due to advanced age and multiparty, there is a risk of deep vein thrombosis (DVT). I will advice her about mobility, good hydration and light exercise. There is a risk of polycythemia in baby and hypoglycaemia after delivery and so early feeding should be started in baby. The baby may need admission in neo-natal unit for monitoring of blood sugar level. Effect of pregnancy on Dm. GDM which was diagnosed first time in pregnancy may be temporary which will stay only in pregnancy and soon after the delivery of placenta will disappear. It may persist in few women even after delivery especially in those who need high dose of insulin in pregnancy as their true DM was unmasked in pregnancy first time. Few women develop DM in latter life. Usually in pregnancy effects of DM are transient. C I will tell her that 10-20% of women have good diabetic control by diet control. They need to take low fats and proteins contents . They ideally should take short and long acting insulin . They should check their blood sugar level pre and post breakfast, lunch and dinner. They can take oral antiglycaemic agents like metformin but there is may be nogood control and if she needs after delivery , contraindicated in breast feeding as they can cause hypoglycaemia. +
		Posted by Srivas P. Fri Jul 11, 2008 08:31 pm
(a) Her BMI >40 kg/m2 alone puts her at high risk for developing GDM. Other risk factors like prior baby >4.5Kg, prior GDM, family history of DM in 1st degree relatives and Family of origin from susceptible populations (Asian, Middle east) strengthen the high risk assessment for GDM. Informed decision should be taken from woman regarding testing for GDM. Risk assessment using potential diabetic features has 50% sensitivity and 66% specificity in detecting GDM. Screening for GDM using Glycosuria is highly sensitive but with poor specificity while measurement of Random blood sugar has low sensitivity (40%) but high specificity. These tests are not advocated for screening. 1 hr 50 gm glucose challenge test at 7.8 mmol/l threshold has high sensitivity 79% and high specificity 91% and is advocated for screening for GDM. She should be screened at first AN visit and again at 24-28 weeks. If this is abnormal a 2hr 75gm OGTT is best used for diagnostic purposes using WHO criteria. If this woman also has prior history of GDM she should be screened at first visit, 16-18 wks and again at 28 weeks. Detecting GDM is important because undetected and uncontrolled GDM result in higher risk of macrosomia with shoulder dystocia, prolonged labor and maternal injuries due to traumatic delivery. Prior detection of GDM help take earlier interventions during pregnancy and labor, decreasing both maternal and neonatal morbidity and mortality, though there may be an overall increase in Induction of labor or Caesarean sections. (b) Her gestational diabetes may disappear soon after delivery but may recur in next pregnancy. She is at risk of developing diabetes mellitus in later life which may be 36% over next 20 years and she would need screening for diabetes at 6weeks post partum and yearly thereafter. In this pregnancy if her diabetes is controlled well with diet, exercise or if necessary with hypoglycemic agents her pregnancy is likely to be uneventful with normal maternal and neonatal outcome. However uncontrolled diabetes during pregnancy puts her at risk of developing gestation hypertension and iatrogenic or spontaneous preterm labour. She is at risk of macrosomia both due to GDM and due to maternal obesity. Macrosomia may contribute to difficult vaginal delivery, prolonged labor, shoulder dystocia, maternal injuries like cervical tear and atonic PPH. Neonatal morbidities due to shoulder dystocia and difficult delivery include neonatal death, Erb’s palsy, Klumke’s paralysis, fracture clavicle and humerus. There may be torticollis due to lateral stretching of neck, facial nerve paralysis and rarely diaphragmatic paralysis. The degree of these complications depend on severity of shoulder dystocia and recovery too may range from complete in most cases to some having long term disabilities. Just like babies of frankly diabetic mothers, these babies too are at risk of RDS, hypoglycemia, hypocalcaemia, hypomagnesaemia. Baby may also have polycythemia and neonatal jaundice. Babies are also at higher risk of obesity and developing type2 diabetes mellitus later in life. c) If GDM is detected she may get controlled on diet and exercise alone but 10-20% patients may require oral hypoglycemic agents or Insulin if diet and exercise do not control the sugar levels after 1-2 weeks. Hypoglycemic therapy may also be required if USG suggests incipient macrosomia. Hypoglycemic options include regular insulins and newer insulin analogues like lispro and aspart and if still uncontrolled may be put on oral hypoglycemic agents like metformin and glibenclamide as benefits of better glycemic control outweigh the risks due to these agents. I would give her information booklets about gestational diabetes and record this discussion in her notes.
