CASE 02

Name :
Age : 36 years
House Wife
From:
In her 3rd pregnancy
Known patient with type 2 diabetes
mellitus
Admitted due to back pain and lower
abdominal pain for 3 days
at 36wks of POA

Past Obs History

1st pregnancy (2005)
By a NVD, at term (39 weeks)
Birth weight 2.960 Kg
No maternal or fetal complications
Currently : 8 year old boy

Type 2 DM diagnosed in 2007 (7 years ago)

Was on,
Metformin 500mg b.d
Glibenclamide 5mg b.d

2nd pregnancy (2008)

By a NVD at term (39 weeks)
Birth weight 3.690 Kg
Antenatal period was complicated with
type 2 DM
Insulin from the onset of pregnancy up to
delivery
Baby was in NICU for 3 days for
monitoring
6 years old girl
Diagnosed with Hypothyroidism in 2013
and has been on thyroxin since then

Current Pregnancy
Not a planned pregnancy
Was not on preconception folic acid
It was confirmed by a urine dip test on 7 th week
of POA due to absence of periods for 3 weeks.
LMP on 3rd December 2013
She is sure of the dates.
She had regular menstrual cycle of 28 days,
bleeding lasted for 3 days.
She was not on any hormonal contraceptive
methods.
Therefor EDD is on 10th September 2014 and
POA 36 weeks

At conception,
She was on Metformin 500mg b.d
and glibenclamide 5mg b.d until 7th
week
Thereafter Insulin aspart
Not sure if DM was under control at
the time of conception
Has had eye referral

1st Trimester
Booking visit was on 12th week of POA
Booking investigations done
FBC
PPBS
Normal
VDRL
UFR
Blood group A+
No complications such as bleeding PV,
febrile illnesses or excessive pregnancy
symptoms.
Dating scan was not done
Was on 10 units of Insulin aspart t.d.s

2nd Trimester
Has started iron and calcium
supplements
after 12th week
Had felt quickening around 18th week
of POA
Anomaly scan at 22nd week no
abnormalities detected
Has had tetanus toxoid but not
worm treatment
Several BSS done higher values

3rd Trimester
2nd USS scan was done at 29th week no
abnormalities detected. Growth was adequate.
At 31 weeks admitted to NFTH with lower
abdominal pain and for blood sugar control
Ix
16th Jul
17th July(bfast)
17th (lunch)
PPBS
350 mg/dl
241 mg/dl
224 mg/dl
(breakfast)
UFR NAD
FBS 166 mg/dl (74-100mg/dl)
TSH 2.01 IU/ml (0.34-5.60 IU/ml)
T3 2.80 pg/ml(2.5-3.9 pg/ml)
T4 0.64ng/dl (0.58-1.64 ng/ml)

Managed with:
IM Dexamethasone 6 mg b.d 12 hourly 4
doses
Nifedipine SR 20 mg b.d
Thyroxine 75 mcg/daily
Currently she is on
Insulin aspart 28 U (mane)
28 U (day)
24 U (nocte)
Metformin 500 mg t.d.s

Currently,
Back pain radiating to lower abdomen
No associated symptoms such as fever,
vomiting or headache
No signs of mucoid vaginal bleeding or
dribbling
No urinary symptoms (dysuria,
frequency)
No constipation
She has been regularly followed up and
her BP was normal throughout

 Past Medical History

Type 2 DM for 7 years
Hypothyroidism for 1 year
Past Surgical History
Allergic History

NAD

Drug History
She is on drugs for DM
Thyroxine 75 mcg/day
Family History
Both her parents have DM, HT , dyslipidemia & IHD
No Thyroid Diseases

Social History
Her husband is 36 years old Accountant
Non smoker and non alcoholic
They live with her parents
Has good family support
She stores insulin in the refrigerator door
Administers insulin on her own to her
thigh
She is aware of hypoglycaemic symptoms
Her educational level is upto O/Ls

Examination

General examination
Height: 1.66m
Weight: 57kg
BMI: 20.6 kg/(m*m)
Not pale
No thyroid enlargement
No oedema

Cardio Vascular System examination

PR : 72 b.p.m. Regular rhythm,
normal volume
Peripheral pulses were present
BP 120/70 mmHg
No scars on the chest, no deformities
Apical beat 5th ICS mid clavicular line
1st and 2nd Heart sounds were audible.
No murmurs or thrills

Respiratory System examination

RR- 16 / min
Trachea central, symmetrical chest
expansion
Vocal fremitus normal
Resonant lung fields
Vesicular breathing heard without
any added sounds

Abdominal examination

Abdomen symmetrically enlarged

Linea nigra and striae gravidarum present
Hernial orifices intact
SFH 36cm, compatible with POA
Single fetus
Cephalic presentation. Head 3/5 th palpable
abdominally
Longitudinal lie, Right OA position
Adequate liquor volume
Approximate size 3.0 kg
No Contractions felt

Summary
A 36 year old mother of two presented with back
pain and lower abdominal pain for 3 days duration at
36 weeks of POA.
She is a known type 2 Diabetic and a hypothyroidic
who is currently on insulin (28 units mane and noon,
24 units at night with Metformin 500mg b.d) and
thyroxin(75microg).
Frist pregnancy uneventful.
2nd pregnancy with type two diabetes mellitus.
However had no complications
General and systemic examination was uneventful
Abdominal ex: single live fetus, cephalic
presentation in longitudinal lie at right OA position.
Adequate liquor volume with an approximate size of

Problem list
Diabetes Mellitus complicating
pregnancy
Known hypothyroidic patient
Development of abdominal pain at
36 weeks

Management
Investigations
USS 36 weeks no abnormality
BSS after breakfast, lunch, dinner
UFR

Treatment
Betamethasone 12 mg 24 hourly (2 doses)
Thyroxine
75 mcg/daily
Insulin s/c
28 U (mane)
28 U (day)
24 U (nocte)

Thank you!