Prepared and presented by:

Case 6 Dr. Sadaf Fatima

Helping hand:
Dr.Shagufta(leader)
Dr.Ahmad shehzad and all
group members.
A 20-year-old girl is referred by her obstetrician to your clinic. She is a
student of nutrition sciences and is married for last 3 months. She never
Case 6
visited a doctor to discuss her plans of pregnancy. Currently she is 5
weeks pregnant and was found to have Fasting blood glucose of 315
mg /dl on her routine antenatal tests. Her obstetrician had started her on
medical nutrition therapy and arranged an urgent appointment with you
for her diabetes care. She denies any polyuria/polydipsia but agrees to
losing few kilos of weight in past few months which she relates to being
busy due to her wedding. She has stopped simple sugars from her diet
but is not following the medical nutrition therapy. Right now she is quite
confused about all this and is unsure of what is happening. There is no
significant past medical or surgical history. Her parents have type 2
Diabetes diagnosed during the fourth decade of life
 ON EXAMINATION
A young, cooperative girl,
Dehydration – nil
BMI – 21 kg/m 2
Thyroid – Goiter – nil,
Nodules – nil
Acanthosis nigricans – nil
Rest of exam - unremarkable
Q.1;What is her likely diagnosis?
How can u confirm it?
Differential diagnosis:
1.Pre-existing type 1 diabetes
2. Pre-existing type 2 diabetes
3. MODY
Investigations:
1.Routine labs including: CBC, RFTs, LFts, TFTs, lipid profile, ACR
2.C-peptide levels
3.Genetic testing: Anti GAD, islet cell antigen(ICA 512),insulin
autoantibodies(IAA),zinc transporter 8(zn T8)
4.Genetic testing for MODY: HNF alpha and glucokinase
 Q.2;What is her risk of
miscarriage and congenital
malformations in the fetus?

Women with type 1 an type 2 have increased risk of miscarriage, pre-eclampsia, preterm labour, fetal
congenital anomaly, large for gestational age babies, and stillbirth.

The risk of having a baby with a major congenital malformation(neural tube defects and cardiac
malformations) or experiencing a stillbirth is increased three to four fold when hba1c becomes more than 8.

The Hyperglycemia and adverse pregnancy outcomes study(HAPO) showed that the odds of having a large
for gestational age babies increased linearly as blood glucose level increased.
Bell R, Glinianaia SV, Tennant PW, et al. Peri-conception hyperglycaemia and nephropathy are associated with risk of congenital anomaly in
women with pre-existing diabetes: a population-based cohort study. Diabetologia 2012;55:936-47.
Women with gestational
diabetes
also at increased risk of pre-eclampsia, preterm labour, large for gestational age babies, and
stillbirth, but because GDM usually affects the mother in later pregnancy (after embryogenesis),
it is not associated with an increased risk of major congenital anomaly.

Weissgerber TL, Mudd LM. Preeclampsia and diabetes. Curr Diab Rep 2015;15(3):9.
 Q.3How will you counsel her?

• Patient education about disease and its complications in pregnancy like congenital
abnormalities, chances of abortion, pre eclampsia, macrosomic babies, still birth.
• Mode of delivery(most likely c-section)
• Diet modification(MNT) like proper balanced diet with short frequent meals
• Physical activity after every meal walk for 10 to 15 min.
• Glucose monitoring multiple times and maintain glucose levels below the following
target levels:
• Fasting 5.3 mmol/l , 95mg/dl
• 1 hour after meal 7.8 mmol/l, 140mg/dl
• 2 hour after meal 6.4 mmol/l , 115mg/dl
• Counseling about hypoglycemia and how to manage it by herself or family members.
• Frequent antenatal visits
 QUESTION 4

Give her a management plan (considering she has cost

constraints)?
 Target of Management
TargetSMBGs
Fasting plasma glucose levels of 70to 95mg/dl
Plasma glucose level 1 hr after meals <140mg/dl
Plasma glucose levels 2 hrs after meals <120
Insulin doses need to be titrated closely as need of insulin may increase after 20week
Gestational Age
Relaxing glucose targets to some extent for initial days to avoid hypoglycemia will be a good
approach.
Target Hba1c levels is below 6.5% to be repeated in each trimester
Additionally add high dose= Folic Acid 5mg PO × OD to avoid risk of Neural Tube defect of fetus.
Treatment options;
Ideal management should be basal bolus regimen+/- metformin (MULTIPLE DAILY INECTIONS)
Like glargine/detemir bedtime with aspart/lispro befoe meals.

