Week 4:Case Scenario 2
Table 1
1-hour Oral Glucose Tolerance Test (OGTT) After a 50-g oral glucose load in pregnant women
Normal Range (Negative)
Abnormal range (Positive)
1 hr
<140 >/=140
Table 2
Criteria for Abnormal Result on 100-g, 3-Hour Oral Glucose Tolerance Test in Pregnant Women
Blood Sample
National Diabetes Data Group Criteria
Carpenter and Coustan Criteria
Fasting
105
95
1 hr
190
180
2 hr
165
155
3 hr
145
140
What defines a positive 3 hr gtt result (failed result)? In order to determine a positive result, at least 2 levels must be greater than or equal to the thresholds listed. All thresholds presented as mg/dL (Gonzalez-Gonzalez. Et al., 2022).
Table 3
Define and differentiate between the following Postpartum disorders:
Definition
Signs and symptoms
Management of the Diagnosis
Postpartum Blues
Symptoms of overwhelming sadness, mood swings, uncontrollable crying and irritability that occurs postpartum but resolves within two weeks (Jordan, 2018).
Overwhelming sadness, weepiness, irritability and depressive thoughts occurring after birth for up to two weeks (Jordan, 2018).
Postpartum blues generally resolves spontaneously. Allowing adequate time for sleep and asking other family members to help to ease the overwhelming feelings and fatigue for the patient. If symptoms persist beyond two weeks or any suicidal ideation is suspected, the patient should be evaluated for postpartum depression (Epocrates, 2024).
Postpartum Depression
Severe symptoms of depression occurring within the first year after childbirth that meets standard diagnostic criteria and persists for more than 2 weeks (Jordan, 2018).
DSM-5 criteria is met with major depression with permpartum onset.Insomnia, changes in appetite, energy and feelings of depression lasting longer than two weeks are symptoms of this disorder (Epocrates, 2024)
For mild to moderate cases psychotherapy is the initial treatment. This is important for lactating patients. SSRIs like bupropion and mirtazapine are appropriate when psychotherapy is unseuccessful. CBT helps to modify dysfunctional thoughts. Close monitoring is essential for these patients (Epocrates, 2024).
Postpartum Obsessive Compulsive Disorder
An overestimation of inherent threat or risk and an intolerance of uncertainty (Epocrates, 2024).
Exaggerated behaviors such as excessive handwashing used to try to control thoughts (Epocrates, 2024).
CBT is the first line of treatment during pregnancy and the post part period. SSRIs may be prescribed with careful consideration of breastfeeding mothers and treatment for the mother may be of higher importance  (Epocrates, 2024).
Postpartum Psychosis
Delusions that result in a psychotic break that occurs within the first year after giving birth (Jordan, 2018).
Hallucinations, bizarre behavior, severe insomnia and a manic or depressed mood may require hospitalization (Epocrates, 2024).
The initial treatment is ensuring the safety of the mother and baby. Hospitalization for the mother and finding a caregiver to care for the child is paramount. An antipsychotic an lithium are usually the preferred treatment to stabilize the patient. Adjunctive psychotherapy is recommended once the patient’s symptoms are stabilized (Epocrates, 2024).
Table 4
Definition
Presentation (include Signs and Symptoms)
Management of the Diagnosis
Puerperal Fever
Postpartum infection with a fever greater than 100.4 °F of the breasts, uterus, cervix, ovaries, fallopian tubes, vagina, or cesarean section incision (Jordan, 2018).
Fever, chills, foul smelling discharge, uterine tenderness, tachycardia, headache, temperature>100.4 F, and midline abdominal pain are all symptoms (Epocrates, 2024).
IV antibiotics Clindamycin 900 mg IV q 8 hrs and Gentamicin 5 mg/kg q 24 hours. Ampicillin 2 g IV q 6 hours may also be indicated if no favorable response occurs after 24-48 hours with the Clindamycin and Gentamicin (Epocrates, 2024).
Postpartum Hematoma
Postpartum hematomas are a form of postpartum hemorrhage caused are produced by an accumulation of hematic material in the connective tissue near the vagina, cervix, or parametrium in response to a vascular injury (RedondoVillatora et al., 2022).
Painful swelling in the  perineum/ vagina and  vulva resulting in a bulge with purplish discoloration as a result of a tear or trauma during delivery (redondo Villatora, 2023).
