Gestational Diabetes Mellitus case studies by Diabetesasia.org

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Case studies

• Gestational Diabetes Mellitus

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Case study 1 Mrs. C

• Mrs. C is a 22 year old primigravida coming for
  her first antenatal checkup at 12 weeks of
  gestation.
• On examination, she is 152 cm tall and weighs 69
  kg. BMI, 30 kg/m2
• She does not have a family history of diabetes.
• Does she need to be screened for diabetes?
• If so, when?
• What screening test is to be used?

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Mrs. C.

• Mrs. C had a fasting blood glucose done
• Her results are as follows.
• Does she have diabetes?
• Does she have GDM?
• Does she need to be tested again?
• If so, when?

Time 0 hr (Fasting)
Glucose mmol/L(mg/dL) 4.7 (86)
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Mrs. C

• Mrs. C undergoes repeat testing at 26 weeks
  gestation.
• Her results on the 75 gm glucose load (fasting)
  are as follows.
• Does she have GDM?
• If yes, what treatment is indicated?
• When will you review her and using what tests?

Time 0 hr (Fasting) 1 hour 2 hour
Glucose mmol/L(mg/dL) 4.8 (88) 10.3 (186) 8.9 (161)
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Mrs. C

• After 2 weeks, her results were as follows
• Is her glycemic control adequate?
• What is the next line of treatment?
• What other test can help assess level of glycemic
  control?

Fasting blood glucose mmol/L (mg/dL 5.2 (93)
2 hour postprandial blood glucose mmolL (mg/dL) breakfast 8.6 (156)
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Mrs. C

• Mrs. C is put on 4 units of rapid acting insulin
  before breakfast and advised to monitor her blood
  glucose daily. She does well.
• After 2 weeks, her reports are as follows.
• Is her glycemic control adequate?
• What is the next line of treatment?

Fasting blood glucose mmol/L (mg/dl) 6.5 (118)
2 hour postprandial blood glucose mmol/L(mg/dl) breakfast 7 (126)
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Mrs. C

• Mrs. C is now on 6 units of NPH insulin at
  bedtime in addition to 4 units of rapid acting
  insulin before breakfast. She starts complaining
  of excess hunger during the early hours of the
  morning.
• Her reports are as follows.
• Are these values acceptable?
• What is the next line of treatment?

mmol/L (mg/dL)
Fasting BG 3.3 (61)
2 hour postprandial BG 5.6 (102)
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Mrs. C

• Her insulin dose has stabilized
• NPH 8 units at bedtime
• rapid acting insulin 6 u before breakfast, 4
  units before lunch and 4 units before evening
  meal.
• Mrs. C goes into labour at 39 weeks.
• Should she have been induced earlier?
• Should a C-Section be considered?
• How should her insulin be managed during labour
  and delivery?

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Mrs. C

• Following delivery, blood glucose levels
  normalised and she was able to stop insulin.
• After 6 weeks, she underwent an OGTT, the results
  of which are as follows.
• What is the diagnosis?
• What is her risk of developing diabetes in the
  future?
• When should she be tested next?

Time 0 hour (Fasting) 2 hours
Glucose mmol/L (mg/dl) 4.5 (82) 7.0 (127)
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Case study 2 Mrs. S
Mrs. S is a 35 year old nulliparous lady and has
suffered two miscarriages in the last three
years. After the last miscarriage she was
diagnosed with PCOS and has been on metformin
since. She did not test her blood glucose levels
during either of her previous pregnancies. Her
mother has diabetes. She presents at 12 weeks
gestation What else do you need to know?
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Mrs. S

• Does she need to be screened for diabetes?
• If so, when?
• What screening test is to be used?
• Should the metformin be continued?
• What is the purpose of metformin?

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Mrs. S

• Mrs S has an OGTT at 13 weeks gestation
• Are these results ok?
• Should she be retested? When?
• What management strategies should be considered?

Fasting 2 hour
Glucose mmol/L(mg/dl) 6.0 (108) 9.0 (162)
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Case Study 3 Mrs M

Mrs. M, 30/F Primigravida LMP 13/10/12 EDC 
28/07/13 Regular cycles Spontaneous conception
10 months after marriage No family history of DM
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Mrs M

• Fasting BG at 6 weeks

Fasting
8.8 mmol/L (160 mg/dL)
What would you advise now? Trial of MNT or
medications right away? Any other tests? What
risks to the pregnancy will you discuss with this
lady?
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Mrs M

• Normal scan at 12 weeks with a low risk of Downs
• 19- 20 week scan plus fetal echo was normal
• When will you advise next scan?
• Glucose results as in next slide. Patient not
  very regular with SMBG and not following the meal
  plan

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Mrs M Blood glucose record
Gestational age FBS mmol/L (mg/dL) 1 h PPBS mmol/L(mg/dL) A1c Medication
15 5.9 (107) 6.9 (125) 8.1 Premix 70/30 18 - 0 - 18 Metformin 500 BD
18 7.1 (129) 10.1 (183) 7.2 22 - 0 - 22 Metformin BD
19 5.3 (97) 9.6 (173) 26 - 0 - 20 Metformin BD
5.8 (105) 8.7 (157) 6.5
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Mrs M

• 29 week scan
• Ask to comment

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Mrs M

• She comes in with c/o discomfort and abdominal
  pain at 30 weeks
• How will you manage her now?
• Uterus is irritable with some tightening on and
  off

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Mrs M

• Tocolytic which drug and dose
• Steroids dose / concerns in GDM

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Mrs M

• Uterine contractions settle. UTI picked up and
  treated with appropriate antibiotics
• She is now 37 weeks
• FBS 5.5mmol/L (100mg/dL) 1 hr PPBS 8.3 mmol/L
  (150 mg.dL) on
• Regular (soluble) 26-10-14 NPH 0-0-12
• Comes in with decreased movements
• What would your approach be?

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Case Study 4

• Mrs. C, a 32 year old primigravida
• Reports for the first antenatal checkup.
• She is obese with a body mass index of 35 kg/m2,
  both her parents have diabetes.
• Her OGTT results are as follows.
• Her HbA1c is 9.2.
• What type of diabetes does this patient have?
• What is the ideal line of treatment?
• What is the prognosis for the pregnancy and for
  future resolution of diabetes?

Time 0 hr (Fasting) 1 hour 2 hour
Glucose mmol/L(mg/dL) 10.6 (192) 16.0 (288) 14.6 (263)