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7/18/2019 Case Presentation O&G
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CASE PRESENTATION 3
Low Xie Yee
Chandra Rubnee
Malvinder SinghCaroline
Aswini
Kalichandren
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HISTORY TAKING
LOW XIE YEE
0!0!000"
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• #ersonal $is%or&
• Chie' Co()lain
• $is%or& O' #resen% Illness
• $is%or& O' #resen% #regnanc&
• #as% Obs%e%rics $is%or&
• Mens%rual $is%or&
•*&necological $is%or&
• #as% Medical $is%or&
• #as% Surgical $is%or&
• +a(il& $is%or&
• ,ie% $is%or&• #ersonal $is%or&
• Social $is%or&
• ,rug $is%or&
O-.LI/E
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• /AME WA/ RA+I,A$
• A*E 1"
• RACE MALAY
• RELI*IO/ ISLAM
• OCC-#A.IO/ $O-SEWI+E
•
*RA2I,I.Y 3• #ARI.Y 14
• LM# -/S-RE
• E,, !5 OC. !05 6,A.I/*
SCA/7• #OA 18w 5d
• ,OA 9 OC. !05
• ,OC ! OC. !05
#ERSO/AL
$IS.ORY
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C$IE+ COM#LAI/
$er chie' co()lain was : Increase 're;uenc& o' urina%ion 'or ! (on%hs
!: Alwa&s 'eel hungr& and %hirs%& 'or a (on%h
1: +a%igue 'or a (on%h
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$O#I
• 5 da&s ago have an%ena%al chec<u) on 18 w o'
ges%a%ion
• MO*.. abnor(al
• Re;uired ad(i%%ed 'or observa%ion
• Increase 're;uenc& o' urina%ion 'or )ass %wo(on%h
• -rine color is s%raw and no% concen%ra%ed
• Alwa&s 'eel %hirs%& and dr& (ou%h
• Alwa&s 'eel hungr&
• 'a%igue
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•
According %o (ada( Wan Ra'idah= 5 da&s ago'ro( (& cler<ing da%e o' ! Oc%ober !05= she
wen% %o clinic 'or her A/C on 18 w o' ges%a%ion:
She %old %ha% she has been diagnosed as *,M
on 1! w o' ges%a%ion: She was as<ed %o run a%es% 'or her blood sugar level and also MO*..:
.he resul%s ob%ained were abnor(al=
sugges%ive o' *,M and no insulin is being
ad(inis%ered: .here'ore she was re;uired %o bead(i%%ed in $.AR 'or observa%ion )ur)oses un%il
%he end o' her )regnanc& as she was s%a&ing
'ar 'ro( $.AR: $er blood sugar level is
(oni%ored wi%h blood sugar )ro'ile:
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• She clai( %ha% she had increase 're;uenc& o'
(ic%uri%ion 'or )ass %wo (on%h s%ar%ed since
1!w o' ges%a%ion: She wen% %o )ass urine (ore
%han 0 %i(e )er da&: $owever she doesn>%
have d&suria: She (en%ion %ha% her urine
colour a))ear %o be s%raw colour and no%
concen%ra%ed: She also denied -.I s&()%o(ssuch as 'ever= loin )ain and hae(a%uria: She
doesn>% had abdo(en )ain and u%erine
con%rac%ion:
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• She clai( %ha% she was having e?cessive %hirs%
and dr& (ou%h: Ever&da& she need %o in%a<e a
lo% o' wa%er %o ease her %hirs%: She also increaseher ;uan%i%& o' 'oods due %o her hunger
es)eciall& during nigh% %i(e: She will %a<e ! slice
o' bread ever& nigh% be'ore slee)ing:
•She 'el% e?cessive 'a%igue un%il hardl& %o con%inueher dail& household wor< and need a long res%:
She denied %ha% she having shor%ness o' brea%h
and ches% )ain: She also %old %ha% she have no
s&()%o(s o' )ica such as craving 'or ice cube or'ingers nail and so on 'ound: She had no
vo(i%ing a'%er ! w o' her ges%a%ion: She can 'eel
her 'oe%us and %he 'oe%al <ic< was alwa&s (ore
