A Case Study of GDM and Neonatal Complicatins

1. PG CME 2016-17
GESTATIONAL DM COMPLICATING THE
NEONATAL OUTCOME : A Case Study
CASE PRESENTATION BY – DR BISWAJIT PANDA
POST-GRADUATE DEPT. OF O&G, SCB MEDICAL COLLEGE, CUTTACK

2.  Mrs. KOUSALYA BEHERA, 27 YEARS
HF
 A Primigravida
 From Buxibazar, Cuttack attended
 Antenatal OPD at GA 37 week 2 day
 on 30.05.2016 for Safe Confinement

3. H/O PRESENT ILLNESS
 Patient had been diagnosed as a case of Gestational
DM since last 4 months at SCB Medical College and
was having Regular Antenatal Check ups since then.
 This time She had TERM pregnancy and Her Fasting
Blood Glucose was 118 mg/dl for which she again
attended the Antenatal Clinic.
 She had no Specific Complaints during this check up.

4. `
O/H: Married for 1&1/2 year
Primigravida
ANC - 6 USG - 2
(1st trimester ANC was Uneventful. On 2nd Trimester she
developed Gestational DM and was put on Insulin therapy. She
was advised ANC every 4 weeks with Self Monitoring Blood
Glucose)
M/H: Menarche 12 years age
PMC = 3-4 d/26-28d Regular Average
LMP = 11.9.2015

5. PAST HISTORY –
 No H/O Diabetes, HTN, Thyroid Abnormality, TB, Asthma,
Epilepsy, Rheumatic Heart Disease.
PERSONAL HISTORY -
 No H/O Past Surgery or Chronic Drug Intake.
 Middle SES. Education upto Graduation.
 No Addiction or Habituation. Bladder and Bowel habits
Normal. On Mixed Indian Diet. Housewife with Sedentary
lifestyle.
FAMILY HISTORY -
 Father has Type II DM detected 2 years back. No F/H of HTN.

6. GENERAL EXAMINATION
 Pt Conscious, Oriented, Afebrile
 No pallor. No icterus. B/L PEDAL EDEMA present. No Lymphadenopathy.
 Temp: 98.2 F
 PR:82/min Regular Good Volume
 BP:120/70 mm hg
 No Thyromegaly. Both Breasts normal.
 Ht-146cm Wt-62kg
SYTEMIC EXAMINATION
 CHEST: CLEAR,B/L VBS
 CVS: S1+ S2+ M0
 CNS: Normal

7.  P/A-
INSPECTION – Abdomen Protuberant. Umbilicus Central.
Striae Present. No previous Scar.
PALPATION : Uterus 34 wk size
Cephalic Vx=4/5 LOA
Relaxed, FHR=142/ min
 P/S- no leaking, no bleeding
 P/V- Cx long Os closed
HS -3 Pelvis Clinically Adequate

8. 1st ANTENATAL CHECK UP(16.11.2015)
1st trimester ( GA 9 weeks 3 days)
 HIV,HbSAg,HCV-NEGATIVE
 Hb-13 g%
 FBS-80mg/dl
 S. TSH-1.9 Iu/dl Rx
 VDRL-NON REACTIVE 1. Tab. Folic Acid (5mg) OD
 TOXO-NEGATIVE 2. Tab. Zincovit 1 tab. OD

9. 2nd ANTENATAL CHECK UP (08.02.2016)
2nd trimester (GA 21 weeks 2 day)
 Hb-11.8%
 Blood Grouping-B+ve
 FBS-98 mg/dl Rx
 2hr. PPBS-123 mg/dl 1.Tab. Iron 1 tab OD
 S. TSH-1.73 iu/dl 2.Tetanus Toxoid 2nd dose
3. Advice: 75 gm OGTT
USG (TIFA Scan) – SLIUF at AGA 19 wk 6 day
with NO GROSS CONGENITAL ANOMALY

10. 75 gm. OGTT (09.02.2016)
 FBS-101 mg/dl
 1 hr-250 mg/dl
 2 hr-205 mg/dl
 HbA1C-7.2%
Endocrinology consultation
 Inj. HUMALOG (Lispro) 6 units s/c b.Bf
4 units s/c b.L