		Posted by Hethere D. Sat Jul 12, 2008 07:22 pm
a- We inform her that in view of her age and high BMI; she is at increased risk of developing GDM particularly if she has positive family history of first degree relatives, however, this usually occur in the second half of pregnancy. If she found to have high blood sugar at this gestation (12 weeks) this means that she may have already diabetes mellitus which is unrelated to pregnancy. Urine test is not specific and should not be used for screening, also fasting and random blood sugar and glucose challenge test. OGTT is the gold standard and is done at 16-18 wks gestation and repeated at 28 weeks gestation if the first one was normal. We advice also for 1-hour post prandial blood sugar which should be less than 7.8 mmol/dl. We inform her also that her risk of developing GDM increased if she had a macrosomic baby before (> 4.5 kg) or had GDM in previous pregnancies . b- We tell her that GDM is not associated with increase incidence of fetal congenital abnormalities as it usually occurs after the period of fetal organogenesis. However, uncontrolled blood sugar can lead to development of macrosomic baby with subsequent complication like birth trauma to the mother and to the fetus also birth asphyxia. Also there is increased incidence of induction of labour and caesarean delivery. We inform her that she will be at risk of developing DM type II later on in her life. The neonate is at risk also of developing hypoglycaemia, hypomagnesaemia and seizures. In addition the baby may get RDS, polycythemia and jaundice. c- We advice for diet control jointly arranged with dietician. The patient should be followed up in a diabetic care clinic. Weight reduction is not advised during pregnancy but the patient should avoid high increment in weight. Insulin is prescribed if blood sugar remains elevated. The first choice will be short acting Insulin. Oral hypoglycemic drugs should not be prescribed in pregnancy; however, there is current data about safety of use of metformin. Full information is given to the patient and consent is taken. The patient will need more frequent antenatal visit with close monitoring and serial fetal growth scan for early detection of macrosomia and polyhydramina.
		Posted by SHAGUFTA T. Sun Jul 13, 2008 02:26 am
a). I will inform the woman that GDM is a condition of glucose intolerance which occurs in pregnancy & usually resolves after delivery. It affects 2-5 % of all pregnancies. As she is obese with BMI of 40 Kg/ sq.M. & age 39 years, she is at risk of developing GDM. I will take past obst. history regarding GDM in any pervious pregnancy, fetal macrosomia ,shoulder dystocia , operative vaginal delivery, C/S, unexplained still birth etc. F/H of diabetes in any 1st deg. Relative and I would like to know her ethnicity. I will counsel her to make informed decision for screening of GDM by 2 Hrs. 75 mg OGTT ideally done at 24-28 weeks gestation but to be done early in her case in view of risk factors. I will tell her that if GDM is not detected and controlled might lead to poor maternal,fetal and neo-natal outcome which can be reduced by good glycemic control through out pregnancy & labour. In most cases this is achieved by diet & exercise. Only 10 to 20 % might need hypoglycemic agents. Written information leaflet will be provided on OGTT , diet n exercise. b). I will explain her the diagnosis and its possible outcome regarding her own health her fetus and neonate, in this pregnancy and in long term. Diagnosis of GDM may lead to increased monitoring & interventions during pregnancy & labour. She will be under care of multidisciplinary team including senior obstetrician , diabetologist ,dietician, diabetic Midwife, GP and social worker . Regarding her health ,Iwill explain her about the risk of developing hypoglycemic attacks, ketoacidosis , PIH, PET , polyhydramnios , fetal microsomia & measures how to control &prevent hypoglycemia. Intra partum she will be at high risk of shoulder dystocia , operative vaginal delivery C/S &post partum there is risk of PPH. In later life she will be at risk of recurrence of GDM in future pregnancy by 66%., 70 % life time risk of developing NIDDM and 5 to 10 % IDDM. Regarding fetal & neonatal risk I will inform her that the risk of congenital anomaly, preterm labour, unexplained death & macrosomia is high if uncontrolled GDM. At the time of delivery there is risk of trauma shoulder distocia ,brachial plexus injury .Neonate might develop hypoglycemia which can be avoided by good maternal glycemic control during pregnancy & labour & early feeding of baby. Neonatologist to be present at time of delivery. In long run baby is at risk of developing obesity, diabetes. I will advise her regarding self monitoring of glucose at home, signs &symptoms of hypoglycemia & its management, frequent antenatal visits , fetal monitoring by USS, biophysical profile , CTG. Written information leaflets & documentation of clear plan of delivery in file. c). From the diagnosis of GDM she will be cared by MDT in joint diabetic antenatal clinic along with frequent monitoring to achieve good glycemic control. Aim is to keep FBS at 3.5 -5 mmol/dl and 2 hr. PPBS <7 mmol/dl. I will explain her the importance of diet & exercise. Diet with carbohydrate of low glycemic index, lean protein including oily fish , to reduce calorie intake to < 25Kcal/Kg/day, and moderate exercise of 30 min./day will be enough to control in 2/3 cases. Only 10 to 20 % will need hypoglycemic agents like insulin (regular & rapid acting) if diet and exercise failed to control in 1-2 wks time or USG diagnosed macrosomia (EFBW of >4.5 Kg.).