%han 0 <ic< )er ! hours:
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$IS.ORY O+ #RESE/. #RE*/A/CY
1ST TRIMESTER
@ -n)lanned@ Miss ! (on%h o' (ens%rual@ ,a%ing scan on 9w ges%a%ion@ ,e%ec%ion o' single e(br&o@ lood grou) O4
@ -rine rou%ine B /@ +CB /@ $b level B /@ Screening %es%B 2E 'or $sAg= 2,RL D $I2@ #B /
@ Weigh%"0<g@ $eigh% 30c(@ MI !":" <g(F@ MO*.. G +AS.I/* B 5:0((olL
/O/+AS.I/* B ":9 ((olL@ +olic acid given
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2ND TRIMESTER
@ Ano(al& scan on 5w B /uchal %hic<ness is !:9c(@ .e%anus inHec%ion
s% on !0w !nd on !5w
@ +C B /
@ $b level B /@ MO*.. G +AS.I/*B 3:0((olL
/O/+AS.I/*B :0((olL@ # B /@ -%erine siJe
@ Weigh% "3<g@ uic<ening on !0 w
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3RD TRIMESTER
+e%us grow%h scan+C B /
$b level B /MO*.. +AS.I/*B 7.0mmol/L /O/+AS.I/* B 9.8 mmol/L,iagnose *,M on 1!w+e%us (ove(en%
#B /-%erine siJeWeigh% 0:3<gCo()lains o' #ol&uria
#ol&di)sia #ol&)hagiaIron su))le(en% given
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#AS. OS.E.RIC $IS.ORY→ *3 #14
G YEAR PREGNANCY LABOR PEPERIM BABY REMARK
!000 +-LL .ERM /ORMALS#O/.A/EO-S2A*I/AL,ELI2ERY6S2,7
REAS.+EE,I/* -#.O ! YEARS
+EMALE1:K* ALI2E
! !000 AOR.IO/ A.9W #OA CO/S-MEOC# +OR1MO/.$
,DE ,O/E due %o)eriod be%ween !)regnancies were%oo close:
1 !00! +-LL .ERM /ORMAL S2, REAS.+EE,I/* -#.O ! YEARS
MALE5:0 K* ALI2E
5 !008 +-LL .ERM /ORMAL S2, REAS.+EE,I/* -#.O ! YEARS
MALE1:33K* ALI2E
3 !05 #RESE/.#RE*/A/CY
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ME/S.R-AL $IS.ORY
Menarche ! &ears old
,ura%ion o' 'low 0 da&s
C&cle leng%h !910 da&sC&cle Regular
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*&necological his%or&
Consu(e OC# A'%er s% )regnanc& in!000 'or 1 (on%hs
Sugges%ive S.I /O
*&necological)roble(
/O
#A# s(ear $is%or& /o% done
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#AS. ME,ICAL $IS.ORY
.$YROI, ,ISEASE /O
$Y#ER.E/SIO/ /O
,IAE.-S MELLI.-S /O
RE/AL ,ISEASE /O
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#AS. S-R*ICAL $IS.ORY A##E/,ICI.IS /O
S#LEE/O/A.OMY /OC$OLECYS.EC.OMY /O
LA#AROSCO#IC S-R*ERY +OR
I/+ER.ILI.Y
/O
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+AMILY $IS.ORY
+a%her Alive= "5
$is%or& o' h&)er%ension 'or 1 &ears
Mo%her ,ied in !0! a% age 3! due %o hear%'ailure$is%or& o' h&)er%ension and %&)e II,M
Siblings 3 siblings= all alive
$is%or& o' %&)e II ,M on one siblingand o%hers were heal%h& and nohis%or& o' (alignanc&
*rand(o%her $is%or& o' (ul%i)le )regnanc& 6%wins7
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,IE. $IS.ORY
•/O/ 2E*E.A.IA/
• /O +OO, ALLER*Y
• -/,ER*O ,IE. CO/.ROL ,-E .O *,M
• CO/S-ME C-# O+ LOW +A. MILK #ER ,AY
• #ERSO/AL $IS.ORYSMOKI/* /O
ALCO$OL ,RI/KI/* /O
,R-* A-SE /O
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SOCIAL $IS.ORY
Married 'or 3 &ears since 888
$usband wor<ed as lorr& drive
Mon%hl& inco(e around RM1000
S%a&ing wi%h 'a%her in law
,R-* $IS.ORY
,o no% consu(e an& drug be'ore )regnanc&/o an& drug allerg&
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P!"#$%&l E'&m$(&)$o(
Chandra rubnee a)
Shan(uga(0!0!030339
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*eneral E?a(ina%ion
