Professional Documents
Culture Documents
Chandra Rubnee
Malvinder Singh
Caroline
Aswini
Kalichandren
CASE PRESENTATION 3
HISTORY TAKING
OUTLINE
Personal History
Chief Complain
History Of Present Illness
History Of Present Pregnancy
Past Obstetrics History
Menstrual History
Gynecological History
Past Medical History
Past Surgical History
Family History
Diet History
Personal History
Social History
Drug History
PERSONAL
HISTORY
CHIEF COMPLAIN
Her chief complain was :
1. Increase frequency of urination for 2 months
2. Always feel hungry and thirsty for a month
3. Fatigue for a month
HOPI
4 days ago have antenatal checkup on 39 w of
gestation
MOGTT abnormal
Required admitted for observation
Increase frequency of urination for pass two
month
Urine color is straw and not concentrated
Always feel thirsty and dry mouth
Always feel hungry
fatigue
Unplanned
Miss 2 month of menstrual
Dating scan on 8w gestation
Detection of single embryo
Blood group : O+
Urine routine = N
FBC= N
Hb level = N
Screening test= -VE for HBsAg, VDRL & HIV
BP= N
Weight:60kg
Height : 150cm
BMI : 26.6 kg/m
MOGTT FASTING = 4.0mmol/L
NONFASTING = 6.8 mmol/L
Folic acid given
2ND TRIMESTER
Anomaly scan on 14w = Nuchal thickness is 2.8cm
Tetanus injection
1st on 20w
2nd on 24w
FBC = N
Hb level = N
MOGTT FASTING= 5.0mmol/L
NONFASTING= 7.0mmol/L
BP = N
Uterine size
Weight : 65kg
Quickening on 20 w
3RD TRIMESTER
Fetus growth scan
FBC = N
Hb level = N
MOGTT- FASTING= 7.0mmol/L
NONFASTING = 9.8 mmol/L
Diagnose GDM on 32w
Fetus movement
BP= N
Uterine size
Weight : 70.5kg
Complains of
Polyuria
Polydipsia
Polyphagia
Iron supplement given
YEAR
PREGNANCY
LABOUR
PUEPERIUM
BABY
2000
FULL TERM
NORMAL
SPONTANEOUS
VAGINAL
DELIVERY
(SVD)
BREAST
FEEDING UP
TO 2 YEARS
FEMALE
3.1KG
ALIVE
2000
ABORTION AT
8W POA
2002
FULL TERM
NORMAL SVD
BREAST
FEEDING UP
TO 2 YEARS
MALE
4.0 KG
ALIVE
2009
FULL TERM
NORMAL SVD
BREAST
FEEDING UP
TO 2 YEARS
MALE
3.55KG
ALIVE
2014
PRESENT
PREGNANCY
CONSUME
OCP FOR
3MONTH
REMARK
MENSTRUAL HISTORY
Menarche
Duration of flow
Cycle length
Cycle
12 years old
7-10 days
28-30 days
Regular
Gynecological history
Consume OCP
Suggestive STI
Gynecological
problem
NO
NO
Not done
NO
NO
NO
NO
NO
NO
NO
NO
FAMILY HISTORY
Father
Alive, 64
History of hypertension for 3 years
Mother
Siblings
DIET HISTORY
NON- VEGETATIAN
NO FOOD ALLERGY
UNDERGO DIET CONTROL DUE TO GDM
CONSUME 1 CUP OF LOW FAT MILK PER DAY
PERSONAL HISTORY
SMOKING
ALCOHOL DRINKING
DRUG ABUSE
NO
NO
NO
SOCIAL HISTORY
Married for 15 years since 1999
Husband worked as lorry drive
Monthly income around RM3000
Staying with father in law
DRUG HISTORY
Do not consume any drug before pregnancy
No any drug allergy
Physical Examination
General Examination
Patient lying down in a supine position
comfortably .
Patient is conscious and cooperative.
Patient is alert and is average built and well
nourished .
No cannula or IV drip.
ID tag is present.
Vital parameters
General Examination
Systemic Examination
Cardiovascular
system .
Cardiovascular examination
Inspection
Chest wall move symmetrically with
respiration.
