Gestational Diabetes and Shoulder Dystocia

Chapter 90 Gestational Diabetes and Shoulder Dystocia




Clinical Case Problem 1 Screening for and Diagnosis of Gestational Diabetes Mellitus


An obese 29-year-old is at 25   weeks of gestation and has had an uncomplicated pregnancy. Diabetes mellitus runs in her family, and she asks you about screening for gestational diabetes mellitus (GDM).



Select the best answer to the following questions




1. Which of the following statements concerning the 2008 U.S. Preventive Services Task Force (USPSTF) recommendations on GDM screening is correct?


a. the USPSTF recommends universal screening for GDM

b. the USPSTF recommends screening of only high-risk women for GDM

c. the USPSTF recommends against any screening for GDM

d. the USPSTF states that there is insufficient evidence to recommend for or against universal screening for GDM

2. Which of the following is not a risk factor for GDM?


a. family history of diabetes mellitus

b. history of glucose intolerance of any kind

c. age <20 years

d. history of a macrosomic infant

e. obesity

f. current glucosuria

3. What is the incidence of GDM in the United States?


a. <1%

b. 2% to 5%

c. 10% to 20%

d. 30% to 40%

4. Which of the following statements regarding the 50-g 1-hour oral glucose challenge test (GCT) is (are) true?


a. it is administered between 30 and 32   weeks of gestation

b. a threshold of either 130 or 140   mg/dL is equally acceptable

c. a threshold of either 130 or 140   mg/dL is equally sensitive

d. if it is negative (normal) at a gestational age earlier than the recommended screening time, it does not need to be repeated

e. patients should be fasting

f. all of the above

5. Your patient’s 1-hour GCT result is positive (abnormal), and a 3-hour oral glucose tolerance test (GTT) is administered 2   days later. Which of the following is true regarding the 3-hour GTT?


a. it is a nonfasting test

b. a single abnormal value does not increase the risk of macrosomia

c. two abnormal values are required for a positive (abnormal) test result

d. a fasting glucose concentration of 120   mg/dL is a normal value


Clinical Case Problem 2 Management of GDM


A 26-year-old presents at 26   weeks. She has no past medical history. Her urinalysis has been negative for protein and glucose. She has had an uneventful pregnancy so far but now comes to see you after two abnormal values on her 3-hour GTT a few days ago. Her blood pressure is 118/64   mm Hg. She appears mildly overweight. Her fundal height is 27   cm. A random glucose concentration today is 156. You educate her about GDM, diet, and the importance of checking her glucose level.



6. What is the most appropriate next step?


a. have her return in a week to review her home glucose log

b. admission to the hospital for inpatient control of her GDM

c. order hemoglobin A1c level

d. order fetal echocardiography

e. order 24-hour urine protein analysis

7. Which of the following is the most sound diet and exercise advice for this patient?


a. ideally, she should gain no weight for the remainder of the pregnancy

b. carbohydrates should be eliminated from her diet and replaced with protein and healthy fats

c. her nutritional goal is 1200 to 1600 calories/day

d. brisk walking for 20 minutes three times a week is encouraged

8. She understands home glucose monitoring and is willing to follow your instructions. What daily home glucose monitoring schedule do you recommend?


a. four random measurements

b. a single fasting morning measurement

c. a fasting morning measurement and a measurement 1 hour after each meal begins

d. a fasting morning measurement and a measurement 1 hour after each meal ends

9. She has greatly improved her diet and lifestyle. She returns at 28   weeks with the following averaged glucose measurements: fasting, 99; 1-hour postprandial, 129; 2-hour postprandial, 124. Which of the following is true?


a. glargine insulin (Lantus) is not approved by the Food and Drug Administration (FDA) for use in pregnancy

b. her glucose measurements are normal according to the guidelines of the American College of Obstetricians and Gynecologists (ACOG)

c. metformin has been shown to be unsafe in pregnancy

d. glyburide crosses the placenta but has not been shown to injure the fetus

10. Which of the following is a reasonable plan when GDM is well controlled with diet and there are no other complications?


a. delivery by 39 weeks

b. twice-weekly nonstress testing (NST) and biophysical profile (BPP) beginning at 32 weeks

c. fundal height does not need to be measured as long as euglycemia is achieved

d. none of the above

11. Which of the following is a reasonable plan when GDM is well controlled with insulin or oral hypoglycemics and there are no other complications?


a. biweekly NST beginning at 30 weeks

b. twice-weekly NST and BPP beginning at 32 weeks

c. delivery by 41 weeks

d. cesarean section if more than 200 units of insulin/day are required


Clinical Case Problem 3 Shoulder Dystocia


Janie, a 33-year-old, presents to the hospital in active labor at 39   weeks. She reports that all her previous deliveries have been vaginal and uncomplicated. Prenatal records indicate good dating criteria and that she has GDM well controlled with insulin. Her vital signs are normal, fetal heart tones are reassuring, and her cervical examination is 4/90%/−3 with a cephalic fetus and intact membranes. Contractions occur every 3 to 4 minutes.




12. In the adjacent room is a laboring woman without GDM. Otherwise, neither woman has any other risk factors for shoulder dystocia. Assuming their fetuses are the same weight, what can be said about their relative risk of shoulder dystocia?


a. GDM increases the risk of macrosomia only; because the fetal weight is known to be the same in these women, the relative risk is the same

b. the woman without GDM is at increased risk

c. Janie is at increased risk only if her intrapartum glucose concentration is not well maintained

d. Janie is at increased risk despite identical fetal weight

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Oct 1, 2016 | Posted by in GENERAL SURGERY | Comments Off on Gestational Diabetes and Shoulder Dystocia

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