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 Table of Contents 
CASE REPORT
Year : 2019  |  Volume : 8  |  Issue : 5  |  Page : 1772-1774  

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


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

Date of Web Publication31-May-2019

Correspondence Address:
Dr. Ahmad Najmi
Department of Pharmacology, 3rd Floor, All India Institute of Medical Sciences Bhopal, Saket Nagar, Bhopal - 462020, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_290_19

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  Abstract 


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.

Keywords: Abortion, antenatal visit, gestational diabetes mellitus, insulin, screening


How to cite this article:
Najmi A, Atal S, Sadasivam B, Singh P, Ray A. Early onset gestational diabetes mellitus: A case report and importance of early screening. J Family Med Prim Care 2019;8:1772-4

How to cite this URL:
Najmi A, Atal S, Sadasivam B, Singh P, Ray A. Early onset gestational diabetes mellitus: A case report and importance of early screening. J Family Med Prim Care [serial online] 2019 [cited 2019 Dec 11];8:1772-4. Available from: http://www.jfmpc.com/text.asp?2019/8/5/1772/259431




  Introduction Top


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 Top


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 (HbA1c) 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 HbA1c 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]


  Discussion Top


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.


  Conclusion Top


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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
WHO. Definition, Diagnosis and Classification of Diabetes Mellitus and Its Complications. Part I: Diagnosis and Classification of Diabetes Mellitus WHO/MCD/MCS/99. 2nd ed. Geneva: WHO; 1999. p. 1–59.  Back to cited text no. 1
    
2.
American Diabetes Association. Gestational diabetes mellitus. Diabetes Care 2001;24(Suppl 1):S77-9.  Back to cited text no. 2
    
3.
Inzucchi SE. Diabetes in pregnancy. In: Burrow GN, Duffy TP, editors. Medical Complications During Pregnancy. 5th ed. Philadelphia: WB Saunders; 1999. p. 25-51.  Back to cited text no. 3
    
4.
Buchanan TA, Xiang AH. Gestational diabetes mellitus. J Clin Invest 2005;115:485-91.  Back to cited text no. 4
    
5.
Cho HY, Jung I, Kim SJ. The association between maternal hyperglycemia and perinatal outcomes in gestational diabetes mellitus patients: A retrospective cohort study. Medicine (Baltimore) 2016;95:e4712.  Back to cited text no. 5
    
6.
Rani PR, Begum J. Screening and diagnosis of gestational diabetes mellitus, Where do we stand. J Clin Diagn Res 2016;10:QE01-4.  Back to cited text no. 6
    
7.
American Diabetes Association. Pharmacologic approaches to glycemic treatment: Standards of medical care in diabetes–2019. Diabetes Care 2019;42(Suppl 1):S90–102.  Back to cited text no. 7
    
8.
Toledano Y, Hadar E, Hod M. Safety of insulin analogues as compared with human insulin in pregnancy. Expert Opin Drug Saf 2016;15:963–73.  Back to cited text no. 8
    
9.
Cowie CC, Rust KF, Byrd-Holt DD, Eberhardt MS, Flegal KM, Engelgau MM, et al. Prevalence of diabetes and impaired fasting glucose in adults in the U.S. population: National health and nutrition examination survey 1999–2002. Diabetes Care 2006;29:1263–8.  Back to cited text no. 9
    
10.
Sheffield JS, Butler-Koster EL, Casey BM, McIntire DD, Leveno KJ. Maternal diabetes mellitus and infant malformations. Obstet Gynecol 2002;100:925–30.  Back to cited text no. 10
    
11.
Dirar AM, Doupis J. Gestational diabetes from A to Z. World J Diabetes 2017;8:489-511.  Back to cited text no. 11
    




 

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  Case History
  Discussion
  Conclusion
   References

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