gestational diabetes hesi case study quizlet

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Clinical pearls, case study: complicated gestational diabetes results in emergency delivery.

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Ginny Lewis; Case Study: Complicated Gestational Diabetes Results in Emergency Delivery. Clin Diabetes 1 January 2001; 19 (1): 25–26. https://doi.org/10.2337/diaclin.19.1.25

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A.R. is a 33-year-old caucasian woman initially diagnosed with diabetes during a recent pregnancy. The routine glucose challenge test performed between 28 and 29 weeks gestation was elevated at 662 mg/dl. A random glucose completed 1–2 days later was also elevated at 500 mg/dl. A follow-up HbA 1c was elevated at 11.6%. Additional symptoms included a 23-lb weight loss over the past 3–4 weeks with ongoing “flu-like” symptoms, including fatigue, nausea, polyuria, and polydypsia.

A.R. had contacted her obstetrician’s office when her symptoms first appeared and was told to contact her primary care provider for the “flu” symptoms. She had called a nurse triage line several times over the previous 2–3 weeks with ongoing symptoms and was told to rest and take fluids.

She presented to her primary care provider 3 days after the HbA 1c was drawn for ongoing evaluation of hyperglycemia. At that time, she was symptomatic for diabetic ketoacidosis. She was hospitalized and started on an insulin drip.

A.R.’s hospitalization was further complicated with gram-negative sepsis, adult respiratory distress syndrome, and Crohn’s disease with a new rectovaginal fistula. She was intubated as her respiratory status continued to decline and was transferred to a tertiary medical center for ongoing management. She required an emergency Caesarian section at 30 1/7 weeks gestation due to increased fetal distress.

A.R. had no family history of diabetes with the exception of one sister who had been diagnosed with gestational diabetes. Her medical history was significant for Crohn’s disease diagnosed in 1998 with no reoccurrence until this hospitalization. Her pre-pregnancy weight was 114–120 lb. She had gained 25 lb during her pregnancy and lost 23 lb just before diagnosis.

A.R.’s blood glucose levels improved postpartum, and the insulin drip was gradually discontinued. She was discharged on no medications.

At her 2-week postpartum visit, home blood glucose monitoring indicated that values were ranging from 72 to 328 mg/dl, with the majority of values in the 200–300 mg/dl range. A repeat HbA 1c was 8.7%. She was restarted on insulin.

1.  What is the differential diagnosis of gestational diabetes versus type 1 diabetes?

2.  At what point during pregnancy should insulin therapy be instituted for blood glucose control?

3.  How can communication systems be changed to provide for integration of information between multiple providers?

Gestational diabetes is defined as “any degree of carbohydrate intolerance with onset first recognized during pregnancy. This definition applies whether insulin ... is used for treatment and whether or not the condition persists after pregnancy.” 1 Risk assessment is done early in the pregnancy, with average-risk women being tested at 24–28 weeks’ gestation and low-risk women requiring no additional testing. 1 , 2 A.R. met the criteria for average risk based on age and a first-degree family member with a history of gestational diabetes.

Screening criteria for diagnosing diabetes include 1 ) symptoms of diabetes plus casual plasma glucose >200 mg/dl (11.1 mmol/l), or   2 ) fasting plasma glucose >126 mg/dl (7.0 mmol/l), or   3 ) 2-h plasma glucose >200 mg/dl (11.1 mmol/l) during an oral glucose tolerance test (OGTT). 3 For women who do not meet the first two criteria, a glucose challenge test (GCT) measuring a 1-h plasma glucose following a 50-g oral glucose load is acceptable. For those women who fail the initial screen, practitioners can then proceed with the OGTT. 1  

In A.R.’s case, she most likely would have met the first criterion if a casual blood glucose had been measured. She had classic symptoms with weight loss, fatigue, polyuria, and polydypsia. Her 1-h plasma glucose following the glucose challenge was >600 mg/dl, which suggests that her casual glucose would also have been quite high.

Medical nutrition therapy (MNT) is certainly a major part of diabetes management. However, with this degree of hyperglycemia, MNT would not be adequate as monotherapy. Treatment for gestational diabetes includes the use of insulin if fasting blood glucose levels are >95 mg/dl (5.3 mmol/l) or 2-h postprandial values are >120 mg/dl (6.7 mmol/l). 1  

Several days passed from the time of A.R.’s initial elevated blood glucose value and the initiation of insulin therapy. While HbA 1c values cannot be used for diagnostic purposes, in this case they further confirmed the significant degree of hyperglycemia.

