13-pregnancy & Dm
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DIABETES & PREGNANCY
JEHAD AL-HARMI DEPARTMENT OF OBS & GYN FACULTY OF MEDICINE/ KUWAIT UNIVERSITY
DEFINITION • Persistent state of hyperglycemia due to lack, or diminished effectiveness, of endogenous insulin • Very common medical complication of pregnancy; variable incidence from 0.5 – 15%
TYPES-1 Abnormal glucose metabolism in pregnancy: 1. Overt, pregestational, or pre-existing DM 2. Gestational diabetes (GDM): • • • •
First diagnosed during pregnancy May persist after delivery May include a small group of overt DM Has many similarities to NIDDM
1. Impaired glucose tolerance test (IGTT)
TYPES-2 Pregestational DM: 1. Type I or IDDM: • •
Usually juvenile onset May be associated with autoimmune disease
1. Type II or NIDDM: • • •
Usually adult onset Occurs more frequently in the obese Has a stronger familial component
CLASSIFICATION MODIFIED WHITE CLASSIFICATION:
A1 A2 B C D F R H T
GDM on diet GDM on insulin Onset after age 20 years, or duration less than Onset &/or duration between 10-20 years Onset before age 10 years, or duration more Nephropathy Proliferative (not background) retinopathy Coronary artery disease Renal transplant
10 years than 20 years
RISK FACTORS-1 WHAT ARE THE RISK FACTORS OF GDM?
RISK FACTORS-2 1. Family h/o DM (1st degree relative) 2. Previous h/o GDM – Recurrence rate is 60-70%. Why not 100%? What are the predictors?
3. Glycosuria – Before 16/52 – >2 occasions
4. Polyhydramnios (AFI > 25 cm)
RISK FACTORS-3 5. Age > 30 years 6. Obesity (BMI > 27 kg/m²) 7. Polyuria 8. Polydypsia 9. Excessive weight gain (> 18 kg)
RISK FACTORS-4 10. Previous h/o: 1. Recurrent spontaneous abortions 2. Unexplained SB or NND 3. Baby with major congenital anomalies (CNS, cardiac, skeletal) 4. Big baby (> 4500 g) 5. Recurrent PE 6. Recurrent candidaiasis
DIAGNOSIS - 1 SCREENING: – Why? – Whom? – How? – When?
DIAGNOSIS - 2 SCREENING: • Glucose loading/challenge test (GLT): – No special preparation – 50 g glucose; measure plasma BS after 1 hour – For low-risk: screen at 26-28/52 – For high-risk: screen at booking & if result negative repeat at 26-28/52
DIAGNOSIS - 3 • If GLT > 10 or FBS > 7.2 mmol/l no need for further testing; patient is diabetic • If GLT 7.3-10 mmol/l proceed to oral glucose tolerance test (OGTT)
OGTT – 3 days on diet containing 150 g CHO daily – Fasting 8 - 14 hours. 100 g glucose load – Measure plasma levels – No smoking or excessive activity
• Normal values: – FBS –1h –2h –3h
5.3 mmol/l 10 1 high value = IGTT 8.6 2 high values = GDM 7.8
GLUCOSE METABOLISM IN PREGNANCY • GLYCOSURIA: – Often seen during pregnancy due to ↓ renal threshold of glucose excretion & incomplete reabsorption in the renal tubules
• GLYCEMIA: – FBS usually lower by 0.5 mmol/l; PPBS higher – Higher highs & lower lows
EFFECTS OF DIABETES ON PREGNANCY - 1 WHAT ARE THE MATERNAL COMPLICATIONS OF DM?
EFFECTS OF DIABETES ON PREGNANCY - 2 MATERNAL - 1: 1. DKA fetal & / or maternal death 2. Hypoglycemia (if severe & prolonged) may lead to fetal death. But usually better tolerated than hyperglycemia 3. Polyhydramnios PROM, & unstable lie 4. PET especially in presence of renal impairment (20-40%, up to 60%)
EFFECTS OF DIABETES ON PREGNANCY - 3 MATERNAL - 2: 5. Macrosomia (25% of IDM have BW >4000 grams; 60% are LGA with BW >90th percentile) CPD, operative delivery, shoulder dystocia, trauma, & PPH 6. UTI & pyelonephritis 7. Vulvovaginal candidaiasis
EFFECTS OF DIABETES ON PREGNANCY - 4 WHAT ARE THE FETAL/NEONATAL COMPLICATIONS OF DM?