•#a%ien% l&ing down in a su)ine )osi%ionco('or%abl& :
• #a%ien% is conscious and coo)era%ive:
• #a%ien% is aler% and is average buil% and well
nourished :• /o cannula or I2 dri):
• I, %ag is )resen%:
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•
.e()era%ure 1": degree Celsius• #ulse ra%e 80 )er (inu%e :
• lood )ressure 1090 (($g
• #ressure is %a<en while )a%ien% is
in %il%ed )osi%ion : Wh&
Vital parameters
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*eneral E?a(ina%ion
•/O ic%erus e&es= no )allor seen in conHunc%iva:
• Chloas(a is observed:
• Oral h&giene is good :
• /O angular s%o(a%i%is or glossi%is sugges%ing
absence o' ane(ia or vi%a(in ! de'icienc& :• /O %h&roid enlarge(en% or l&()hadeno)a%h&:
• /O 2# rise :
•
/O clubbing nails= ca)illar& 'illing %i(e N!sec=)al( was war(= )in<ish and (ois%:
• /O varicose veins :
• /O )i%%ing ede(a :
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S&s%e(ic E?a(ina%ion
Cardiovascular
s&s%e( :
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Cardiovascular e?a(ina%ionIns)ec%ion
• Ches% wall (ove s&((e%ricall& wi%h
res)ira%ion:
#al)a%ion
• A)e? bea% was loca%ed a% 3%h in%ercos%al
s)ace le'% (idclavicular line: /o heave and
%hrill: Auscul%a%ion
• S and S! heard and no (ur(urs
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Res)ira%or& S&s%e(
Ins)ec%ion• Ches% wall (ove s&((e%ricall& wi%h
res)ira%ion and no% in res)ira%or& dis%ress
#al)a%ion
• .rachea was cen%rall& loca%ed:
• /or(al ches% e?)ansion and %ac%ile vocal
're(i%us:
• #ercussion
• Resonance
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Con%inua%ion :::
Auscul%a%ion• Air en%r& is e;uall& bila%eral and nor(al
vesicular brea%h sound heard: .here were
no rhonchi heard:
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Obs%e%ric E?a(ina%ion
•#a%ien% co()lain% o' no )ain a% %he 8 regionso' abdo(en:
• Abdo(en is dis%ended b& a gravid u%erus
su))or%ed b& %he )resence o' lines nigra
and s%riae gravidaru( and s%riae albicans• Abdo(en is so'% :
• /O scar )resen% :
• -(bilicus is cen%rall& loca%ed and 'la%%ened:
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•+lan< is 'ull :
• S&()h&sis 'undal heigh% is 1"c(
• Clinical 'undal heigh% is a% 50wee<s o'
)eriod o' ges%a%ion
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Local E?a(ina%ion
LEO#OL,>s MA/E-E2ER
• +undal gri) %here is a broad so'% irregular
(ass sugges%ive o' 'e%al breech
• Righ% la%eral gri) %here are s(all <nob li<e
s%ruc%ure sugges%ive o' 'e%al li(bs
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• Le'% la%eral gri) %here is s(oo%h curved
resis%ance sugges%ive o' 'e%al bac<
• s% )elvic gri) .here is ballo%able s(oo%h
hard globular (ass sugges%ive o' 'e%al head
• !nd )elvic gri) Con'ir(s %he s% )elvic gri)
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• .he head o' 'e%us is engaged:
• %his is single%on 'oe%us in longi%udinal lie wi%h
ce)halic )resen%a%ion = )lacen%a an%erioru))er seg(en% :
• Li;uor a(oun% is ade;ua%e
• Es%i(a%ed 'oe%al weigh% wi%h ohnsons
'or(ula 61"7? 33B193gra(s• +oe%al hear% ra%e is !9bea%s )er (inu%e
heard along %he s)inou(bilical line:
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SMMARY
Mada( Wan Ra'idah is a% 18%h wee<
5da&s o' )eriod o' ges%a%ion wi%h 'undal
