GESTATIONAL DIABETES

MELLITUS

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PATIENT DETAILS

Name : N.A.Z

R/N : AM 00158255

Age : 29 years old

Sex : Female

Race : Malay

Occupation : Clerk at Jabatan Kayu

Date of Admission : 11 March 2010

Date of Clerking : 13 March 2010

Gravida : 1 (primid)

Para : 0

Last Normal Menstrual Period (LNMP) : 5 June 2009

Expected Date of Delivery (EDD) : 12 March 2010

Period of Amenorrhea (POA) : EDD + 1 day

INTRODUCTION

Puan NAZ, a 29 year-old lady G1 P0 currently at 40 weeks 1 day of period of amenorrhea.

Her last normal menstrual period was 5 June 2009 and expected date of delivery was 12

March 2010.

CHIEF COMPLAINT

She was referred from Klinik Kesihatan Gombal Setia for induction of labour at 40 weeks of

gestation due to gestational diabetes mellitus.

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HISTORY OF PRESENT PREGNANCY

She suspected her pregnancy after she missed her period associated with dizziness and

nauseates especially in the morning. Then she did urine pregnancy test (UPT) by herself and

the result turned to be positive. She went to a private clinic to reconfirm the pregnancy and

did UPT again at the clinic. She did her first scan there but during that time, nothing could be

seen because she claimed that the fetus still too small.

The first booking was done at Klinik Kesihatan Dewan Bandaraya Kuala Lumpur

(DBKL) at 8 weeks of gestation. Blood and urine test had done and she did not know the

results except she had been told that all the results were normal. The booking blood pressure

was 110/80 mmHg and remain normotensive throughout the pregnancy. The height and

weight during booking was 150 cm and 54kg. The blood group was AB positive and there

was no anemia.

She went for regular checkup every month and all were uneventful until about 28

weeks of gestation, she had been diagnosed to have gestational dibetes mellitus after

modified glucose tolerance test (MMGT) had done. She had been asked to do MGTT because

of excessive weight gain. She gained 4kg in a month for two consecutive months. During this

time there was increased frequency of micturition. However there were no polyphagia and

polydipsia

She was advised on diabetic diet to control her blood glucose level. She claimed that

her latest dextrostix was 6.3 taken during admission to the ward. Because the good control of

diabetes mellitus, she was planned for induction of labour at 40 weeks. Now she was keen for

induction of labour.

The induction of labour was succeed and she had delivered a 2.45 kg baby boy at 4.45

am on 14 March 2010 through spontaneous vaginal delivery.

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PAST OBSTETRIC HISTORY

No past obstetric history since this was her first pregnancy.

PAST GYNAECOLOGY HISTORY

She is married for 10 months. She got her menarche when she was 12 years old. Since then,

her periods were regular, once in a month with the flow of 8 days. She denied any form of

contraception. There were no dysmenorrhea and menorrhagia. She never had any pap smear

done. This is unplanned pregnancy but she is happy about it.

PAST MEDICAL AND SURGICAL HISTORY

No past medical and surgical history.

SYSTEMIC REVIEW

Cardiovascular system

No palpitation, chest pain, dyspnoea, cyanosis

Respiratory system

No night sweats, cough, wheezing, haemoptysis. No symptoms of upper respiratory tract

infection.

Gastrointestinal system

No haematemesis, malaena, dysphagia, altered bowel habit

Central nervous system

Oriented to time, place and person, no loss of consciousness, drowsiness, headache, blurring

of vision, no tingling, numbness and weakness in the upper and lower limbs.

Musculoskeletal system

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No muscle wasting, limitation of movement, muscular pain, joint swelling, joint pain.

Endocrine system

No swelling in the neck

Urinary system

No sign and symptoms of urinary tract infection. No frequency, urgency and no dysuria.

FAMILY HISTORY

There was no history of diabetes mellitus, hypertension and heart diseases run in family.

There was also no history of multiple pregnancy in family.

