EVALUATING A PREGNANT PATIENT WITH DIABETES MELLITUS
Student Guide
Gen. Data:
This is a case of FK 38 year old G3P1 (1011) from Las Piñas City who is admitted for the first time in this
institution on November 23, 2022
Chief Complaint:
Decreased Fetal Movement
Past Medical History:
No previous history of medical illness, no surgical operations done
Personal and Social History:
The patient is a high school graduate, presently operating her own carinderia store with one sexual
partner, her common-law 40 year old husband who is a family driver. She’s a non-smoker, non-alcoholic
beverage drinker.
Family History:
The patient’s mother and brother has diabetes mellitus. Her husband has diabetes mellitus. No history
of hypertension nor other heredo-familial diseases reported.
Menstrual History:
She had her menarche at age of 10 years. Subsequent menstrual periods came irregularly lasting 3-5
days in duration, consuming 3 pads per day with no other accompanying symptoms.
Gynecological History:
She had occasional vaginal pruritus with whitish curd-like discharge.
Contraceptive History:
She has no history of contraceptive use.
Obstetric History:
G3P1 (1011)
G1 – 2018 full term spontaneous vaginal delivery at Fabella Hospital 9 lbs. 3 oz. Live Baby boy No
complications
G2 – 2020 spontaneous abortion (9 weeks) with dilatation and curettage at Fabella Hospital.
G3 – present pregnancy
PMP: November, last week, 2021
LMP: January, first week, 2022
AOG by LMP: ?
EDC by LMP: ?
Antenatal History:
The patient had a total of 5 prenatal check up at the JONELTA clinic. She first sought consultation at the
JONELTA clinic when she started perceiving fetal movement at around the end of July 2022. She did not
suspect that she was pregnant earlier because of her irregular menstruation. On first consultation:
BP=120/80, HR=80 bpm, T=36.2° C, BMI= 35 FU=14 cm FHT: 140bpm. She was advised to have CBC,
urinalysis, HbsAg, Vdrl which were all normal. Random blood sugar was 240mg/dl. She had a pelvic
ultrasound on August 15 2022 which revealed: Single, Live, Intrauterine pregnancy, 24 1/7 weeks AOG by
average biometry, breech presentation, normohydramnios, anterior placenta, grade 2. She was advised
diabetic diet, exercise, self-monitoring blood glucose, insulin treatment and fetal kick count. On ff-up 2
hour postprandial blood sugar ranged from 180- 200mg/dl. She was not able to comply with her diet,
exercise, and insulin treatment diligently. Repeat ultrasound on October 10, 2022 biophysical profile
showed: Single, Live, Intrauterine pregnancy, 32 4/7 weeks AOG by average biometry (large for gestational
age), cephalic presentation, normohydramnios, anterior placenta, grade 2, bps 8/8. She was advised again
to adhere to her treatment regimen strictly and to do fetal kick count. Biophysical profile was requested
every week alternating with non-stress test. On October 28, 2022, repeat ultrasound with BPS showed:
Single, Live, Intrauterine pregnancy, 34 3/7 weeks AOG by average biometry (large for gestational age),
cephalic presentation, normohydramnios, anterior placenta, grade 2 with BPS 8/8. Estimated Fetal Weight
was large for gestational age. Her FBS ranged from 120-140mg/dl, 2 hour post prandial blood sugar ranged
180-250 mg/dl. She was still not compliant with her diet, exercise, and insulin injection. She was
subsequently lost to follow-up until a few hours prior to admission when she perceived decreased fetal
movement.