EFFECTS OF DIABETES ON PREGNANCY - 5 FETAL & NEONATAL - 1: 1. Spontaneous abortion 2. Macrosomia shoulder dystocia asphyxia &/or trauma 1. Erb’s palsy, Klumpke’s palsy 2. Facial palsy, Horner’s syndrome 3. Clavicular or humeral fractures
3. IUFD in late pregnancy 4. Prematurity (double)
EFFECTS OF DIABETES ON PREGNANCY - 6 FETAL & NEONATAL - 2: 5. FD during labor; secondary to acute & chronic hypoxia 6. Hypoglycemia especially in 1st 48 hours after delivery • Maternal hyperglycemia fetal hyperglycemia fetal hyperinsulinemia hyperplasia & hypertrophy of fetal pancreatic islets of Langerhans neonatal hypoglycemia (Pederson hypothesis) • Check RBS frequently and start early feeding
EFFECTS OF DIABETES ON PRGNANCY - 7 FETAL & NEONATAL - 3: 7. RDS or HMD 8. Hypocalcemia 9. Polycythemia & neonatal jaundice 10. Congenital anomalies: 1. 2. 3. 4.
Sacral agenesis & caudal regression CNS : open NTD. Role of folic acid? CVS : TOGV, VSD, ASD Renal
INFANT OF DIABETIC MOTHER
EFFECTS OF PREGNANCY ON DIABETES • NIDDM patients will require insulin because oral hypoglycemic agents relatively contraindicated. Why? • IDDM patients will require higher doses of insulin • Existing retinopathy & nephropathy may worsen
PROGNOSIS-1 • PNM associated with DM has decreased 10 X in the past 40 years because of better glycemic control, reduction of early IOL, & advances in neonatal care • Benefits of tight glycemic control: – Early pregnancy: decrease possibility of abortions & fetal anomalies – Later pregnancy: decrease the rate of macrosomia & PNM
PROGNOSIS-2 RULE OF 15: – 36% of women with GDM develop DM within 15 years – 15% of pregnant patients have abnormal GLT – 15 % of those have abnormal OGTT – 15 % of those require insulin therapy – 15% of patients with GDM have macrosomic babies (BW> 4000 grams)
MANAGEMENT - 1 PRECONCEPTION COUNSELING - 1: – Timing of pregnancy & importance of Hb A1c levels in detecting control over the past 30-40 days • Hb A1c produced by slow glycosylation • Normal range 3-4% • If level > 12% associated with increased risk of complications
– Postponement of pregnancy till later age not advisable. Why?
MANAGEMENT - 2 PRECONCEPTION COUNSELING - 2: – Re-education – Ideal control: • Glucose home monitoring by capillary sampling • Patient injects herself with insulin • Close relatives able to deal with emergencies
– Long-term effects on off-spring: • Childhood obesity • Early-onset type II DM
MANAGEMENT - 3 ANC - 1: – Team approach (obstetrician, physician, nurse, dietician) – Additional testing: • RFT, 24-hour urine collection for total protein & creatinine clearance rate • Fundoscopy • MSU for C&S • Fetal echocardiography
MANAGEMENT - 4 ANC - 2: – Insulin dose & frequency may have to be increased (up to 2-3 X in later pregnancy) – Glucose home monitoring (as opposed to repeated hospital admissions) increases compliance, improves results, & reduces cost – Visits every 2/52 till 32/52, then weekly till delivery
MANAGEMENT - 5 ANC - 3: – U/S in T1 for viability & confirmation of GA – U/S at 20-24/52 for anomalies – U/S at 32-36/52 for growth – Daily FKC starting at 32/52 – Weekly NST starting at 32/52; increase to twice weekly at 34-36/52 – Weekly BPP may also be carried out
MANAGEMENT - 6 GDM: – Diabetic diet for 1/52 – BSP: 7 readings – If controlled with diet, recheck FBS & PPBS every 1-2/52 – If insulin is needed, admit to hospital
MANAGEMENT - 7 DIET: – 30-35 kcal/kg of ideal body weight (range = 1800-2800 kcal/ day) – 3 meals + 3 snacks – 50 % CHO (complex & high fiber) + 30 % fat + 20 % protein – 25 % breakfast + 30 % lunch & dinner + 5 % each snack – Consistency in dietary intake and activity level
MANAGEMENT - 8 INSULIN THERAPY - 1: – If initial FBS > 9 mmol/l – If diet does not provide satisfactory control within 1-2/52 • • • • •
FBS < 5.3 mmol/l Pre-prandial < 6 THIS IS 1-hour PPBS < 7.8 “TIGHT GLYCEMIC 2-hour PPBS < 6.7 CONTROL” Not less than 4
MANAGEMENT - 9 INSULIN THERAPY - 2: – Total dose: • T1 0.5 units/kg actual body weight • T2 0.6 • T3 0.7
– Dose divided into 2/3 in am + 1/3 in pm – AM dose further divided into 1/3 short-acting + 2/3 intermediate- acting – PM dose divided in 1/2
MANAGEMENT - 10 INSULIN THERAPY - 3: – Alternative regimen: • 3 pre-prandial doses of short-acting insulin • 1 dose of intermediate-acting insulin at bedtime if FBS high
– Reduced compliance but better glycemic control – What is the role of continuous subcutaneous insulin infusion pumps?
