PATIENT DETAILS
NAME: RJ
AGE : 36 YEARS OLD
RACE : MALAY
OCCUPATION: HOUSEWIFE
R/N NO: 842-10
INTRODUCTION AND CHIEF COMPLAINT
Puan RJ, 36 years old Malay housewife, gravida 2 para 1, and presently at 38 weeks
period of gestation was electively admitted for lower segment cesarean section due to gestational
diabetes mellitus and on insulin treatment. She has history of gestational diabetes mellitus during
her first pregnancy and was delivered a macrosomic baby via emergency cesarean section.
Besides that, she has a strong family history of diabetes mellitus.
Her last menstrual period was on 15 March 2010 and she was sure of the date. Her cycle
has been regular occurring 28-30 days. Previously, she was on oral contraceptive pills (OCP)
since 1 month after delivering her first child, which is in 2005 until early 2007. Therefore, her
expected date of delivery will be on 22 Disember 2010.
HISTORY OF PRESENTING PREGNANCY
This is an unplanned pregnancy but wanted. She suspected her pregnancy when she
missed her period in April for about a month. She did urine pregnancy test herself and the result
turned out to be positive. Therefore, she went to the nearest general practitioner for confirmation
and as suspected, her pregnancy was verified by another urine pregnancy test. However, she
denied any scan done.
She hed her booking at Klinik Kesihatan Sungai Besi at 8 weeks period of amenorrhea
and antenatal screening was done including blood and urine investigations, as well as infectious
screening. She did not know the result except she was told that all were normal. Her booking
blood pressure was 110/70. Her height is 141cm and her weight was 63kg. She also did her first
modified glucose tolerance test (MOGTT) during this time. It was indicated to her due to strong
previous history of Gestational Diabetes Mellitus during her first pregnancy and strong family
history, as both her parents are diabetics. She did not remember all the results however; she was
told that it was abnormal. She claimed that no ultrasound scanning was done during booking, and
she was given a referral letter to Hospital Ampang for further management of her Gestational
Diabetes Mellitus one week after the visit.
Subsequently, she had a visit in Hospital Ampang. In Hospital Ampang, her first
ultrasound was done and she claimed that it was correspond to her date. Besides that, her second
MOGTT was done and it turned out to be abnormal. However, she did not know the exact
results. Therefore, doctor decided to do another blood test on her which was a Blood Sugar
Profile (BSP). The first BSP was done and the reading showed slight increased during pre-lunch and
pre-dinner in which the patient cannot remember the results. As the consequences of that, she was
prescribed with subcutaneous actrapid (10/14/8) and insulatard 10 unites in which she has to inject the
medication subcutaneously 4 times per day, before breakfast, before lunch, before dinner and
before go to bed at night.
She went for several antenatal visits at the same clinic (Klinik Kesihatan Sungai Besi) and
all of them were uneventful. She was compliance to her medication and controlled her diet. She
claimed that several ultrasounds scanning done at that clinic.
Upon her usual antenatal visit at about 30 weeks period of gestation, another BSP done
and the results turned out to be very high and abnormal again. She claimed that on that time, she
was not compliance to the medication and was not control her diet. Therefore, she was
prescribed with higher dosage from her current medication which was subcutaneous actrapid
(18/16/14) unites. Since then, her blood glucose was under controlled.
On her last antenatal visit at KK Sungai Besi, the doctor gave her an appointment to be
electively admitted to Hospital Ampang for induction of labour for trial of scar since she had an
elective lower segment cesarean section previously. However, the patient refused and she opted
for another elective lower segment cesarean section. After several discussions with the
consultant, the consultant agreed to admit her for an elective cesarean section tomorrow.
On further questioning, the patient also claimed that she had nocturia, polyuria,
polydypsia and polyphagia since second month of her pregnancy. However, she was denied of
having blurring of vision, numbness of hands and feet, dysuria, skin lessions and symptoms and
signs of hypoglycemic attack such as dizziness, vertigo and syncope.
Otherwise, there are no symptoms of urinary tract infection and upper respiratory
infection, no history of fever and the fetal movement is good. Now, she was not in labour with
no symptoms of show, leaking liquor and contraction pain. Moreover, the fetal movement was
good.