Palpation
Apex beat was located at 5th intercostal
space left midclavicular line. No heave and
thrill.
Auscultation
S1 and S2 heard and no murmurs
Respiratory System
Inspection
Chest wall move symmetrically with
respiration and not in respiratory distress
Palpation
Trachea was centrally located.
Normal chest expansion and tactile vocal
fremitus.
Percussion
Resonance
Continuation ...
Auscultation
Air entry is equally bilateral and normal
vesicular breath sound heard. There were
no rhonchi heard.
Obstetric Examination
Patient complaint of no pain at the 9 regions
of abdomen.
Abdomen is distended by a gravid uterus
supported by the presence of lines nigra
and striae gravidarum and striae albicans
Abdomen is soft .
NO scar present .
Umbilicus is centrally located and flattened.
Flank is full .
Symphysis fundal height is 36cm
Clinical fundal height is at 40weeks of
period of gestation
Local Examination
LEOPOLD's MANEUEVER
Fundal grip- there is a broad soft irregular
mass suggestive of fetal breech
Right lateral grip - there are small knob like
structure suggestive of fetal limbs
SUMMARY
PROVISIONAL DIAGNOSIS
PROVISIONAL DIAGNOSIS
Madam Wan Rafidah a 36 years old
Muslim housewife with G5P3+1 at 39
weeks and 4 days of period of gestation
with singleton fetus in longitudinal lie
with cephalic presentation associated
with Gestational Diabetes Mellitus and
not in labour.
DIFFERENTIAL DIAGNOSIS
1. Gestational Diabetes Mellitus
Supporting points
1. No detected presence of
Diabetes Mellitus(type 1 or
2) before 20 weeks of period
of gestation
2. Family history of DM
3. Detections occurs in week
39 of gestation
4. Overweight
5. Age above 35 years old
6. Polyuria
7. Polydipsia
8. Polyphagia
9. Previous big baby > 4.0 kg
Points against
Points against
1. Polyuria
2. Polydipsia
3. polyphagia
1.
2.
3.
4.
Not lean
No past history
No family history
Patients age is 37
years old
5. Weight not decreasing
Points against
1. Polyuria
2. Polydipsia
3. Polyphagia
4. Overweight
5. Family history
6. Age
4. Not smoking
Points against
1. Polyuria
4. Hyperthyroidism
Supporting points
Points against
1. Increase appetite
1. Enlargement of thyroid
is not detected.
2. No weight loss.
3. Normal TSH in blood
test.
Caroline Sundralingam
012 012 100 017
Risk factors
Screening
Normal
Abnormal
Random
11.1 mmol/L
Fasting
7.0 mmol/L
11.1
mmol/L
7.0 mmol/L
MOGTT
1. Previous gestational diabetes
MOGTT done @ 16-18 weeks of gestation
If negative, repeat test @24 weeks of gestation
2. Other risk factor
MOGTT done @22-26 weeks
If negative, repeat test @34 weeks of gestation
MOGTT- Procedure
75g oral glucose tolerance test
1. 3 days prior to test consume minimum 150g
carbohydrate
2. Fast 12hr
3. Morning: Fasting blood glucose level
measured, drawn from maternal venous blood
4. Drink glucose preparation within 10mins
5. Take 2HPP reading
Plasma
venous
Capillary
whole blood
Fasting
6.1 mmol/L
2 HPP
7.8 mmol/L
5.6mmol/L
7.8 mmol/L
Diagnosed GDM
1. Glycosylated hemoglobin (HbA1c)
. Serum blood sample taken
. Reflect glycemic control over previous 23months
. Normal range: 4.7-6.3% (non-pregnant)
4.5-5.7% (early pregnancy)
4.4-5.6% (late-pregnancy)
Further Ix
1. Urine FEME
. If nitrites positive, indicative of UTI
. Further test Urine culture & sensitivity
2. TFT
MANAGEMENT
Aswini A/P Nalla Mutthu
Krishna Gandi
012013050215
Antenatal Management
First trimester
1. Receive dietary instruction
and nutrition counseling.
