Antenatal Case

Presentation and
Discussion
Jonathan Matthews
Case 1: Mrs. JH
 Case: Mrs. JH
 40 year old female attending the antenatal clinic.
 G5 P2+2
 2 x Caesarean section
 1 x miscarriage
 1 x termination of pregnancy
 Currently 28 weeks gestation, all tests and scans so far
NAD.
 Of Indian ethnicity but born and raised in UK.
 No symptoms herself. No PMH.
 FHx of T2DM (Father and brother).
 Case: Mrs. JH
 O/E:
 BMI: 34 kg/m2
 BP: 130/90 mmHg
 SFH: 34cm
 FHR: Normal
 Urinalysis: 1+ glycosuria

 How would you proceed with this case?

 What features of the case would suggest such an
approach?
 Case: Mrs. JH
Order a Glucose Tolerance test

Why?:

 FHx of close relatives with DM.

 Indian ethnicity
Results of GTT:
 Obesity
 Glycosuria O/E  Pre-test BM: 6.4 mmol/L
 Maternal age
 2-hour BM: 13.3 mmol/L
 Case: Mrs. JH

Diagnosis:

Gestational Diabetes

 Why?

 GTT > 11.1 mmol/L 2-hours post glucose load.

 Diabetes in Pregnancy
 Two groups of DM patients to consider:

 Pre-existing DM

 Gestational DM
 Gestational DM: Physiology
 State of relative insulin-resistance in pregnancy.
 Why?
 Increased secretion of Oestrogen, progestogen, human
placental lactogen (hPL), cortisol.
 Many secreted by placenta.
 Leads to increased insulin secretion.

 Normal woman = ok.

 Susceptible patient = unable to meet demand.
 Normal
Pregnancy

Insulin
secretion

Gestational DM

Duration of pregnancy
Pancreatic capacity

A - Pre pregnancy (Basal)

B - Pregnancy (Basal)
C
A B

C – Pregnancy plus increased

demand
 Gestational DM: Risk factors
 BMI > 30 kg/m2
 Hx of Macrosomic baby (4.5 kg+).
 PMH of Gestational DM
 FHx of DM in first degree relatives.
 Family origin (South Asia, Black
Caribbean, Middle Eastern).

 Glycosuria 2x in ANC.
 Polyhydramnios
 Gestational DM: Screening
 Consider in any pregnant woman who is at risk of GDM.

 Pre-test counseling (Rx requirements, untreated risk,

monitoring requirements).

 Definitive diagnosis via 2-hour GTT.

 Usually conducted between 24-28 weeks.

 Gestational DM: Monitoring
 Self-monitoring of blood glucose at home.

 Follow-up in Antenatal clinic with Diabetic specialist input.

 USS assessment of amniotic fluid volume and fetal growth to be

monitored every 4 weeks (28 weeks to 36 weeks).

 Monitoring of fetal well-being (using CTG) recommended after 38

weeks (earlier if evidence of IUGR).
 Gestational DM: Management
 Instructed in good diet and exercise programme.

 Hypoglycaemic therapy:

 When?

 What form?
 GDM: Effect on the pregnancy
 Macrosomia
 Shoulder dystocia
 Polyhydramnios
 Neonatal hypoglycaemia
 Neonatal respiratory distress syndrome
 Increased risk of still birth
 Hypothermia
 Reduced APGAR
 Premature labour
 Hyperbilirubinaemia
 Maternal diabetes persisting post-partum
 Neonatal Diabetes
Does GDM greatly increase
the risk of congenital
abnormalities?
 No – Why?
 Increased risk of congenital malformation with
ESTABLISHED DM.

 Organogenesis approximately 1st 7-9 weeks of life.

 Not really of concern to gestational DM, typical onset later in

pregnancy.
Case 2: Mrs RL
 Case: Mrs RL
 Midwife referral of a 34 year old female (G4 P0+3).
 C/O lower abdominal pains and blood loss over 5 days.
 Pregnancy confirmed by:
 Home pregnancy test
 Dating scan at 12 weeks (viable uterine pregnancy)

 All booking tests normal.

