a case of t2dm & hypothyroidism with 7 months pregnancy requiring very high insulin
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A TYPE 2 DIABETIC & HYPOTHYROID PREGNANT WOMAN WITH VERY HIGH INSULIN REQUIREMENT
DR. A.B.M. KAMRUL HASANMD THESIS PART (EM)
DEPT OF ENDOCRINOLOGY, BSMMU
CASE SUMMARY
• Name: Mrs. Y• Age: 42 years• Occupation: Section officer, DU Library• Address: Rampura, Dhaka• Date of admission: 5 Apr 2014
CASE SUMMARY (cont.)
• Diagnosed case of Type 2 DM, Primary Hypothyroidism & Dyslipidaemia
• Presented with:
• 7 months Pregnancy• Very high Insulin requirement to control blood glucose
CASE SUMMARY (cont.)
• Married for 10 years• Normal previous menstrual history:
regular, 282 days, average flow• Never used any contraceptive• Trying for baby since marriage• Husband has no fertility problem• Has strong family history of DM & CVD
CASE SUMMARY (cont.)
• Diagnosed as Type 2 DM 8 years back during pre-anaesthetic check up for laparoscopic evaluation of infertility
• Very high initial blood glucose (27.5 mmol/l)• Had typical symptoms of DM• Had no micro- or macro-vascular diabetic complications
at diagnosis• Metformin was prescribed, 1500 mg/day• Glimeperide 1 mg/ day was added later on• Did not receive diabetes education• Weight 48 kg, BMI 22.83
CASE SUMMARY (cont.)
• Almost regular brisk walking for about 45 min• Avoided sweetened foods & excess fatty foods; no
carbohydrate restriction• Poorly controlled blood glucose
(FBS 9-10 mmol/l, 2HABF 12-14 mmol/l, HbA1c 9.5%)
• Glimeperide was replaced by Gliclazide 6 months later• No history of hypoglycaemia
CASE SUMMARY (cont.)
• Diagnosed as primary hypothyroidism 7 years back with Serum TSH 93 mIU/L during evaluation of infertility
• Levothyroxine 150 g/day was given• Regular follow up and Levothyroxine dose was adjusted
accordingly
CASE SUMMARY (cont.)
• Diagnosed as dyslipidaemia 5 years back
(TG 358 mg/dl, TC 202 mg/dl)• Fenofibrate 200 mg/day was prescribed• Changed to Tab Fenatrol 145 mg/day 2 years back due
to poor control of hypertriglyceridemia• Discontinued herself 5 months before pregnancy
CASE SUMMARY (cont.)
• Attended Endocrine OPD, BIRDEM on 10 Nov 2013 with amenorrhea for 1½ months (LMP: 25 Oct 2013)
• Urinary pregnancy strip test was positive• Body weight 51.5 kg, BP 100/70 mmHg• Medication at diagnosis of pregnancy:
• Gliclazide 80 mg 1½+0+1• Metformin 500 mg 1½+1+1½ • Levothyroxine 50 g 2½+0+0
• Pregnancy was unplanned
CASE SUMMARY (cont.)
• Investigations at diagnosis of pregnancy:
Name of investigation Results
FBS 11.6 mmol/l
Bl. Glucose 2HABF 15.0 mmol/l
S. Creatinine 0.6 mg/dl
Lipid Profile TG 124 mg/dl, TC 160 mg/dl, HDLC 35 mg/dl, LDLC 99 mg/dl
S. TSH 0.37 mIU/L
S. FT4 18.10 pmol/L
USG Early intrauterine pregnancy of about 06 weeks
CASE SUMMARY (cont.)
• Treatment given at diagnosis of pregnancy:• OAD was stopped• Pregnancy diabetic diet• Exercise limitation• Instructed about use of glucometer & adjust insulin dose
according to blood glucose levels• Split mixed insulin was started:
» Regular Insulin (Actrapid): 8+6+8 (2) unit» NPH Insulin (Insulatard): 6+0+6 (2) unit
• Folic acid 5 mg bd• Levothyroxine 50 g 2½+0+0
• Regular follow up of blood glucose with own Glucometer• Patient increased the dose of insulin according to SMBG reports• Followed up by an endocrinologist at private chamber
CASE SUMMARY (cont.)
• Admitted to dept of endocrinology, BSMMU on 05 Apr 2014
• Medications during admission :– Actrapid 76+98+78 U & Insulatard 86+0+76 U per day (Total
414 units insulin per day)– Levothyroxine 50 g 2+0+0 – Iron, Calcium, Multivitamin & minerals supplements– Progesterone
CASE SUMMARY (cont.)
• Physical examination:• Height 145 cm, Weight 67 kg, BMI 32.31
kg/m2
• BP 120/75 mmHg, no postural drop• Mild anaemia, mild pedal oedema• Thyroid gland normal, clinically euthyroid• Insulin injection sites: normal• Acanthosis nigricans: absnent• Fundoscopic examination: normal• Lower limbs: normal sensation, ankle jerks
normal, peripheral pulses present• Other systems: normal
CASE SUMMARY (cont.)
Date Investigation Results Action Taken
14.11.13 FBS: 11.6 mmol/l2HABF: 13.3 mmol/lHbA1c: 9.9%
Actrapid: 18+18+18 (2)Insulatard: 16+0+16 (2)
25.11.13(Actrapid: 26+26+26 (2)Insulatard: 24+0+24 (2)
FBS: 8.3 mmol/l2HABF: 8.3 mmol/l2HAL: 9.1 mmo9l/lUSG: 8+ weeks single live pregnancy
Actrapid: 28+30+26 (2)Insulatard: 28+0+28 (2)
09.12.13 FBS: 8.0 mmol/l2HABF: 4.7 mmol/lBL: 5.8 mmol/l2HAL: 8.3 mmo9l/lBD: 6.3 mmol/l2HAD: 7.1 mmol/l
Actrapid: 36+42+36 (2)Insulatard: 32+0+28 (2)
CASE SUMMARY (cont.)
