CASE

PRESENTATION
Aakriti Shankar Ganesh
4 t h Year, MBBS
HISTORY
Case Presentation
◦ Mrs. Sharanya Devi, 36 y/o female residing in Porur, homemaker by
occupation, belonging to Socioeconomic Class 4, booked and immunised,
with LMP on 31-Jul-2020, EDD on 07-May-2021 and GA 38 weeks + 5
days. Her obstetric score is G2 P1 L1.

◦ She has been admitted for safe confinement and institutional delivery.
HOPI
◦ At 21 weeks of gestation she was diagnosed to have gestational diabetes
mellitus after being tested through OGTT. She was advised to control her
diet and prescribed Metformin.
◦ Transabdominal ultrasound done at 30 weeks period of gestation revealed
macrosomic baby with estimated foetal weight of 3.2kg. She was prescribed
Insulin in addition to Metformin to control her blood sugar level.
◦ She was referred to SRMC 4 days ago due to further increase in estimated
foetal weight to 4.2kg.
Antenatal History – 1st Trimester
◦ Booked and immunized
◦ Spontaneous pregnancy, confirmed at home by urine pregnancy test after 45
days of amenorrhoea
◦ Folic acid tablets taken
◦ Dating scan done at 8 weeks - normal
◦ NT Scan done at 14 weeks - normal
◦ No H/o excessive vomiting, bleeding or discharge P/V , fever with rash,
exposure to radiation, burning micturition, drug intake.
Antenatal History – 2nd Trimester
◦ 2 doses  of TT injection given at 4th and 5th month
◦ Anomaly scan done at 21 weeks - normal
◦ Quickening  felt at 5th month.
◦ Iron and calcium tablets taken.
◦ OGTT at 21 weeks– Gestational Diabetes Mellitus (FBG – 150mg/dL; PPBG –
190mg/dL; HbA1c – 8.2%)
◦ Advice: Metformin + Diet modification + Exercise
◦ No H/o burning micturition, no fever, no drug/medication intake
◦ No H /o bleeding or discharge P/V
Antenatal History – 3rd Trimester
◦ Foetal movement perceived well
◦ Iron and calcium tablets continued.
◦ Growth scan done at 30 weeks – macrosomic baby
◦ OGTT at 30 weeks: GDM
◦ Advice: Metformin + Mixtard Insulin
◦ No H/o episodes of sweating, headache or palpitation
◦ No H/o, burning micturition.
◦ No H/o bleeding, draining, discharge P/V.
Number of Antenatal Visits
◦ 1st Trimester – 2
◦ 2nd Trimester – 3
◦ 3rd Trimester - 5
Past Obstetric History
Sl. Date of GA, BW, Sex of Institution Mode of Comp Development
No Delivery Baby of Delivery Delivery licatio
ns
1 15-Sept- 40 weeks SRMC NVD - Normal growth and
2006 3.5kg development.
Female Breastfed until 2 years.
Current age: Daughter is now alive and
15 yrs well

• H/o secondary infertility for 15 years after the first pregnancy

• No H/o of abortions or MTP
• No H/o of contraception use
Past History
Medical History
◦ No H/o DM/HTN/TB/RF/BA/CAD/Epilepsy/Thyroid Disease
◦ No H/o Blood transfusion.
◦ No H/o allergies to drugs
Surgical History
◦ No significant history
Drug History
◦ No significant history
Treatment History
◦ Metformin: ___ mg/day
◦ Insulin: Mixtard Insulin ___ Units/day
Menstrual History
◦ Menarche: 12 yrs age
◦ LMP: 31-Jul-2020
◦ Cycle length: 5/28-30 days, regular
◦ Number of pads: 2-3/day
◦ No clots, no dysmenorrhoea
Marital History
◦ Married in 2005
◦ Non-consanguineous marriage
◦ No H/o contraceptive use
Personal History
◦ Mixed diet
◦ Normal Bowel & Bladder movement
◦ Not a smoker
◦ Does not consume alcohol or any other drugs
Family History
◦ Mother – K/C/O Diabetes Mellitus
◦ None significant family history
Social History
◦ Own home, pucca house – 2 bedroom
◦ Water Supply: Water tanker
◦ No water stagnation
◦ Sanitary latrine present
◦ Garbage disposal: Weekly collection by municipal corporation
◦ No mosquito, rats, cockroach nuisance
EXAMINATION
General Examination
◦ Conscious, oriented to time, place, person
◦ Moderately built and nourished
◦ Ht: 154cm ; Wt: 73kg
◦ Pre-pregnancy Wt: 61 kg; BMI: 25.72
◦ No pallor, icterus, cyanosis, clubbing, generalized lymphadenopathy, pedal edema
◦ Thyroid Examination – Normal
◦ Breast Examination - Normal
Vitals
◦ Pulse: 88 beats/min
◦ BP: 118/78 mm of Hg
◦ Respiratory Rate: 20 breaths/min
◦ Temperature: Afebrile
Systemic Examination