		Posted by Sabahat S. Sun Jul 13, 2008 06:39 pm
a) I would like to ask about some more information from history to assess her, to provide with more precise information like previous H/OGDM, macrosomic babies, first degree relatives with diabetes and her ethnic origin. I will inform her that gestational diabetes is a condition of carbohydrate intolerance that appears or first recognized during pregnancy and in most of the cases it resolves completely after delivery. I will explain to her that she is in need of screening for GDM as she is at high risk of developing it because of her high BMI ,the risk may be higher in presence of other factors. If the condition is not detected and treated ,it is associated with increased maternal morbidity, perinatal morbidity and mortality. On the other hand if detected timely and managed appropriately ,having good glycaemic control throughout pregnancy, will reduce risk of complications. I will explain about conduct of the test, that it is a simple blood test which is done after an overnight fast(8-12 hours),initially a fasting sample of blood is taken ,then a specified amount of glucose drink ( 250-300 ml) is given to ingest, followed by another sample of blood after 2 hours of drink. This test is performed at 24-28 weeks of gestation, but if she had gestational diabetes in previous pregnancy then it will be done earlier at 16-18 weeks and would be repeated at 28 weeks if the first test is normal.(NICE Guidelines).The results of blood test may be normal ,in that case she can be reassured, or may reveal impairment of glucose tolerance or frank diabetes. In case of impairment, she needs monitoring of blood sugar(timed RBS,glycosuria) in the following antenatal visits with life style and dietary modifications. The perinatal outcome is usually similar to healthy population. If diagnosis of gestational diabetes is made then she will be managed by extra monitoring and care involving multidisciplinary approach including obstetrician, diabetologist,diabetic nurse, midwife and dietitian. I will provide her with written information regarding GDM and OGTT. b)I will explain the diagnosis to her . She will be explained that GDM has short term and long term implications on for both mother and baby.If diabetes remains well controlled ,pregnancy is likely to be uneventful with . However when uncontrolled ,she is at risk of developing gestational hypertention,preterm labour, infections(UTI,candidiasis) .She is at risk of having macrosomic baby both due to diabetes as well as obesity-macrosomia may result in prolong labour,difficult vaginal delivery ,shoulder dystocia ,maternal injuries, PPH and increased rate of ceasarean delivery. She can be reassured that she is not at risk of having fetal congenital anomalies from diabetes persa.Neonatal morbidity may be related to macrosomia resulting in difficult delivery ,birth trauma and shoulder dystocia.These may result in Erabs palsy or fracture of humerus or clavicle. These complications may resolve spontaneously or result in long term disabilities depending on severity. The neonate is at risk of hypoglycaemia,RDS,metabolicdisturbance,polycythemia and jaundice. Regarding long term implications,she is at risk of recurrence(66%)ofdiabates in her next pregnancy.She may develop type 2 diabates in later life,her life time risk is 70% as compared to 10% of general population.She also carries 5-10% risk of type 1 diabetes ,as a slowly progressive form which may be unmasked by pregnancy.Her baby is at risk of obesity and developing type2 diabetes later in life. I will stress on need of care and monitoring at joint antenatal-diabetic clinic to have good glycaemic control and fetal surveillance. Written information on GDM, and address of Diabetes UK will be provided to her. c)Aim of treatment is to achieve a good glycaemic control to avoid complications and healty out come.It can be achieved by dietary adjustment with exercise and medications.She should be referred to specialist dietician for advice.Diet should provide 25kcal/kg body weight.Active weight reduction is not appropriate.She should be encouraged to have moderate physical activity for at least 30 min/day.Hypoglycaemic therapy should be considered in addition if diet and exercise fail to maintain glycaemic control over a period of 1-2 weeks or if USS shows incipient fetal macrosomia at diagnosis. Hypoglycaemic therapy should be tailored according to individual need.Regular insulin ,rapid acting insulin analogues (lispro,aspart) and or oral hypoglycaemic agents metformin and glibenclamidemay be considered.Informed consent about medication should be obtained and documented,when rapid acting insulin or oral durgs are used since these are not licensed for use in pregnancy in UK,but are widely used and accepted to be safe.
