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Case Study: Pregnancy and Early-Onset Type 1 Diabetes

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Case Study: Pregnancy and Early-Onset Type 1 Diabetes CASE STUDIES Case Study: Pregnancy and Early-Onset Type 1 Diabetes Christian D. Herter, MD, CDE Presentation C.B. received no nutrition informa- Commentary C.B., a 24-year-old woman, came to tion, but her mother taught her carbohy- Patients with type 2 diabetes are almost our clinic for a diabetes consultation drate counting. They were told that always obese (>20% over IBW). As after being referred by her mother, who metformin was the treatment choice but discussed in a previous issue of is one of our regular patients and has would not be started until our office Clinical Diabetes by Hansen et al.,1 type 1 diabetes herself. The older suggested it. obesity and family history of obesity woman’s diagnosis was made else- Besides being 3 weeks late with her are present in virtually all patients with where 7 years before she sought care menstrual period and having some type 2 diabetes. This is perhaps the with our office and had been based on breast tenderness, C.B. had no other most important risk indicator when her lean frame (5% below ideal body symptoms of pregnancy. Her mother considering the diagnosis. Patients with weight [IBW] based on height) at pres- was the only family member with dia- type 2 diabetes not only have a strong entation and relatively normal insulin betes of any type. C.B. and her husband family history of the disease,2 but also sensitivity (insulin requirements have had been trying to conceive for the past frequently have family members with a always been <0.5 U/kg/day). No anti- 3 months. preponderance of macrovascular condi- body studies or C-peptide levels were On exam, C.B. was a pleasant tions. done at the time of diagnosis. young woman with a weight of 67 kg People with type 1 diabetes are not Her daughter, C.B., was diagnosed and a height of 147 cm (IBW = 65 kg, usually obese and typically do not pres- with type 2 diabetes at a community therefore only 3% over IBW). Except ent with a clear family history of the clinic in a rural area near Seattle 3 for mild bilateral thyromegally, her disease. Often, there is weight loss at weeks before her visit with us. The physical exam was normal. Her home diagnosis, which is seldom a feature of diagnosis was based on her lack of blood glucose monitoring data were type 2 diabetes. Insulin sensitivity is ketones at presentation, “low” present- well ordered but revealed chaotic fluc- spared, so small doses of insulin pro- ing blood glucose of 254 mg/dl, and tuations, with several readings above duce potent hypoglycemic results. age at diagnosis. 400 mg/dl in the mornings and below Though not measured in this case, the Oral agents were suggested for 100 mg/dl at midday. Her HbA1c was presence of certain specific antibodies, C.B., but her mother insisted on insulin 9.2% (normal 4.0–6.0 %). A serum such as islet cell antibody (ICA) or therapy. Her primary care provider was pregnancy test was positive. anti–glutamic acid decarboxylase anti- concerned about this, noting that body (anti-GAD64) are common at insulin is rarely the best first-line treat- Questions diagnosis and even diagnostic when ment in patients with type 2 diabetes, 1. How certain is the diagnosis of type 2 hyperglycemia is evident. but prescribed a temporary regimen for diabetes in this patient? C.B. was lean and was aware of no her to use until her appointment with 2. What course of action is indicated in overweight relatives. She and her moth- me. At bedtime, she was told to take patients presenting with hyper- er were the only family members with 2–4 U of NPH, depending on her bed- glycemia when pregnancy is diag- diabetes. Although she did not present time blood glucose level, as obtained nosed? with ketones, this is a notoriously bad with home blood glucose monitoring. 3. How should C.B. be counseled as to diagnostic marker. Patients with type 2 She was also given a sliding scale for her risk of congenital anomalies if diabetes can present with ketones if lispro to be taken before eating, she decides to continue the preg- they have fasted or are seriously ill. depending on her blood glucose read- nancy? Age at diagnosis also is not a reliable ings. If her blood glucose value was 4. What methods should be used to marker for either disease, since both <150 mg/dl, she was instructed to take screen for pregnancy in women with types of diabetes can occur in young or no supplemental lispro. diabetes? older people. Although she had not 22 Volume 19, Number 1, 2001 • CLINICAL DIABETES CASE STUDIES University of Washington Medical Center 1989-94 (N = 192) nant. This should be a part of the 40% interview every time she visits your 35% office. 