MANAGEMENT - 11 INSULIN THERAPY - 4: – HR / Actrapid: • Onset of action after 30 minutes • Peak effect within 2 hours
– HN / Monotard: • Onset of action after 2 hours • Peak action within 10 hours
MANAGEMENT - 12 JAMEELA – 24 year old – G1 – GA = 26/5 – GLT = 11 mmol/l – Weight = 100 kg
MANAGEMENT - 13 • IGTT: – Repeat OGTT after 4/52 if test was done before 28/52 – Dietary advice; especially for those with high FBS. Occasional FBS & PPBS – FKC & NST as for normal pregnancy
• Others: – Oral hypoglycemic drugs (Glyburide) – Exercise (upper body CV training)
MANAGEMENT - 14 LABOR & DELIVERY - 1: – DM on insulin IOL at 38-39/52 – GDM A1 IOL at 40/52 – IGTT IOL at 41-42/52 (overdue ) – Aim for vaginal delivery. But LCSC rates are higher for diabetics (up to 60%) because of FD & macrosomia
MANAGEMENT - 15 LABOR & DELIVERY - 2: – On day of delivery: • Reduce am dose of intermediate-acting insulin (1/3-1/2 usual dose) • Start IV fluids D5% in NS at 125 cc/h • RBS 1-2 hourly. Check urine each void for glucose & ketones • Start IV insulin if RBS > 6.7 mmol/l • Continuos FHR monitoring • Pediatrician to examine baby after delivery
MANAGEMENT - 16 PNC - 1: – Insulin requirements decrease after delivery – GDM A1 normal diet, FBS & PPBS after 2 days. 75-gram, 2-hour OGTT 6/52 later – GDM A2 diabetic diet, BSP after 2 days, OGTT 6/52 later
MANAGEMENT - 17 PNC - 2: – 5-20% of GDM patients continue to have DM after delivery – Pre-existing diabetics can go back to prepregnancy regimen
MANAGEMENT - 18 PNC - 3: – Breast-feeding should be encouraged; take into account increased caloric demand. How much? – 30-50% of patients with GDM develop type II DM within 20 years; especially if obese – Diabetogenic effect of pregnancy increased by repeated pregnancies & obesity
MANAGEMENT - 19 FAMILY PLANNING: – Advice regarding limiting size of family in presence of retinopathy or nephropathy – Low-dose OCP if young, non-obese, & normotensive – IUCD – Barrier methods – Sterilization
CASE - 1 SALMA – 22 year old lady. MF 2/12 – IDDM since the age of 9 years – Had renal transplant last year – Attends for pre-conceptual counseling – Outline management
CASE - 2 NADIA – 30 year old lady. MF 5 years – G6 P0+2+3+2. Previous LSCS X 2 – IDDM since the age of 22 years – GA = 6/52 – Attends for her booking ANC visit – Outline management
CASE - 3 FAWZIA – 40 year old lady. MF 18 years – G7 P5+1+0+7. Previous LSCS – GDM on insulin – GA = 37/52. Breech presentation – EFW by U/S +/- 4000 g – Outline management
CASE - 4 NAEEMA – 30 year old lady. MF 5 years – Juvenile DM. G6 P2+0+3+2 – G 4: LSCS for failed VE. BW = 3700g – G 5: VBAC. BW = 3200g – GA = 37/52. SFH = 42 cm. EFW = 4000g. Hb A1c = 12% – Outline plan for delivery
CASE - 5 RIHAB – 22 year old lady. MF 1 year – G1 P1+0+0+1 – Delivered 3 days ago. FTND after IOL for GDM A1. BW = 3200 g – She plans to breast-feed her baby – She seeks contraceptive advice
THE END
JEHAD AL-HARMI DEPARTMENT OF OBS & GYN FACULTY OF MEDICINE/ KUWAIT UNIVERSITY
DEFINITION • Persistent state of hyperglycemia due to lack, or diminished effectiveness, of endogenous insulin • Very common medical complication of pregnancy; variable incidence from 0.5 – 15%
