CASES: DIABETES AND PREGNANCY

Transcription

1 CASE 1: Visit 1: Ms. Sunny Disposition is a 32 yo G2P1001 who is approximately 15 weeks here for her first prenatal visit. She has already had an US but records not yet received. Pmhx: Unremarkable, no chronic medical problems, no meds. Obstetrical hx: G1 born in 2000 notable for 8 pound 10 ounce male born at term via NSVD. He has a developmental delay and is 10 years old but has IQ of 6 year old per mom. On physical exam 98 KG, height 158 cm, BMI 40 BP 110/56 P 92 Otherwise normal full exam. What do you want to order? 4 days later labs are back. All prenatal labs are within normal limits except HbA1C 7.9. US at 8 weeks 1 day puts her at 14 weeks today. What is her diagnosis? What is the treatment plan? Visit 2: Sunny is now at 17 weeks. Went to DM education, got glucometer, told lancets not covered by insurance. What do you do? Visit 3: Sunny is at 18 weeks. Got lancets through insurance. Fastings now , 2-hour postprandials are in the 120's. 1

2 What do you want to do? What side effects do you need to warn patient about? Visit 4: Sunny is at 19 weeks and has 5 elevated fastings in range and 2 elevated post prandials in the 130's. Now what would you like to do? 19 wk US: HC 48% AC 57% EFW 51% placenta posterior and normal AFI. Recommendation on scan is to repeat in 4 weeks as cardiac outflow tracts not well seen. Visit 5: Sunny is at 20 weeks and has 4 elevated fastings in range, post-prandials 2 elevated at 2 different meals. What adjustments would you make? Visit 6: Sunny is at 22 weeks and missed one visit. She had some low sugars in the 60's with symptoms and decreased self to 7.5 mg qhs. Visits 7,8,9: Well controlled. Noted at 25 weeks to be size> dates fundal height at 30 cm. 26 wk US: HC 75% AC 47% EFW 57% afi 15.6 cm posterior placenta no previa. No gross fetal abnormalities. Normal echo. Visits 10-11: has 2 elevated fastings at visit 11 and glyburide increased to 10 mg po qhs. Visit 12: 30 weeks well controlled. 2

3 Not seen again in clinic until 34 weeks. Missed 32 week US. Visit 13: Forgot log. Per patient controlled. US ordered stat and set up for antenatal testing. What does antenatal testing include? When do we usually set this up for? 34 week US: HC 96% AC> 97% EFW 3248 grams > 90% AFI % placenta posterior, breech. Visits14-15: weeks: 1 abnormal lunch postprandial, o/w all nl per pt, but didn't bring log. GBS negative. Visit 16: vertex in antenatal testing IOL scheduled for 39 weeks. At 37 6/7 seen in OB Triage with elevated SBP 140, pr/cr ratio 0.8, nl PIH labs. Asymtomatic. What do you think, would you send her home? IOL started: cervix closed/ thick/ high. Miso placed, once at 1 cm cook catheter placed. From there went quickly 4 hours to complete. Pushed 2 minutes. Shoulder dystocia relieved after 1 minute with McRobert's, Suprapubic pressure and internal wood screw maneuver. No laceration. Baby girl 4575 grams. Required 1-week management in hospital for sugars. Ms. Sunny at 12 weeks postpartum HBA1C 7.0. Type 2DM now diagnosed. This is a real case. In retrospect, was there anything that could have been done differently? 3

4 CASE 2: Ms. Positively Beaming is a 26 yo G1P0 is 11 weeks 6/7 days by an ultrasound at Carenet here to establish prenatal care. PMHx: Previous diagnosis of PCOS on Metformin 1000 mg XL. No other past medical problems. Pex: 128 KG, BP 120/70 P 60 Morbidly Obese. What do you want to order? 2 days later labs are back: HBA1C 6.3, FBS 86. What is the diagnosis? What do you want to do? Visit 2: Dating confirmed and now 15 weeks. Placed on metformin 1000 mg bid as XL not well studied in pregnancy. Scheduled for 2-hour glucose tolerance test at 18 weeks. Visit 3: Now 19 weeks. 1 abnormal on 2-hour glucose tolerance test. Started checking sugars but has not met with DM education. Fastings: 62, 96, 196, 108. PP ok except breakfast 156 and 2 dinner PP 140, 142. What do you recommend? Visit 4, 5,6: Adjusting insulin. NPH at 20 units per night, increased from 10 units over phone. Breakfast PP 1 elevated 134, lunch 1 elevated 122, Dinner 1 at 142. Started on Lispro 5 unit per meal. 4