11. 12.02.2016
FBS = 94 mg/dl
1hr PPBS = 155 mg/dl
2hr PPBS = 136 mg/dl
15.02.2016 Rx
FBS = 82 mg/dl Same dose of insulin Continued
1hr PPBS = 137 mg/dl
2hr PPBS = 122 mg/dl

12. FOLLOW UP (2nd & 3rd TRIMESTER)
DATE FBS (mg/dl) 1hr PPBS (mg/dl) 2hr PPBS (mg/dl)
28-02-2016 84 134 120
14-03-2016 92 129 117
29-03-2016 87 142 128
17-04-2016 82 126 111
28-04-2016 89 137 126
15-05-2016 94 176 148
30-05-2016 118 252 242

13. INVESTIGATIONS (30.05.16)
(GA 37 week 2 day)
 FBS-118 mg/dl
 1 HR PPBS-252 mg/dl
 2 HR PPBS-242 mg/dl
Endocrinology consultation
 inj. Humalog 14 U S.C. BBF
( Lispro ) 8 U S.C. BL
4 U S.C. BD

14. Rx
 LEFT LATERAL POSITION
 DFMC
 ROUTINE INVESTIGATIONS
 USG (Obs. scan) for FBPP and AFI status
 FBS, PPBS (1hr & 2hr) every alternate day
 Endocrine Consultation
 Ophthalmology Consultation

15. INVESTIGATIONS (31.5.16)
 Hb-12.0 g%
 PCV-37%
 TLC-8000/mm3
 DC-N66 L30 E4 M0 B0
 TPC-1.2 LACS/cu mm
 S.TSH-2.13 IU/dl F.T3-2.05 pg/dl F.T4-1.02 ng/dl
 S. Sodium-142 mmol/l
 S. Potassium-3.8mmol/l
 S. Urea-14.2 gm/dl
 S. Creatinine-0.6mg/dl
 URINE- Albumin NIL. Ketone Body NIL. RBC NIL. Pus Cell 1-2/HPF

16. USG (01.06.16)
 SLIUF AT AGA 32 weeks 1 days +- 3 wk In cephalic
presentation
With Placenta fundal early grade III
AFI=8.71 cm
EFW=1.89 kg+-282 gm (IUGR)
WITH NORMAL COLOUR DOPPLER STUDY

17. REPEAT INVESTIGATIONS (5.6.16)
 FBS-93 mg/dl
 1 hr PPBS-134 mg/dl
 2 hr PPBS-119 mg/dl
 HbA1c-6.9%
 S. Sodium-138mmol/l
 S. Potassium-4.7mmol/l
 S. Urea-14mg/dl
 S. Creatinine-0.5mg/dl

18. On 7.6.16 morning (GA 38 weeks and 3 days)
 C/O-REDUCED FETAL MOVEMENTS SINCE LAST 2-3 HOURS
 O/E- Pt conscious oriented afebrile
No pallor, No icterus, B/L PEDAL EDEMA present
PR-78/min
BP-118/86 mmHg
Chest/CVS-NAD
 P/A- Uterus 34 weeks size
cephalic relaxed FHR-164/min
 P/S- NO LEAKING
 P/V-Cx long OS closed

19. USG (07.06.16)
 SLIUF AT AGA 32 weeks 3 days
 With FHR - 170/MIN
 WITH Compromised Feto-placental Circulation
(Cerebro-Placental Ratio=0.9)
PLAN :
Skip morning dose of insulin and urgent LSCS

20. OT NOTE
 TYPE-LSCS UNDER SA
 INDICATION-TERM GDM + IUGR + FETAL DISTRESS
 INCISION-TRANSVERSE
 Under all aseptic measures, LSCS under SA done. Male / 2.1 kg /
10.40 am / 7.6.16 delivered by Vx . Baby cried spontaneously after
birth. Liquor was reduced and thick meconium stained. Resuscitation
was done by neonatologist and the baby sent to SNCU. Placenta and
membrane delivered in toto in 5 mins. Uterus closed in double layers.
Bilateral tubes and ovaries healthy. Abdomen closed in layers after
proper hemostasis. Tab misoprostol 800mg P/R given. Subcuticular
stitch given.

