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Case Presentation. Obstestrics 성균관대학교 의과대학 m5 손의영 Pt ID : 10755559 김 0 경 30/F. Chief Complain. Amenorrhea for 38 + 3 weeks with decreased Fetal movement ( NST non-reactive) Onset : 2011-06-13. Obstetric History. Para : (1) - (0) - (0)(,) - (1)(0,1) 최종 월경 시작일 : 2010-09-17

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Case presentation

Case Presentation

Obstestrics

성균관대학교 의과대학

m5 손의영

Pt ID : 10755559

김0경 30/F


Chief complain

Chief Complain

  • Amenorrhea for 38 + 3weeks with decreased Fetal movement (NST non-reactive)

    • Onset : 2011-06-13


Obstetric history

Obstetric History

  • Para : (1) - (0) - (0)(,) - (1)(0,1)

  • 최종 월경 시작일 : 2010-09-17

  • 분만 예정일 : 2011-06-24


Present illness

Present Illness

  • Prenatal check at SMC OBGY since 6 + 5주 by Pf 노정래

  • Last Pap : 2008-10 특이사항(No)

  • Serum screening test : Quad test (-)

  • 11-03-02 50g oral GTT

    • ▲146 mg/dL

  • 11-04-09 100g oral GTT

    • ( 78 - ▲220 - ▲214 - 144 ) mg/dL

  • CBC : 특이사항 (No)


Other history

Other History

  • PMHx.

    • HTN/DM/Tb/hepatitis/Allergy ( - / - / - / - / - )

    • Prev. GDM (이전 임신시27주경 진단)

    • 약물력: 엽산제, Oral iron, glibenclamide2.5mg/d for 1 wk

    • 수술력: (No)

  • FHx.

    • 당뇨 : (+), 모친

    • 고혈압 (-), 유전질환 (-)

  • SHx.

    • Marriage : 기혼 (26세)

    • smoking: no

    • alcohol: no


Review of system

Review of System

  • Obstetric symptoms

    • Fetal movement (Yes)

    • Uterine contraction (Yes) : Irregular

    • Vaginal bleeding (No)

    • Watery vaginal discharge (No)

  • General symptoms

    • 임신 전 체중 : 53kg 현재 체중 : 61.7kg

  • 그 외 이상 소견 없음


Physical exam

Physical Exam

  • General appearance

    • Not so ill looking

    • Mental status : Alert

  • Abdomen

    • Palpitation : Distended d/t pregnancy

    • Tenderness (No)

    • Rebound tenderness (No)


Physical exam1

Physical Exam

  • 산과 진찰소견

    • FHR : Normal by USG Normal by Doppler (Heart rate 140-150 bpm)

    • Presenting part : Cephalic

    • Cervix dilatation : Closed

    • Effacement : NE

    • Station : -1

    • Vaginal discharge : Normal

    • Rupture of membrane (No)

    • Vaginal bleeding (No)


Assessment

Assessment

  • Pregnancy: 38 + 3 weeks

    • c decreased FM (NST non-reactive)

    • c GDM

    • c prev. GDM


Case presentation

Plan

  • 치료계획:Intravenous Pitocin

  • 퇴원계획:자연분만 후 합병증 없으면 PP#2 퇴원


Hospital course

Hospital Course

  • 2011-06-14 분만 (38 + 4 weeks)

  • 분만 시간 : 11:18

    • Induction(Yes)

    • Prostaglandin (No)

    • Dinoprostone (No)

    • Misoprostol (No)

    • Oxytocin(Yes)


Hospital course1

Hospital Course

  • 2011-06-15 PP#1【검사명】 【단위】 【시행일】 【결과】------------------------------------------------------------Hb, Blood g/dL2011-06-13 17:07 ▼10.8 2011-06-15 07:38 ▼10.8------------------------------------------------------------

    Dressing done : episiotomy site clear, no hematoma익일 퇴원 예정


Gestational diabetes

Gestational Diabetes

  • Classification

    • Overt DM : 임신 전에 당뇨로 진단 된 경우

    • Gestational DM : 임신 중에 당뇨로 진단된 경우

  • Diagnosis of GDM

    • Screening : 1hr 50g OGTT (PA 24~28 weeks) 140 이상이면 확진 검사!

    • Diagnosis : Overnight fasting 후 100g OGTT fasting/1h/2h/3h – 105/190/165/145이 중 2개 이상 기준치 초과 시 확진!


Gestational diabetes1

Gestational Diabetes


Gdm risk strategy

GDM – Risk & Strategy

  • 평가는 반드시 첫 번째 PN visit 때 이루어져야 한다.

  • Low risk : 다음을 모두 만족

    • Member of an ethnic group with a low prevalence of GDM

    • No known diabetesin 1st-degree relatives

    • Age < 25 years

    • Weight normal before pregnancy

    • Weight normal at birth

    • No history of abnormal glucose metabolism

    • No history of poor obstetrical outcome

  • Low risk 에서는 Routine serum glucose 측정 안 해도 된다.


Gdm risk strategy1

GDM – Risk & Strategy

  • Average risk : PA 24~28주에 평가

    • Two-step : 50g OGTT  100g OGTT

    • One-step : 100g OGTT on all subjects

  • High risk : 가능한 빨리 혈당 검사 한다.

    • 다음 중 한 가지 이상 만족

    • Severe obesity

    • Family History of T2DM

    • Personal History of GDM


Gdm complications

GDM – Complications

  • Maternal Effects

    • Diabetic retinopathy

    • Diabetic nephropathy

    • Diabetic neuropathy

    • C-sec rate↑, maternal risk↑

    • Pre-eclampsia

    • Ketoacidosis

    • Infection : genital tract, respiratory tract

    • Difficult delivery d/t large fetus


Gdm complications1

GDM – Complications

  • Fetal Effects

    • Abortion

    • Malformation

    • Hydramnios

    • Respiratory distress

    • Hypoglycemia

    • Hypocalcemia

    • Hyperbilirubinemia

    • Cardiac hypertrophy

    • Macrosomia


Gdm treatments

GDM – Treatments

  • Diet

  • Exercise

  • Insulin : FBS < 95 mg/dL, PP2 < 120 mg/dL으로 유지되지 않으면 투여 (ADA, 2006)

  • 분만 : near term 에 분만

    • PA가 확실하면 38주 이후 분만

    • PA가 불확실하면 38주 경에 L/S ratio 측정하여L/S ratio ≥ 2이면 분만심한 고혈압이 있으면L/S ratio < 2이어도 분만


References

References

  • Williams Obstetrics, 23rd Edition


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