heigh% o' 50 wee<s=s&()h&sio 'undalheigh% o' 1"c( wi%h a single%on 'ea%us
wi%h a longi%udinal lie and ce)halic
)resen%a%ion= head is engaged:
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PRO*ISIONAL DIAGNOSIS
MAL2I/,ER SI/*$ AL AC$I.ARA
SI/*$
0!0!0009!*RO-# C
OS.E.RICS D *Y/AECOLO*Y
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#RO2ISIO/AL ,IA*/OSIS
Mada( Wan Ra'idah a 1" &ears oldMusli( housewi'e wi%h *3#14 a% 18
wee<s and 5 da&s o' )eriod o' ges%a%ion
wi%h single%on 'e%us in longi%udinal liewi%h ce)halic )resen%a%ion associa%ed
wi%h *es%a%ional ,iabe%es Melli%us and
no% in labour:
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,I++ERE/.IAL ,IA*/OSIS
: *es%a%ional ,iabe%es Melli%us
Su))or%ing )oin%s #oin%s agains%
: /o de%ec%ed )resence o',iabe%es Melli%us6%&)e or!7 be'ore !0 wee<s o' )eriod
o' ges%a%ion!: +a(il& his%or& o' ,M1: ,e%ec%ions occurs in wee<
18 o' ges%a%ion5: Overweigh%
3: Age above 13 &ears old": #ol&uria: #ol&di)sia9: #ol&)hagia8: #revious big bab& P 5:0 <g
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!: .&)e ,iabe%es Melli%usSu))or%ing )oin%s #oin%s agains%
: #ol&uria!: #ol&di)sia
1: )ol&)hagia
: /o% lean!: /o )as% his%or&
1: /o 'a(il& his%or&5: #a%ien%s age is 1&ears old
3: Weigh% no% decreasing
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1: .&)e ! ,iabe%es Melli%usSu))or%ing )oin%s #oin%s agains%
: #ol&uria!: #ol&di)sia
1: #ol&)hagia5: Overweigh%3: +a(il& his%or&": Age
: /o )as% his%or& recorded!: Albu(inuria no% de%ec%ed
1: Regular (ens%rual c&cle #ol&c&s%ic ovar& s&ndro(echarac%eriJed b& irregular (ens%rual)eriods= e?cess hair grow%h and obesi%&
5: /o% s(o<ing
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5: -rinar& .rac< In'ec%ionSu))or%ing )oin%s #oin%s agains%
: #ol&uria : /o 'ever or high grade'ever
!: /o )ain or a burning'eeling duringurina%ion:
1: /o blood in urine
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5: $&)er%h&roidis(
E?cessive %h&roid hor(ones causes increased
glucose )roduc%ion in %he liver= ra)id absor)%ion o'
glucose %hrough %he in%es%ines and increased insulin
resis%ance:
Su))or%ing )oin%s #oin%s agains%
: Increase a))e%i%e : Enlarge(en% o' %h&roidis no% de%ec%ed:
!: /o weigh% loss:1: /or(al .S$ in blood%es%:
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I(+,#)$-&)$o( &( #%,,($(- o-,#)&)$o(&l $&,),#
Caroline Sundralinga(
0! 0! 00 0
Ri < ' %
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Ris< 'ac%ors
• Age over 2 ",&#
• MI 24-/m5• Increased weigh% gain during )regnanc&
• #revious h? o' large'orges%a%ionalage in'an%s
•
$? o' ges%a%ional diabe%es in )revious )regnanc&• Eleva%ed 'as%ingrando( blood glucose levels
during )regnanc&
• 6&m$l" !' o' diabe%es in 'irs%degree rela%ive6s7
• $? o' (e%abolic X s&ndro(e• $? o' %&)e or %&)e ! diabe%es
• #revious h? o' m&%o#om$&4-= s%illbir%h= I-,=
recurren% (iscarriage
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Screening
•
ALL )a%ien%s visi%ing an%ena%al clinic 6Mala&sia7screened using rando( blood sugar)os% )randial
blood sugar
• Diagnostic of DM in pregnant and non pregnant
Bloo Gl:%o#, l,+,l Nom&l A(om&l
Rando( : ((olL Q:((olL
+as%ing :0 ((olL Q:0 ((olL
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MO*..
