RACGP KFP 2016.1.8 – Letifa has Gestational Diabetes

by | Feb 8, 2018

Letifa, a 21 year old woman presents in December at 26 weeks gestation of her first pregnancy.  She had her initial bloods and ultrasound done at her old practice before she moved to the area.  She reports    She was overweight before her pregnancy with a BMI of 32.  She is Muslim and often wears head scarfs like a hijab and sometimes covers her arms and legs.  She takes no medication or allergies.  Her blood pressure is 122/74.  She is rhesus negative.  

What investigations do you want to request for Letifa? List 4 

  1. FBE
  2. Blood antibody screen
  3. 2 hour 75g OGTT
  4. Vitamin D levels

GPCC – This question seems benign but in order to answer it you’d have to memorise the entire rouine in antenatal care, when a reasonable expectation is hat you’d be able to look it up in real practice. In order to hav memorised this you’d have to memorise the entire schedule of care.  The schedule is described pretty well in Murtaghs, p 1013 or somewhere around there, I usually just look it upon every time.

This is an example of my opinion how the KFP is an exercise in rote learning for the most part with a  bit of clinical reasoning in there. Its a myth that its just ” a day of General practice” and that its about “clinical reasoning”. Its mainly about memorising everything.

Case continued.  Letifas blood results come back.  Her FBE is normal and blood group B+.  Her OGTT shows  a fasting level of 4.9 mmol/L, 1 hour 10.2 mmol/L, 2 hour 8.7 mmol/L and her vitamin D is 35 nmol/L

GPCC – Whats the normal range of Vitamin D? What level should you be aiming for in pregnancy? There is much debate over what constitutes an adequate number and its a number you should know.

How will you manage the OGTT results? List 5

  1. Refer to obstetric medical specialist for GDM review
  2. Educate patient she has gestiational diabetes (would this be a mark??)
  3. Limiting weight gain  (?not sure about this, in RACGP but …)
  4. Blood glucose self monitoring aiming for 4-6mmol/L preprandially and <7mmol/L postprandially (IS THIS OVERCODING)? (Probably okay, more specific than overcoming)
  5. Nutritional advice to reduce BGL
  6. Safe increase in physical activity to reduce BGL
  7. Postpartum oral glucose tolerance test at 6–12 weeks

RACGP – In this question good answers were those that focussed on specific management for diabetes within pregnancy and not diabetes in general or general advice in pregnancy (such as somoking, alcohol, or dietary changes unrelated to diabetes).  Regarding the vitamin D deficiency, offering treatment in line with the appropriate public Australian guidelines gained more marks.  Again being concise as well as focussed on whatis required in thee case of such deficiency during pregnancy.

Reference – https://www.racgp.org.au/your-practice/guidelines/diabetes/13-diabetes-and-reproductive-health/133-gestational-diabetes-mellitus. Theres a really good RACGP or Think GP ALM on this topic that clarified for me as well.

How will you manage the vitamin D results? List 2

  1. Commence a cholecalciferol/vitamin D at 1000 IU daily
  2. Maintenance dose of 1000 IU recommended at least until the cessation of lactation
  3. Exposure of face, hands and arms to at least 6-30 minutes of mid-morning or mid-afternoon sunshine per day
  4. Repeat vitamin D assay 6 months post natally

GPCC – NB – exact duration depends on the guidelines you read.  MJA recommend 6-7 minutes where as some recommend 15-30 minutes.  Hence flexibility is given.  The stem makes it clear that she only “sometimes” covers her arms and legs suggesting can exposure certain body parts.

https://www.mja.com.au/journal/2012/196/11/vitamin-d-and-health-adults-australia-and-new-zealand-position-statement

Do you repeat the vitamin D levels?  Some guidelines like the SA perinatal guidelines suggest yes at 6 months postnatal, however the WA guildelines say repeating is not required.  Due to thi fairly typical confusion and contradiction between guidelines, marks were given for stating this.

http://www.sahealth.sa.gov.au/wps/wcm/connect/a7af1a004eee85fc8135a36a7ac0d6e4/Vitamin+D+Deficiency_policy.pdf?MOD=AJPERES&CACHEID=ROOTWORKSPACE-a7af1a004eee85fc8135a36a7ac0d6e4-m2DDpEp  

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In this case we see a 21 year old patients being diagnosed with gestational diabetes in the early stages of her pregnancy.  The cases required subsequent management of the diabetes in the context of being pregnant as well as vitamin D deficiency at the same time.

In this question good answers were those that focussed on specific management for diabetes within pregnancy and not diabetes in general or general advice in pregnancy (such as somoking, alcohol, or dietary changes unrelated to diabetes).  Regarding the vitamin D deficiency, offering treatment in line with the appropriate public Australian guidelines gained more marks.  Again being concise as well as focussed on whatis required in thee case of such deficiency during pregnancy.

Articles Tagged with Topic “Women’s health”