SOCIAL HISTORY

She is working as a clerk at Lembaga Kayu. Currently she lives with her husband and her

mother-in-law at a double storey terrace house. She is not smoking but her husband does.

However both of them did not consume alcohol and not a drug user. Her husband is a

photographer. They are financially stable.

DRUG AND ALLERGY HISTORY

She has no drug and allergy history.

PHYSICAL EXAMINATION

General Examination

On examination, the patient was lying supine comfortably supported by one pillow. She was

alert and conscious to time and place. She was clinically pink, not in pain and not in

respiratory distress. The hydration status was good.

Vital signs:

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 Pulse : 88 beats/min, regular rhythm, good volume
Blood pressure : 140/87 mmHg
Respiratory Rate : 24 breaths/min
Temperature : 37 ᵒC (afebrile)

Weight: 74.5 kg
Height : 152 cm
BMI : 32.3

General Examination

 Hand Examination

The hand was warm and dry. There were no palmar erythema, clubbing and the

palmar crest was not pallor.

 Head Examination

Eyes: No conjunctival pallor and no jaundice.

Oral: The oral hygiene was good as well as the hydration status. No central cyanosis.

 Neck Examination

Thyroid gland was not enlarged. Jugular Venous Pressure (JVP) was not raised. No

palpable cervical lymph nodes.

 Leg Examination

There were no pitting edema, no calf tenderness and no varicose vein noted on both

legs.

Specific Abdominal Examination

Inspection:

The abdomen was distended by gravid uterus as evidence by linea nigra. The umbilicus was

centrally located and inverted. No scar or dilated veins noted.

Palpation:

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The abdomen was soft and non tender. The uterus was not irritable. The clinical fundal height

measures 40 cm and correspond to 40 weeks of gestation, which was correspond to the date.

There was a singleton fetus in longitudinal lie with fetal back at left side of the mother. The

presentation was cephalic with head was about 3/5 palpable. Liquor was adequate and the

estimated fetal weight was about 2.8- 3.0 kg.

Auscultation:

Fetal heart was heard and the rate was about 160 beats per minute.

Other systems examination

1. Cardiovascular Examination

Heart sound was dual rhythm and no murmur. First and second heart sound heard. No

added sound.

2. Respiratory Examination

Lungs were clear. No crepitation and no rhonchi. The air entry was equal bilaterally.

3. Musculoskeletal system

The power was 5/5, the tone was normal, no hyperreflexia and no muscle wasting and

no twitching for all limbs. Barbinski sign was negative.

4. Central Nervous System

All cranial nerves were intact. Reflex and sensory component were intact.

CASE SUMMARY

Puan NAZ, 29 year-old Malay lady G1 P0 currently at 40 weeks and 1 day admitted

electively for induction of labour due to gestational diabetes mellitus on diet control. Her

latest dextrostic was 6.3 mmol/L. On examination, her BMI was 32.3, the fundal height

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measures 40cm and correspond to 40 weeks of gestation. She was not in labour and fetal

movement was good. No signs and symptoms of complication of diabetes noted.

Problem Lists

1. Primigravida

2. Gestational diabetes mellitus on diet control

INVESTIGATIONS

Full Blood Count

RBC 4.62

Hb 11.3

WBC 14.2 K/uL

Hematocrit 35.4 %

Plt 398

Group, Screen and Hold

Blood group AB

Rhesus Rh +ve

Antibodies Not detected

MANAGEMENT

Antenatal

1. CTG daily

2. Labour progress chart 4 hourly

3. Strict fetal kick chart

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 4. Diabetic diet

5. For induction of labour after discuss with specialists

DISCUSSION

Gestational diabetes is carbohydrate intolerance of variable severity, with onset or

first recognition of hyperglycaemia during pregnancy.1 Studies have shown that gestational

hyperglycaemia is associated with higher incidence of adverse maternal and foetal outcomes

than is seen in normal pregnancy. Untreated gestational diabetes mellitus (GDM) was

demonstrated to have increased perinatal mortality rate up to fourfold compared with that of

control.1

Morbidity related to macrosomia includes shoulder dystocia with birth injury and

perinatal asphyxia in the foetus. In the mother it causes more genital tract injury, obstructed

labour, uterine atony and increased risk of caesarean section. The importance of diagnosis of