: #revious ges%a%ional diabe%es
MO*.. done "9 wee<s o' ges%a%ion
I' nega%ive= re)ea% %es% !5 wee<s o' ges%a%ion
2. O)!, $#4 &%)o
MO*.. done !!!" wee<s
I' nega%ive= re)ea% %es% 15 wee<s o' ges%a%ion
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MO*.. #rocedure3g oral glucose %olerance %es%
: 1 da&s )rior %o %es% consu(e (ini(u( 30gcarboh&dra%e
!: +as% !hr
1: Morning +as%ing blood glucose level
(easured= drawn 'ro( (a%ernal venous blood5: ,rin< glucose )re)ara%ion wi%hin 0(ins
3: .a<e !$## reading
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Resul%s indica%ing abnor(ali%&
+as%ing ! $##
#las(a
venous
Q": ((olL Q:9 ((olL
Ca)illar&whole blood
Q3:"((olL Q:9 ((olL
6&#)$(- 2HPP
P:0 ((olL P:9((olL
W$O cri%eria
$.AR
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,iagnosed *,M
1. Gl"%o#"l&), !,mo-lo$( HA1%@: Seru( blood sa()le %a<en
@: Re'lec% gl&ce(ic con%rol over )revious !
1(on%hs
@: /or(al range 5:":1 6non)regnan%7
5:33: 6earl& )regnanc&7
5:53:" 6la%e)regnanc&7
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+e%al well being
• l)&#o:( A(nio%ic 'luid inde? 6oligo#ol&h&dra(nios7
Macroso(ic 'e%us 6abdo(en circu('erence7
Congeni%al ano(alies 69!0w7
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6:)!, I'
1. $(, 6EME@: I' ni%ri%es )osi%ive= indica%ive o' -.I
@: +ur%her %es% T-rine cul%ure D sensi%ivi%&
2. T6T
@: Measure .S$= . D .₃ ₄
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MANAGEMENT
– Aswini A# /alla Mu%%hu
Krishna *andi –0!01030!3
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An%ena%al Manage(en%•
+irs% %ri(es%er
: Receive die%ar& ins%ruc%ion
and nu%ri%ion counseling:
!: Modera%e e?ercise )rogra(:
1: Moni%oring o' blood glucose
5: Screening 'or (icrovascular
co()lica%ions
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An%ena%al Manage(en%•
Second %ri(es%er : Moni%oring o' blood glucose
!: Ano(al& scan a% 9!0 wee<s=
'e%al echocardiogra( a% !!!5
wee<s:
1: Serial grow%h scans 'or
A(nio%ic +luid Inde? and
abdo(inal circu('erence:
5: Surveillance 'or (a%ernal
co()lica%ions:
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An%ena%al Manage(en%•
.hird %ri(es%er : Moni%oring o' blood glucose
!: Assess 'e%al weigh%
1: ,iscuss %i(ing and (ode o'deliver&
D$,)
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D$,)
Ea% (eals on a regular schedule%hroughou% %he da&
Ea% s(aller a(oun%s o'carboh&dra%es a% each (eal
Add a nigh%%i(e snac< %o (eal)lan
E(,-" ,;:$,m,()
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E(,-" ,;:$,m,()
Female 60 kg
Carbohydrate (65% !50Prote"# ($0% 0Fat (&5% $'0
Carbohydrate
$00 gmProte"# ($0% $5gmFat (&5% $gm
"et Carbohy) Prote"# Fat *Arab"a# bread 30 gm +++ +++Chee,e 5 gm $0 gm $0 gm-o#ey 50 gm & gm 3 gm.la,, o/ m"lk $0 gm 5 gm 5 gm*Total 5 gm $ gm $' gm
Carbohydrate (65% 50Prote"# ($0% 0Fat (&5% &&0
Carbohydrate
$30 gmProte"# ($0% &0gmFat (&5% &&gm
"et Carbohy) Prote"# Fat *R"1e '0 gm +++ 6 gm1h"1ke# 5 gm $5 gm $& gmSalad 30 gm ! gm ! gmOra#ge $0 gm +++ +++***Total $&5 gm $ gm && gm
Carbohydrate (65% 330Prote"# ($0% 50Fat (&5% $&0
Carbohydrate
65 gmProte"# ($0% $0gmFat (&5% $$gm
"et Carbohy) Prote"# Fat *T2#a ,a#d"1h !5 gm $& gm $0 gmA44le $5 gm +++ +++Tea +++ +++ +++ *Total 5 gm $ gm $' gm
