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CLINICAL CASE STUDY: Gestational Diabetes

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on 6 May 2014

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Transcript of CLINICAL CASE STUDY: Gestational Diabetes

CLINICAL CASE STUDY: Gestational Diabetes
Patient Information
Name: Julia Hargrove
Age: 39 years old



Occupation: Curator
Education: A Bachelor of Science Degree in History
Living Facilities: A three bedroom house in Grogee, Virginia
Patient Information
Ethnic Origin: African-American
Sex: Female


Family: Mother and Aunt
Husband (married 9 yrs)
An infant son


The patient walks to and from work each day.
Review of Literature
Crowther, C. A., Hiller, J. E., Moss, J. R., McPhee, A. J., Jeffries, W. S., & Robinson, J. S. (2005). Effect Of Treatment Of Gestational Diabetes Mellitus On Pregnancy Outcomes. New England Journal of Medicine, 352(24), 2477-2486. Retrieved April 21, 2014, from http://dx.doi.org/10.1056/NEJMoa042973
What is Gestational Diabetes?
Gestational diabetes is a condition characterized by high blood sugar levels. This is typically recognized during pregnancies whereas approx. 4% of pregnant women have gestational diabetes.
Reason for Admission
The patient was seen for her routine obstetric care. While at the health center she shared that she had been feeling sick in the afternoons and often times she struggled in keeping food down.


The patient also has a growing concern for the amount of weight that she is gaining.
Medical History
During the patient's first pregnancy her child weighed 8.4 pounds. The patient did not obtain gestational diabetes, but did struggle to lose weight after giving birth.



Family history:
Patient has a history of type II diabetes (aunt)
Patient's mother passed of myocardial infarction
Patient does not know any other family members


Nutritional History
24 hour recall and recall of typical day was requested from patient
Clinical Chemistry
Glycosylated haemoglobin (HbA1c) 40mmol/mol
Ketone body Negative
Anti-glutamic acid decarboxylase Negative
Low –density lipoprotein 80 mg/dl
High-density lipoprotein 79 mg/dl
Triglycerides 58 mg/dl
Total cholesterol 128 mg/dl
Fasting plasma glucose 104.4 mg/dl
Blood pressure (systolic/diastolic) 118/70 mmHg

Fasting Plasma Glucose
Measures blood sugar levels.

Results 70-100 mg/dl is normal range

Results 100-125 mg/dl indicates pre-diabetes

Results over 126 mg/dl indicates diabetes




The patients FPG level is 104.4 mg/dl
Now what...?
Drug and Nutrient Interactions
Name




Insulin









Metformin
Nutritional Assessment
Recommended Diet
Review of Literature
Kim, C., Newton, K. M., & Knopp, R. H. (2009). Gestational Diabetes And The Incidence Of Type 2 Diabetes: A Systematic Review . Diabetes Care, 25(10), 1862-1868. Retrieved April 22, 2014, from the Diabetes Journal database.
A risk factor of have GDM is developing type II diabetes after birth. Professors at Univ. of Michigan conducted a study to indicate the incidence of type II diabetes in gestational diabetes patients.
Select patients were selected to receive dietary advice, blood glucose monitoring and insulin therapy. These woman were compared to other patients who were receiving such care. End results indicated that trial patients had better perinatal outcomes.
Review of Literature
Ben-Haroush, A., Yogev, Y., & Hod, M. (2004). Epidemiology Of Gestational Diabetes Mellitus And Its Association With Type 2 Diabetes. Diabetic Medicine, 21(2), 103-113. Retrieved April 21, 2014, from http://dx.doi.org/10.1046/j.1464-5491.2003.00985.x
24 hour recall

Breakfast

muffin and bottle and water,
Lunch

Chicken salad and crackers
Dinner

Meatloaf, cabbage and white rice.

Snacks

A pack of peanuts, a bag handful of dehydrated bananas and a zip lock bag of cheerios.

4 bottles of water
Typical Day

Breakfast
Starbucks sandwich and a caramel mocha latte with an extra shot of caffeine
Lunch
A package of crackers, some sort of fruit and a peanut butter sandwich, that was pre-made at home.
Dinner
The items served at dinner is vary dependent of what her four year old son likes to eat. Usually finger foods, fast food and nothing orange or green.

Lots of water
The patient will be placed on tighter diet restrictions and have to increase the amount of exercise. If these preliminary steps do not work then the patient may be put on insulin or other medications.
Effect

Glucose-Insulin Interaction exhibit
hypoglycemia or hyperglycemia based on glucose tolerance testing. Morbidly obese persons. With abnormal Glucose-Insulin Interaction may indicate insulin resistance. A deficiency may induce fatigue, headaches, nausea, disorientation, dizziness, cold hands and feet,glucose intolerance.


May cause risk of B12 deficiency. If deficiency goes untreated then can cause nerve damage leading to inability to walk. Liver stores B12. Liver Acidosis

Weight: 152.1 pounds
Height: 5 ft 1 in

So far the patient has gained 17.6 lbs during course of pregnancy (Avg range is 16-22 pounds)

Pre-pregnancy BMI is 28.4 kg/m2. This indicates that patient was overweight.
5 servings of fresh fruits and vegetables (including at least one serving of a dark orange vegetable, two servings of dark green leafy vegetables, and one serving of
citrus fruit
)

6 servings of enriched, whole-grain breads and cereals

3 servings of nonfat or low-fat milk or milk products

2-3 servings of extra-lean meats, chicken without the skin, fish, or cooked dried beans and peas

8 glasses of water

Exercise
Walk more. Up to 20 minutes per day including the route to work
Immediate Recommendations
Try to allow her child to help her prepare meals.

Pre-pack salads for work

Replace all snack foods with fresh fruit

For breakfast trips to Starbucks, cut having coffee to two to three times a week.

Fast food should be eaten at minimum twice a week

Try to take the long route to work increasing the time to five or plus minutes.
Nutrient Needs for Pregnant women
Folic acid 400 to 800 micrograms (mcg) (0.4 to 0.8 mg) in the early stages of pregnancy

Iron 27 milligrams (mg)

Calcium 1,000 milligrams (mg);

Vitamin A 770 micrograms (mcg); 750 mcg

Vitamin B12 2.6 micrograms (mcg)

To improve your health, how ready/willing are you to…
1 2 3 4 5

Significantly modify your diet
Take nutritional supplements each day
Keep a record of everything you eat each day
Modify your lifestyle (ex: work demands, sleep habits, physical activity) Practice relaxation
techniques
Engage in regular exercise/physical activity
Have periodic lab tests to assess your progress

Lytic Scale
ADIME
A: Assessment
Obtained clinical chemistry lab values. Nutrition related problems were the fpg levels in relation to the development of gestational diabetes.
D: Diagnosis
The fgp level of 10.4 mg/dl indicated a pre-diabetic state for the patient. Nutrition intervention in the form of developing a nutritional plan was implemented.
I: Intervention
A diet plan tailored to the patient's needs was developed in efforts to not cause the development of type II diabetes, preterm labor or other serious problems. If diet and excersice do not work then the patient will have to use drugs (insulin or metformin)
M: Monitoring
Determine if any progress was made by rechecking blood glucose levels at checkups.
E: Evaluation
Determine if plan is being followed and if predicted nutritional/health related outcomes are met. The overall goal is to rid the patient of GDM.
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