1. Case studies
In this presentation we will review hypoglycaemia – the causes, signs and symptoms, treatment, and prevention.
We will also discuss unawareness of hypoglycaemia and hypoglycaemia in special situations.

2. Case study #1: Mrs. C
Mrs. C is a 22 year old primigravida coming for her first antenatal checkup at 12 weeks of gestation.
On examination, she is 152 cm tall and weighs 69 kg. BMI, 30 kg/m2
She does not have a family history of diabetes.
Does she need to be screened for diabetes?
If so, when?
What screening test is to be used?
Even though this lady has none of the risk factors for diabetes, she still needs screening since she belongs to a high risk ethnic group.
Should we be doing 75 gm GTT ? or just fasting so early?

3. Mrs. C. Mrs. C had a fasting blood glucose done
Her results are as follows.
Does she have diabetes?
Does she have GDM?
Does she need to be tested again?
If so, when?
Time
0 hr (Fasting)
Glucose mmol/L(mg/dL)
4.7 (86)
This woman is at risk of diabetes because of her weight.
Her fasting result is normal, therefore she does not have diabetes.
However she needs to be retested at 24 to 28 weeks of gestation. Why?

4. Mrs. C Mrs. C undergoes repeat testing at 26 weeks’ gestation.
Her results on the 75 gm glucose load (fasting) are as follows.
Does she have GDM?
If yes, what treatment is indicated?
When will you review her and using what tests?
Time
0 hr (Fasting)
1 hour
2 hour
Glucose mmol/L(mg/dL)
4.8 (88)
10.3 (186)
8.9 (161)
This lady has GDM, she only needs 1 elevated result to be diagnosed, she has 2 elevated results.
She can be initiated on a trial of lifestyle modification for 2 weeks
What education is required? Meal plan - meals spread over the day, spreading carb out, etc and regular activity, monitoring blood glucose either at home or when to come back to clinic, importance of keeping BG down, risks to baby and mother, follow up plans
Who would see her about her diet? Dietitian if at all possible
Review in 2 weeks – fasting and 1 or 2 hour post meal BG

5. Mrs. C After 2 weeks, her results were as follows
Is her glycemic control adequate?
What is the next line of treatment?
What other test can help assess level of glycemic control?
Fasting blood glucose mmol/L (mg/dL
5.2 (93)
2 hour postprandial blood glucose mmolL (mg/dL) breakfast
8.6 (156)
Postprandial checks can be done at either 1 hour (normal <7.8mmol/L (140 mg/dl)) or 2 hours (normal < 6.7mmol/L(120mg/dl))
Even after trial of lifestyle modification, the postprandial glucose level is above target. She can be started on a small dose of prandial insulin.
Long term indices of glycemic control include serum fructosamine and glycated hemoglobin. Is it necessary to do these tests – would you change treatment based on the results?
Do you want to know about the other meals?
What education is required?
Who will teach her to give the insulin?

6. Mrs. C
Mrs. C is put on 4 units of rapid acting insulin before breakfast and advised to monitor her blood glucose daily. She does well.
After 2 weeks, her reports are as follows.
Is her glycemic control adequate?
What is the next line of treatment?
Fasting blood glucose mmol/L (mg/dl)
6.5 (118)
2 hour postprandial blood glucose mmol/L(mg/dl) breakfast
7 (126)
Her the fasting glucose levels are high. The patient will need to be put on NPH or detemir insulin at bedtime.
What would you want to know before starting the NPH or detemir?
How will you decide how much NPH or detemir to start with?
What education does she need about NPH or detemir?
What about her other meals? Do you want to know any other levels?

7. Mrs. C
Mrs. C is now on 6 units of NPH insulin at bedtime in addition to 4 units of rapid acting insulin before breakfast. She starts complaining of excess hunger during the early hours of the morning.
Her reports are as follows.
Are these values acceptable?
What is the next line of treatment?
mmol/L (mg/dL)
Fasting BG
3.3 (61)
2 hour postprandial BG
5.6 (102)
Should she be using NPH or detemir? What is the difference?
The patient’s fasting glucose levels are unacceptably low. The bedtime dose of insulin needs to be reduced.
Would you consider giving her an algorithm for adjusting her own insulin?
What has she been doing when she gets a low value in the morning?
What about BG at other times of the day?
How should she monitor for the rest of the pregnancy?