PAST OBSTETRIC HISTORY
She was diagnosed to have Gestational Diabetes Mellitus at 20 weeks period of amenorrhea
during her first pregnancy and was on Insulin. She delivered her first child in 2005 via elective
lower segment caesarean section (LSCS) due to macrosomic baby and was giving birth to a girl
with 4.54 kg of weight. Currently the child is well and healthy.
PAST GYNAECOLOGICAL HISTORY
She attained her menarche at the age of 11 years old. Her menstrual cycle is about 28- 30 cycle,
regular and lasts for about 7 days. She claimed of having dysmenorrhea and menorrhagia and she
was on oral contraceptive pills (OCP) since 1 month after delivering her first child, which is in
2005 until early 2007. No history of Pap smear done. This is her first marriage. This is an
unplanned pregnancy but wanted.
PAST MEDICAL AND SURGICAL HISTORY
Nil
FAMILY HISTORY
Both her parents are diabetics and both are on Oral hypoglycemic agent. Otherwise, the other
siblings are well and healthy.
SOCIAL HISTORY
She is a housewife, non smoker and not consuming alcohol. Her husband is a computer
technician, a smoker of 4-5 sticks per day but not consuming alcohol. Their gross monthly
income is about RM30
DRUG AND ALLERGY HISTORY
She was on hematinics, obimin, calcium tablets, Actrapid and Insulin. She was allergic to
seafood and dust. Otherwise, no known drug allergy claimed.
PHYSICAL EXAMINATION
GENERAL INSPECTION
On general inspection, the patient was lying supine comfortably supported with one pillow. She
was conscious and alert, and clinically pink. She was not in pain and not in respiratory distress.
The hydration status was fair.
Vital signs:
1) Pulse : 92 bpm, regular rhythm, good volume
2) Blood pressure : 110/70 mmHg
3) Respiratory rate: 20 breaths per minute
4) Temperature : 37.0°C, afebrile
GENERAL EXAMINATION
Hand examination
Her hands were warm and dry. Her palmar crests were not pallor. There was peripheral cyanosis.
Head examination
Her conjunctivae were pink and there was no jaundice. Her oral hygiene was good and hydration
status was fair. There was no central cyanosis.
Neck examination
Thyroid gland was not enlarged. JVP was not raised. No palpable cervical lymph nodes.
Leg examination
There was no pitting edema, no calf tenderness and no varicose veins noted on both legs.
Other systems examination
Cardiovascular examination
The apex beat located at right 5th inter-costal space, lateral to mid-clavicular line. First and
second heart sound heard, no murmur detected and no additional sound heard.
Respiratory examination
Lungs were clear and air entry was equal bilaterally.
Breast examination
Breasts were bilaterally symmetrical with hyperpigmented areolar and normal everted nipple.
There were no skin changes, mass, eczema, retraction of the nipple and other abnormalities
noted.
SPECIFIC EXAMINATION OF THE ABDOMEN
Inspection
The abdomen was distended by a gravid uterus as evidence by linea nigra and striae gravidarum.
The umbilicus was centrally located and flat. There was a horizontal scar located at the
suprapubic area measuring about 12 cm and healed well.
Palpation
On palpation the abdomen was soft and non tender. The uterus was not irritable. The clinical
fundal height corresponds to 38 weeks period of gestation and measured 36 cm. There was a
singleton fetus in a longitudinal lie with fetal back on maternal right. The presentation is cephalic
with head is about 3/5 palpable. Liquor is clinically adequate and the estimated fetal weight is
about 2.8-3.0 kg.
Auscultation
Fetal heart was heard and the rate was 140 beats per minute.
SUMMARY
Puan RJ, 36 years old Malay Housewife, currently at 38 weeks period of gestation, was
electively admitted for lower segment cesarean section due to gestational diabetes mellitus and
on insulin treatment with a background history of gestational diabetes mellitus and had an
elective cesarean section in previous pregnancy. Currently she has no sign and symptoms of
labour and fetal movement was good. On examination, there was a singleton fetus in a
longitudinal lie with cephalic presentation and estimated fetal weight was 2.8-3.0 kg.
