Dr. Rutul Thakker: Type-1 Diabetes & Pregnancy: Concordance with Technology
CASE OVERVIEW
Pregnancies affected by T1DM are at increased risk for preterm delivery, preeclampsia, macrosomia, shoulder dystocia, intrauterine fetal demise, fetal growth restriction, cardiac and renal malformations, in addition to rare neural conditions such as sacral agenesis. Intensive glycemic control and preconception planning have been shown to decrease the rate of fetal demise and malformations seen in pregnancies complicated by T1DM. A 27 years old female from a small town of Gujarat has type-1 diabetes and hypothyroidism since last 14 years. She has reported two miscarriages, both in 1st trimester. She was referred to AHC diabetes care centre by her gynaecologist for better glucose control and pre conception counselling. On taking history it was found that she had two episodes of diabetic ketoacidosis in last one year.
DIAGNOSIS
Her HbA1C was 9.7% at the first pre-conception visit. She was on premix human insulin 30/70 twice a day and levothyroxine 25 mcg. Her site of insulin injection was upper arm and thighs with few sites of lipodystrophies, self-monitoring of glucose was poorly practice and understood. Her c-peptide level was 0.03 nl/dl , serum creatinine was 0.7, TSH level was 4.1 mlU/L.
RESULTS
With all efforts poured towards DSME, she conceived after 4 months from her first visit when HbA1C came down to 6.8%. At 37 weeks, she delivered healthy baby of 3.1 kg by caesarean section. Baby did not develop hypoglycaemia or any other complications.
TREATMENT
During her first pre-conception visit at AHC, extensive counselling was provided on type 1 diabetes and pregnancy. Basal bolas therapy was initiated and strict glucose targets were set prior to conception. Structured SMBG was explained and its importance was emphasized. Insulin injection techniques were explained and she was advised to take insulin on abdomen. Site rotation, frequency of changing needles, checking insulin pen regularly for air bubbles was all taken care. Dietary counselling was done by dietician on low GI diet and exercise with life style modification. An individualized diet chart was prescribed.
On 2 months follow up, her glucose values were fairly under control with few mild hypoglycaemic episodes. During this visit, she was introduced with the concept of insulin correction doses prior to each meal and basics of carbohydrate counting. AGP (Ambulatory Glucose Profile) was also introduced and applied for the first time to get a better picture on glucose excursions and variability. Management of hypoglycaemia and ways to prevent hypo events were clearly explained.
After 4 months from her first visit, with up-titration of levothyroxine to 50 mcg, she achieved target TSH of < 2.5 prior to conception. She was reinforced with DSME (Diabetes Self-Management Education), importance of each trimester, especially 1st trimester was emphasised as it is associated with complications of foetal anomalies. AGP was applied in subsequent trimesters.
Strict insulin regime that comprise of structured SMBG, understanding of insulin with carbohydrate counting and insulin correction factors are the imperative parameters that guide towards achieving the targeted glucose levels. Above all, self-discipline and determination on patients’ part make a difference. Technology acts as a cherry on the top for such complicated cases.
