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? Pap, Prenatal labs, HbA1C and fasting blood sugar if feasible. Consider TSH. 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? Type II DM. What is the treatment plan? Call patient and order test strips, glucometer, lancets, send to diabetes education. Offer to send patient to genetic counseling (Type 2 DM is at higher risk of congenital abnormalities). Follow weekly. 1

2 Visit 2: Sunny is now at 17 weeks. Went to DM education, got glucometer, told lancets not covered by insurance. What do you do? Call pharmacy, check and see which glucometer and lancets are covered and order correct ones. Don't do what Jessi did and give her $20 to get lancets covered...never saw that money again! Visit 3: Sunny is at 18 weeks. Got lancets through insurance. Fastings now , 2-hour postprandials are in the 120's. What do you want to do? Start meds. OB/GYN covering for holiday started on Glyburide 2.5 po qhs, but discuss that this is not what we recommend starting her on. At least 5 mg po q day. Discuss metformin and insulin as alternatives. What side effects do you need to warn patient about? Hypoglycemia with insulin and glyburide. Diarrhea with metformin. 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? There are alternatives but she was increased to 5 mg po qhs of glyburide. 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. 2

3 What adjustments would you make? Glyburide adjusted to 2.5 mg po q am and 7.5 mg qhs. 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. 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? Weekly AFI and bi-weekly NST When do we usually set this up for? 32 weeks if well controlled, weeks if poor control. 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. 3

4 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? No. Presumed preeclampsia based on elevated pr/cr ratio and elevated BP. Considering past 37 weeks, she should be delivered. 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? Considering 34 week Ultrasound, could have considering repeat US weeks and consider delivering at 37 weeks. She had dating based on 8 week US, but if dating was poor would consider doing amniocentesis for fetal lung maturity if considering delivering at 37 weeks. HBA1C in every trimester might have determine if patient being non-compliant with recommendations. 4

5 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? Pap, Prenatal labs, HbA1C and fasting blood sugar if feasible. Consider TSH. Discuss MSAFP testing. Dating ultrasound as Carenet (pro-life church affiliated organization) ultrasound is not a true medical US (That's what I've been told in the past, but on their website it does say US are reviewed by radiologists). 2 days later labs are back: HBA1C 6.3, FBS 86. What is the diagnosis? Uncertain. If she was not on metformin then it would be glucose intolerant, but metformin makes diagnosis less clear. She could be a Type II DM whose BS level is improved because of metformin. What do you want to do? Schedule for sequential screen if interested, set up for genetic counseling, diabetes education. Order repeat screen. 2 hour OGTT ordered at 18 weeks. Order glucometer, test strips, lancets. 5

6 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? Again, go through options. As was already on Metformin, felt she would likely need insulin so she was given Rx for insulin, lancets, and syringes. She was set up for insulin teaching with pharmacist. Fetal Echo and US for anatomy scheduled at 20 weeks. 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. 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? Type II DM are at risk for chronic organ injury so should order: EKG, baseline PIH labs, 24-hour urine protein for baseline, urine microalbumin, baseline eye exam. HBA1C in every trimester remembering not accurate, but can give indicator if poor control. Visit 8: 28 weeks. 4 elevated fastings at 97,98, 101, 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. 6

7 Visit 9: 30 weeks. adjusted to 15 units with meals and 30 units of nph qhs. WT 132 KG. What would you order now? Antenatal testing should start at 32 weeks. 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? Uterine-placental insufficiency leading to less insulin resistance. What should be done? As she is at term, good idea to schedule IOL now. 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. 7

8 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: Present if time allows... 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 What labs/test should be ordered? Get old records. HBA1C at 10 weeks Order PIH labs, Baseline 24 hour urine protein, urine microalbumin, EKG, set up optho referral, fetal echo, genetics counseling if not already done. Repeat HbA1C. 8

9 What should we do with her sugars? Send to DM education, consider metformin as may increase insulin sensitivity. This was offered but patient refused. 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. 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? Antenatal testing 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. 9