◦ CVS: S1, S2 (+)nt, no murmurs

◦ RS: Bilateral air entry (+)nt, normal vesicular breath sounds, no
rhales/rhonci
◦ CNS: No focal neurological deficit
Inspection
◦ Uniform longitudinally distended abdomen with flanks full
◦ Umbilicus - midline, everted
◦ Linea nigra, stria gravidarum (+)nt
◦ No scars, sinuses, dilated veins
◦ Hernial orifices - free
Palpation
◦ Fundal Height 36 weeks, flanks full.
◦ Symphysio-fundal height: 36 cm
◦ Foetus in longitudinal lie
◦ Fundal grip – broad, soft, non-ballotable mass in fundus, probably breech.
◦ Lateral grip - curved, smooth resistance felt over left side indicating foetal spine.
Nodularity felt on the right side, probably limb buds.
◦ 1st Pelvic grip – hard, mobile, ballotable mass, probably head, 4/5 felt per abdomen.
◦ 2nd Pelvic grip – hands converge, findings of 1 st pelvic grip confirmed
Auscultation
◦ Foetal Heart Rate – 146 beats per minute, regular, heard in the left spino-
umbilical line.

◦ Pelvic Examination – Not Done

SUMMARY
SUMMARY
◦ Mrs Sharanya Devi, 36 y/o female, G2 P1 L1 at 38 weeks + 5 days period
of gestation and EDD on 07-May-2021, with history of secondary infertility
for the past 15 years, has been currently diagnosed with gestational diabetes
mellitus, with poor glycaemic control, and is on metformin and insulin
injection. She has a single macrosomic foetus in cephalic presentation with
normal foetal heart sounds. She has been admitted for safe confinement and
institutional delivery.
MANAGEMENT
Investigations
◦ Screening/diagnostic test:
◦ Glucose Challenge Test
◦ OGTT
◦ DIPSI
◦ IADPSG
Treatment
◦ Medical
◦ Medical Nutritional Therapy (Diet)
◦ Exercise – 45-60 mins
◦ Glucose monitoring – 6 value
◦ Pharmacotherapy
◦ Oral Hypoglycaemic Agents
◦ Insulin Therapy
◦ Delivery
◦ Good glycaemic control – Term
◦ Poor glycaemic control – 37 weeks
◦ Foetal/Maternal complications – as required
Obstetric management of DM
Antepartum:
• Maternal serum α-FP
• Foetal morphology
• Foetal echocardiogram

• NST
• Biophysical Profile
• Doppler velocimetry

• Foetal macrosomia
• Polyhydramnios
Obstetric management of DM
Intrapartum:
• Monitor dilation & descent
• Electronic Foetal Heart Monitoring
• Anticipate shoulder dystocia

• Target glucose: <140mg%

• Monitor glucose 4-6 hourly
• Monitor hourly capillary glucose

• Insulin
• Bedtime dose given, withhold morning dose
• Add soluble insulin to 5% dextrose infusion
DISCUSSION
Tests for GDM Diagnosis
◦ Glucose Challenge Test
◦ OGTT
◦ DIPSI
◦ IADPSG
Two Step Approach for Diagnosis
Glucose Challenge Test
◦ 50g oral glucose irrespective of last meal
◦ Measure plasma glucose
 1hr later: <130mg% or <140mg%
Glucose Tolerance Test
◦ Done if values exceed the above cut-off
◦ WHO OGTT Test
Oral Glucose Tolerance Test (OGTT)
◦ Diagnostic Test
◦ 100g of glucose in fasting state
◦ WHO Cut-off:
Fasting: <95 mg%
1hr: <180 mg%
2hr: <155 mg%
3hr: <140 mg%
Oral Glucose Tolerance Test (OGTT)
◦ Diagnostic Test
◦ 75g of glucose in fasting state
◦ IADPSG Cut-off:
(International Association of Diabetes and Pregnancy Study Groups)
Fasting: <92 mg%
1hr: <180 mg%
2hr: <153 mg%
DIPSI –
(Diabetes in Pregnancy Study Group of India)
◦ 75g oral glucose irrespective of last meal
◦ Measure plasma glucose 2hrs later
◦ > 140 mg%: Gestational Diabetes mellitus
◦ > 120mg%: Impaired gestational glucose intolerance
One Step Approach for Diagnosis
◦ Done at 1st prenatal visit, repeated at 24-28 weeks.
◦ CRITERIA:
◦ GDM
◦ FBG: >92 mg% and <126 mg%
◦ Overt Diabetes
◦ FBG: >126 mg%
◦ HbA1c: >6.5%
◦ RPG: > 200 mg%
HIGH RISK
WOMEN
Complications of GDM
Complications of GDM
THANK YOU
REFERENCE
Essentials of
Obstetrics – Lakshmi
Seshadri