REVIEW OF SYSTEMS
CNS: no dizziness, no blurring of vision
CVS: no chest pain, no easy fatigability
Resp: no dyspnea, no cough, no colds
GIT: no nausea, no vomiting, no epigastric pain, (+) polyphagia, (+) polydipsia
GUT: no dysuria, no urgency, no frequency, (+) polyuria
Musculo-Skeletal: no myalgia, no arthralgia
Hema: no bleeding tendency
PHYSICAL EXAMINATION
General Survey:
Patient is awake, coherent, not in cardio-respiratory distress
Vital Signs:
BP=120/80 HR=85bpm RR=28 T=36.8°C BMI=40
HEENT:
Pink palpebral conjunctivae, anicteric sclerae
Chest & Lungs:
Symmetrical chest expansion, clear breath sounds
Heart:
Adynamic precordium, normal rhythm and rate
Abdomen: globular, No contraction noted
FU = 40cms. FHT = not appreciated EFW = 4000grams
LM1 = Breech
LM2 = Fetal back right, Fetal small parts left
LM3 = cephalic
LM4 = not engaged
Inspection:
Normal external genitalia, no gross pooling of fluid in the vagina, (+) curd-like discharge
cervix 1-2 cm dilated, beginning effacement, station (-) 3, normal clinical pelvimetry.
Extremities:
Full and equal pulses, grade 2 edema.
Guide Questions:
1. Calculate the AOG and EDC by LMP. Calculate the AOG and EDC by transvaginal
ultrasound? What is your admitting impression?
AOG AND EDC BY LMP
January (1)
30
February
28
March
31
April
30
May
31
June
30
July
31
August
31
September
30
October
31
November (23)
23
Total
326
326 days/7= 46 4/7 weeks
age of gestation by LMP
01/01/2022
-3 +7
EDC: 10/08/2022
AOG AND EDC BY TVS
August (15)
16
100 days/7= 14 2/7 weeks +
24 1/7 weeks = 38 3/7 weeks
September
30
age of gestation by UTZ
October
31
November (23)
23
02/27/2022
-3 +7
EDC: 12/04/2022
Total
100
2. What is the risk of this patient having diabetes mellitus in pregnancy?
 Age >30 years old due to the combined effects of increasing insulin resistance and
impaired pancreatic islet function with aging.
 Computed body mass index is 40 and classified as obese class III
 Family history: mother and brother has diabetes mellitus
 Gynecological history: occasional vaginal pruritus with whitish curd-like discharge
o When blood sugar levels are high, the body starts to get rid of excess
sugar through bodily fluids, including vaginal secretions. Yeast gets its

energy from sugar, so the vaginal environment makes it easy for yeast
to multiply, overgrow, and turn into a yeast infection.
o High blood sugar also interferes with immune system functions (the
body's defense system) that help fight off yeast infections. This means
uncontrolled diabetes can make it more difficult to prevent and get rid
of a vaginal yeast infection
Obstetric history - History of delivering a macrosomic baby from her previous
pregnancy.
o Higher amount of blood glucose passes through the placenta into the
fetal circulation. As a result, extra glucose in the fetus is stored as body
fat causing macrosomia, which is also called 'large for gestational age'
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o Macrosomia increases the risk of shoulder dystocia, clavicle fractures
and brachial plexus injury and increases the rate of admissions to the
neonatal intensive care unit.
o For the mother, the risks associated with macrosomia are cesarean
delivery, postpartum hemorrhage and vaginal lacerations.
Previous delivery of macrosomic baby, Previous spontaneous abortion
FBS, RBS and 2-hr postprandial blood sugar are beyond normal range
Review of systems revealed patient experiencing the 3 P’s, polyphagia, polydipsia,
and polyuria.
o These findings are seen in cases of diabetes mellitus.
Patient has a BMI of 40 which is classified as Obese Class II
Present pregnancy shows FH of 40cm and EFW of 4000grams which Is beyong the
normal range
Upon physical examination, there is a curd-like discharge suggestive of yeast
infection which is common in people with excess glucose, seen in this patient.