21. POST-OP Rx
 NPO for 24 hr.s
 IVF- RL 1 PINT  D5 1 PINT WITH 6 U INSULIN  NS 1
PINT  RL 1PINT  D5 1 PINT WITH 6 U INSULIN  NS 1
PINT over 24 hr.s
 Inj. OXYTOCIN 10 Units In 1st 3 pint IVF
 Inj. PIPERACILIN + TAZO (4.5g) IV TID
 Inj. METRON(400) IV TID
 Inj. MIKACIN(500) IV BD
 Inj. DICLONAC IM BD
 Inj. PANTOP(40) IV OD
 W/F Vitals, I/O Chart, Bleeding P/V

22. POST-OP RBS
 7.6.16 EVENING  146 mg/dl
 8.6.16 MORNING  96 mg/dl
 8.6.16 EVENING  108 mg/dl
 9.6.16 MORNING  114 mg/dl

23. POST OP
 Ist POD- Oral Sips
 2nd POD- Liquid and Semisolid diet
 3rd POD- Foley’s Removed. Diabetic diet Started
 4th POD- Diabetic diet & Dressing
FBS - 115 mg/dl 1 hr PPBS - 208 mg/dl
ENDOCRINE CONSULTATION: Inj. INSULIN ® 6U B.Bf 4U B.L 2U
B.D
 5th POD & 6th POD- Diabetic diet
 7th POD- FBS - 102 mg/dl 1 hr PPBS - 160 mg/dl
Inj. INSULIN ® same dose continued
 8th POD- DISCHARGE

24. BABY FOLLOW-UP
DAY-1
Tachypnea : 68 breaths/min with Nasal Flaring
RBS = 28 mg/dl
DIAGNOSIS- TTNB + HYPOGLYCEMIA + MAS
Rx
1. Intubation followed by Suction
2. Oxygen Inhalation
3. Glucose Infusion Rate (6 mg/kg/min)
4. Inj. Ampicilin(200mg) IV TID & Inj. Gentamycin(8mg) IV OD
5. Blood Culture to R/O Chemical Pneumonitis
Evening RBS – 37 mg/dl

25. BABY FOLLOW-UP(cont.)
DAY-2
RR-48/min & RBS-44mg/dl
Rx
1. Oxygen Inhalation cont.
2. Glucose Infusion cont.
3. Inj. Ampicilin + Inj. Gentamycin cont.
DAY-3
RR-46/min, No Nasal Flairing. Chest X-ray Normal.
RBS-76mg/dl & Blood Culture - NO GROWTH
Rx
1. OG tube feeding of Expressed Breast Milk Started
2. Oxygen, GIR and Injectable Antibiotics stopped

26. BABY FOLLOW-UP(cont.)
DAY-4
Baby ICTERIC – TCB 18 mg/dl
Rx - LED PHOTOTHERAPY. EBF cont. Breast Feeding Tried.
DAY-5
TCB 16 mg/dl
Rx - Phototherapy cont. Breast feeding started.
DAY-6
TCB 13 mg/dl
Rx- Phototherapy Stopped. DISCHARGED after 24 hr.s

27. ADVICE ON DISCHARGE :
1. Glucose Monitoring Twice Weekly  Endocrine Consultation
regarding Insulin Therapy
2. Post-OP follow up after 45 days
3. Contraception : Barrier Method or POP (From 2nd Month to 7th
month)
4. Next Pregnancy to be Planned just after 3 years without Delay
5. PreConceptional Councelling regarding Diet, Exercise and
Glycemic Control.
6. Newborn Baby to be Checked up after 7 days

28. Follow Up Investigations
DATE (PPD) FBS(mg/dl) 1 hr. PPBS (mg/dl) T/t
10.06.16 (4day) 115 208 Insulin
13.06.16 (1wk) 102 160 Insulin
20.06.16 (2wk) 92 145 Diet & Exercise
04.07.16 (4wk) 84 134 Diet & Exercise
02.08.16 (8wk) 91 121 Diet & Exercise
01.09.16 (12wk) 87 128 Diet & Exercise

29. SUMMARY
My patient 27 yr HF Primigravida at GA 37 wk 2 d
admitted to ANW with Gestational DM. She was
treated Conservatively with Insulin for Glycemic
Control. Then the Pregnancy was terminated at GA
38 wk 3 d by LSCS for Fetal distress. Post OP period
was uneventful. The Newborn baby suffered from
Complications of Maternal Diabetes and admitted to
SNCU. Both mother and baby were discharged
healthy on 8th POD.

30. )