INVESTIGATIONS
Full blood count (FBC)
Justification
Full blood count was investigated to check for the presence of anemia and any infection. This is
important to determine whether she is able to withstand to any insult such as bleeding especially
after the operation and to ensur that she was not infected before undergo the cesarean section.
Results
Haemoglobin 13.8 g/dL
Haematocrit 39.5 %
White Blood Cells 8.7 K/uL
Antibody Screening Result Antibodies Not Detected
Interpretation
All the results were within normal range. She was not anemic and was not infected.
Ultrasound scan
Justification
Ultrasound is a more accurate method of estimating fetal size which important in this case to rule
out macrosomic fetus. Measurement can be taken of the head and abdominal circumference to
evaluate the size of the fetus. Besides that, it is important to check for the liquor because
pregnant women with diabetes mellitus are at high risk to develop polyhydromnios. Other that
that, evaluation of congenital defect and placenta can be done at same time.
Results
Fetus was in cephalic. Fetal biometry was as followed
Biparietal diameter: 94.4 mm
Abdominal circumference: 80.3 mm
Femur length: 72.5 mm
There was no congenital anomaly detected. Placenta was in the upper segment and amniotic fluid
index was 11
Interpretation
Fetal biometry were correspond to weeks of gestation. Otherwise, there was no abnormality.
Cardiotocograph (CTG)
Justification
This provides general information about fetal condition based on its heart rate at that point of
time. It also detects uterine contractions.
Results
Baseline heart rate: 152 beats/minute
Variability: 5-10 seconds
Acceleration: present
Deceleration: absent
Contractions: 1 in ten minutes
Interpretation
This is a reactive cardiotocogram and signifies that the fetus was in good condition and not in
any distress.
Others Investigation
• Indirect -immunoglobulin : Negative
• ABO + Rh : AB positive
• HbsAg : Non reactive
• HIV screening : Non reactive
MANAGEMENT
Pre-operative
Patient was asked for verbal as well as written consent.
All the pre-operative investigations were reviewed
Blood was sent for group cross match.
Anaesthetist had been informed to review the patient to make sure that she is fit for the surgery.
Patient was kept nil by mouth for 12 hours prior to surgery.
Lactulose was given for bowel preparation before the surgery.
Intra-operative
Lower segment cesarean section
Post-operative
After stable, patient was transferred to the ward and vital signs were monitored 4hourly.
She was allowed to take food orally after fully regained her consciousness.
She was transfused with 4 pints Dextrose saline over 24 hours.
She was put on strict input/output and pad charting.
Urinary catheter was inserted and kept for 24 hours.
She was given C.Tramadol 50mg tds as well as IM Lucrin 3.75mg
PROGRESS
Total blood loss = 400mls.
She had good pain control and her vital signs were stable.
Physical examinations revealed no abnormality.
Wound inspection noted intact suture with no evidence of wound infection
Discussion
Gestational Diabetes Mellitus is defined as Diabetes Mellitus that first diagnosed during
pregnancy and resolved after delivery. During early pregnancy, increase in estrogens,
progesterone and other pregnancy-related hormones leads to lower glucose level. As gestation
progresses, insulin sensitivity started to decrease and glucagon started to be released hence
posprandial glucose level will be high compared to the non-pregnant lady. Therefore, maternal
insulin secretion will be increase sufficiently in order to compensate with this physiological
changes. GDM occurs when there is insufficient insulin secretion to counteract the pregnancy-
related decrease in insulin sensitivity. This was what happening in this patient. She was
diagnosed to have diabetes mellitus since the first trimester whereby abnormalities in her blood
sugar level was noted during her first booking at 8 weeks period of gestation.
In the second trimester, placenta increases secretion of insulinase, which break down the
insulin. Therefore, by this stage fasting and postprandial glucose level will be higher in
gestational diabetes mellitus.
At her first booking, she was diagnosed to have diabetes mellitus by modified modified
oral glucose tolerance test (MMOGTT). It was indicated to her as she had a strong family history
of DM in her first degree relatives and she also delivered a macrosomic baby weight 4.54 during
her first pregnancy. To diagnose GDM in a pregnant lady via MMOGTT, two readings of blood
sugar level are taken. First reading is after 8 hours fast and the second one will be two hours after
taking 75 mg of glucose in 300 ml of water. The results should be more than 7.8 mmol/L for
fasting blood glucose and more than 11.1 mmol/L for the two hours after taking 75 mg of
glucose in 300 ml of water to confirm the diagnosis of gestational diabetes mellitus. Other
indication for MMOGTT are, two times glycosuria at antenatal visit, unexplained abortions and
still birth, previous congenital abnormalities, polyhydromnios and presents of signs and
symptoms of diabetes mellitus such as polyuria, polydipsia, polyphagia and peripheral
neuropathies.
