Pre existing DM with Pregnancy managed well with the help of technological advances viz CSII,CGMS,encountering variety of complications & difficulties which was managed well leading to better foetal outcome irrespective of multiple maternal comorbidities

2. - 34 yrs/Female
- Awaiting for 2nd Pregnancy
- k/c/o Type 2 DM,Hypertension,Hypothyroidism
 Current Medicines
- Metformin SR 1gm BID
- Gliclazide 40 BID
- Teneligliptin 20 OD
- Dapagliflozin 5 OD
- Pioglitazone 15 OD
- Telmisartan 40 OD
- Levothyroxine 75 mcg OD
- Vit B12 supplement

3. Relevant Past History
 Gestational DM in 1st Pregnancy @ 29yrs age (G2A1L1 with G1 LSCS)
 After 1 yr post delivery,BG unconrolled & on OAD since then
 On Diagnosis, BG F 229,PPL 286 (No osmotic symptoms)
 Family History of DM in 3 generations (Probable MODY)
- Grandparents (Maternal)
- Mother & Father
- All Uncles & Aunts (Maternal)
- Siblings (Both Brothers)
 Other Comorbidities
- Hypertension since 4 years
- Primary Hypothyroidism since 3 years
- Obesity (Grade I)

4. Current Clinical Profile/Lab values
 Pulse = 90/min,reg , BP = 130/90 mmhg Rt Arm sitting
 Wt = 69kgs, BMI = 27 kgs/m2
 Lab Reports s/o
- BG F = 129,PPL 170, HBA1C = 7.16%
- mTSH = 3.36
- Lipids 193/153/46/116
- HB = 11.8 gm%,Creat = 0.8,SGPT = 19
- Urine RM s/o Alb NIL,Sug 2+,PC 2-3/hpf
- Urinary ACR 24 mcg/mg of Creat

5. Counselling
 Prognosis,risks involved
 Need for Treatment revision
 Parameters to be corrected
 Target BP,BG,TSH prior to & post conception (And
pregnancy to be deferred till that)
 Patient agreement & active participation in treatment
and goals achievement

6. Treatment Revision
Previous Medicines Revised Treatment
- Metformin SR 1gm BID
- Gliclazide 40 BID
- Teneligliptin 20 OD
- Dapagliflozin 5 OD
- Pioglitazone 15 OD
- Telmisartan 40 OD
- Levothyroxine 75 mcg OD
- Vit B12 supplement
- Premixed Insulin (Reg +
NPH) (Human Mixtard
30/70)
12 BBF - 8 BDNR
- Metformin SR 1gm BID
- Nifedipine Retard 20 HS
- Levothyroxine 75 OD

7.  After Rx revision & lab parameters brought down to acceptable limits,patient
was advised trial for conception
 Patient conceived in couple of months
 At 6 weeks Pregnancy,
Pulse 108/min, BP = 154/94 mmhg,Wt = 71.1 kg (2 kgs gained)
BG F 154,PPL 254, mTSH 2.8
 Rx revision
- Inj H. Mixtard Insulin dose increased ( 22 BBF – 14 BDNR)
- Cap Nifedipine R 30 HS (Dose increased)
- Labetelol 100 OD (added)
- Thyroxine dose increased to 100 mcg
-
Conception

8.  Blood Glucose
- Fasting/Pre meal < 95 mg%
- PP meal 1 hr < 140 mg%
- PP meal 2 hr < 120 mg%
- HBA1C < 6% (if it can be achieved without significant hypoglycaemia)
 Blood Pressure < 130/80 mm hg (120-160/80-105)
 TSH < 2.5
Treatment Goals in Pregnancy

9. End of 1st trimester
 Pulse = 90/min,BP = 124/86 mmhg, Wt = 71.8 kgs
 SMBG
- Fasting/Pre meals = 106 – 185
- PP Meals 2 hrs = 140 - 237
 S. Fructosamine = 157 (N = 122-136)
 Insulin modified
- Regular Insulin 8 BBF - 4 BL - ***
- NPH Insulin 16 BBF - *** - *** - 8 Bedtime
 Aspirin 75 added (Prophylactically to avoid PreEclampsia)

10. 2nd Trimester
 i/v/o Maternal & foetal risks involved due to
uncontrolled DM,option of CSII given to patient
 And CSII (Continuous Subcutaneous Insulin
Infusion), conventionally known as Insulin Pump
started to the patient
 Cross Consultation with Endocrinologist done

