DIABETES MELLITUS AND

HYPERTENSION
COMPLICATING PREGNANCY
a report by
AHMAD ASHRAF ILMAN BIN ZULBAHRI (110281)
for a case at
HOSPITAL AMPANG
supervised by
DR SALLEHA BINTI KHALID
for
PAG 4019 OBSTETRICS POSTING

MAY 2015

Patient information
Name:

Mrs L.L.L.

Race:

Chinese

Age:

33

Parity:

G2P0+1

LMP:

16 August 2014

EDD:

23 May 2015

Date of admission:

7 May 2015

Date of clerking:

7 May 2015

Mrs L.L.L. was a 33-year old Chinese housewife, G2P0+1 at 38 weeks period of
amenorrhoea (POA), a known case of diabetes mellitus type II and hypertension complicating
pregnancy, who was admitted for induction of labour. There were no symptoms of labour and
foetal movements were good.
Her hypertension was detected in 2010 during a routine medical checkup. The blood pressure
was noted to be borderline and she was not started on treatment. During the checkup she was
also diagnosed to have hypercholesterolaemia and was started on treatment (perindopril and
simvastatin). Her diabetes mellitus was diagnosed in 2013 during her miscarriage and she
was started on oral hypoglycaemic agents (metformin and gliclazide).
She also complained of back pain. Otherwise she complained of no other symptoms.
The first day of the patients last menstrual period was on 16 August 2014 and she was sure
of her dates. Her menstrual cycle was regular and she was not on any hormonal
contraceptives. Therefore, her expected date of delivery is 23 May 2015.
Current pregnancy history
This was an unplanned but wanted pregnancy. The patient suspected that she was pregnant
when she was amenorrhoeic for one month. She went to a GP on 20 September 2014, urine
pregnancy test was done and came out positive. She was on treatment for diabetes mellitus
and hypercholesterolaemia, and the GP consulted her to stop all medications.

She had her booking visit at Klinik Kesihatan Batu 9, Cheras on 23 September 2014 at 5
weeks POA. On booking, her BMI was 28.2. She was normotensive with a blood pressure of
129/80 mm Hg. Her blood group was B+. Her haemoglobin level upon booking was 12.4
gm/dL, and HIV screening as well as VDRL test were both non-reactive. However, her urine
sugar was 4+ and her blood sugar level was 20.8 mmol/L.
She was referred to Hospital Ampang for her high sugar level. She was admitted for one
week and started on subcutaneous insulin (actrapid and insulatard). After that, she was under
Hospital Ampang combined clinic and KK Batu 9 biweekly follow up. She had to do regular
blood sugar profile (BSP) and blood pressure (BP) monitoring.
Ultrasound scan done on 14 October 2014 at 8 weeks POA showed a viable foetus. She was
started on T. aspirin 75 mg OD on 25 November 2014 at 14 weeks POA. A dating scan was
done on 10 December 2014 at 16 weeks POA. The parameters corresponded to the dates and
the EDD was followed. BSP and BP monitoring were good until 31 December 2014 at 19
weeks POA when she complained of headache and her BP reading was 144/62. She was
started on T. methyldopa 250 mg BD.
Detail scan was performed on 7 January 2015 at 20 weeks POA and no abnormalities were
detected. Antitetanus toxin injections were given on the 25th and 33rd week POA. On 29 April
2015 at 36 weeks POA, her haemoglobin level was 10.0 and she was started on oral iron
fumarate. She was planned for admission on 7 May 2015 for induction of labour on 8 May
2015.
Past obstetrics history
This was her second pregnancy. Her first pregnancy was in 2013 which resulted in
miscarriage at 9 weeks POA. She went to a GP after she was having per vaginal bleeding and
abdominal pain. No evacuation of retained product of conception was performed. She was
diagnosed to have diabetes mellitus at this point.
Past gynaecological history
She attained her menarche at 15 years old. Her menses was regular with a 28-30 days cycle
and flow of 7 days. She experienced no dysmenorrhoea, no intermenstrual bleeding, no postcoital bleeding, and no dyspareunia. She was not on any hormonal contraception. Her last

Pap smear was done last year and the result was normal. She was not vaccinated for HPV
infection. She had no other gynaecological problem.
Past medical and surgical history
Besides hypertension, hypercholesterolaemia, and diabetes mellitus, she had no other
significant known medical illness. She had a breast lump excision in 2006 and claimed it was
uncomplicated.
Drug history
She was allergic to seafood. Prior to admission, she was on oral methyldopa, oral aspirin,
subcutaneous actrapid and subcutaneous insulatard. She did not take any traditional
medication.
Family history
Her mother was diagnosed to have hypertension and was currently on treatment. Otherwise,
her family history was unsignificant. There was no family history of multiple pregnancy,
genetic disorders, or haematological problems.
Social history
She was a housewife. Her husband worked as an aluminium installer. They were married in
2010 and lived together in Cheras. Both she and her husband were moderate drinkers and
smokers. She stopped smoking and drinking after confirmation of pregnancy by the GP.
Physical examination
On examination she was alert and conscious and lied flat on the bed. She was pink, her
hydration status was fair with good pulse volume at 88 beats per minute in regular rhythm.
Her blood pressure was 119/72 mm Hg and her respiratory rate was 20 breaths per minute.
Her peripheries were warm and the capillary reaction time was less than two seconds. She
was afebrile with a body temperature of 36.9 C.
Abdominal inspection showed a distended abdomen by gravid uterus as evidenced by linea
nigra and striae gravidarum. The umbilicus was inverted and centrally located. Light
palpation revealed a soft abdomen with normal temperature. The uterus was not irritable. The
clinical fundal height corresponds to 38 weeks of gestation and the symphysiofundal height

