Pregnancy, Childbirth, & the Puerperium


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/G17_F1.jpg"}},{"insert":"\n\nYou enjoy your work at the obstetric clinic\u2014except for the administrative red tape. Morning rush over, you\u0027re gulping a cup of coffee while trying to fill up some paperwork at the same time. \n\n\u201cDoctor, you\u0027ve got a patient,\u201d your nurse says.\n\n\u201cSend her in,\u201d you reply, setting your coffee aside.\n\nA few moments later, 29-year-old Martha is sitting in front of you.\n"}]}


{"ops":[{"insert":"Martha is currently at 26 weeks of gestation of her first pregnancy. You first saw her two weeks ago\u2014she\u0027d moved cities, and needed a new obstetrician. Her pregnancy has been without issues. She has been in excellent health for the whole of her life, with unremarkable medical, surgical, gynecological, and obstetric histories. She is not on any medications or supplements currently.\n\nMartha is in today to review the results of her fetal morphology ultrasound scan and second-trimester screening for diabetes mellitus. The fetal ultrasound shows nothing untoward. However, the screening non-fasting 50g oral glucose challenge test (OGCT) is 146 mg\/dL (normal: \u003C140 mg\/dL). You recall that first trimester screening for diabetes mellitus was negative.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/G17_F3.jpg"}},{"insert":"\n\n\u201cHow do my results look, doctor?\u201d Martha asks.\n\nYou explain that her OGCT was positive, and that you\u0027ll need to evaluate her further. Martha anxiously asks several questions which you proceed to answer. \n"}]}


{"ops":[{"insert":"You feel uneasy, and decide to take a look at your medical reference. Half a minute later, you realize which investigation you should order next.\n"}]}


{"ops":[{"insert":"You decide to order an oral glucose challenge test (OGTT). A short while later, Martha takes your leave, prescription in hand.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/G17_F7.jpg"}},{"insert":"\n\nThe following day, Martha is back with the results of the OGTT. These are as follows:\n\nFasting (at 0 hours): 107 mg\/dL (\u003C95)\nAt 1 hour: 175 mg\/dL (\u003C180)\nAt 2 hours: 165 mg\/dL (\u003C155)\n"}]}


{"ops":[{"insert":"You put the investigation results aside.\n\nWhich of the following diagnoses are you thinking of?\n"}]}
1. Preexisting diabetes
2. Gestational diabetes mellitus
3. Gestational impaired glucose tolerance


{"ops":[{"insert":"You contemplate if this might be preexisting diabetes, but then discard the idea.\n"}]}


{"ops":[{"insert":"You consider if this might be gestational impaired glucose tolerance, but then realize that Martha meets the diagnostic criteria for gestational diabetes mellitus (GDM).\n"}]}


{"ops":[{"insert":"You realize that Martha now meets the diagnostic criteria for gestational diabetes mellitus (GDM).\n"}]}


{"ops":[{"insert":"You proceed to carefully brief Martha about her condition, paying attention to the importance of lifestyle changes, such as exercise and dietary modifications. You ask her to return in two weeks for a follow-up.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/G17_F13.jpg"}},{"insert":"\n\nTwo weeks pass. Martha is back for her appointment. She has also brought along the repeat OGTT results. These are as follows:\n\nFasting (at 0 hours): 90 mg\/dL (\u003C95)\nAt 1 hour: 131 mg\/dL (\u003C180)\nAt 2 hours: 117 mg\/dL (\u003C155)\n\n\u201cThis is great, Martha,\u201d you tell her, conveying the good news.\n"}]}


{"ops":[{"insert":"\u201cDoctor, does this mean that I\u0027m a diabetic? Will I need to be treated forever?\u201d Martha asks.\n\nHow will you respond?\n"}]}
1. “No, this is temporary. It should resolve after delivery.”
2. “I can't say. This may or may not resolve after delivery.”
3. “Yes, this is true. You'll need lifelong treatment.”


{"ops":[{"insert":"You are about to reply in the affirmative, when you realize that you\u0027re about make a mistake. Shaking your head slightly, you start over.\n"}]}


{"ops":[{"insert":"You are about to reply in the negative, when you realize that the reality is more nuanced. Shaking your head slightly, you start over.\n"}]}


{"ops":[{"insert":"You explain that GDM may or may not resolve following delivery. Martha intently listens to you, and nods in understanding\n"}]}


{"ops":[{"insert":"Consultation over, Martha thanks you for all your help and makes her way out. She\u0027ll continue to need your help both during this pregnancy and afterwards. But for now:\n\nWell done!\n"}]}

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