GDM relates not only to potential immediate morbidities at the time of birth but long term

sequelae for the child. Obesity, development of type 2 diabetes mellitus, intellectual and

neurological development and mental problems are known long term sequelae.2

For the mother, GDM is a very strong risk factor for the development of type 2

diabetes later in life. Published studies show that after GDM, 35-60% of women develop type

2 diabetes within 10 years.3 Therefore it is prudent that gestational diabetes is diagnosed and

appropriate treatment and monitoring instituted.

Rationale of GDM screening include it allows identification GDM and hence

treatment disposition thereby reducing the associated maternal and neonatal risk. It also

allows identification of a group of women who have an increased risk of developing diabetes

mellitus later in life.

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 In the public health service in Malaysia, screening for gestational diabetes is done

selectively where only patients with risk factors are screened and diagnosed using a 1-step

75g OGTT. This is done at least once at or around 24 weeks gestation, unless there are

indications for it to be done earlier.4

Patients were considered to be risk-factor positive if any of the following is present:

o age 35 years and above

Gestational diabetes mellitus was diagnosed if the 75 g oral glucose tolerance test

showed venous plasma level of <7.0 mmol/L after an overnight fast and at least 7.8mmol per

litre at two hours, based on the WHO(1999) criteria.5

Antenatally, pregnant women with diabetes should be managed in a joint clinic with

an obstetrician and physician. The aim for treatment is to maintain the blood glucose level as

near normal as possible, with a combination of diet and insulin. All women with diabetes

should be instructed self-monitoring with their own glucose meter. Input from dietician is

important and often a nurse or midwife specialist will act as an adviser to adjust the dose of

insulin.6

Fetal growth and development should be monitored by serial ultrasound scans,

biophysical profiles and umbilical artery Doppler recordings.7

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 If good diabetic control is achieved and there are no other complications, it should be

possible to allow the pregnancy to proceed to full term. Induction of labour and vaginal

delivery can be achieved with the careful regulation of blood glucose levels during labour and

continuous fetal monitoring. If there is any evidence of fetal distress or delay in progress of

labour, delivery should be affected by caesarean section.7

Patient who has been diagnosed to have GDM should be reassessed after at least 6

weeks post partum. If sugar levels are normal post partum, these patient should be monitored

at least 3 yearly. All women should receive contraceptive advice and counselling regarding

fure pregnancies.8

REFERENCES

1. Meztger BE, Coustan DR. Summary and recommendations of the Fourth International

Workshop-Conference on Gestational Diabetes Mellitus. The Organizing Committee.

Diabetes Care. 1998;21(Suppl 2):B161-7

2. Report of the Expert Committee on Diagnosis and Classification of Diabetes Mellitus.

Diabetes Care. 1997;20(7):1183-97

3. Meztger BE, Buchanan TA, Coustan DR, et al. Summary and recommendations of the

Fifth International Workshop-Conference on Gestational Diabetes Mellitus. Diabetes

Care. 2007;30(Suppl 2):S251-60

4. Malaysian Diabetes Guideline 2009. Available from: diabetes.org.my

5. World Health Organization. Definition, Diagnosis and Classification of Diabetes

Mellitus and its Complications. Report of a WHO Consultation. 1999.

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6. Philip NB. Obstetrics By Ten Teachers, 18th Edition. Hodder Arnold Publication,

London. 2006. p 186.

7. Malcom S, Ian MS. Essential Obstetrics and Gynaecology, Fourth Edition.Elsevier,

USA. 2006. p 114.

8. Carr DB and Gabbe, S. Gestational Diabetes: Detection, Management and

implications. Clinical Diabetes. 1998; 16(1): 4-11