TYPES-1 Abnormal glucose metabolism in pregnancy: 1. Overt, pregestational, or pre-existing DM 2. Gestational diabetes (GDM): • • • •
First diagnosed during pregnancy May persist after delivery May include a small group of overt DM Has many similarities to NIDDM
1. Impaired glucose tolerance test (IGTT)
TYPES-2 Pregestational DM: 1. Type I or IDDM: • •
Usually juvenile onset May be associated with autoimmune disease
1. Type II or NIDDM: • • •
Usually adult onset Occurs more frequently in the obese Has a stronger familial component
CLASSIFICATION MODIFIED WHITE CLASSIFICATION:
A1 A2 B C D F R H T
GDM on diet GDM on insulin Onset after age 20 years, or duration less than Onset &/or duration between 10-20 years Onset before age 10 years, or duration more Nephropathy Proliferative (not background) retinopathy Coronary artery disease Renal transplant
10 years than 20 years
RISK FACTORS-1 WHAT ARE THE RISK FACTORS OF GDM?
RISK FACTORS-2 1. Family h/o DM (1st degree relative) 2. Previous h/o GDM – Recurrence rate is 60-70%. Why not 100%? What are the predictors?
3. Glycosuria – Before 16/52 – >2 occasions
4. Polyhydramnios (AFI > 25 cm)
RISK FACTORS-3 5. Age > 30 years 6. Obesity (BMI > 27 kg/m²) 7. Polyuria 8. Polydypsia 9. Excessive weight gain (> 18 kg)
RISK FACTORS-4 10. Previous h/o: 1. Recurrent spontaneous abortions 2. Unexplained SB or NND 3. Baby with major congenital anomalies (CNS, cardiac, skeletal) 4. Big baby (> 4500 g) 5. Recurrent PE 6. Recurrent candidaiasis
DIAGNOSIS - 1 SCREENING: – Why? – Whom? – How? – When?
DIAGNOSIS - 2 SCREENING: • Glucose loading/challenge test (GLT): – No special preparation – 50 g glucose; measure plasma BS after 1 hour – For low-risk: screen at 26-28/52 – For high-risk: screen at booking & if result negative repeat at 26-28/52
DIAGNOSIS - 3 • If GLT > 10 or FBS > 7.2 mmol/l no need for further testing; patient is diabetic • If GLT 7.3-10 mmol/l proceed to oral glucose tolerance test (OGTT)
OGTT – 3 days on diet containing 150 g CHO daily – Fasting 8 - 14 hours. 100 g glucose load – Measure plasma levels – No smoking or excessive activity
• Normal values: – FBS –1h –2h –3h
5.3 mmol/l 10 1 high value = IGTT 8.6 2 high values = GDM 7.8
GLUCOSE METABOLISM IN PREGNANCY • GLYCOSURIA: – Often seen during pregnancy due to ↓ renal threshold of glucose excretion & incomplete reabsorption in the renal tubules
• GLYCEMIA: – FBS usually lower by 0.5 mmol/l; PPBS higher – Higher highs & lower lows
EFFECTS OF DIABETES ON PREGNANCY - 1 WHAT ARE THE MATERNAL COMPLICATIONS OF DM?
EFFECTS OF DIABETES ON PREGNANCY - 2 MATERNAL - 1: 1. DKA fetal & / or maternal death 2. Hypoglycemia (if severe & prolonged) may lead to fetal death. But usually better tolerated than hyperglycemia 3. Polyhydramnios PROM, & unstable lie 4. PET especially in presence of renal impairment (20-40%, up to 60%)
EFFECTS OF DIABETES ON PREGNANCY - 3 MATERNAL - 2: 5. Macrosomia (25% of IDM have BW >4000 grams; 60% are LGA with BW >90th percentile) CPD, operative delivery, shoulder dystocia, trauma, & PPH 6. UTI & pyelonephritis 7. Vulvovaginal candidaiasis
EFFECTS OF DIABETES ON PREGNANCY - 4 WHAT ARE THE FETAL/NEONATAL COMPLICATIONS OF DM?