2. Moderate exercise program.
3. Monitoring of blood glucose
4. Screening for microvascular
complications
Antenatal Management
Second trimester
1. Monitoring of blood glucose
2. Anomaly scan at 18-20 weeks,
fetal echocardiogram at 22-24
weeks.
3. Serial growth scans for
Amniotic Fluid Index and
abdominal circumference.
4. Surveillance for maternal
complications.
Antenatal Management
Third trimester
1. Monitoring of blood glucose
2. Assess fetal weight
3. Discuss timing and mode of
delivery
Diet
Eat meals on a regular schedule
throughout the day
Energy requirement
Female 60 kg
60 Kg X 30 kcal = 1800
kcal with 30% extra= 2100
Kcal
Breakfast
kcal
700
Carbohydrate (65%)
Protein (10%)
70
Fat (25%)
180
Carbohydrate
100 gm
Protein (10%)
gm
DietFat (25%)
Carbohy.
gm bread
Arabian
30 gm
Cheese
Honey
Glass of milk
Total
5 gm
50 gm
10 gm
95 gm
450
15
Lunch
900
kcal
Carbohydrate (65%)
Protein (10%)
90
Fat (25%)
220
Carbohydrate
130 gm
Protein (10%)
gm
_DietFat (25%)
Ricegm
Protein 17
Fat
----10 gm 10 gm chicken
2 gm
3 gm Salad
5 gm
5 gm_ Orange
17 gm 18 gm Total
Carbohy.
80 gm
5 gm
30 gm
10 gm
125 gm
590
Dinner
500
kcal
Carbohydrate (65%)
Protein (10%)
50
Fat (25%)
120
Carbohydrate
65 gm
20
Protein (10%)
gm
22
Fat (25%)
Fat _Diet
Carbohy.
gm
6 gm Tuna
sandwich
45 gm
Protein
--15 gm 12 gm Apple
4 gm
4 gm Tea
-----___ Total
19 gm 22 gm
15 gm
--95 gm
330
10
11
Protein Fat _
12 gm
10 gm
--------_
17 gm 18 gm
Self-monitoring of Blood
Glucose
TEST
GLUCOSE
LEVELS (MG PER
DL [MMOL PER L])
Fasting
< 96 (5.6)
One-hour
postprandial
Two-hours
postprandial
Insulin Indications
Blood glucose not maintained by diet.
Insulin dose is individualized and
adjusted according to the patients
blood glucose levels.
Adverse effects :
Hypoglycemia
Symptoms of
Hypoglycemia
Very hungry
Very tired
Shaky or trembling
Sweating or clamminess
Nervous
Confused
Like youre going to pass out or faint
Blurred vision
Intrapartum Management
Delivery by cesarean section usually is
favored when fetal distress has been
identified.
Delivery planned at 38 weeks or 39
weeks gestation.
GDM on diet can be delivered at 40
weeks.
Maintain normoglycemia.
Post Partum
Management
DISCUSSION
KALICHANDREN A/L ARUMUGAM
012013050221
TYPE
Type 1 diabetes
(Insulin Dependent
Diabetes Mellitus)
Type 2 diabetes
(Non Insulin
Dependent
Diabetes).
DEFINITION
Carbohydrate intolerance resulting in
hyperglycemia of variable severity with onset
or first recognition during pregnancy
SYMPTOM
Feeling thirsty more often than usual
Urinate more often
RISK FACTOR
PATHOPHYSIOLOGY
Early in pregnancy, maternal oestrogen
and progesterone increase and promote
pancreatic
-cell
hyperplasia
and
increased insulin release
As pregnancy progresses, increased
levels of human placental lactogen,
cortisol, prolactin, progesterone, and
estrogen lead to insulin resistance in
peripheral tissues.
COMPLICATION
EFFECT ON PREGNANT WOMEN
Preterm labor
Polyhydramnios
Pre-eclampsia
Hyperglycemia
COMPLICATION
COMPLICATION
COMPLICATION
Conclusion
Gestational diabetes is a common problem .
Risk stratification and screening is essential
in almost all pregnant women
Tight glycemic targets are required for
optimal maternal and fetal outcome
Patient education is essential to meet these
targets
Long term follow up of the mother and
baby is essential
REFERENCE
DC Dutta Textbook of Obstetrics