In order to monitor the sugar level, another blood test was done to this patient and it is
called blood sugar profile (BSP). In this test, blood will be taken four times to monitor the
glucose level which are pre breakfast, pre lunch, pre dinner and before bedtime. The aim for a
normal non-diabetic pregnant lady will be (5,6,6,7)mmol/L respectively. For this patient, she was
asked to do a weekly BSP for close monitoring, as this is a high-risk pregnancy.
After this patient is diagnosed to have gestational diabetes mellitus, doctor started her on
subcutaneous Insulin, the short acting, actrapid and the long acting insulatard. There are three
methods of treatment for GDM, which are by strict diet control, oral hypoglycemic agent and
Insulin. Usually doctor will decided to start them on strict diet control in which no medication
given however, they have to control the diet accordingly. Oral hypoglycemic agent (OHA)
usually was not prescribed because of incompliance of the patient due to frequent vomiting
especially in the first trimester. Besides that, during pregnancy, effect of progesterone causes
decrease in intestinal motility. Due to this condition, there will be more absorption along the
gastrointestinal tract. Hence, more OHA will be absorbed and this will cause the patient to
develop hypoglycemic state. As in this patient, the GDM was diagnosed in the first trimester, and
the doctor straight away started her on Insulin due to the reasons mentioned.
The goal of management in GDM patient is to ensure that they remain normoglycemic
throughout the pregnancy. This is because several complications will occur if that was not
achieved. Study done in Australia entitled Gestational diabetes mellitus -- management
guidelines shown that, maternal complication in GDM are recurrent vulvovaginal candidiasis,
pregnancy induced hypertension, retinopathy, thromboembolic disease, obstructed deliveries and
gastric neuropathy. In rare instances, heart failure and eclampsia might occur. On the other hand,
one of the article prepared by Malaysia gynecologists shown that among the fetal complications
are miscarriage, congenital abnormalities such as neural tube defect, microcephaly, sacral
agenesis, renal abnormalities and heart abnormalities, pre-term labor, polyhydromnios,
macrosomia, intrauterine growth restriction (IUGR) and unexplained intrauterine death.
However, in this patient none of these complications has developed.
The mode of delivery for patients with GDM will be either vaginal delivery or cesarean
section. Usually those who are on diet control, doctors would like to prolong their pregnancy up
to 40 weeks while those on insulin will be up to 38 weeks period of gestation only. In this
patient, at first doctor decided to induced her at 38 weeks and wanted to do trial of scar on her.
During her last antenatal visit, doctor incharged explained about her mode of delivery, which are
either lower segment cesarean section, LSCS or normal delivery. The doctor said that by doing a
trial of scar risk of scar dehiscence is only 0.5%, however it may increases with induction. Since
her current fetus is much smaller than the previous one, she may try for normal delivery, as the
success rate will be 60-80%, for 6-8hours. However, if there is obstetric indication LSCS will be
conducted on her. However, this patient was disagreed and she opted for elective lower segment
cesarean section.
At first, the doctor decided to do a trial of scar or vaginal birth after cesarean (VBAC)
since she has had only one episode of LSCS and the doctor does not want to create another scar
on her body. Besides that, VBAC is very beneficial for planning on a future pregnancy as it will
not create another scar on the uterus. The more scars you have on your uterus, the greater the
chance of problems with a later pregnancy. VBAC will also give lesser pain after delivery hence,
fewer days in the hospital and a shorter recovery at home. In addition, it will also put the patient
at a lower risk of infection.
Gestational diabetes mellitus -- management guidelines
The Australasian Diabetes in Pregnancy Society
Linda Hoffman, Chris Nolan, J Dennis Wilson,
Jeremy J N Oats and David Simmons
MJA 1998; 169: 93-97