30% % Spontaneous Abortion 3. All women with diabetes who are of 25% % Birth Defects reproductive age should be counseled 20% before they are pregnant about the 15% need to optimize metabolic control and plan pregnancy and the risks of 10% spontaneous abortion and birth 5% defects associated with poor metabol- 0% ic control. 4. In diabetes, the risks of spontaneous <6% >10% abortion and fetal anomalies are 6.0 to 6.9%7.0 to 7.9%8.0 to 8.9%9.0 to 9.9% directly related to metabolic control Standardized HbA1c at First Prenatal Visit at the time of conception as well as Figure 1. Preliminary data showing a relationship between presenting HbA1c and rate of throughout the pregnancy. Hyper- spontaneous abortion and birth defects in pregnant women with diabetes. Printed with glycemia is most destructive to fetal permission of the investigators. development during the first trimester of gestation. experienced weight loss, her extreme and miscarriage is an important, and sensitivity to insulin did not suggest sometimes grave, necessity. Women REFERENCES type 2 diabetes. Finally, presenting who have had poor preconception con- serum glucose is not always a meaning- trol of their diabetes are at greater risk 1Hansen JR, Fulop MJ, Hunter MK: ful diagnostic test to assist clinicians in of spontaneous miscarriage, and those Type 2 diabetes mellitus in youth: a grow- with sustained hyperglycemia during ing challenge. Clinical Diabetes, 18:52–56, distinguishing between type 1 and type 2000 2 diabetes. the first trimester have a higher rate of 2American Diabetes Association: C.B.’s primary care physician did major malformations.3,4 Brown et al.5 at Report of the Expert Committee on the not know about her plans to conceive a the University of Washington Medical Diagnosis and Classification of Diabetes child. The notion that insulin is not usu- Center have observed specific risk rela- Mellitus (Committee Report). Diabetes Care 23 (Suppl 1):S4–S19, 2000 tionships between presenting HbA 3 ally the best first therapeutic choice in 1c Mimouni F, Tsang RC: Pregnancy out- type 2 diabetes is correct in most cases. level and the risk of poor outcomes. come in insulin-dependent diabetes: tempo- However, none of the available oral Their preliminary unpublished data, ral relationships with metabolic control dur- agents is currently approved for use in presented in Fig. 1 with permission of ing specific pregnancy periods. Am J Perinatol 5:334–38, 1988 pregnancy, so insulin was the only the investigators, graphically illustrate 4 the profound effect of hyperglycemia at Kitzmiller JL, Buchanan TA, Kjos S, option here. Combs CA, Ratner RE: Preconception care When pregnancy is diagnosed dur- the time of conception. for diabetes, congenital malformations, and ing a period of overt hyperglycemia, spontaneous abortions (Technical Review). hospitalization for rapid metabolic cor- Clinical Pearls Diabetes Care 17:1502–1513, 1996 5 rection is suggested to reduce the rate 1. Obesity and family history of type 2 Brown Z, Gabe S, Holing E: Elevated diabetes are present in virtually all glycated hemoglobin at first prenatal visit of spontaneous abortion and fetal predicts increased birth defects and SABs: anomalies. Hospitalization is, therefore, patients with the disease. They are preliminary data from an ongoing study. strongly recommended for all women strong markers. Age, the presence of Department of Obstetrics and Gynecology, who present with hyperglycemia at ketones at diagnosis, and presenting University of Washington Medical Center, diagnosis of pregnancy. Our patient serum glucose are poor indicators. April 2000 was advised to proceed immediately to 2. Every woman with diabetes who is of Christian D. Herter, MD, CDE, is in the regional prenatal center, where she reproductive age must be counseled private practice in Seattle, Wash. He was promptly admitted. about contraception and family plan- also functions as a satellite preceptor Counseling expectant mothers ning and asked if there is even the for the Mayo Medical School in about the risks of fetal malformations slightest chance she could be preg- Rochester, Minn. CLINICAL DIABETES • Volume 19, Number 1, 2001 23 CASE STUDIES Case Study: A 36-Year-Old Woman With Type 2 Diabetes and Pregnancy Diane M. Karl, MD Presentation continued insulin on her own and is already poorly controlled on maximal C.M. is a 36-year-old Spanish-speaking resumed taking glyburide 10 mg twice sulfonylurea treatment suggests a longer Mexican-American woman with a 3- daily. duration of diabetes. This supports the year history of type 2 diabetes. She possibility that her poor obstetrical his- was seen in her primary physician’s Questions tory may have been related to undiag- office because of a missed menstrual 1. Is there a relationship between nosed (and, therefore, uncontrolled) dia- period; a pregnancy test was positive.
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