Keywords
hyperglycemia in pregnancy - HIP - self-monitoring blood glucose and nutrition - social
burden
At Arogyam Health Care
Anthropometric data were collected and detailed history was taken on the first visit—weight
65 kg; BMI 28.1; laboratory investigations: HbA1C 9.1%, RBS 234 mg/dL); lipid profile:
TG 189 mg/dL, LDL165 mg/dL, C-peptide 3.04; thyroid (TSH) 2.86 IU/mL; hemoglobin 9.9
g/dL; urine examination shows presence of sugar ++; and S.creatitine 0.8 mg/dL. Antibodies
test was done to rule out other type of diabetes (GAD antibodies [glutamic acid decarboxylase]
value was 3 units/mL which suggests it was normal.)
Her prescription included premix insulin with metformin 500 thrice a day.
Flash glucose monitoring was advised intermittently and targets were set, FBS to be
less than 95 mg/dL and PPBS to be less than 120 mg/dL. Along with strict SMBG four
times a day with pre and post meals.[5]
[6]
Prescription was change to basal bolus regimen.[5]
Diabetes educator and nutritionist counseled her on gestational diabetes and the importance
of diet, insulin technique, hypoglycemia, and correction dose.
The diet part was tackled with utmost care, as the woman is eating for two. The calories
intake during first trimester was set to 1,500 kcal, as the nutritional need during
this period does not increase. For second and third trimesters the calorie intake
was 2,600 kcal and 2900 kcal, respectively. In addition, her diet was modified according
to her hyperglycemic condition, keeping in mind her nutritional status, which should
not be hampered. For breakfast, she was advised to add complex carbohydrates with
more fibers and protein, for example, moong-moth (pulses), khakra, and added fruits and nuts. Her lunch included multigrain roti (whole wheat flour,
rolled oats, and millet flour in equal proportion) and a small bowl of green leafy
vegetable (sabzi) and daal. Jaggery and sugar, common Gujarati ingredients, were removed completely.
A small bowl of salad was added (cucumber and tomatoes.) Rice was removed from her
diet and her dinner included sprouts/oats khichdi or khichdi with one part of brown rice, along with curd or buttermilk. Enough amounts of fat
and protein were added in form of paneer, tofu, and cheese and protein powder. Seeds rich in omega 3 fatty acid were added—chia
seeds, pumpkin seeds, sunflower seeds, and flax seeds. Her snacks included a handful
of peanuts and roasted chickpeas. Before going to bed, she was advised to take a cup
of milk without sugar to avoid hypoglycemia. She was advised to avoid social treats
and eating out (familiar and unfamiliar food) and emphasis was given to repeat simple
meals.[7] Few cheat days’ food was coped up by correction doses.[5]
Follow-up was scheduled every 2 months. A constant contact with patient was maintained
through mobile application and phone calls, when needed. Dose was titrated accordingly.
Her husband and family members played a supportive role throughout her pregnancy.
Her mother-in-law was worried as she thought this might be infertility because of
diabetes. She was supportive and took care of her diet part at her best. Her husband
was very concerned and accompanied her during her follow-up visits at the clinic.
In addition, he played a role of a mediator between her and a doctor, by sending the
SMBG data punctually and titrating the dose as suggested by the doctor[5]
[8] ([Table 1]).
Table 1
Change in average blood glucose level during gestational period
|
Date (2018)
|
March 29
|
June 19
|
August 27
|
November 6
|
|
HbA1C %
|
9.1
|
7.1
|
6.2
|
6.6
|
On November 25, 2018, with well-controlled glucose level she delivered a male baby
at LadyCare Hospital, Ahmedabad, weighing 2.61 kg, length 49 cm, and head circumference
33 cm. APGAR score was 8. The baby developed physiological jaundice, which did not
require phototherapy, as reported by the pediatrician. No other medical complications
were observed. The AGP report of the patient ([Fig. 1]) shows flat median line with narrow thickness, which suggests that the glycemic
variability is less with average glucose profile 6% and 5.3%.
Fig. 1 Graphical representation of daily glucose variations through ambulatory glucose profile.
Fig. 2 Seven days ambulatory glucose profile, showing average glucose value of the day,
frequency of hyperglycemia and hypoglycemia in a day and time in range.
Conclusion
Early diagnosis can help to reduce the rate of infertility and certain fetal anomalies.[3] Following diagnosis, the condition can be safely dealt by continuous glycemic monitoring,
lifestyle changes, nutritional counseling, and appropriate use of insulin/medicines.
Extensive glucose monitoring is the best tool to treat such challenging case, as it
acts like a window through which physician could observe and respond to the daily
influences on blood glucose.[5]
[8] In addition, emerging technology such as Ambulatory Glucose Monitoring is one of
the great boons to patients as well as to the diabetologists as it helps in management
of diabetes.