Ice packs should be applied to the perineum for the first 24 hours to minimize swelling. Non-Narcotic analgesia should be administered to ease pain for breastfeeding mothers. Surgical evacuation may be indicated to evacuate large hematomas (Epocrates, 2024).
Secondary (delayed) Postpartum Hemorrhage
(SPPH) is defined as significant vaginal bleeding occurring between 24 hours after placental delivery and within 12 weeks postpartum (Chainarong, 2022).
SPPH presents with sudden significant uterine bleeding that may due to retained products of conception (Chainarong, 2023).
First responders may administer transexamic acid to stop the bleeding and transport to the hospital.  NASG may be used to prevent hypovolemic shock. Patient must be stabilized and the origin of bleeding must be identified and stopped with  pelvic CTA or MR/MRA to identify vascular abnormalities. A balloon tamponade may assists with stopping the bleeding while tests are performed. Surgical procedures such as dilation and curettage may be performed (Epocrates, 2024).
Sore Nipples
Can be a result of poor latching technique with breastfeeding, or a candida infection (Epocrates, 2024).
Sore or cracked nipples with poor latching and/ or sharp shooting pain caused by Candida (Epocrates, 2024).
Position baby so the nipple rests comfortably against the soft palate at the back of their mouth. Change breast pads at each feed, wear a cotton pad to let air circulate. For Thrush/Candida infections of the breast use a topical miconazole 10% or clotrimazole anti fungal cream (Epocrates, 2024).
Mastitis
Breast infection caused by S. Aureus occurring most commonly in lactating women (Epocrates, 2024).
Present as firm, red, and tender area of the breast with erythema and pain. Flu like symptoms may also present (Epocrates, 2024).
In milder cases caught within 12 -24 hours acetaminophen 325-100 mg q4-6 hrs and cold compresses may help with milk expression. In more severe cases, antibiotic therapy dicloxacillin 250-500 mg PO q 6 hours for 10-14 days (Epocrates, 2024).
Breast Abscess
This is caused by a localized collection of pus in the breast tissue and often caused by S. Aureus (Epocrates, 2024.
Painful, swollen, mass in breast (Epocrates, 2024).
Breast abscess requires the removal of pus through incision and drainage and antibiotic therapy (Epocrates, 2024).
Jennifer is a G2P1, 31-year-old pregnant female at 24 weeks EGA who has come to the clinic for her 24-week prenatal visit and recommended screening tests.  Jennifer’s one-hour glucose test result is 156 mg/DL.  Her BP is 118/78 T 98.7 F, P 68, RR 18, fundal height is 25 cm, no protein in the urine, weight is 145 lbs at 5 lbs increased from the last visit 4 weeks ago, her height is 5’ 5”.
SUBJECTIVE
Chief Complaint: The patient is concerned about failing her one-hour glucose test and would like to know what she can do to manage her glucose levels and prevent pregnancy complications.
History of Present Illness: (OB/GYN History: (G2P1A0L1) LMP 10/2023. Before this pregnancy, the patient reported her menses as being regular with onset at 13 years of age. The patient reports her first pregnancy as “uncomplicated” with a vaginal delivery at 39 weeks. The patient’s last PAP was on 12/21/2023 with normal results. Mammogram N/A.
Sexual History: The patient reports being in a monogamous relationship with her male partner of 6 years. The patient denies any history of STIs, denies IPV, and reports feeling safe at home. The patient reports having 3 sexual partners before her husband.
PMH: No medical conditions were reported by the patient.
PSH: No previous surgical history was reported by the patient.
Immunization Status: The patient is up to date with all of her MMR, Hep B, Varicella, COVID-19, HPV, Influenza, and TDAP vaccinations with no history of any reactions.
Medications: No prescribed or OTC medications.
Allergies: NKDA
Family History: 
Paternal Grandfather: deceased at 86, cardiovascular disease.
Paternal Grandmother: deceased at 84, no medical conditions.
Maternal Grandfather: deceased at 91, DM II.
Maternal; Grandmother: deceased at 87, hypertension.
Father: Age 56, hypertension.
Mother: Age 52, no medical conditions. 