60 g 30 k1al 7 $'00k1al "th 30% e8tra7 &$00
1al9reak/a,t 00
k1al:2#1h 00
k1al"##er 500
k1al
Sel'(oni%oring o' lood
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Sel' (oni%oring o' lood*lucose
.ES.*L-COSE
LE2ELS 6M* #ER,L UMMOL #ER LV7
+as%ing N 8" 63:"7
Onehour
)os%)randialN 50 6:!7
.wohours)os%)randial
N !0 %o ! 6":7
I li I di %i
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Insulin Indica%ions• lood glucose no% (ain%ained b& die%:
• Insulin dose is individualiJed andadHus%ed according %o %he )a%ien%sblood glucose levels:
Adverse e''ec%s
$&)ogl&ce(ia
Symptoms of
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Symptoms ofHypoglycemia
• Very hungry• Very tired
• Shaky or trembling
• Sweating or clamminess
• Nervous
• Confused• Like you’re going to pass out or faint
• Blurred vision
I M
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In%ra)ar%u( Manage(en%
• ,eliver& b& cesarean sec%ion usuall& is'avored when 'e%al dis%ress has been
iden%i'ied:
• ,eliver& )lanned a% 19 wee<s or 18wee<s ges%a%ion:
• *,M on die% can be delivered a% 50
wee<s:• Main%ain nor(ogl&ce(ia:
#os% #ar%u(
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#os% #ar%u(
Manage(en%• Reassess blood glucose level:
• Counsel regarding die%= weigh% loss
and e?ercise:
• reas% 'eeding:
DISCSSION
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DISCSSION
KALIC$A/,RE/ AL AR-M-*AM
0!01030!!
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.Y#E
.&)e ! diabe%es6/on Insulin
,e)enden%
,iabe%es7:
.&)e diabe%es6Insulin ,e)enden%
,iabe%es Melli%us7
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,E+I/I.IO/
Carboh&dra%e in%olerance resul%ing inh&)ergl&ce(ia o' variable severi%& wi%h onse%
or 'irs% recogni%ion during )regnanc&
SYM#.OM
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SYM#.OM
•+eeling %hirs%& (ore o'%en %han usual
• -rina%e (ore o'%en
RISK +AC.OR
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RISK +AC.OR
#A.$O#$YSIOLO*Y
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#A.$O#$YSIOLO*Y
@ Earl& in )regnanc&= (a%ernal oes%rogen
and )roges%erone increase and )ro(o%e
)ancrea%ic cell h&)er)lasia andincreased insulin release
@ As )regnanc& )rogresses= increased
levels o' hu(an )lacen%al lac%ogen=cor%isol= )rolac%in= )roges%erone= and
es%rogen lead %o insulin resis%ance in
)eri)heral %issues:
COM#LICA.IO/
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COM#LICA.IO/
#reecla()sia#re%er( labor
#ol&h&dra(nios $&)ergl&ce(ia
E++EC. O/ #RE*/A/. WOME/
COM#LICA.IO/
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COM#LICA.IO/
COM#LICA.IO/
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COM#LICA.IO/
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COM#LICA.IO/
C l i
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Conclusion
• Gestational diabetes is a common problem .
• Risk stratification and screening is essentialin almost all pregnant women
• Tight glycemic targets are required for
optimal maternal and fetal outcome• Patient education is essential to meet these
targets
•Long term follow up of the mother and baby is essential
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RE+ERE/CE
,C ,u%%a .e?%boo< o' Obs%e%rics
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