Date Investigation Results Action Taken
16.12.13 FBS: 5.5 mmol/l2HABF: 7.5 mmol/lBL: 6.3 mmol/l2HAL: 5.8 mmo9l/l2HAD: 9.0 mmol/l
Actrapid: 40+44+30 (2)Insulatard: 38+0+32 (2)
13.01.14 FBS: 6.5 mmol/l2HABF: 5.6 mmol/lBL: 4.2 mmo9l/l2HAD: 10.3 mmol/l
Actrapid: 50+58+44 (2)Insulatard: 54+0+46 (2)
30.01.14 FBS: 6.3 mmol/l2HABF: 10.0 mmol/l2HAL: 4.0 mmo9l/lBD: 5.4 mmol/l2HAD: 5.6 mmol/lHbA1c: 5.7%S. TSH: 2.30 µIU/mlCBC: Hb 9.8 g/dl, Neutrophiloic LeucocytosisUrine RE: normal
Actrapid: 56+70+50 (2)Insulatard: 62+0+54 (2)
CASE SUMMARY (cont.)
Date Investigation Results Action Taken
24.02.14 FBS: 4.7 mmol/l2HABF: 6.0 mmol/lBL: 3.6 mmol/l2HAL: 5.8 mmol/lBD: 6.0 mmol/l2HAD: 9.2 mmol/l
Actrapid: 66+88+66 (2)Insulatard: 74+0+68 (2)
11.03.14 FBS: 5.0 mmol/l2HABF: 5.8 mmol/lBL: 6.0 mmo9l/l2HAL: 8.2 mmol/lBD: 5.5 mmol/l2HAD: 9.3 mmol/l
Actrapid: 76+98+78 (2)Insulatard: 86+0+76 (2)
17.03.14 HbA1c: 5.4%S. TSH: 2.88 mIU/L
CASE SUMMARY (cont.)
Date Investigation Results
27.03.14 USG of Pregnancy: Anomaly Scan:
•A single pregnancy is seen. The gestational age corresponds with 26 wks & 3 days (±2 wks). The approximate fetal wt is 946 gm (±138). EDD by fetal size is 30.06.2014. clinical EDD is 30.06.2014•No major structural abnormality is seen in the present study•The AFI is higher than normal•Placenta is posterior, grade 0 and well free from the OS. No retroplacental collection is seen•The fetal presentation is cephalic
CASE SUMMARY (cont.)
Date Investigation Results Action Taken
29.03.14 FBS: 5.2 mmol/l2HABF: 5.0 mmol/l2HAL: 6.4 mmo9l/lBD: 5.0 mmol/l2HAD: 6.0 mmol/l
Actrapid: 76+98+78 (2)Insulatard: 86+0+76 (2
07.04.14 FBS: 5.6 mmol/l2HABF: 7.2 mmol/l2HAL: 5.7 mmol/l2HAD: 5.5 mmol/l
Actrapid: 74+98+74 (2)Insulatard: 80+0+72 (2)
09.04.14 FBS: 4.1 mmol/l2HABF: 9.3 mmol/lBL: 7.0 mmo9l/l2HAL: 6.3 mmol/l2HAD: 6.3 mmol/l
Actrapid: 70+94+70 (2)Insulatard: 76+0+68 (2)
CASE SUMMARY (cont.)
Date Investigation Results Action Taken
12.04.14 FBS: 5.2 mmol/l2HABF: 5.0 mmol/l
2HAL: 5.6 mmol/l2HAD: 5.3 mmol/l
Actrapid: 68+92+68 (2)Insulatard: 74+0+66 (2)(patient was discharged with this dose)
13.04.14 FBS: 4.6 mmol/l2HABF: 8.5 mmol/l2HAL: 6.9 mmol/l2HAD: 6.4 mmol/l
Actrapid: 68+92+68 (2)Insulatard: 74+0+66 (2)
14.04.14 FBS: 4.6 mmol/l2HABF: 9.0 mmol/l2HAL: 7.2 mmol/l
Actrapid: 68+92+68 (2)Insulatard: 74+0+66 (2)
CASE SUMMARY (cont.)
INCREASING TREND OF INSULIN REQUIREMENT BY THE PATIENT
PROVISIONAL DIAGNOSIS
• Type 2 DM• Primary Hypothyroidism• 7 months Pregnancy• Insulin Resistance
CASE SUMMARY (cont.)
• Investigations done after hospital admission:
Name of the investigation Result
S. Creatinine 0.7 mg/dl
SGPT 37 U/L
FPG 3.0 mg/dl
Fasting Plasma Insulin 236 U/ml (normal: 2-25 U/ml)
Fasting Insulin x Fasting GlucoseHOMA-IR = 22.5 = 31.56
CASE SUMMARY (cont.)
• Hospital course:• Insulin technique was verified and found faulty
which was corrected• Strengthening of dietary control• SMBG• Replacement of the insulin vials• Reduction of insulin requirement by 30 units per
day!
PROBLEMS
• How to overcome this pregnancy induced insulin resistance?
This high dose insulin continued?Start Metformin?Go for Basal- Bolus regimen of insulin analogues?
• Peri-partum follow up.
ACKNOWLEDGEMENT
• Prof. Md. Farid Uddin
Founder Chairman & Course Co-ordinator,
Department of Endocrinology, BSMMU
• Prof. M.A. Hasanat
Department of Endocrinology, BSMMU
• The Patient & her attendants• All the colleagues of my department