Extremities revealed grade 2 edema which may indicate kidney damage secondary
to hyperglycemia
3. On initial consultation, what diagnostic examinations will you request for?
 Complete Blood Count
 Urinalysis
 Blood Typing
 VDRL, HbsAg, HIV1/HI2
 Transvaginal and transabdominal Ultrasound
 FBS/HbA1C/RBS
Screening for GDM should be done:
•
In Filipino Gravidas with no other risk factors and normal FBS/HbA1C/RBS results,
screening will be done at 24-28 weeks AOGvia 2 hour 75 grams OGTT
o If OGTT results are normal, the next OGTT test will be done at 32 weeks or
earlier if the patient and fetus present with symptoms of hyperglycemia.
o Criteria using 75g OGTT
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Fasting blood glucose: >92 mg/dL
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1-hour OGTT: 180 mg/dL
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2-hour OGTT: >153 mg/dL
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In Filipino Gravidas who presents with risk factors for GDM should immediately be
tested with 2-hour 75g OGTT at first consult
o Criteria for Overt DM
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Fasting blood glucose: >126 mg/dL (7 mmol/L)
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HbA1c > 6.5%
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RBS > 200 mg/dL (11.1 mmol/L) + symptoms of hyperglycemia
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2 hours 75g OGTT >200 mg/dL (11.1 mmol/L)
4. What is the maternal antepartum management for diabetes mellitus in this patient?
 FIRST TRIMESTER
o Achieve euglycemic state with proper DM diet, physical activity and
medications for diabetes.
o Multiple daily injections of insulin than oral hypoglycemics
o Total caloric intake 30-35 kcal/kg with low glycemic food index
o 3 meals, 3 snacks, 30% Carbohydrates, 40% Fat, 20% Protein
o 4 point CBG monitoring of blood glucose
 SECOND TRIMESTER
o Maternal Serum AFP determination to detect neural tube defects and
anomalies at 16-20 wks
 THIRD TRIMESTER
o Continuous fetal monitoring and surveillance:
o Fetal heart rate monitoring
o Biophysical profile
o Contraction stress test
o Fetal movement count
5. What are the effects of Diabetes Mellitus on the developing fetus?
Spontaneous
abortion
Malformation
s
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Poor glycemic control has been found to be associated with early miscarriage.
(Initial HbA1C > 12% or with persistent pre-prandial glucose concentrations>
120 mg/dL)
Incidence of major malformations are doubled in cases of pregnant women
with diabetes mellitus (Type 1). Moreover, cardiovascular malformations
account for more than half (4x) of the anomalies detected in such cases
this is due to poor control preconceptually or in early pregnancy
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Fetal overgrowth is more commonly seen in pregestational diabetes
Altered fetal patients. Maternal hyperglycemia prompts fetal hyperinsulinemia. This in
turn stimulated excessive somatic growth. However, the brain may not be
growth
as affected.
Overt diabetes has been known to be a risk factor for preterm delivery,
Preterm
owing it to the
Delivery
medical and obstetrical complications that come with hyperglycemia.
The risk of fetal death is 3-4 times higher in women with overt diabetes
mellitus. Such cases of fetal demise are “unexplained” because common
factors like placental insufficiency, placental abruption, IUGR, or
Unexplained
oligohydramnios are not identified. These stillbirths are thought to result
fetal demise
from poor glycemic control and maternal ketoacidosis.
Fetuses are typically large for gestational age and expire late in the
pregnancy, particularly before labor or at the third trimester.
diabetic pregnancies are often complicated by the presence of excess
amniotic fluid
Hydramnios
(polyhydramnios >24cm). This can be defined as an AFI of >24 by the third
trimester. Note that increase in AFI parallels glucose level in amniotic fluid.
6. What are the effects of pregnancy of the Maternal Diabetes Mellitus?
Diabetic
nephropathy
This is the common complication which most often forces preterm delivery
in a diabetic
pregnant patient. Special risk factors: any vascular complication and
preexisting proteinuria, with or without chronic hypertension
This is considered as the leading cause of end-stage renal disease. Clinically
detectablenephropathy starts with microalbuminuria > 300mg/24hr.
Diabetic
retinopathy
This is the most important cause of visual impairment in patients < 60 years
of age, and it is worsened by pregnancy
Diabetic
neuropathy
This pertains to diabetic gastropathy in pregnant women brought about
by peripheral symmetrical sensorimotor diabetic neuropathy. It causes
nausea and vomiting,
nutritional problems and difficulty with glucose control.
