Table 1
1-hour Oral Glucose Tolerance Test (OGTT) After a 50-g oral glucose load in pregnant women
Table 2
Criteria for Abnormal Result on 100-g, 3-Hour Oral Glucose Tolerance Test in Pregnant Women
Table 3
Define and differentiate between the following Postpartum Disorders:
Normal Range (Negative) Abnormal Range (Positive)
1 hour < 140 mg/dL 130 – 140 mg/dL
Blood Sample National Diabetes Data Group Criteria
Carpenter and Coustan Criteria
Fasting 105 mg/dL 95 mg/dL
1 hour 190 mg/dL 180 mg/dL
2 hours 165 mg/dL 155 mg/dL
3 hours 145 mg/dL 140 mg/dL
What defines a positive 3-hour glucose tolerance test result (failed result)? Two or more threshold glucose levels on the 3-hour test must be met or exceeded.
Definition Signs and Symptoms
Management of the Diagnosis
Postpartum Blues
Short-lived mood change
Sadness, weepiness, mood swings, irritability that occurs in the first few days to 10 days postpartum; lasts less than two weeks
Family support, uninterrupted rest, exercise, adequate fluids, nutritious meals
Table 4
Postpartum Depression
Depression occurring within the first year postpartum that meets standard diagnostic criteria; lasts longer than two years
Crying, feeling sad, overwhelmed, lack of interest in daily activities, lack of interest in infant, feeling sub- inadequacy
Home support, therapy
Postpartum Obsessive- Compulsive Disorder
Need to perform repetitive physical or mental actions
Onslaught of intrusive thoughts or rituals SSRIs and CBT
Postpartum Psychosis
Psychotic episode (delusions or break with reality) occurring within the first year after birth
Auditory and visual hallucinations, various unexplained behaviors, i.e. smelling smoke
Immediate care i.e. emergency room
Definition
Presentation
(include Signs and Symptoms)
Management of the Diagnosis
Puerperal Fever
Temp. 100.4 F or greater during
postpartum period caused by bacterial infection in the reproductive tract or breasts
Genital tract or wound infections
breast engorgement, dehydration, DVT
CBC w/ diff, urine analysis, cultures, radiology and/or ultrasound.
Antimicrobial therapy
Postpartum Hematoma
Collection of blood in the vaginal, perineal, pelvic, or abdominal tissue, post childbirth
Evidence of blood loss:
Decrease hematocrit
Severe perineal and/or rectal pain
Management varies on size.
Small hematomas can reabsorb; moderate to large hematomas may need I&D
Secondary (delayed) Postpartum Hemorrhage
Excessive bleeding that occurs between 24 hours after birth until six weeks postpartum
Hemorrhage bleeding
Masses suspicious for retained placental fragments
Uterotonic agents: ergonovine, methylergonovine, oxytocin, a prostaglandin analog, or tranexamic acid. Surgical referral for suction evacuation to stop bleeding
Sore Nipples
The most common reasons for abandoning exclusive breastfeeding.
Sore, painful, cracked.
infection: exudate, increased erythema, pus, or dry scab
Warm compresses, green tea bag compresses, coconut oil, hydrogel dressing, nipple shields, wash nipples with soap & water once daily, topical mupirocin, peppermint oil, topical low dose steroids for inflammation; antibiotic: Miconazole for
C. albicans
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 urine/ protein in urine, weight is 145 lbs at 5 lbs increased from last visit 4 weeks ago, her height is 5’ 5”.
Demographic Data
• 31-year-old-female
Mastitis
Acute inflammation of the interlobular connective tissue of the breast that may include an infection. S. aureus is the main causative bacteria.
Erythema, pain, swelling, fever.
Pain described as sharp, needlelike, with burning sensation.
Symptoms associated with infection: fever 101 F or greater, area red, tender, and hot; muscle aches & malaise, elevated heart rate, nausea, chills, red streaks on the breast.