Social History: The patient denies tobacco, drug, and alcohol use. The patient lives with her husband and their daughter age 4 in a two-bedroom apartment and is a stay-at-home mother.
ROS
General/Constitutional: The patient denies having a fever, chills, or unintentional weight loss or gain.
Cardiovascular: The patient denies any shortness of breath, chest pain, or heart palpitations. 
Respiratory: The patient reports no difficulty breathing, and no cough. 
Gastrointestinal: The patient reports regular bowel movements occurring every other day with occasional constipation that is relieved with Senna herbal tea. 
Endocrine:(+) The patient reports increased urination at night, frequency, and thirst. The patient denies an intolerance to cold or dizziness. 
Reproductive/ Genitourinary: The patient reports no dysuria, abnormal bleeding, malodorous or abnormal discharge, no pelvic pain, and regular fetal movement especially when she is at rest. 
Neurological: The patient denies any difficulty with memory, balance, or visual changes.
OBJECTIVE
PHYSICAL EXAM
GENERAL/CONSTITUTIONAL: The patient is afebrile, well-nourished, and in no acute distress.
VITAL SIGNS: Temp: 98.7 F, BP: 118/78, HR: 80, RR: 16, O2 Saturation: 98%, Weight: 145 Height: 5’5” BMI: 24.1 (healthy weight)
Cardiovascular: Regular rate and rhythm. No thrills or bruits. No JVD and no edema. 
Respiratory: The lungs are clear to auscultation bilaterally with normal vesicular sounds. 
Endocrine: Negative ketones in urine noted. No signs or symptoms of high or low blood sugar were observed.
Gastrointestinal: No abdominal guarding, tenderness, or distention was noted.
Reproductive/Genitourinary: EGA 24 weeks, fundus measuring 25 cm. Abdomen soft, protuberant and non-tender. No abnormal or malodorous vaginal discharge, no abnormal bleeding. No CVA tenderness.
Neurological: Cranial nerves intact. No cognitive impairment or neurological abnormalities were noted.
Assessment/Diagnosis: 
Primary Diagnosis:
024.419 A2 Gestational Diabetes Mellitus in pregnancy is estimated that 7% of pregnancies are complicated by GDM during pregnancy due to insulin antagonism caused by placental hormones leading to carbohydrate intolerance (Qunitanilla-Rodriguez, 2023). It is determined that the patient has A2 GDM and needs insulin medications to control blood glucose, if she makes diet and lifestyle modifications, but fails the three-hour glucose test and has an AIC >6.0% (Qunitanilla-Rodriguez, 2023).
DDX:
024.419 A1 GDM Diet-controlled gestational diabetes- Gestational diabetes occurs during pregnancy due to pancreatic beta cell dysfunction causing carbohydrate intolerance that can be well-controlled with a restricted diet and lifestyle modifications (Quintanilla-Rodriguez et al., 2023). The patient failed the one-hour glucose test and hadn’t implemented diet and lifestyle modifications before taking the 1-hour glucose test. 
O40 Polyhydraminos- An excessive buildup of increased amniotic fluid that surrounds the baby in the uterus occurring in 1-2% of pregnancies and may increase the fundal height measurements (Cash, 2024). The patient is measuring only 1 cm larger than her EGA of 24 weeks (Fantasia et al., 2021).