Preeclampsia
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Diabetic
ketoacidosis
Infections
This is most often encountered in women with type 1 diabetes. It may
develop with hyperemesis gravidarum, infection, insulin noncompliance, Bmimetic drugs given for tocolysis, and corticosteroids administration.
Pregnant woman usually develops ketoacidosis at lower blood glucose
thresholds than when nonpregnant DKA
Infection rates are higher in diabetic patients. Common diseases include
candida
vulvovaginitis, urinary and respiratory tract infections, and puerperal pelvic
sepsis
7. What is the ideal antenatal surveillance for this developing fetus?
 Ultrasonogram to assess fetal size every 4-6 weeks from 26 to 36 weeks
 Fetal monitoring and surveillance
 16-20 weeks, maternal AFP determination to detect neural tube defects and
anomalies by UTZ.
 32-34 weeks, testing for fetal movement counting, fetal heart rate monitong,
biophysical profile evaluation 2x a week, and contraction stress test.
8. What are the expected neonatal complications in the event this fetus survives?
 Hypoglycemia – caused by hyperplasia of the fetal Bislet cells brought
about by maternal hyperglycemia
 Hypocalcemia – metabolic derangement in neonates of diabetic mothers
 Hyperbiliribunemia and Polycythemia – fetal response to hypoxia
brought about by hyperglycemia-mediated elevation in maternal
affinity for oxygen and getal oxygen consumption
 Cardiomyopathy – ventricular hypertrophy due to hyperinsulinemia
9. What is the ideal route of delivery and anesthesia for this pregnancy?
 The ideal route of delivery for this patient is through cesarean delivery. This is to
avoid a possible traumatic birth of a large fetus in the mother and since
vulvovaginal candidiasis is being considered, this may prevent the vertical
transmission of infection to the fetus
 Regional anesthesia will be given. Either spinal or epidural anesthesia may be
appropriate for the patient, provided that maternal glycemic control is
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satisfactory, the patient receives aggressive preanesthetic volume expansion
with a non-dextrose containingbalanced salt solution and hypotension is treated
aggressively with ephedrine
10. What is the postpartum management for this pregnancy?
POST-DELIVERY
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Persistent hyperglycemia in early puerperium is uncommon and can be excluded →
Fasting or random capillary blood glucose levels before discharge
•
Elevated values should be confirmed with fasting plasma glucose (>126 mg/dL or
7.0 mmol/L) or postprandial glucose (>200mg/dL or 11.1 mmol/L)
•
Pharmacologic therapy should be continued to maintain good glycemic control and
provide sufficient calories for lactation &infant well-being
•
All types of insulin, glyburide or glipizide can be safely used by breastfeeding women.
POSTPARTUM PERIOD
•
The Fifth International Workshop Conference on Gestational Diabetes recommended
that women diagnosed with gestationaldiabetes undergo evaluation with a 75-g oral
glucose tolerance test at 6 to 12 weeks postpartum and other intervals thereafter.
The following are the recommendations
o
Post delivery (1-3 days) Fasting or Random Plasma Glucose
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To detect persistent; overt diabetes
o Early post partum (6-12 week); 75-g, 2-hr OGTT
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Postpartum classification of glucose metabolism
o 1-yr postpartum; 75-g, 2-hr OGTT
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Assess glucose metabolism
o Annually; Fasting plasma glucose
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Assess glucose metabolism
Triannually; 75-g, 2-hr OGTT
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Assess glucose metabolism
o Pre Pregnancy; 75-g, 2-hr OGTT
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Classify glucose metabolism
Strict proper diet modification and exercise programs for the patient to follow.
o
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COUNSELLING
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Counselling about birth control and family planning. Effective contraception is a must
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in order to properly plan out and manage succeeding conceptions in the future.
Educate the patient on the importance of diet modifications and exercise programs
since there was difficulty in adhering to the recommendations antenatally.
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