Feed or pump on the affected side. Frequent feedings, breast compressions, topical ricinoleic acid; heating pad, castor oil,
Antibiotics:
First line: Dicloxacillin or Flucloxacillin; Cephalexin
Second line: Clindamycin or Bactrim DS
Breast Abscess
A potential complication of mastitis r/t untreated, delayed, inadequate, or incorrect treatment for mastitis. Abscess formation increases with smoking.
Hard, red, and tender area on the breast.
If incapsulated, must be drained either surgically or needle aspiration. Abscess drainage should be cultured to determine antibiotic sensitivity.
Continue breast feeding and/or pumping.
Subjective
Chief Complaint (CC): 31-year-old-female, G2P1 at 24 weeks EGA, presents to the clinic for a routine follow up 24-week prenatal visit and recommended screen tests.
History of Present Illness (HPI): 31-year-old-female, G2P1 at 24 weeks EGA, presents to the clinic for a routine follow up 24-week prenatal visit and recommended screening tests. The one- hour glucose test result is 156 mg/dL; the patient has gained 5 lbs in the past 4 weeks; the fundal height is 25 cm; and POCT urine dipstick is (-) for protein.
Past Medical History (PMH):
• Medical History: o Denies history of HTN, diabetes, elevated cholesterol o Denies complications with previous pregnancy o Denies abnormal pap smears • Hospitalizations: o Spontaneous vaginal delivery: 2023- no complications • Medications: o Prenatal vitamin daily • Allergies: o No known drug allergies o No know food allergies • Immunizations: o Influenza vaccine: 10/2024 o Covid Vaccines: 2021 & 2022 o HPV Vaccines: x3 doses at 12 years old • Preventative Health Maintenance: o PAP: last pap at 30 years o Eye exams: every 2 years, last exam 2024 o Dentals exam & cleaning: last dental visit 1/2025 o STI screening: at 21 years old; 2020, and at each pregnancy diagnoses: 2023 & 2025 • Family History: o Mother: hyperlipidemia o Father: HTN, Hyperlipidemia o Maternal Grandmother: hyperlipidemia o Maternal Grandfather: HTN, Hyperlipidemia o Paternal Grandmother: hyperlipidemia
o Paternal Grandfather: HTN, DM Type II o Maternal great-grandmother: hyperlipidemia o Maternal great-grandfather: HTN, Hyperlipidemia o Paternal great-grandmother: Hypertension o Paternal great-grandfather: HTN, DM Type II • Social History: o Nutrition: Eats a balanced diet and occasional take out o Exercise: denies o Denies history of illegal drug use o Sexual history: 2 lifetime partners; 1 partner for the past 5 years o Sexual intercourse with males o History of STIs: denies o Contraception: male condoms o Menstrual history: 1st menstrual cycle at 13 years old o Occupation: Elementary school teacher o Caffeine: Green and black tea o Smoking: denies cigarette and vaping o Alcohol: 2-3 glasses a week prior to pregnancy
Review of Symptoms:
• General: denies fever/chills, (+) fatigue, (+) increased thirst • Psychological: denies anxiety and depression • Neurological: denies headaches and dizziness • Eyes: denies blurry vision • Ears: denies ringing in ears • Nose, Mouth, and Throat: denies nasal congestion, dry mouth, sore throat • Cardiology: denies chest pain • Respiratory: denies shortness of breath • Breast: denies breast pain • Gastrointestinal: denies abdominal pain, nausea/vomiting, diarrhea, constipation, heartburn • Genitourinary: denies burning; (+) frequency and urgency • Musculoskeletal: denies muscle, joint, back pain • Skin: denies itching • Gynecological: Denies discharge, bleeding, pelvic cramping, leaking of fluids; denies
Braxton Hicks • Heme/Lymph/Endo: denies heat/cold intolerance
Objective:
Vital signs: B/P: 118/78; HR: 68; T: 98.7 F; RR: 18