PLAN
DIAGNOSTIC LABS: HA1C, TSH, Free T4, CBC, and CMP to assess for underlying metabolic or endocrine disorders. Urine dipstick for ketones and urine analysis for UTI (Fantasia et al., 2021). AIC should be <6%. Perform a 3-hour fasting OGTT and draw fasting glucose before administering a 100 g glucose load. An additional test is necessary with a 100-g, 3-hour oral glucose tolerance test if the values for the first hour are over 180 mg/dL, the second hour is over 155 mg/dL,  or the third hour is more than 140 mg/dL. The presence of two or more abnormal results establishes the diagnosis of gestational diabetes (Quintanilla-Rodriguez, 2023). A nutritional consult is necessary. Serial ultrasonography to analyze and monitor fetal growth, and weight, and assess for polyhydraminos at 28, 32, and 36 weeks. Macrosomia is the leading risk factor for shoulder dystocia for infants of mothers with GDM during a vaginal delivery (Cash, 2024). PHARMACOLOGIC: Humulin (human) Insulin therapy is the preferred medication therapy for managing GDM and may be indicated if it is determined the patient fails the 3-hour OGTT with dietary and lifestyle modifications. A typical starting dose during pregnancy is 0.7 to 1.0 units/kg d in four divided doses based on current pregnancy weight. (Fantasia et al., 2021). In this case, this would equate to 46 to 68 units of Humulin Insulin in four divided doses ranging from 12.5-17 units at breakfast, lunch, dinner, and bedtime based on blood glucose test results. The ACOG and ADA prefer the use of insulin regimens for the management of diabetes during pregnancy but have endorsed the use of oral anti-hyperglycemic agents such as metformin and glyburide under specific circumstances based on limited data (Sandu et al., 2020). Metformin should be avoided when a patient has hypertension, preeclampsia, or is at risk for lower intrauterine growth  Glyburide is a sulfonylurea or insulin alternative that may be started at o 2.5?mg before breakfast and 2.5?mg before the evening meal. Doses can be increased as needed up to 5?mg in the morning and 5?mg in the evening for a total daily dose that does not usually exceed 10?mg/day as long as blood glucose levels improve in one week. Levels that don’t improve within one week of therapy may require insulin administration (Jordan, 2018). Risks of Insulin therapy or antihyperglycemic medications include hypoglycemia which may require the emergency administration of Glucagon. Benefits of treatment include preventing the risks of DM II in mother, preterm labor, macrosomia, cervical dystonia, and hypoglycemia in the newborn. NON-PHARMACOLOGIC: Order a Nutrition consult for dietary modifications to control glucose levels and reduce perinatal complications. The ADA recommends that pregnant women with a normal BMI (BMI, 18.5-24.9 kg/m2) should reasonably take in 30 kcal/kg/day (Sandu et al., 2021). The recommended weight gain during pregnancy for women with a BMI of 18.5–24.9 is 11 to 16 kg (Jordan et al., 2018). Encourage exercise practices such as walking or swimming for 30 minutes each day, 5 days a week. The patient should limit carbohydrate intake, self-monitor, test, and record glucose levels four times a day, fasting, and two hours after meals. Exercise lowers your blood sugar so have 15-gram glucose tablets and/or skim milk on hand in case of a hypoglycemic episode (Cash, 2024). PATIENT EDUCATION: Having GDM and uncontrolled blood glucose levels can result in your baby gaining too much weight, which increases your risks for restricted intrauterine growth, pre-term delivery, and having an emergency C-section. It may also cause complications such as low blood sugar for your baby at birth, cervical dystonia, jaundice, and childhood obesity (Sandu et al., 2020). You will need to test and record your blood glucose first thing in the morning, before and after lunch, before and after dinner, and possibly at bedtime. Your insulin needs may change throughout your pregnancy due to pregnancy hormones. Insulin therapy is safe for your baby and does not cross the placenta like sugar does.  and your insulin dosage may change weekly. The goal of your fasting blood sugar before breakfast is below  95 mg/dL. Your blood glucose goals before meals and 2 hours after meals are>120 mg/dL. Your blood glucose should stay at or below 60 mg/dL throughout the night. If your blood glucose is greater than 150 mg/dL, you need to test your urine for ketones. If you have diarrhea, have a UTI, or have any kind of illness or infection or if you are unable to eat you need to test for ketones. You will need to be seen twice a week from 32 weeks gestation to delivery or as recommended by your healthcare provider (Fantasia et al, 2021). Self-monitor for signs of hypoglycemia and hypoglycemia. Signs of hypoglycemia include excessive sweating, feeling faint, headache vision changes, irritability, hunger, and lethargy. Always carry emergency glucagon with you and let family and friends know you are diabetic. Signs of hyperglycemia include increased thirst, urinary frequency, blood, ketones or sugar in your urine, labored breathing, fruity breath, nausea, and vomiting. You must notify your health care provider if you have moderate or large ketones in your urine, you have any signs of infection, you are unable to eat or have diarrhea, your blood glucose is below 50 mg/dL and you feel hypoglycemia symptoms, or if your blood sugar is greater than 175 mg/dL for two consecutive readings (Cash, 2024). CALL 911 and seek emergency treatment if you have abnormal vaginal bleeding or experience reduced fetal movement (Cash, 2024).