Introduction: (150-200 words)

• Define GDM
• Literature review
• Incidence/prevalence and epidemiology of GDM in Australia
• Diagnosis

Case:

Mrs AKN is a 30 years old female gravida 1 parity 0, at 38 weeks gestation with singleton intrauterine life fetus when this history was taken. She was admitted at 9 am to the Maternity Ward for IOL on the background of Insulin Dependent Gestational Diabetes Mellitus (IDGDM). She was diagnosed with GDM at 14 weeks gestation. Her diabetes was not controlled initially on diet control and then she was switched to insulin at 22 weeks gestation. She has no previous history of diabetes. She was also found to have hypothyroidism at 27 weeks gestation. She also reported having oligohydramnios and last ultrasound scan showed an Amniotic fluid index (AFI) of 6 cm, which was reported as mild oligohydramnios.

Mrs AKN has a 31 days regular cycle and 3-5 days of bleeding. Her last menstrual cycle was 1/11/2016 and the expected day of delivery was 11/08/2017. She has no other significant history. Mrs AKN hasn’t used contraceptives before and therefore doesn’t have a significant contraception history.

Mrs AKN’s antenatal follow ups have been normal since the start of this pregnancy. On ultrasound, fetus has normal gestational age and no other complications.

Mrs AKN denied any previous medical or surgical history. Patient’s mother was diagnosed with Type 2 DM at the age of 43 years old with no other notable family history. Mrs AKN denied any smoking, alcohol, illicit drug use history in the past.

Patient was induced with cervidil pessary 10 mg at 10 am for IDGDM and mild oligohydramnios. Patient was asked to wait 24 hours before considering other options of induction.

On examination, Mrs AKN looked comfortable in bed. Her vital signs were within the normal range. On abdominal examination, she had linea nigra, and striae gravidarum. Fundal height measured 37 cm, fetal lie was longitudinal, with a cephalic presentation. Fetal head was fully engaged. On vaginal examination, patient was 2-3 cm dilated, -2 station, with medium consistency, and intact membranes. Fetal heart rate was 140-144 beats per minute and present fetal movement.

At 07:00 am next morning, patient was contracting 2 in 10 mins contractions. Membrane was artificially ruptured 24 hours after the cervidil and 40 units of IV Syntocinon was started at 14:00 at a rate of 15mls/hr. Syntocinon was increased to 45mls/hr at 15:30. At 1540, patient was fully dilated and contracting 4 contractions in 10 mins. Active pushing started at 15:45. Patient delivered at 17:38 with forceps delivery and episiotomy. Epidural anaesthesia was used for pain relief during labour. Patient’s labour was complicated with high blood pressure and heart rate. These complications were not related to the gestational diabetes. Patient proceeded to have episiotomy and lift-out forceps delivery due to decreased maternal effort.

Management 1 (150 words maximum):

• Presents important points and issues from the patient’s history, presentation and physical examination. Discusses the patient’s management including investigations and tests performed with relevance to the presented case.

Mrs AKN was investigated for GDM at 14 weeks gestation with fasting GGT and 2-hour GGT. She then was diagnosed with GDM. Following her diagnosis, Mrs AKN was referred to the diabetic educator and she was managed through diet control. Her diabetes wasn’t controlled on diet and she was switched to Insulin at 22 weeks. She takes Novorapid 6 units pre-breakfast, 8 units pre-lunch, 6 units pre-dinner. She also takes Protophine 8 units at bedtime. She was also asked to record her Blood Sugar Levels (BSL) four times a day. Before and after breakfast, after lunch, and after dinner.

Discussion part 1: (350 words)

(using current literature and guidelines): That’s the main discussion

• Determines the main points and discusses challenges, alternative options and/or deficits in the management of the case presented.

• Management of GDM according to the New South wales guidelines? Compare it guidelines to i.e. NICE or Western Australia guidelines, which one shows better outcomes? Possible complications for both mother and fetus?

Management 2: (100 words)

• Presents important points and issues from the patient’s history, presentation and physical examination. Discusses the patient’s management including investigations and tests performed with relevance to the presented case
• Please write relevant information from history >> see management part 1.

Discussion part 2: (250 words)

(using current literature and NSW guidelines) compare it to other guidelines “Induction of labour Queensland guidelines”, Western Australia guidelines, NICE guidelines. DON’T to all of them just the relevant ones to the patient (IOL at 38 weeks)

• Determines the main points and discusses challenges, alternative options and/or deficits in the management of the case presented.

• Induction of labour (IOL) in GDM and Oligohydramnios pregnant women? When to start induction in healthy intrauterine fetus and why? How to choose method of induction and why?

• Isolated Oligohydramnios at Term as an Indication for Labor Induction: A Systematic Review and Meta-Analysis (helpful article)

Conclusion (150-200 words):

What do you think of the management of this case? Adequate? And why?

References:

Please use Vancouver style.

Cervidil:

• Tathem, K., Harris, L. J., O’Rourke, P. and Kimble, R. M. (2012), Dinoprostone vaginal pessary for induction of labour: Safety of use for up to 24 h. Aust N Z J Obstet Gynaecol, 52: 582–587. doi:10.1111/j.1479-828X.2012.01482.x

IOL:

• Isolated Oligohydramnios at Term as an Indication for Labor Induction: A Systematic Review and Meta-Analysis