Plasma blood glucose values initially improved in the immediate postpartum period. A.R. was sent home without medications but instructed to continue home glucose monitoring.

At her 2-week postpartum visit, whole blood glucose values were again indicating progressive hyperglycemia, and insulin was restarted. A.R.’s postpartum weight was 104 lb—well below her usual pre-pregnancy weight of 114–120 lb. Based on her ethnic background, weight loss, abrupt presentation with classic diabetes symptoms, and limited family history, she was reclassified as having type 1 diabetes.

In immune-mediated, or type 1, diabetes, b-cell destruction can be variable, with a slower destruction sometimes seen in adults. 3 Presentation of type 1 diabetes can also vary with modest fasting hyperglycemia that can quickly change to severe hyperglycemia and/or ketoacidosis in the presence of infection or other stress. 3 A.R. may have had mild hyperglycemia pre-pregnancy that increased in severity as the pregnancy progressed.

The final issue is communication among multiple health care providers. A.R. was part of a system that uses primary care providers, specialists, and triage nurses. She accessed all of these providers as instructed. However, the information did not seem to be clearly communicated among these different types of providers. A.R. called triage nurses several times with her concerns of increased fatigue, nausea, and weight loss. The specialist performed her glucose challenge with follow-up through the primary care office. It seems that if all of these providers had the full information about this case, the diagnosis could have been made more easily, and insulin could have been initiated more quickly.

1.  Hyperglycemia diagnosed during pregnancy is considered to be gestational diabetes until it is reclassified in the postpartum period. Immune-mediated diabetes can cause mild hyperglycemia that is intensified with the increased counterregulatory hormone response during pregnancy.

2.  Insulin therapy needs to be instituted quickly for cases in which MNT alone is inadequate.

3.  The GCT is an appropriate screening test for an average-risk woman with no symptoms of diabetes. In the face of classic symptoms of diabetes, a casual plasma glucose test can eliminate the need for the glucose challenge.

4.  As part of the health care industry, we need to continue to work on information systems to track patient data and share data among multiple providers. Patients can become lost in an ever-expanding system that relies on “protocols” and does not always allow for individual differences or for cases with unusual presentation.

Ginny Lewis, ARNP, FNP, CDE, is a nurse practitioner at the Diabetes Care Center of the University of Washington School of Medicine in Seattle.

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• v.8(5); 2019 May

Early onset gestational diabetes mellitus: A case report and importance of early screening

Ahmad najmi.

1 Department of Pharmacology, All India Institute of Medical Sciences, Bhopal, India

Shubham Atal

Balakrishnan sadasivam, pooja singh.

Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance with onset or first recognition during pregnancy. Screening for GDM is usually done at 24–28 weeks of gestation. In this case, we report a 31–year-old woman who developed gestational diabetes at 6 weeks in two successive pregnancies. She was in the perceived high-risk group to develop gestational diabetes. The first pregnancy terminated in spontaneous abortion at 10 weeks. In the second pregnancy, institution of insulin therapy at diagnosis was associated with a successful outcome. This case highlights the need of screening for gestational diabetes at the first antenatal visit in the high-risk group.

Introduction

Gestational diabetes mellitus is a heterogeneous medical entity that includes women with pregnancy induced glucose intolerance and women with undiagnosed diabetes discovered during pregnancy.[ 1 , 2 ] Normal pregnancy is characterised by mild fasting hypoglycaemia, a moderate rise in postprandial plasma glucose, and hyperinsulinemia.[ 3 ] The postprandial hyperglycaemia is due to pregnancy induced physiological insulin resistance which may be due to involvement of hormones-like cortisol, prolactin, progesterone, and human placental lactogen.[ 4 ] GDM is known to be associated with adverse maternal and foetal outcomes like maternal hypertension, caesarean deliveries, development of diabetes, foetal macrosomia, need for neonatal ICU care, etc.[ 5 ] This case points out the need of screening for gestational diabetes early in the pregnancy in the high-risk group which includes women with history of previous GDM.

