A Case of T2DM & Hypothyroidism with 7 Months Pregnancy Requiring Very High Insulin

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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• Physical examination:• Height 145 cm, Weight 67 kg, BMI 32.31

• 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

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

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

16.12.13 FBS: 5.5 mmol/l2HABF: 7.5 mmol/lBL: 6.3 mmol/l2HAL: 5.8 mmo9l/l2HAD: 9.0 mmol/l

13.01.14 FBS: 6.5 mmol/l2HABF: 5.6 mmol/lBL: 4.2 mmo9l/l2HAD: 10.3 mmol/l

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

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

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

17.03.14 HbA1c: 5.4%S. TSH: 2.88 mIU/L

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

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

09.04.14 FBS: 4.1 mmol/l2HABF: 9.3 mmol/lBL: 7.0 mmo9l/l2HAL: 6.3 mmol/l2HAD: 6.3 mmol/l

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

14.04.14 FBS: 4.6 mmol/l2HABF: 9.0 mmol/l2HAL: 7.2 mmol/l

INCREASING TREND OF INSULIN REQUIREMENT BY THE PATIENT

PROVISIONAL DIAGNOSIS

• Type 2 DM• Primary Hypothyroidism• 7 months Pregnancy• Insulin Resistance

• 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

• 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

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

A Case of T2DM & Hypothyroidism with 7 Months Pregnancy Requiring Very High Insulin

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