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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

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  1. Case Presentation Obstestrics 성균관대학교 의과대학 m5 손의영 Pt ID : 10755559 김0경 30/F

  2. Chief Complain • Amenorrhea for 38 + 3weeks with decreased Fetal movement (NST non-reactive) • Onset : 2011-06-13

  3. Obstetric History • Para : (1) - (0) - (0)(,) - (1)(0,1) • 최종 월경 시작일 : 2010-09-17 • 분만 예정일 : 2011-06-24

  4. 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 OGTT (26+3wks) • ▲146 mg/dL • 11-04-09 100g OGTT (29+1wks) • ( 78 - ▲220 - ▲214 - 144 ) mg/dL • CBC : 특이사항 (No)

  5. Other History • PMHx. • HTN/DM/Tb/hepatitis/Allergy ( - / - / - / - / - ) • Prev. GDM (이전 임신시27주경 진단) • 약물력 : 엽산제, Oral iron, glibenclamide 2.5mg/d for 1 wk • 수술력: (No) • FHx. • 당뇨 : (+), 모친 • 고혈압 (-), 유전질환 (-) • SHx. • Marriage : 기혼 (26세) • smoking: no • alcohol: no

  6. 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

  7. Physical Exam • General appearance • Not so ill looking • Mental status : Alert • Abdomen • Palpitation : Distended d/t pregnancy • Tenderness (No) • Rebound tenderness (No)

  8. 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)

  9. Assessment • Pregnancy: 38 + 3 weeks • c decreased FM (NST non-reactive) • c GDM • c prev. GDM

  10. Plan • 치료계획: Intravenous Pitocin(Propess insertion 하지 않고 익일 pitocin start하여 induction) • 퇴원계획: 자연분만 후 합병증 없으면 PP#2 퇴원

  11. Hospital Course • 2011-06-14 분만 (38 + 4 weeks) • 분만 시간 : 11:18 • Induction (Yes) • Prostaglandin (No) • Dinoprostone (No) • Misoprostol (No) • Oxytocin (Yes) • Baby

  12. Hospital Course • 2011-06-15 PP#1【검사명】 【단위】 【시행일】 【결과】------------------------------------------------------------Hb, Blood g/dL 2011-06-13 17:07 ▼10.8 2011-06-15 07:38 ▼10.8------------------------------------------------------------ Dressing done : episiotomy site clear, no hematoma익일 퇴원 예정

  13. 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!

  14. Gestational Diabetes

  15. 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.

  16. 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

  17. 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

  18. GDM – Complications • Fetal Effects • Abortion • Malformation • Hydramnios • Respiratory distress • Hypoglycemia • Hypocalcemia • Hyperbilirubinemia • Cardiac hypertrophy • Macrosomia

  19. 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 있으면 L/S ratio < 2이어도 분만

  20. References • Williams Obstetrics, 23rd Edition

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