11. CSII & Consumables

12. CSII (Pump TDD) =
Avg of Reduced Dose (Inj dose * 0.75) & Weight Dose (Kg * 0.5)
 Aspart Insulin
# Basal (19.25 units/24 hrs)
- 12am to 7am = 0.5 units/hr
- 7am to 7pm = 1 unit/hr
- 7pm to 12am = 0.75 units/hr
# Bolus (11 units/24 hr)
5 bbf – 2 bl – 2 bdnr
And 2 units sos before mid meal snacks

14. 3rd Trimester
 On subsequent visits,CSII dose modified as per targets
 WT = 79.5 kgs (Gained 8 kgs)
Pulse = 92/min, BP = 132/78 mmhg

S. mTSH = 3.61 # LT4 dose increased to
100mcg Daily, with 50 mcg in additional dosage on Wed & Saturday
 CSII
- Basal (12am – 7am = 0.95/hr, 7am – 9pm = 1.05/hr, 9pm-12am = 1.00/hr)
- Bolus (18 – 25 – 25)
 SMBG
Fasting 110-120 PPBF 1 hr 152-205 PPBF 2 hrs 128-131
BL 92-96 PPL 1 hr 162-210 PPL 2 hrs 148-158
BDNR 107-112 PPD 1 hr 186-197 PPD 2 hrs 148-150
3am 130

16. Week 34 of Pregnancy
 Patient developed recurrent & multiple boils over
suprapubic area on previous Caesarean section Sx scar
(? Hyperglycaemia induced or vice versa leading to
increased insulin doses)
 Total requirement of Daily Insulin was 102 units/24 hrs
 HBA1C = 5.7% (Mismatch with SMBG)
 CGMS (Continuous Glucose Monitoring System)
started to cross check unusually high Insulin dose
requirement

17. CGMS

19. CGMS s/o
# Hypoglycaemia (12am-7am,12pm-3pm,8pm-11pm)
# Hyperglycaemia (9am-10am,1pm-7pm)
 CSII modified
# Basal
7am – 9pm = 0.65 units/hr, 9pm-7am = 0.95 units/hr
# Bolus
22 – 30 – 24
 SMBG post revision of Rx
pre meals 85-131,PP meal 2 hrs = 130-155, 3 am = 110

20. Week 35th of Gestation
Pulse 88/min, BP = 120/84 mmhg, Wt = 85 kgs
HBA1C 5.5%,mTSH 1.6
 Aspirin omitted at 35th week
 Elective LSCS planned at 37th week of Gestation
(Planned to stop CSII & start IV DNS + AHI 8 units peri
operatively with target RBG 100-120mg%
 However,Emergency LSCS done at higher centre
towards end of 36th week,
Baby had mild resp distress at birth,but later was fine

21. Post Partum Period
 1 week post LSCS,patient presented in emergency with
Acute severe Breathlessness (DOE IV NYHA),Orthopnoea,Pedal Oedema
P – 90/min,reg,BP = 170/104 mmhg,RS = Left LZ & basal crepts,RR 46/min,spo2 90%
 Provisionally thought of CCF (Fluid overload Vs HTN induced ) vs PTE
 Investigated #
- S. pro BNP 2485 (cardiac failure > 400)
- CT Pulm Angio = Cardiogenic Pulm Oedema (no e/o PTE)
- Venous Doppler both LL # No e/o DVT
 Rx
- Inj Pre mixed Insulin(30/70),
Metformin,Bisoprolol,torsemide+spironolactone
- LT4 75 mcg OD (reverted back to pre pregnancy dose)

22. Final Outcome
 Pre existing DM with Pregnancy managed well with the
help of technological advances viz
CSII,CGMS,encountering variety of complications &
difficulties which was managed well leading to better foetal
outcome irrespective of multiple maternal comorbidities
 Mother went throught her high risk Pregnancy fairly
well,No eclampsia; however Post LSCS,CCF developed
which was managed well & patient didn’t have any sequalae
of the same ahead
 Baby didn’t have significant Macrosomia or any significant
complications post birth/congenital abnormalities or
perinatal complications

23. Take Home Message
 DM with Pregnancy should be planned well in
advance so as to revise Rx beforehand so as to
avoid complications
 Involve patient in the Rx and keep Rx target
oriented ,watching/foreseeing complications with
timely intervening
 It’s a team work,don’t hesitate to take help/cross
consultations
 Be vigilent throughtout Pregnancy & Post Partum
period to counter complications and be proactive

24. Thank You Doctor