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

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

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.

`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

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.

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

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/ minP/S- no leaking, no bleedingP/V- Cx long Os closed HS -3 Pelvis Clinically Adequate

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

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

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

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

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

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

RxLEFT LATERAL POSITIONDFMCROUTINE INVESTIGATIONSUSG (Obs. scan) for FBPP and AFI statusFBS, PPBS (1hr & 2hr) every alternate

dayEndocrine ConsultationOphthalmology Consultation

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

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

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

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

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

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.

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

POST-OP RBS

7.6.16 EVENING 146 mg/dl8.6.16 MORNING 96 mg/dl8.6.16 EVENING 108 mg/dl9.6.16 MORNING 114 mg/dl

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

BABY FOLLOW-UPDAY-1 Tachypnea : 68 breaths/min with Nasal Flaring RBS = 28 mg/dlDIAGNOSIS- TTNB + HYPOGLYCEMIA + MASRx1. Intubation followed by Suction2. Oxygen Inhalation3. Glucose Infusion Rate (6 mg/kg/min)4. Inj. Ampicilin(200mg) IV TID & Inj. Gentamycin(8mg) IV OD5. Blood Culture to R/O Chemical Pneumonitis

Evening RBS – 37 mg/dl

BABY FOLLOW-UP(cont.)DAY-2 RR-48/min & RBS-44mg/dlRx1. 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 GROWTHRx4. OG tube feeding of Expressed Breast Milk Started5. Oxygen, GIR and Injectable Antibiotics stopped

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

ADVICE ON DISCHARGE :1. Glucose Monitoring Twice Weekly Endocrine Consultation

regarding Insulin Therapy2. Post-OP follow up after 45 days3. Contraception : Barrier Method or POP (From 2nd Month to

7th month)4. Next Pregnancy to be Planned just after 3 years without

Delay5. PreConceptional Councelling regarding Diet, Exercise and

Glycemic Control.6. Newborn Baby to be Checked up after 7 days

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

SUMMARYMy 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.

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