Gestational Diabetes

Patient Presentation:
30 year old female, K.W. presents to the hospital per physician order with increased blood glucose (300 mg/dl) and glycosuria.  The patient is 5’5, 180 lbs, no allergies, only home medication is Phenergan® (12.5 mg-25 mg PO PRN), no chronic illnesses.  K.W. had a twin sister, no family history of diabetes or major illnesses.  K.W. is currently pregnant with her first child, G1P0, at 24 weeks gestation, no complications thus far in the pregnancy. Upon admission she has no signs or symptoms of hyperglycemia, no obstetrical complaints.  Pt states feeling “fine” with only complaints of occasional nausea and increased fatigue.

Diagnosis:
Dx: Gestational Diabetes
Labs (upon admission): Glucose 350 mg/dl, BP 128/84, P 84 R 20 T 98.4ºF,
OGTT with a 3 hour glucose 160 mg/dl (normal <140 mg/dl)

Treatment:
Outcome:
The patient was discharged days later and was later admitted again at 32 weeks with increased blood sugar, with report of “mostly” compliant at home of prescribed insulin.  The patient presents to the labor and delivery unit at 38 weeks and 3 days at 5 cm dilated, 80% effaced, and at -1 station.  The patient’s VS are BP 130/89, P 90, R 22, T 99.0 ºF and blood sugar of 150 mg/dl.  The physician orders q2h blood sugar checks with a sliding scale.  She gets an epidural, spontaneously ruptures membranes (SROM) at 7 cm dilated, and progresses quickly to completely dilated a couple hours later.  The patient received one dose of insulin while in labor.  The patient pushes for 2.5 hours, and delivers the head of the infant.  There was a shoulder dystocia for 2 and a half minutes, with McRobert’s maneuver (having the patient pull legs as far back as possible to open the pelvis), supra-pubic pressure (the RN presses firmly at the supra-pubic area to aid in the shoulder coming under the pubic bone).  The baby was delivered and handed over to the NICU team.  APGAR 4/8.  The baby was 9 lb and 10 oz.  The baby was admitted to the NICU with tachypnea, irregularity of temperature regulation, and hypoglycemia (40 mg/dl).  The mother has no postpartum complications, blood glucose returned to normal while in the hospital.  The baby remained in the NICU for 2 days being monitored, and was discharged home.
Case created by Katherine Whitmire, 2011.