Gestational Diabetes mellitus

1. Under the guidance of,
Dr Prasanta Nayak,
Department of Obstetrics & Gynaecology
By Nabeel Rashid Hasan
9th Semester, Roll 49, Regd: 1741401052

2. CASE REPORT
1) PATIENT PARTICULARS:
 Name: Mrs Sabitri Das
 Age: 33 years old
 Sex: Female
 Obstetric Score: G3P1A1L1 at 33 weeks of gestation
 Religion: Hinduism
 Occupation: Teacher
 Address: Kalinga Nagar, Bhubaneswar
 Husband: Mr Kishore Das, 36, Bank Employee
 Socio-economic Status: Middle Class
 Date: 28th July 2021 (28/07/2021)

3. 2) CHIEF COMPLAINTS:
 Patient complains of:
 Itching & foul smell since 10 days.
 Persistent scanty Vaginal Discharge since 8 days.
 Mild Dysuria since 7 days.
3) HISTORY OF PRESENT ILLNESS:
 The patient was apparently alright 11 days back. To start with, she developed foul
smell & itching 10 days back, followed by scanty discharge 8 days back & mild
dysuria 7 days back. Discharge was curdy white & scanty.
 Patient is ambulatory & was consulted in OPD.

4. 4) HISTORY OF PRESENT PREGNANCY:
 First Trimester:
 First Visit at 1.5 months of amenorrhea. Pregnancy was confirmed by UPT &
USG. (27/01/2021)
 Routine check-ups were performed.
 No Nausea/ Vomiting/ Bleeding PV.
 Folic Acid (400 µg daily) was prescribed.
ROUTINE TESTS PERFORMED (1st TRIMESTER)
CBC Normal OGTT Normal
Blood Group/ Rh A+ HbA1c Normal
HHH Negative Dating Scan Normal (for gest. Age)
VDRL Negative NT/NB Normal
TFT Normal Urine Analysis Normal

5.  Second Trimester:
 Routine Check-ups done at 21st , 25th week. (19/05/2021)
 USG: Normal, AC < 35 cm.
 Anomaly Scan (at 5th month): (-)ve for Anomalies
 OGTT (Oral Glucose Tolerance Test):
 Done at 6th Month (25th week)
 75g glucose given and Blood Sugar levels measured after 2 hours.
 2-hour PGBS: 170 mg/dl
 Therefore, diagnosed as Gestational Diabetes (GDM) at 25 weeks.
 Treated with Dietary Management: MNT
 Iron & Calcium Supplements prescribed.
 2 doses of TT administered.
 Third Trimester:
 Patient had routine ANC visits till now.
 Present today (28/07/2021) for check-up at 33 weeks.

6. 5) MENSTRUAL HISTORY:
 Patient attained Menarche at 13 years old.
 Patient had regular menses coming every 28-30 days.
 Bleeding was normal lasting 4-5 days.
 LMP (Last menstrual period) was on 09/12/2020 (9th December) with
amenorrhea since then.
 Therefore, by Naegle’s Rule, she is 33 weeks pregnant.
 Therefore, EDD is 16/09/2021 (16th September).
 No H/O spotting, bleeding or discharges since LMP.

7. 7) OBSTETRIC HISTORY:
 Married for 5 years (non-consanguineous)
 G1:
 Conceived 1 baby before.
 3 year old boy FTVD,4kg
 (+) H/O difficult Vaginal delivery.
 All developmental milestones are normal.
 G2:
 (+) History of 1 miscarriage/ spontaneous abortion 1 year ago.
 No history of MTPs.
 Therefore, she is G3P1A1L1
 G3: Present Pregnancy.
8) HISTORY OF PAST ILLNESSES:
 No history of Diabetes mellitus, Tuberculosis, Asthma/COPD, Hypertension,
Heart Disease, Hypo/Hyperthyroidism, rhematic diseases.

8. 9) MEDICAL/TREATMENT HISTORY:
 No relevant past surgical history/ medical history/ gynaecological interventions.
 No past history of procedures/ No history of recent exposure to radiation/
teratogenic drugs/ toxins.
10) HISTORY OF IMMUNISATION:
 Immunised against all diseases as per NIS.
 Immunised against Rubella.
11) FAMILY HISTORY:
 (+) for D.M: BOTH parents are Diabetic.
 No other relevant Family History.

9. 12) PERSONAL HISTORY:
 Normal Bowel Bladder Habits.
 Normal Sleeping Pattern.
 No addictions.
 Mixed Indian Diet:
 Following Dietary patterns for GDM.
 Low Glycaemic Index foods.
 Controlled carbohydrate intake as per diet chart.
 Folate pills, Iron & Calcium Supplements as prescribed.
 (+) History of OCP use (MALA-D) for 1 year after marriage, which was
discontinued prior to first conception.