Insulin NPH is the preferred and cheap long acting preparation in pregnancy but with with
diabetes controlled on long acting analogue preparation can continue the same preparation.
Use lispro even 5 tims a day even before snack times to control glucose levels.
Q.5;What will you communicate
to her obstetrician?
Consider patient in hi-risk group of antenatal visits, so that she can visit clinic more with her
glucose monitoring chart
Frequent ultrasound of fetal well being
Refer her for retinal assessment
Add aspirin 150mg from 12th week of pregnancy till delivery
Talk to obs about management plans during and after pregnancy fo blood sugar levels
Talk to obs about delivery method options and complications like preterm labour, macrosomic
babies, still birth.
Deliver the baby no later than 39 weeks
Ideally, arrange contact with the joint diabetes and antenatal clinic every one to two weeks throughout pregnancy.
She should be offered continuous glucose monitoring (CGM) during pregnancy to help her achieve the tight
glycemic targets required whilst also reducing their risk of hypoglycaemia.
The target range should be 3.5-7.8 mmol/L and should be achieved as early as possible as women who achieve
this are less likely to have babies that are large for gestational age and the pregnancy complications that go with
this.
If not having CGM, she will need to test her blood glucose seven or more times each day. She should be advised
to maintain her blood glucose above 4 mmol/L and to have ready access to quick acting carbohydrate.
Insulin requirements can be more than double in pregnancy due to pregnancy related hormones which increase
insulin resistance so women often need more frequent repeat prescriptions of insulin. This increase usually starts
from week 20 and may platHbA1c should be checked at least once in each trimester.
Blood ketones must be checked if she is unwell for any reason. You should arrange immediate admission to
hospital if the result indicates ketoacidosis.
She is advised to take low dose aspirin (75 to 150 mg) once daily from 12 weeks until the birth of the baby.
(Women with pre-existing type 1 or type 2 diabetes are at high risk of pre-eclampsia)
From week 36 strict glucose monitoring is advised during this period.
 Antenatal appointments

Booking Appointment:
• Confirm viability of pregnancy and gestational age at seven to nine
weeks
• Discuss with her obs care the extent of diabetes related complications
(including neuropathy and vascular disease).
• Offer retinal assessment
• Offer renal assessment
• 11 to 13 weeks nuchal translucency scan
16 weeks:
• Offer self monitoring of blood glucose or a 75 g two hour OGTT.
20 weeks:
• Offer an ultrasound scan for detecting fetal structural abnormalities, including examination of the
fetal heart (four chambers, outflow tracts, and three vessels)
28 weeks:
• Offer ultrasound monitoring of fetal growth and amniotic fluid volume
32 weeks:
• Offer ultrasound monitoring of fetal growth and amniotic fluid volume
• Offer all routine investigations normally scheduled for 31 weeks in routine antenatal care
34 weeks:
• No additional or different care for women with diabetes
36 weeks: Offer ultrasound monitoring of fetal growth and amniotic fluid volume. Provide
information and advice about:

• Timing, mode, and management of birth

• Analgesia and anesthesia
• Changes to blood glucose lowering therapy during and after birth
• Care of the baby after birth
• Initiation of breastfeeding and the effect of breastfeeding on blood glucose control
• Contraception and follow up
37+0 weeks to 38+6 weeks:
• Offer induction of labour (or caesarean section if indicated) to women with type 1 or
type 2 diabetes.
38 weeks:
• Offer tests of fetal wellbeing
39 weeks:
• Offer tests of fetal wellbeing
Q.6;Follow up.
Most women who develop diabetes have more frequent antenatal visits(once or twice weekly)
especially if insulin is in the management plan.
The purpose of these visits are
1. Monitor mother and baby’s health
2. Discuss diet plan
3. Review blood sugars
4. Adjust dose of insulin(as it is common to change the dose as the pregnancy progresses)
FOLLOWUP for Treatment
Adjustment
Every 48 to 72 hrs to titrate the dose of Insulin till BG Control Values achieved.
For every 10 mg change in BG Control Values titrate Insulin by 1 unit
If FBS is raised : basal Insulin NPH/Detemir
If PPG is raised: bolus Insulin Lipro /Aspart
According to Nice 2020 Guideline
Fasting 5.3 mmol/l
1 hr PPG 7.8 mmol/l
2 hr PPG 6.4 mmol/l
Maintain glucose level above 4 mmol/l
After reaching controlled blood glucose levels, follow up with the patient every 1-2 weeks as per
NICE guidelines

Can use Telemedicine, Whatsapp group to follow the patient.

Educate the patient about SMBG and self adjustment of Insulin dose after delivery
 7How will your management differ if
Q,
she had presented to you before
pregnancy?
LIFESTYLE CHANGES
Proper diet (balanced diet with complex carbs)
Physical activity
BLOOD GLUCOSE TARGETS
She should be counselled about her rbs and fbs levels
Contraception should be advised till her sugar levels are within the range
Aim for HbA1c <= 6.5 ideally.
Pregnancy should be planned. if hba1c is > 10 then she should avoid pregnancy as it has a risk of
major congenital anomalies.
Start of tab folic acid before conception as it reduces the chances of congenital abnormalities