EFFECTS OF DIABETES ON PREGNANCY - 5 FETAL & NEONATAL - 1: 1. Spontaneous abortion 2. Macrosomia shoulder dystocia asphyxia &/or trauma 1. Erb’s palsy, Klumpke’s palsy 2. Facial palsy, Horner’s syndrome 3. Clavicular or humeral fractures
3. IUFD in late pregnancy 4. Prematurity (double)
EFFECTS OF DIABETES ON PREGNANCY - 6 FETAL & NEONATAL - 2: 5. FD during labor; secondary to acute & chronic hypoxia 6. Hypoglycemia especially in 1st 48 hours after delivery • Maternal hyperglycemia fetal hyperglycemia fetal hyperinsulinemia hyperplasia & hypertrophy of fetal pancreatic islets of Langerhans neonatal hypoglycemia (Pederson hypothesis) • Check RBS frequently and start early feeding
EFFECTS OF DIABETES ON PRGNANCY - 7 FETAL & NEONATAL - 3: 7. RDS or HMD 8. Hypocalcemia 9. Polycythemia & neonatal jaundice 10. Congenital anomalies: 1. 2. 3. 4.
Sacral agenesis & caudal regression CNS : open NTD. Role of folic acid? CVS : TOGV, VSD, ASD Renal
INFANT OF DIABETIC MOTHER
EFFECTS OF PREGNANCY ON DIABETES • NIDDM patients will require insulin because oral hypoglycemic agents relatively contraindicated. Why? • IDDM patients will require higher doses of insulin • Existing retinopathy & nephropathy may worsen
PROGNOSIS-1 • PNM associated with DM has decreased 10 X in the past 40 years because of better glycemic control, reduction of early IOL, & advances in neonatal care • Benefits of tight glycemic control: – Early pregnancy: decrease possibility of abortions & fetal anomalies – Later pregnancy: decrease the rate of macrosomia & PNM
PROGNOSIS-2 RULE OF 15: – 36% of women with GDM develop DM within 15 years – 15% of pregnant patients have abnormal GLT – 15 % of those have abnormal OGTT – 15 % of those require insulin therapy – 15% of patients with GDM have macrosomic babies (BW> 4000 grams)
MANAGEMENT - 1 PRECONCEPTION COUNSELING - 1: – Timing of pregnancy & importance of Hb A1c levels in detecting control over the past 30-40 days • Hb A1c produced by slow glycosylation • Normal range 3-4% • If level > 12% associated with increased risk of complications
– Postponement of pregnancy till later age not advisable. Why?
MANAGEMENT - 2 PRECONCEPTION COUNSELING - 2: – Re-education – Ideal control: • Glucose home monitoring by capillary sampling • Patient injects herself with insulin • Close relatives able to deal with emergencies
– Long-term effects on off-spring: • Childhood obesity • Early-onset type II DM
MANAGEMENT - 3 ANC - 1: – Team approach (obstetrician, physician, nurse, dietician) – Additional testing: • RFT, 24-hour urine collection for total protein & creatinine clearance rate • Fundoscopy • MSU for C&S • Fetal echocardiography
MANAGEMENT - 4 ANC - 2: – Insulin dose & frequency may have to be increased (up to 2-3 X in later pregnancy) – Glucose home monitoring (as opposed to repeated hospital admissions) increases compliance, improves results, & reduces cost – Visits every 2/52 till 32/52, then weekly till delivery
MANAGEMENT - 5 ANC - 3: – U/S in T1 for viability & confirmation of GA – U/S at 20-24/52 for anomalies – U/S at 32-36/52 for growth – Daily FKC starting at 32/52 – Weekly NST starting at 32/52; increase to twice weekly at 34-36/52 – Weekly BPP may also be carried out
MANAGEMENT - 6 GDM: – Diabetic diet for 1/52 – BSP: 7 readings – If controlled with diet, recheck FBS & PPBS every 1-2/52 – If insulin is needed, admit to hospital
MANAGEMENT - 7 DIET: – 30-35 kcal/kg of ideal body weight (range = 1800-2800 kcal/ day) – 3 meals + 3 snacks – 50 % CHO (complex & high fiber) + 30 % fat + 20 % protein – 25 % breakfast + 30 % lunch & dinner + 5 % each snack – Consistency in dietary intake and activity level
MANAGEMENT - 8 INSULIN THERAPY - 1: – If initial FBS > 9 mmol/l – If diet does not provide satisfactory control within 1-2/52 • • • • •
FBS < 5.3 mmol/l Pre-prandial < 6 THIS IS 1-hour PPBS < 7.8 “TIGHT GLYCEMIC 2-hour PPBS < 6.7 CONTROL” Not less than 4
MANAGEMENT - 9 INSULIN THERAPY - 2: – Total dose: • T1 0.5 units/kg actual body weight • T2 0.6 • T3 0.7
– Dose divided into 2/3 in am + 1/3 in pm – AM dose further divided into 1/3 short-acting + 2/3 intermediate- acting – PM dose divided in 1/2
MANAGEMENT - 10 INSULIN THERAPY - 3: – Alternative regimen: • 3 pre-prandial doses of short-acting insulin • 1 dose of intermediate-acting insulin at bedtime if FBS high
– Reduced compliance but better glycemic control – What is the role of continuous subcutaneous insulin infusion pumps?