10. 13) GENERAL EXAMINATION:
 Orientation: Oriented to time, place & person.
 Build: OBESE with BMI = 29
 Temperature: 37.5°C
 Pulse: 70 bpm, regularly regular, good volume, no radio-radial/ radio-femoral delay
 BP: 130/90 mmHg (Rt arm, Supine position)
 JVP: Not Raised
 Pallor: Absent
 Icterus: Absent
 Cyanosis: Absent
 Clubbing: Absent
 Lymphadenopathy: Absent
 B/L Pedal Oedema: Absent

11.  Breast Examination:
 Breast development is normal;
 Nipple & Areola are normal, skin is normal
 No cracks, fissures or retractions
 No discharges
 No abnormal lump on palpation.
14) RESPIRATORY SYSTEM EXAMINATION:
 Normal, 13 breaths/min, No rales/ rhonchi/ wheeze.
 Normal Broncho-vesicular breath sounds heard all through lung fields.
15) CVS EXAMINATION:
 Normal Heart sounds (S1, S2 heard), no murmurs.
16) CNS/ MSK EXAMINATION:
 Normal.

12. 17) OBSTETRIC EXAMINATION:
 Inspection:
1. Protuberant Abdomen.
2. Globular/pyriform swelling arising from pelvis.
3. Linea Nigra & Stria Gravidarum (+).
4. Vertically stretched, non-everted umbilicus.
5. Some visible foetal movements (+).
6. No scars, otherwise normal skin.

13.  Palpation:
 Normal, i.e. soft myometrium.
 Foetal parts were not easily palpable (good liquor volume)
 Foetal Movements noted.
 Fundal Height (SFH): 33 cm;
Corresponding to between umbilicus & xiphisternum
~ 32-34 weeks (McDonald’s Rule)
 Fundus below xiphisternum = 32-34 weeks pregnant (Bartholemew’s Rule)

14.  Leopold’s Manoeuvre:
i. Fundal Grip: Firm, irregular non-ballotable mass indicating foetal breech.
ii. Lateral Grip (Foetal Lie): Longitudinal Lie
• Right Lateral: Continuous broad-like resistance felt (foetal back)
• Left Lateral: Multiple knob-like structures felt, slipping under fingers (foetal
limbs)
iii. Pawlik’s Grip (Presenting part/ 1st Pelvic Grip): Cephalic presentation.
iv. Deep Pelvic Grip (2nd Pelvic Grip): Cephalic prominence opposite to foetal back,
i.e. on Left side; Normal, well flexed Foetal head.
 Auscultation:
Foetal heart sounds heard ~ 120-130 bpm, regular in rhythm, heard inside the right spino-
umbilical line.

15. 18) IOV (Inspection of Vulva):
 No visible deformities.
 No visible inflammation/ abscess/ mass.
19) PER SPECULUM EXAMINATION:
 Scanty, Curdy white Discharge seen.
 Associated inflammation seen.
 No bleeding/ mass seen.
 S/O VAGINAL MONILIASIS/ CANDIDASIS.

16. A 33 y/o G3P2A1L1 Female diagnosed GESTATIONAL DIABETES MELLITUS since 2nd
Trimester, now presenting with VAGINAL MONILIASIS in 3rd trimester.

17. 20) INVESTIGATIONS:
POTENTIAL INVESTIGATIONS IN THIS CASE
For Diagnosis of: Tests: Probable Positive Results
Routine CBC Anaemia
PCV/ MCH/ MCV/ MCHC “
Urinanalysis GUT pathologies
GDM (Diagnosis & FU) OGTT GDM
HbA1c “
Foetal Health USG GCAs
Anomaly Scan “
Vaginal Moniliasis
(Candidiasis)
Gram’s KOH Mount Hyphae
Vaginal pH Acidic

18. DISCUSSION
 Definition: GDM is defined as Carb. Intolerance of varying severity with onset or 1st
recognition during the present pregnancy.
 Risk Factors include:
 Family H/O DM
 H/O Previous birth of overweight baby
 H/O Previous Still Birth
 Polyhydramnios/ Recurrent Vaginal Candidiasis (in Present Pregnancy)
 Persistent Glycosuria
 > 30 years old
 Obesity
 2 hour OGTT (75g) is both the screening & diagnostic modality of choice.

