Dr. Tejas Shah: a Case of Gestational Diabetes Mellitus with Polyhydramnios

Gestational Diabetes Mellitus (GDM) is a term used to describe diabetes in pregnant women who were not diabetic before pregnancy. GDM if not well managed can lead to offspring and maternal complications, such as macrosomia, preterm birth, shoulder dystocia, polyhydraminos, congenital anomaly, etc. Integrated personalized diabetes management (iPDM) plays an important role in such cases. Patient X is 38 years old, female with a gestational age of 24-25weeks. Her weight was 65.5 kg.

DIAGNOSIS :

Her 3rd-trimester scan report of 15th January 2021 indicated moderate polyhydraminos i.e. excessive accumulation of amniotic fluid.

Patient X’s biochemical parameters revealed the following:

HbA1c: 6.2% (estimated average glucose: 132 mg/dL)
Fasting blood glucose: 103 mg/dL
Two-hour glucose level (after 75 g oral glucose tolerance test): 181 mg/dL
Triglycerides: 200 mg/dL
LDL: 102 mg/dL
HDL: 36 mg/dL
Urine Albumin Creatinine Ratio: Normal.
The patient was referred to a diabetologist as polyhydraminos is a rare condition caused due to GDM. She was advised for lifestyle modification along with daily 1-hour post-meal sugar readings. A strict follow-up to check for Amniotic Fluid Index (AFI) every 2 weeks was suggested.
She was started with Inj. Levemir 10 units before breakfast and half a tablet of Glyciphage 500 post-meal three times a day.
When the patient came for follow-up after two weeks. The HbA1c was found to be 6.0%, which was under the acceptable range but there was no improvement in the polyhydramnios status. She was then introduced to the concept of SMBG with iPDM. She was advised to adhere to dietary changes, exercise, and SMBG regimen. Unlike prior post-prandial blood glucose of 120 mg/dl to 125 mg/dl, the 1-hour post-meal blood glucose was now maintained near 100 mg/dl. SMBG during iPDM helped the patient to keep a track of glucose level for maintaining it in the preferable range while following all aspects of the treatment.

The medications were changed to 1 tablet of Glyciphage 500 post breakfast and lunch while dinner dosage being the same. Inj. Levemir was continued with the same frequency.
Patient X’s evaluation after 6 weeks revealed that her HbA1c was 5.8%, fasting blood glucose level was 70mg/dL and 1-hour postprandial glucose level was 90 Mg/dl. Although she was in the hypoglycemic stage, her polyhydraminos complaint was completely resolved as indicated by the trimester scan report of 12th March 2021.

Rationale:

As per the HAPO study, targeting glucose level to the lower side of the recommended range results in beneficial outcomes. GDM being diagnosed at later phase of pregnancy, it becomes necessary to manage the complication in short duration and iPDM approach is most important.