Pain: 0/10
Pre-pregnancy weight: 120 lb; Height: 65 inches; BMI: 20.0
Current weight 145 lbs
Pregnancy gain: + 5 lbs in 4 weeks
One hour glucose test result: 156 mg/dL. Positive result
POCT: Urine dipstick: (-) protein
Physical exam:
• Generalized: age appropriate, well developed, well-nourished, no acute distress • Neurological: alert and oriented • Cardiology: no swelling noted to BLE, no murmur • Pulmonary: regular respiratory rate; chest symmetric, no wheezing • Gastrointestinal: abdomen round; non-tender • Musculoskeletal: upper and lower extremities, full range of motion; stable gait • Integumentary: warm and dry • Psychiatric: calm and cooperative • Genitourinary: urine clear, no odor • Gynecological: no vaginal redness or discharge noted • Fundal height: 25cm (acceptable 22-26 cm)
OB Abdominal ultrasound:
• Intrauterine pregnancy singleton • Presentation: Vertex • Fetal cardiac activity present; HR 144 • Amniotic fluid appears adequate • Fetal movements: Yes • Fetal breathing movements: Yes
Differential Diagnosis
(1) Urinary tract infection:
• Positives: frequency, urgency, pregnancy • Negatives: urine clear, no odor, no fevers/chills, no low abdominal/back pain
Final Diagnosis
(1) Gestational diabetes (GD):
• Positives: maternal age > 25, weight gain +5 lbs in 4 weeks, 1-hr glucose teat 156, fatigue, increased thirst, increased urinary frequency and urgency
Plan:
Diagnostic testing
• Urine POCT in office: to r/o UTI: negative for nitrite and/or leukocyte • NST: monitors fetal heart rate in response to their movement • CBC: monitor WBC & platelets, can increase with GD. • 3-hour 100-g OGTT Glucose challenge: to diagnose GD
Medications:
Continue: Prenatal vitamin: Take 1 tablet by mouth daily.
Vaccine: Tdap
Education:
• Normal weight pre-pregnancy: weight gain 1 lb /week during 2nd – 3rd trimester. • Complications of GDM if noncompliant o Maternal: Risk of high blood pressure, preeclampsia, pre-term labor, spontaneous abortion o Fetus: microsomia, macrosomia (makes delivery difficult), still birth o Newborn: elevated bilirubin causes jaundice, hypocalcemia, polycythemia, hypoglycemia • Exercise 30 minutes daily 5 times a week, such as walking • Limit carbohydrates • Eat 3 meals and 2 snacks • Monitor blood glucose at home 4-6 times per day: before meals, and 2 hours after • 3-hour 100-g OGTT: in the morning after fasting overnight • Management for Class GDMA1: o diet, exercise, blood glucose monitoring • Management for Class GDMA2 o Starting with Metformin 500mg by mouth once a day for one week, then increase to 500 mg
to twice a day to decrease side effects o Can increase 500 mg every week to a maximum of 2500 ng o Most common side effects of Metformin: abdominal pain & diarrhea • Insulin o Recommended for BMI > 40
o Serious risk factor is hypoglycemia which can lead to coma or death if not treated immediately
o Symptoms of hypoglycemia: shaking, sweating, agitation, rapid heart rate, clammy skin o Blood glucose < 80 should be treated with 15 gm of glucose • Monitor for type DM and insulin resistance after delivery
Referral/Follow-up
• Referral to dietician or diabetes educator- if positive • Week 28 visit: o NST: o Urogynecology for pelvic floor evaluation, exercises o Transabdominal ultrasound o Amniotic fluid index (AFI) o POCT: urine dipstick • RSV: recommended at 28 weeks to protect the infant from RSV • Tdap: recommended between 27-36 weeks to protect against pertussis (whooping cough)
Health Maintenance:
• Vision exams: every 2 years- 2026 • Dental exams/cleaning: 2 per year- 7/2025 • Pap: 33 years old • Vaccines: 10/2025: annual influenza