5 Visit 7: Elevated x 3: fasting 97, breakfast 140, dinner 128. NPH placed at 25 units and lispro 7 units per meal. Assuming she is Type II DM, what else should be ordered if it hasn't been already? Visit 8: 28 weeks. 4 elevated fastings at 97,98, 101, and 117. PP elevated breakfast 144, dinner 143 otherwise wnl. Echo nl, HC 62% AC 37% EFW 57%. PIH labs, microalbumin, EKG nl. 24-hour urine protein 136 on liters (1500 ml is considered adequate sample). NPH 28 units, lispro 8 units with meals. Visit 9: 30 weeks. Adjusted to 15 units with meals and 30 units of nph qhs. WT 132 KG. What would you order now? Visits 10-14: Well controlled. US 35 weeks: HC 33% AC 13% EFW 26% 2331 grams, afi 13 cm. vertex placenta posterior no previa. Visit 15-16: 36-37weeks, few BS elevated Adjusted to 18/15/18 and 35 units NPH. US 38 weeks: HC 66% AC 75% 3264 grams 79% AFI 19.8 cm Visit 17: 38 weeks. Getting hypoglycemic on 18 units TID lispro and not requiring NPH at all last 3 days. What could be going on? What should be done? 5

6 Outcome: At 38 1/7 brought in for IOL. After 3 day IOL, and developing preeclampsia, and s/p magnesium. Failed to dilate past 5 cm despite 4 hours adequate contractions so primary LTCS was done for failure to progress gram female Apgars 7 and 8 OA. After 6 hour transition in ICN 3 was with mom and went home with mom PPD #2. POSTPARTUM F/U: 8wks PP HbA1C 5.7. Wt 127 KG, which was slightly less than pre pregnancy weight. Encouraged to continue to breastfeed and continue good habits established in pregnancy. CASE 3: Ms. Life on the Bright side is a 35 yo G2P1000 at 20 4/7 weeks by 1st trimester US per her report at Presbyterian who is known Type 2 DM on insulin. She is transferring care because she wants to be very aggressive with her care due to history of death with last baby. Pmhx: Glyburide prior to pregnancy Current meds: NPH 58 units Novolog 36/26/26. OBhx: G1 Born at full term by emergency C/S in Nigeria and per patient died at Day 2 of life from complications of unknown cause. Patient believes it was diabetes related. Patient received very little prenatal care. 8 pound 13 ounce male, no records available. On Pex: BMI 24 BP 128/78 P 76 Fasting Breakfast Lunch Dinner

7 What labs/test should be ordered? What should we do with her sugars? Labs show HbA1c 8.6, repeat 4 weeks later 7.3. PIH labs nl,ekg nl and pr/cr 0.2 done instead of 24 hour urine protein as patient sample inadequate. US 23 weeks: HC 61% AC 62% EFW 58% posterior placenta no previa, echo not done. 27 weeks : echo wnl. 28 weeks: up to 78 units NPH 56/46/30 Novolog, coming to appointments diligently. US 29 weeks: HC 80% AC 77% EFW 75% nl interval growth and nl AFI weeks slight adjustments but essential same insulin requirements What does she need at 32 weeks? US 34 weeks: Vtx HC 68% AC 83% EFW 82% AFI 14 nl interval growth. 36 weeks GBS neg NPH 90 units 68/65/ well controlled 39 weeks Transverse on US. Admitted for ERCS, then vtx. POC glucose 84. Outcome : 3690 grams, oblique lie Apgars 6, 9,10. Repeat LTCS. Initially baby transitioned well but in NBN blood glucose 40 after feeds persistently, taken to NICU, required IV glucose and 2-day stay in NICU. 7