MANAGEMENT - 11 INSULIN THERAPY - 4: – HR / Actrapid: • Onset of action after 30 minutes • Peak effect within 2 hours
– HN / Monotard: • Onset of action after 2 hours • Peak action within 10 hours
MANAGEMENT - 12 JAMEELA – 24 year old – G1 – GA = 26/5 – GLT = 11 mmol/l – Weight = 100 kg
MANAGEMENT - 13 • IGTT: – Repeat OGTT after 4/52 if test was done before 28/52 – Dietary advice; especially for those with high FBS. Occasional FBS & PPBS – FKC & NST as for normal pregnancy
• Others: – Oral hypoglycemic drugs (Glyburide) – Exercise (upper body CV training)
MANAGEMENT - 14 LABOR & DELIVERY - 1: – DM on insulin IOL at 38-39/52 – GDM A1 IOL at 40/52 – IGTT IOL at 41-42/52 (overdue ) – Aim for vaginal delivery. But LCSC rates are higher for diabetics (up to 60%) because of FD & macrosomia
MANAGEMENT - 15 LABOR & DELIVERY - 2: – On day of delivery: • Reduce am dose of intermediate-acting insulin (1/3-1/2 usual dose) • Start IV fluids D5% in NS at 125 cc/h • RBS 1-2 hourly. Check urine each void for glucose & ketones • Start IV insulin if RBS > 6.7 mmol/l • Continuos FHR monitoring • Pediatrician to examine baby after delivery
MANAGEMENT - 16 PNC - 1: – Insulin requirements decrease after delivery – GDM A1 normal diet, FBS & PPBS after 2 days. 75-gram, 2-hour OGTT 6/52 later – GDM A2 diabetic diet, BSP after 2 days, OGTT 6/52 later
MANAGEMENT - 17 PNC - 2: – 5-20% of GDM patients continue to have DM after delivery – Pre-existing diabetics can go back to prepregnancy regimen
MANAGEMENT - 18 PNC - 3: – Breast-feeding should be encouraged; take into account increased caloric demand. How much? – 30-50% of patients with GDM develop type II DM within 20 years; especially if obese – Diabetogenic effect of pregnancy increased by repeated pregnancies & obesity
MANAGEMENT - 19 FAMILY PLANNING: – Advice regarding limiting size of family in presence of retinopathy or nephropathy – Low-dose OCP if young, non-obese, & normotensive – IUCD – Barrier methods – Sterilization
CASE - 1 SALMA – 22 year old lady. MF 2/12 – IDDM since the age of 9 years – Had renal transplant last year – Attends for pre-conceptual counseling – Outline management
CASE - 2 NADIA – 30 year old lady. MF 5 years – G6 P0+2+3+2. Previous LSCS X 2 – IDDM since the age of 22 years – GA = 6/52 – Attends for her booking ANC visit – Outline management
CASE - 3 FAWZIA – 40 year old lady. MF 18 years – G7 P5+1+0+7. Previous LSCS – GDM on insulin – GA = 37/52. Breech presentation – EFW by U/S +/- 4000 g – Outline management
CASE - 4 NAEEMA – 30 year old lady. MF 5 years – Juvenile DM. G6 P2+0+3+2 – G 4: LSCS for failed VE. BW = 3700g – G 5: VBAC. BW = 3200g – GA = 37/52. SFH = 42 cm. EFW = 4000g. Hb A1c = 12% – Outline plan for delivery
CASE - 5 RIHAB – 22 year old lady. MF 1 year – G1 P1+0+0+1 – Delivered 3 days ago. FTND after IOL for GDM A1. BW = 3200 g – She plans to breast-feed her baby – She seeks contraceptive advice
THE END