measured 38 cm. On deep palpation, there was a singleton in longitudinal lie with cephalic
presentation. The foetal back was on the maternal right. The head was not engaged with three
fifths palpable. The liquour was clinically adequate. The estimated foetal weight was 3.0 to
3.2 kg. The foetal heart rate was 128 bpm.
The lungs were clear with vesicular breathing. Cardiovascular examination revealed dual
rhythm and no murmur. All peripheral pulses were felt. Neurological system was intact.
There was no peripheral oedema.
Summary
Mrs L.L.L. was a 33-year old Chinese housewife, a pseudoprimigravida at 38 weeks POA, a
known case of preexisting hypertension and diabetes mellitus type II, admitted for induction
of labour. On examination, there was a singleton in longitudinal lie with cephalic presentation
and the head was not engaged. Liquour was clinically adequate. Otherwise there were no
signs and symptoms of labour, and foetal movements were good.
Differential diagnosis
Based on the history and physical examination, the most probable diagnosis is G2P0+1 at 38
weeks POA with chronic hypertension and preexisting diabetes mellitus, as evidenced by
high episodes of blood pressure in 2010 as well as increased blood pressure before 20 weeks
of pregnancy, and history of preexisting diabetes mellitus on treatment since 2013.
Investigation and management
The patient was admitted to the ward for induction of labour. Cardiotocography (CTG) was
done in the wards and it showed foetal heart rate of 130 beats per minute with good
variability, presence of accelerations and no deceleration. Blood sugar profile, blood pressure,
and symptoms of impending eclampsia were monitored. Hypertensive and diabetic treatments
were continued: she was prescribed subcutaneous actrapid 20/20/22 units, subcutaneous
insulatard 16/22, and tablet methyldopa 250 mg t.d.s.. Aspirin was stopped. Blood was taken
and sent for preeclampsia profile. She was to be induced for labour the next morning.

Discussion
Diabetes mellitus complicates 1-2% of pregnancies (1). Due to effects of pregnancy
hormones such as human placental lactogen, cortisol, glucagon, oestrogen, and progesterone,
pregnancy is a diabetogenic state (1). Therefore, pregnancy can worsen preexisting diabetes if
it is not well controlled (1). Preexisting diabetes can cause maternal hyperglycaemia which
was reflected in this patient whose booking blood sugar was 20.8 mmol/L. High glucose in
maternal blood will cause increased glucose levels in foetal blood, leading to high insulin
production by the foetus (1, 2). Insulin can stimulate growth and cause macrosomia, and
postpartum neonatal hypoglycaemia (1, 2). Poorly controlled diabetes in early pregnancy can
also cause miscarriage or congenital abnormalities (1) therefore it is important to maintain
blood sugar as normal as possible throughout the pregnancy (2), which is a range of 4-6
mmol/L in BSP monitoring. Diabetes mellitus also increases the risk of gestational
hypertension and pre-eclampsia, therefore, given the patient also has chronic hypertension,
this patient was in high risk to develop pre-eclampsia (1, 2). Diabetes also predisposes to
infection such as urinary tract infection, premature birth, and polyhydramnios. Intrauterine
growth restriction (IUGR) and unexplained IUD also have increased risk in diabetes since
diabetes affects vessels and may cause placental insufficiency (1). In terms of management,
NICE guideline recommends immediate treatment of insulin with or without metformin if the
patient has a fasting plasma glucose of 7.0 mmol/L or above, besides change in diet and
exercise (4).
Chronic hypertension affects 3-5% of pregnancies (1). It is defined as blood pressure of
140/90 mm Hg and above taken at two separate occasions at least six hours apart, before 20
weeks period of gestation (3). In our patient, the patient had a history of borderline
hypertension (not on treatment) since 2010 and had an episode of increased BP at 19 weeks
POA with headache, therefore it is preexisting and not gestational hypertension. Patients with
chronic hypertension have a higher risk of developing preeclampsia which can lead to
eclampsia which is life-threatening.
The decision to deliver at 38 weeks was due to the fact that the mother was diabetic on
insulin treatment. NICE guideline recommends that induction of labour should be offered to
patients on insulin treatment at 37 or 38 weeks of gestation (4). Prolonging the pregnancy in
this case may increase the risk of pre-eclampsia due to the presence of diabetes and

hypertension, placental abruption and intra-uterine death, macrosomia that may lead to
difficult labour, and increased incidence of operative or instrumental delivery (1, 2).
Especially since this would be her first child, we should aim for vaginal delivery, and
Caesarean section should be avoided unless indicated.
Reference
1.

Arulkumaran S., Symonds I., Fowlie A. Oxford Handbook of Obstetrics and

Gynaecology (Oxford Medical Publications). Arulkumaran S, Impey L, Hayes K, editors.

New York: Oxford University Press, USA; 2007.
2.

Baker P, Monga A. Obstetrics by Ten Teachers. Clayton SG, etc., editors. New York:

Distributed in the United States of America by Oxford University Press; 2006.

3.

Hypertension in pregnancy | Guidance and guidelines [Internet]. NICE; [cited 2015

May 8]. Available from: https://www.nice.org.uk/guidance/cg107

4.

Diabetes in pregnancy: Management of diabetes and its complications from pre-

conception to the postnatal period | Guidance and guidelines [Internet]. NICE; [cited 2015
May 8]. Available from: https://www.nice.org.uk/guidance/cg63