Patients data

Name -Mrs.S.D.Karunanayake
Age - 28 years
From Awissawella
House wife
In her 2nd pregnancy with a 4 year old
daughter presented at 36weeks and
6days of POA

Previous obstetric history

The first born in 2010 by a c-sectionat
38weeks of POA
It was complicated with GDM
Diagnosed at 24th week POA by OGTT
On dietary control for 1 month, later
changed into insulin 8 units three times
per day
Birth weight 3.525kg
NICU-for 2days
After 6 weeks post partum FBS was normal

HISTORY OF CURRENT PREGNANCY

1st Trimester(0-12weeks)
This is an unplanned pregnancy.
Pregnancy was confirmed by urine hCG after missing
her periods for 2 weeks.
Booking visit at Awissawella clinic (8th week of POA)
Folic acid was started
Basic Investigations done- normal
Hb
UFR
Grouping and Rh - A+
VDRL
PPBS

 LMP on the 8th of November

2013
- irregularmenstural cycle
- According to ultra sound scan the
EDD is 2nd september 2014

1st Trimester(0-12weeks)
At 8th weekof POA, OGTT was done at Awissawella
clinic
OGTT- 310mg/dl (2hr value)
Then was admitted at Castle Hospital at 8th week
of POA for 5days
Insulin wasstarted
Morning 20unit
Day 18unit
Night 18unit
Night 10pm 14unit
8th week of POA HbA1c-11.6

1st Trimester(0-12weeks)
Dating scan at 12th week and fetal
viability was confirmed.
General Health tiredness, non
specific symptoms such as headache
,increased appetite
No complications of 1st trimesterhyperemesis, bleeding PV, vaginal
discharge or fever with papular rash

2nd trimester (12-28 weeks)

Tetanus toxoid given

Perception of 1st fetal movement on
18th week of POA
Fetal anomaly scan-20th week and it
was normal.
Iron & Calcium given after 12th week
Worm treatment not given.
No other complications detected.

3rd trimester(28-40weeks)

Regular clinic visits every 2 weeks.

USS scan-33weeks (fetal weight2.4kg)
BSS done every two weeks and was
normal.

Past medical history migraine

Past surgical history past c section in 2010
Drug history Soluble insulin s/c, lente at night.
Allergic history no known allergies
Family history mother has DM for 5 years.
Social history husband is a businessman. He
is a non alcoholic and a non smoker. She has
adequate family support from her parents and
in laws.she has the capability to store insulin at
home,she is knowledgeable on different sites
on insulin administration.and she is aware of
hypoglycemic symptoms and the actions to
take on such event.

Examination
General examination
Maternal weight- 100.23 kg
Height-162cm(BMI-38.18)
Afebrile
No pallor
Good oral hygiene
No thyroid enlargement
bilateral ankle oedema

Cardiovascular examination
Pulse-70per min regular rhythm, normal
volume
No collapsing pulse, Peripheral pulses were felt
BP - 130/80mmHg
On inspection - No scars or deformities
No parasternal heaves.
Apex beat was felt at 5th ICS in
MCL
1st & 2nd heart sound were
normal
No murmers heard

Respiratory system examination

RR-24perminute
On inspection- no scarsor
deformities
Normal symmetrical chest expansion
Trachea central
Percussion - vocal fremitus normal
Auscultation - vesicular breathing

Abdominal examination
On inspection
Symmetrically enlarged abdomen
Striae gravidarum
Linea nigra
Supra pubic transverse scar
Hernial orifices intact

On palpation
Symphysio fundal height- 40cm whichwas not
compatible with gestational age.
Lower pole Single hard round ballotable mass,3
fifth palpable.
Suggestive of fetal head

Upper pole Smooth less harder broader mass
Suggestive of breech

Single fetus Longitudinal lie in cephalic

presentation, left occipito anterior
position.
approximate fetal weight 3.200 kg
& high liqourvolume

Auscultation
Fetal heart beat was present

Summary
29year old house wifein her 2nd pregnancy was
admitted for confinement,at 36 weeks & 6days of POA.
(later developed SROM) OGTT was done at 8th week and
the 2hr value is 310 mg/dl. Her HbA1c was 11.6 at 8th
week. She was on insulin.

On Ex- CVS ,RS,CNS were unremarkable. Abdominal

examination symphysio fundal height is 40cm which was
higher than POA.
Single fetus longitudinal lie left occipito anterior
cephalic presentation, high liqua volume. Estimated fetal
size is 3.200kg.

Problem list
Gestational diabetes mellitus
Previous c-section
Large for gestational age

Investigations
Assess fetal well being
CTG
Ultra sound polyhydramniose,fetal
weight
Pre op assessment
FBC
Clotting time and bleeding time

Managemet
Diabetic Diet
Break fast-2 slices of bread, one boiled
egg cup of tea/non -fat milk with small
amount of sugar and a sour plantain

Lunch/Dinner brown(unpolished ) rice,

plenty of vegetables,fish/meat and slice
of papaw

10am/4pm -2 bran crackers and a cup

of tea with low sugar

Pharmacological
Management
Soluble Insulin -20 units,18
units,18units
Betamethasone 12mg IM 1dose (2nd
dose was not given )

Surgical management
ELCS

Risk factors

-Age more than 35years

-Previous child with birth weight >3.5 kg
-Previous unexplained still birth
-Recurrentabortions
-Recurrent vaginal candidas or urinary
tract infection
-Obesity and polycystic ovarian disease
-Previous baby with spina bifida or sacral
agenesis

Diabetes in Pregnancy
Pregnancy is a diabetogenic state. Therefore
in pre-diabetic women diabetes mellitus can
develop for the first time in pregnancy. This
is known as gestational diabetes mellitus .
In pregnancy around 24-28th weeks of POA
secretion of human placental lactogen by the
placenta , it increases the cortisol level
These are the diabetogenic hormones which
increases the blood sugar level.

Effects of diabetes to the fetus

1st trimester-
Fetal abnormalities such as congenital
heart diseases & neural tube defects are
common in uncontrolled diabetes.
Recurrent spontaneous abortions

2nd trimester Polyhydramnios

Large for days babies(fetal
macrosomia)
Fetal growth restriction

 Neonate
Hypoglycemia
Respiratory distress syndrome
Jaundice
Electrolyte imbalances
Effects on the mother
Pregnancy induced hypertension
Recurrent urinary tract infections
Vulvo-vaginal candidiasis
Puerperal endometritis
Lactation failure

Thank you !!!