 Last pregnancy ended at 8 weeks (complete miscarriage).
 PMH of PCOS.
 Case: Mrs RL
 O/E:
 Temp: 36.9⁰C
 HR: 80 bpm
 BP: 115/80
 HS and RS normal.
 Abdomen soft, non-tender
 Speculum: Cervix closed, no discharge/blood.
 Bi-manual: Uterus (size ~8-10 weeks, no tenderness, mobile), No
adnexal masses.

 What are the important points of the Hx? What investigation

will you do next?
 Case: Mrs RL
 Important factors:
 Pains and bleeding
 Viable uterine pregnancy
 Hx of recurrent miscarriage
 Hx of early miscarriage
 PMH of PCOS

 Test:
 USS: Visible fetus (47mm crown-rump), intact gestational sac,
no FH detected, no other abnormalities.
 Case: Mrs RL
Diagnosis: Missed (silent) miscarriage

Management: REMEMBER
PSYCHOLOGICAL
 Expectant - “watch and wait” SUPPORT

 Medical - Oral Mifepristone + Intravaginal Misoprostol

 Surgical - Evacuation of retained products of conception

 Recurrent miscarriage causes
Factor Investigations Findings Management

Epidemiological Clinical Hx Maternal/Paternal age, Donor oocytes/sperm,

Number of previous Smoking cessation,
miscarriages, Smoking, alcohol advice.
Alcohol
Antiphospholipid Antibody screen Positive antibodies (i.e. Heparin and aspirin
syndrome and clinical Hx lupus anticoagulant,
anti-caridolipin, anti-B2
glycoprotein I)
Genetic Cytogenetic Chromosomal Referral to clinical
analysis, anomalies (i.e. geneticist, Pre-
Parental Robertsonian implantation screening
karyotyping translocation)
Anatomical USS pelvis, Congenital uterine Surgical correction of
hysteroscopy, malformations, Cervical malformation, Serial
laparoscopy weakness cervical surveillance,
Cervical cerclage
 Recurrent miscarriage causes
Factor Investigations Findings Management

Endocrine Blood tests (i.e. GTT, DM, Thyroid Rx underlying

TFT etc.) disease, PCOS disease

Immune Peripheral blood and NK cells in Immunosuppression?

uterine biopsy peripheral blood/
uterine mucosa
Infection Vaginal swabs etc. Infective reservoir Rx Infective source

Inherited Thrombophilia screen Positive result Heparin Rx in the

thrombophilia (Inc. Factor V Leiden, second trimester
defects Factor II gene
mutation, Protein S
deficiency)

Unexplained recurrent miscarriage – Supportive care +/- aspirin

 References
http://www.keepcalm-o-matic.co.uk/p/chocolate-is-for-life-not-just-for-easter-7/

http://sabotagetimes.com/life/ever-wondered-who-writes-disclaimers-on-food-packets/

http://openvz.org/File:Warning.svg

http://www.markwoodcartoonist.myzen.co.uk/keepfit1.html

http://hqwallpapersplus.com/wp-content/uploads/2013/11/Snow-Mountain-Wallpapers2.jpg

https://www.madison.k12.wi.us/calendars

Royal College of Obstetricians and Gynaecologists, Green-Top Guidline No. 17: The investigation and treatment of
couples with recurrent first-trimester and second trimester miscarriage. April 2011.

C Bottomley & J Rymer, 100 cases in Obstetrics and Gynaecology, 2008, Hodder Arnold: UK.

D Hamilton-Failey, Lecture notes: Obstetrics and Gynaecology, 2009, 3rd edition, Wiley-Blackwell:
UK.

J Pitkin, AB Peattie, BA Magowan, An Illustrated Color Text: Obstetrics and Gynaecology, 2003,
Elsevier Science Ltd: Edinburgh.

NICE Clinical Guidline 63: Diabetes in Pregnancy, 2008.