Case of the Month
September 2007

32-year-old female, diabetic – 7 months pregnant

Dispatch
"Aid 5, 32-year-old female, diabetic and pregnant…not feeling well”

En route your crew discusses the following considerations:

    * OB issues
    * Diabetic issues - glucometry

While en route, the dispatcher updates and states that the patient is now seizing.

Scene Size-up
You arrive at the patient’s apartment and her husband states that she just had a full body seizure and reminds you and your crew that the patient is 7 months pregnant. He leads you into the bedroom where the patient is lying supine on the bed. She is post-ictal, appears pale and diaphoretic. There are no reports of trauma.

Initial Assessment
The patient is pale and diaphoretic. She has a strong radial pulse of 118 and a pressure of 106/P. She is breathing deeply at 20 bpm, is post-ictal and non-communicative. The patient has mild deceribration on painful stimulation. The husband states that she was diagnosed with gestational diabetes a few months ago and life has been very difficult since. He states that she has had lots of problems regulating her blood sugar with the insulin that the Dr. gave her. Your team takes and confirms her blood glucose…it is 16mg/dl.

Initial Treatment
You decide that the patient is SICK based on nature of illness (hypoglycemic seizure – as a result of gestational diabetes) LOC and skin signs. You instruct your partner to initiate high flow oxygen utilizing a non-rebreathing mask and confirm pulse oximetry @ 98% on a NRM. A medic unit is requested and your other crewmember is sent down to the rig to bring up the gurney.

Event and Recent History
Further questioning reveals the patient has been receiving treatment to improve fertility that included clomiphene (Clomid, Serophene). She is 7 months pregnant and is gravida 1 para 0. She was diagnosed with gestational diabetes a number of months ago and was put on injected insulin at that time.

Further Evaluation and Treatment
Your crew moves quickly with this patient and loads her on the gurney for transport. The crew carries the patient downstairs and meets the ALS unit in the street. Paramedics start an IV line, offer D50 (Dextrose), perform endotrachial intubation and perform a rapid transport to a high level labor and delivery (L&D) hospital offering an early notification of the patient’s status.

The patient is briefly seen in the ED prior to transferring her to the L&D. The patient never regained consciousness throughout the EMS field care and subsequent treatment in the hospital. Sadly, the patient experienced significant hypoxic encephalopathy and was pulled from her respirator 2 weeks later and died in the hospital. The baby was taken surgically and remains in the NICU (neonatal intensive care unit) with moderate neurologic deficits – outcome is unclear.

Gestational Diabetes
The best initial treatment is to support ABCs and make a SICK decision. Include ALS, administer oxygen (assist ventilation if needed) perform glucometry (if trained to do so – IV Dextrose may be indicated), pulse oximetry and provide rapid transport to a medical center that can properly assess and treat the patient.

What is Gestational Diabetes?
Pregnant women who have never had diabetes before but who have high blood sugar (glucose) levels during pregnancy are said to have gestational diabetes. Gestational diabetes affects about 4% of all pregnant women - about 135,000 cases of gestational diabetes in the United States each year.

It is unclear what causes gestational diabetes, but we have some clues. The placenta supports the baby as it grows. Hormones from the placenta help the baby develop. But these hormones also block the action of the mother's insulin in her body. This problem is called insulin resistance. Insulin resistance makes it hard for the mother's body to use insulin. She may need up to three times as much (as her normal) insulin to properly regulate her blood glucose.

Gestational diabetes starts when your body is not able to make and use all the insulin it needs for pregnancy and most often terminates after the baby is born (when the pregnancy is over). Without enough insulin, glucose cannot leave the blood and be changed to energy. Glucose builds up in the blood to high levels causing hyperglycemia.