19. Time Carpenter & Couston NDDG
Fasting 95 105
1 hour 180 190
2 hours 155 165
3 hours 140 145
Carpenter & Coustan vs NDDG (National Diabetic Data Group) Criteria
[Based on 100g OGTT test]
1) GDM
2) OVERT DM
FBS > 126 mg/dl
OR 2-hour OGTT (75g) > 200 mg/dl
OR HbA1c > 6.5 %

20. CLASS ONSET FBG 2-hour OGTT Treatment
A Any Age A1: <105 mg/dl
A2: >105 mg/dl
A1: < 120 mg/dl
A2: > 120 mg/dl
A1: Diet
A2: Insulin
CLASS ONSET DURATION a/w Vascular ds Treatment
B > 20 y/o < 10 years None Insulin
C 10-19 y/o 10-19 years None Insulin
D < 10 y/o > 20 years Retinopathy (Benign) Insulin
F Any Any Nephropathy Insulin
H Any Any CAD Insulin
R Any Any Retinopathy (Proliferative) Insulin
T Any Any Renal Transplant Insulin

21. GDM OVERT DM
Common in T3 > T2 Seen ever since T1
DOES NOT cause GCA (anomalies) & abortions. CAUSES GCA & abortions.
Resolves w/i 6 weeks post partum Doesn’t resolve
1st TT: DIET changes 1st TT: INSULIN
2hr OGTT ≥ 140 mg/dl 2hr OGTT ≥ 200 mg/dl

22. MATERNAL FOETAL NEONATAL
Abortions MACROSOMIA (40-50%) Hypoglycaemia
Polyhydramnios Shoulder Dystocia Hypocalcaemia
PIH Delayed Lung Maturity Hypokalaemia
Bacterial Infections Still Birth Hypomagnesaemia
T2DM risk later GCA (Gross Cong. Anomalies) (6%) RDS (Resp. Distress)
Pre-term Labour (26%) Difficult/ Traumatic Delivery Hyper-viscosity Syndrome
PROM, Pre-eclampsia IUGR (rare) HOCM (reversible)
PPH
VULVOVAGINAL CANDIDIASIS
Abruptio Placenta

23.  Anomalies are more common in OVERT > GDM mother
 DELIVERY: Ideally 39 weeks (up to 40)
 Early Term (37-38) is avoided d/t delayed Lung maturity.
 Late Term (>40) is avoided because of already Macrosomic baby.
 Preferred: Vaginal delivery (with Epidural Analgesics)
 LSCS: ONLY i/c/o weight > 4.5 kg
 GCAs:
 CVS Anomalies > NTDs
 CVS: HOCM (cardiac) > VSD (common) > TGA (specific)
 Specific anomalies: Caudal Regression & Sacral Agenesis
 BEST TEST FOR ANC: Level 2 USG/ TIFFA (& Umbilical Art. Velocimetry)
 Shoulder Dystocia:
 Defined as ≥ 1 min passed after head delivery & shoulder not delivered
 HELPERR Protocol

24. TREATMENT
CASE 1: Diagnosed overt Diabetic (before pregnancy) [OGTT > 200 mg/dl]
Start INSULIN (0.7-1 IU/kg) + DIETARY CHANGES
CASE 2: Diagnosed overt Diabetic (during pregnancy) [OGTT > 200 mg/dl]
Start INSULIN (0.7-1 IU/kg)
CASE 3: Diagnosed Gestational Diabetic [OGTT ≥ 140 mg/dl]
Start DIETARY CHANGES
OGTT < 120 mg/dl OGTT > 120 mg/dl
MAINTAIN DIABETIC DIET Start INSULIN (0.7-1 IU/kg)

25.  PREFERRED: Regular + NPH Insulin OR MIXTARD INSULIN
 HOW TO TITRE THE DOSE OF INSULIN (METABOLIC GOALS):
 FBS < 95 mg/dl
 1 hour-PP BSL < 140 mg/dl
 2 hour-PP BSL < 120 mg/dl
 HbA1c < 6.0
 Average Capillary Glucose < 100 g/dl
 Dose increases with pregnancy time.
 Metformin & Glyburite can be tried in non-compliant patients (ONLY i/c/o GDM)
 Supportive Care:
 IV Fluids (NS/ RL)
 IV Potassium & Bicarbonate
 Foetal Monitoring

26.  DIET:
 40-50% carbs, 20% protein, 30-40% fats (saturated fats < 10%)
 High Fibre diet
 3 meal + 3 snacks regimen.
 Frequent self-monitoring of BSL.
 For VULVOVAGINAL CANDIDIASIS/ MONILIASIS:
 VAGINAL DOUCHE is WIDELY NOT RECOMMENDED
 In Non-Pregnant: Oral Fluconazole 150mg on Days 1, 4, 7 followed by 150mg weekly for 6
months
 In Pregnancy: Topical Miconazole/ Clotrimazole
(ORAL AZOLES ARE CONTRA-INDICATED IN PREGNANCY)
 Other Methods of Investigation:
i. Saline Microscopy/ KOH mount
ii. Pap Smear
iii. Culture (GOLD Standard)