		Posted by SK K. Mon Jul 14, 2008 05:03 am
In view of her age, 39 yrs, BMI=40 & high parity. I would categorise this as high risk pregnancy. A) Obesity & advanced age place her at a high risk for diabetes mellitus Hence it is important to screen her for the same . I would advice her to have an oral glucose tolerance test at her booking visit. If normal, I would repeat between 28-32 weeks. It is required that she be overnight fasting before the test. On the day of test ,she should come to the lab before she has eaten or drunk anything and give the fasting blood sugar sample. Thereafter she will be given 75 gms fo glucose. Which she should mix in water and drink it. This is not pleasant for many pregnant women and may induce nausea & vomiting in a few. 2 hours after taking the glucose she should report to the lab for post parandial sample. 5.5 mmol/l for fasting & 7.8 mmol/l for postparandial are considered cutoff levels beyond which, test is termed as impaired and would necessitate full blood sugar profile consisting of 6 values. She is at increased risk of congenital malformation to advanced age & and possible diabetes .i would offer scan for nuchal translucency and biochemical screening for down’s & in view of her age but also inform that in case she turns out to be a diabetic then biochemical screening may not be very reliable .NT would then be considered ideal for screening . I would also provide her with written information for all the above. B) Once she is diagnosed to be a GDM, It would be very important to educate her regarding the implications as there are many. GDM would place her at high risk for developing PIH, recurrent UTI & vulvovaginal infections, pyelonephritis, difficult & operative deliveries, diabetic ketoacidosis, hyperosmolar coma, necessity for regular insulin injections and problems associated with their use ,Also following delivery OGTT would be repeated at 6 weeks and as many as 30 % of the women are diagnosed to persist as diabetic with its long term sequel. For the fetus, there is increased risk of congenital malformations especially if the sugars are very high, though this is a feature of those who were diabetic at the very beginning of pregnancy. GDM also leads t o macrosomia and polyhydramnios and delayed respiratory maturity, sudden IUFD, SIDS, birth injuries due to difficult deliveries,.After the birth baby is at risk for hypoglycemia ,seizures, metabolic & electrolyte imbalance. Also these babies are predisposed to developing diabetes and hypertension later in life. C) It should be stressed to her that good glycemic control alone will help her in having successful & good outcome. There is a need for regular ANC, home blood glucose monitoring, diabetic diet, 30 minutes of exercise eg: walking, compliant medication. She should be given a diet chart & fixed an appointment with the dietician. Advice her on small frequent meals, restriction of calories to 25 K cal/kg, carbohydrates not to constitute more then 30 % of the diet. If on insulin she should be aware of signs of hypoglycemia and always carry some handy biscuits with her. It is important that she has baseline blood investigation FBS, urea & electrolytes, serum creatinine, HBA1c, MSU for routine microscopy & culture. A complete blood sugar profile must be reviewed at regular intervals. Multidisciplinary care involving the obstetricians, dietician, diabetic physician & nurse, general practioner & neonatologist would help in optimizing the outcome. I would also avail the opportunity to impress on her to maintain strict kick chart & need for increased fetal surveillance from 36 weeks onwards. She should be given information leaflets on GDM and also put in contact with support groups.
		Posted by SK K. Tue Jul 15, 2008 01:03 am
please mark my essay thankyou
		Posted by San S. Sun Jul 20, 2008 03:33 am
a)She should be explained that this is a screening test and is appropriate in her due to her increased risk of gestational diabetes. The test would involve a blood test 2 hours after having a sugary drink. Blood glucose level above the normal will diagnose gestational diabetes. The results would be ready up to 24 hours after the test and would be communicated to the patient. A normal results indicate that she is at low risk of developing gestational diabetes and an abnormal results indicate that she would need more surveillance and monitoring through out the rest of her pregnancy. b)Antenatally, she should attend the joint obstetrics and diabetologist clinic. She would be taught to monitor her blood glucose by the specialist midwives/diabetic nurse. She would be given dietary advice and start on insulin if diet control alone is not sufficient.It is important for her to have tight glucose control due to increased fetal risk of macrosomia, polyhydramnios, unexplained stillbirth. She is also at increased risk of preterm labour and cord prolapse should she develop polyhydramnios. She should be aware that there is intrapartum increased risk of shoulder dystocia, oeprative delivery and caesarean section rate should she develop macrosomia. She would be started on glucose potassium infusion during labour to achieve satisfactory glucose control. The use of epidural is safe during labour. After delivery, she would not require any further treatment but would need a repeat GTT at 6 weeks post natal to make sure her blood glucose has returned to normal. She should be made aware of the risk of hypoglycaemia in baby after delivery and she should be encourage to breast feed as soon as possible and more frequent. c)The first and intial option would be dietary control of blood glucose level. She should be advised to have low glycaemic index food and avoid food containing high sugar levels e.g. soft drinks. The second option is usually use if dietary control alone is insufficient. Subcutaneous insulin is safe during pregnancy as it does not cross the placenta. Above methods are use in conjunction with daily blood sugar monitoring after each meals in a diary.