Case of the Month
June 2004

32-year-old female — third trimester seizure

1032 hrs, your annual hose-testing is interrupted by the tones from Dispatch for a 32-year-old female in her third trimester of pregnancy having a seizure. On arrival at the scene, the husband states his wife is 34 weeks pregnant. He also adds that she was diagnosed with diabetes during her pregnancy. You find the patient in bed just finishing what appears to be a generalized tonic/clonic seizure. She is now unconscious (post-ictal) with shallow respirations. Her skin is pale, cool and sweaty. You determine that she has a bounding radial pulse at about 110 and she has no obvious signs of injury or bleeding. Based upon the initial findings of altered mental status, seizure activity and skin signs, you make an initial assessment of SICK!

You update the medic unit with patient status (SICK) and include your intention to perform blood glucometry testing along with assisted ventilations with a BVM and high flow oxygen. You confirm the vital signs: blood pressure 170/84, pulse (radial) @ 110 BPM and bounding, respirations @ 6 BPM and shallow with bilateral breath sounds (pulse oximetry @ 91%). The patient remains unconscious…you are impressed by how pale, cool and moist her skin is (skin signs). You and your partner continue with a physical exam and SAMPLE history from the husband. Your partner presents to you the SAMPLE history and prepares for blood glucometry.

S	—	Signs/symptoms — unconscious with seizure, cool, moist skin
A	—	No known allergies
M	—	5 units NPH insulin (am) and 5 units regular insulin with meals, Allegra
P	—	Insulin dependant diabetes during pregnancy only (gestational diabetes mellitus — GDM)
L	—	Husband didn’t see her eat before he left for work
E	—	Husband called home numerous times — no answer, finally drove home to find her unconscious in bed, then he witnessed the seizure

Assisted ventilation with the BVM results in adequate chest rise and oxygen saturation (pulse oximetry) has risen to 97%. You perform blood glucometry and confirm a reading of 22 mg/dl (LOW on your glucometer). Medics give you an update that they are 3 minutes out; you tell them the patient’s blood glucose level. You continue the ongoing assessment and treatment but are challenged by the cause for this seizure and confirmed hypoglycemia.

Gestational diabetes (GDM)
GDM is defined as insulin dependant (oral or injected) diabetes during pregnancy and most often self-terminates post-partum. When the mother’s insulin response is inadequate, maternal and fetal hyperglycemia can result. The reasons for the pregnancy-induced diabetes include increase demands on glucose by the fetus and hormonal changes with the mother. Abnormal maternal glucose regulation (gestational diabetes or GDM) occurs in 3-10% of pregnancies.

Pregnant women tend to develop hypoglycemia between meals and during sleep. This occurs because the fetus continues to draw glucose across the placenta from the maternal bloodstream, even during periods of fasting. Hypoglycemia becomes increasingly likely as the pregnancy progresses and the glucose demand of the fetus increases.

Everything was done correctly at the BLS level in regards to assessment (SICK), treatment and the testing of the patient’s blood glucose level. Appropriate airway and ventilation was performed with a timely and an accurate short report to the medics.

The lesson from this case: the cause of seizures are many, but that didn’t stop these EMTs from completing an initial assessment and providing immediate care for this patient.

View optional info on gestational diabetes — American Diabetes Association (external link)