Case History

A 31-year-old woman, a housewife, presented to our hospital at six weeks of gestation of her first pregnancy in June 2017. Her body mass index was 23 and blood pressure was 124/78 mm Hg. There was no relevant past medical history. There was a strong family history of type 2 diabetes as both her parents were diabetic. To screen her, a 75 g oral glucose tolerance test (OGTT) was performed. The fasting plasma glucose was 106 mg/dl and 2 h value was 138 mg/dl. Based on the World Health Organisation 1999 criteria, GDM was diagnosed, and necessary dietary advice given.[ 1 ] The pregnancy terminated spontaneously in abortion at 10 weeks. Eight weeks after the abortion, a 75 g OGTT was repeated and this was found to be normal. She was advised to follow a normal diet and to undergo GDM screening as soon as the next pregnancy is detected. She conceived again in February 2018 and underwent a 75 g OGTT at six weeks’ gestation. The fasting value was 108 mg/dl and 2-h value was 210 mg/dl. The result of the glycated haemoglobin (HbA 1c ) testing done at the same time was 6.6% (reference range 6.6–8.3%). The diagnosis of gestational diabetes mellitus was made and insulin therapy in the form of twice daily injections of insulin aspart and once daily injection of insulin lispro was started. Follow ups were done at intervals of 2–4 weeks depending on the glycaemic control achieved. Her average fasting and two hour plasma glucose values were 86 mg/dl and 118 mg/dl, respectively with HbA 1c being less than 6.5%. The insulin doses were increased with advancing pregnancy. At the end of the pregnancy, the total daily insulin dose was 60 units. The weight gain during pregnancy was 12 kg. At 38 completed weeks, an elective caesarean section was planned. A live and healthy female baby was delivered weighing 2800 g. The baby had an uncomplicated neonatal course. The patient's plasma glucose values returned to normal by the next morning and insulin injections were stopped. She underwent a 75 g OGTT at six weeks postpartum, which was normal. She was informed of her high risk of developing type 2 diabetes in later life[ 2 ] and was advised to maintain normal body weight by appropriate dietary modifications and regular physical activity. She was also advised to undergo a 75 g OGTT every 3 years.[ 2 ]

The mechanism of GDM has not been understood properly till date. The most likely cause is human placental lactogen because of a 1000-fold rise in its level during pregnancy and its homology to the known insulin antagonist, the growth hormone.[ 4 ] As the level of this hormone rises with advancing pregnancy, the insulin resistance worsens with time.[ 4 ] It is at its maximum in the third trimester, necessitating a threefold rise in maternal insulin output to maintain euglycaemia.[ 4 ] Mothers with deficient β cell reserve become glucose intolerant at this time. So, gestational diabetes mellitus typically appears late in the second trimester or early in the third trimester.[ 4 ] Based on this fact, the current recommendation for screening for gestational diabetes mellitus is between 24 and 28 weeks of gestation.[ 1 , 3 , 6 ]

According to ADA guidelines 2019, insulin is the preferred medication for pre-existing type 1 and type 2 diabetes not adequately controlled with diet, exercise, and metformin.[ 7 ] For gestational diabetes, insulin is the gold standard. Human insulin, both regular and NPH, and the rapid acting insulin analogues such as lispro and aspart have been licensed for usage in pregnancy. Insulin detemir has been approved for use in pregnancy while glargine is not approved in managing GDM.[ 8 ]

Poorly controlled diabetes both before and during the first trimester of pregnancy can cause major birth defects, spontaneous abortions, and stillbirths.[ 9 ] Despite this well-established fact, more than 60% of women with pre-existing diabetes have difficulty managing their glycaemic control during pregnancy.[ 2 ] Researchers and care providers agree that glycemic control is one of the most important modifiable risk factors in minimizing birth defects of infants born to women with pre-existing diabetes.[ 10 ] While type 1 diabetes management requires insulin and thus leaves little choice during pregnancy, type 2 diabetes may be managed with life-style modifications, oral anti-diabetic agents, and/or insulin. Among oral agents, several new molecular entities[ 11 ] have been added within the last ten years with limited data on pregnancy outcomes.

Gestational diabetes mellitus screening is usually done at 24–28 weeks of gestation since insulin resistance increases especially during the second trimester and hyperglycaemia occurs in women who do not have the ability to produce enough insulin in response to this blood glucose rise. But this case report shows that GDM screening early in the pregnancy, preferably in the first antenatal visit, and insulin therapy have a definite beneficial role in improving the outcome of the pregnancy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest.

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