CASE STUDIES Gestational Diabetes Mellitus
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Case study #1: Mrs. C Mrs. C is a 22 year old primigravida coming for her first antenatal checkup at 12 weeks of gestation. On examination, she is 152 cm tall and weighs 69 kg. BMI, 30 kg/m2 She does not have a family history of diabetes. • Does she need to be screened for diabetes? • If so, when? • What screening test is to be used? 2
Mrs. C. Mrs. C had a fasting blood glucose done Her results are as follows. Time Glucose mmol/L(mg/dL)
• • • •
0 hr (Fasting) 4.7 (86)
Does she have diabetes? Does she have GDM? Does she need to be tested again? If so, when? 3
Mrs. C Mrs. C undergoes repeat testing at 26 weeks’ gestation. Her results on the 75 gm glucose load (fasting) are as follows. Time Glucose mmol/L(mg/dL)
0 hr (Fasting)
1 hour
2 hour
4.8 (88)
10.3 (186)
8.9 (161)
• Does she have GDM? • If yes, what treatment is indicated? • When will you review her and using what tests? 4
Mrs. C After 2 weeks, her results were as follows Fasting blood glucose mmol/L (mg/dL
5.2 (93)
2 hour postprandial blood glucose mmolL (mg/dL) breakfast
8.6 (156)
• Is her glycemic control adequate? • What is the next line of treatment? • What other test can help assess level of glycemic control?
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Mrs. C
Mrs. C is put on 4 units of rapid acting insulin before breakfast and advised to monitor her blood glucose daily. She does well. After 2 weeks, her reports are as follows. Fasting blood glucose mmol/L (mg/dl) 2 hour postprandial blood glucose mmol/L(mg/dl) breakfast
6.5 (118) 7 (126)
• Is her glycemic control adequate? • What is the next line of treatment? 6
Mrs. C Mrs. C is now on 6 units of NPH insulin at bedtime in addition to 4 units of rapid acting insulin before breakfast. She starts complaining of excess hunger during the early hours of the morning. Her reports are as follows. mmol/L (mg/dL) Fasting BG
3.3 (61)
2 hour postprandial BG
5.6 (102)
• Are these values acceptable? • What is the next line of treatment? 7
Mrs. C Her insulin dose has stabilized  NPH 8 units at bedtime  rapid acting insulin 6 u before breakfast, 4 units before lunch and 4 units before evening meal.
Mrs. C goes into labour at 39 weeks. Should she have been induced earlier? Should a C-Section be considered? How should her insulin be managed during labour and delivery? 8
Mrs. C Following delivery, blood glucose levels normalised and she was able to stop insulin. After 6 weeks, she underwent an OGTT, the results of which are as follows. Time Glucose mmol/L (mg/dl)
0 hour (Fasting)
2 hours
4.5 (82)
7.0 (127)
• What is the diagnosis? • What is her risk of developing diabetes in the future? • When should she be tested next?
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Case study #2: Mrs. S Mrs. S is a 35 year old nulliparous lady and has suffered two miscarriages in the last three years. After the last miscarriage she was diagnosed with PCOS and has been on metformin since. She did not test her blood glucose levels during either of her previous pregnancies. Her mother has diabetes. She presents at 12 weeks gestation What else do you need to know? 10
Mrs. S • Does she need to be screened for diabetes? • If so, when? • What screening test is to be used?
• Should the metformin be continued? • What is the purpose of metformin?
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Mrs. S Mrs S has an OGTT at 13 weeks gestation
Glucose mmol/L(mg/dl)
Fasting
2 hour
6.0 (108)
9.0 (162)
Are these results ok? Should she be retested? When? What management strategies should be considered? 12
Case Study #3: Mrs M Mrs. M, 30/F – Primigravida LMP: 13/10/12 EDC : 28/07/13 Regular cycles Spontaneous conception 10 months after marriage No family history of DM
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Mrs M Fasting BG at 6 weeks Fasting 8.8 mmol/L (160 mg/dL)
What would you advise now? Trial of MNT or medications right away? Any other tests? What risks to the pregnancy will you discuss with this lady? 14
Mrs M Normal scan at 12 weeks with a low risk of Downs 19- 20 week scan plus fetal echo was normal When will you advise next scan?
Glucose results as in next slide. Patient not very regular with SMBG and not following the meal plan
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MRS M – Blood glucose record Gestational age
FBS mmol/L (mg/dL)
1 h PPBS mmol/L(mg/dL)
A1c %
Medication
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5.9 (107)
6.9 (125)
8.1
Premix 70/30 18 - 0 - 18 + Metformin 500 BD
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7.1 (129)
10.1 (183)
7.2
22 - 0 - 22 + Metformin BD
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5.3 (97)
9.6 (173)
5.8 (105)
8.7 (157)
26 - 0 - 20 + Metformin BD 6.5
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Mrs M 29 week scan
Ask to comment
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Mrs M She comes in with c/o discomfort and abdominal pain at 30 weeks How will you manage her now?
Uterus is irritable with some tightening on and off
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Mrs M Tocolytic – which drug and dose Steroids – dose / concerns in GDM
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Mrs M Uterine contractions settle. UTI picked up and treated with appropriate antibiotics She is now 37 weeks FBS 5.5mmol/L (100mg/dL) 1 hr PPBS 8.3 mmol/L (150 mg.dL) on Regular (soluble) 26-10-14 + NPH 0-0-12 Comes in with decreased movements What would your approach be?
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Case Study #4 Mrs. C, a 32 year old primigravida Reports for the first antenatal checkup. She is obese with a body mass index of 35 kg/m2, both her parents have diabetes. Her OGTT results are as follows. Time
0 hr (Fasting)
1 hour
2 hour
10.6 (192)
16.0 (288)
14.6 (263)
Glucose mmol/L(mg/dL)
Her HbA1c is 9.2%. • What type of diabetes does this patient have? • What is the ideal line of treatment? • What is the prognosis for the pregnancy and for future resolution of diabetes? 21