8. Mrs. C Her insulin dose has stabilized
NPH 8 units at bedtime
rapid acting insulin 6 u before breakfast, 4 units before lunch and 4 units before evening meal.
Mrs. C goes into labour at 39 weeks.
Should she have been induced earlier?
Should a C-Section be considered?
How should her insulin be managed during labour and delivery?
Most would induce at 38 weeks.
Insulin infusion may not be required during labour but you should increase blood glucose monitoring.

9. Mrs. C
Following delivery, blood glucose levels normalised and she was able to stop insulin.
After 6 weeks, she underwent an OGTT, the results of which are as follows.
What is the diagnosis?
What is her risk of developing diabetes in the future?
When should she be tested next?
Time
0 hour (Fasting)
2 hours
Glucose mmol/L (mg/dl)
4.5 (82)
7.0 (127)
This lady has normal glucose tolerance.
However, her risk of developing diabetes in the future is high and she needs to be tested every year with OGTT.

10. Case study #2: Mrs. S
Mrs. S is a 35 year old nulliparous lady and has suffered two miscarriages in the last three years.
After the last miscarriage she was diagnosed with PCOS and has been on metformin since.
She did not test her blood glucose levels during either of her previous pregnancies.
Her mother has diabetes.
She presents at 12 weeks gestation
What else do you need to know?
An introduction to Mrs. S
Ask if any more information is needed.
Check if they ask for gestational age at miscarriage and then say that she was at 6/7 week gestation at time of miscarriage.
Wait to see if the group asks for the reason for metformin. Her glucose levels were ok and she was on metformin for ovulation induction – that will lead on to the next slide discussion

11. Mrs. S Does she need to be screened for diabetes? If so, when?
What screening test is to be used?
Should the metformin be continued?
What is the purpose of metformin?
This lady has several risk factors for diabetes and needs screening.
The first screening should be done as early as possible during pregnancy. According to the IADPSG, “conventional” criteria, a random glucose at 2 hours post prandial is to be used for screening during 1st trimester. The aim of early screening is to pick up pre-gestational diabetes.
What is the purpose of the metformin?
Can the metformin be continued now that she is pregnant?
What dose should be used?

12. Mrs. S
Mrs S has an OGTT at 13 weeks gestation Are these results ok? Should she be retested? When? What management strategies should be considered?
Fasting
2 hour
Glucose mmol/L(mg/dl)
6.0 (108)
9.0 (162)
Is it necessary to do a GTT at this point or would a fasting and 2 hour PP be adequate?
She has GDM. She is on metformin already – go over her diet.
Switch to insulin – can discuss. Most might continue metformin until 12 weeks gestation to prevent miscarriages, but she is now past 12 weeks so metformin might be stopped
Nutrition and gentle exercise should be discussed with her.

13. Case Study #3: Mrs M Mrs. M, 30/F – Primigravida
LMP: 13/10/12 EDC : 28/07/13 Regular cycles
Spontaneous conception 10 months after marriage
No family history of DM

14. Mrs M Fasting BG at 6 weeks What would you advise now?
8.8 mmol/L (160 mg/dL)
What would you advise now?
Trial of MNT or medications right away?
Any other tests?
What risks to the pregnancy will you discuss with this lady?
Very possibly pregestational diabetes – A1c will help in discussion of risks
Need to get good glycemic control quickly initiate medications – – out patient or admit and initiate.

15. Mrs M
Normal scan at 12 weeks with a low risk of Downs week scan plus fetal echo was normal When will you advise next scan? Glucose results as in next slide. Patient not very regular with SMBG and not following the meal plan
Next scan should be at 28 weeks

16. Mrs M – Blood glucose record
Gestational age
FBS mmol/L (mg/dL)
1 h PPBS mmol/L(mg/dL)
A1c %
Medication 15
5.9 (107)
6.9 (125)
8.1
Premix 70/ Metformin 500 BD 18
7.1 (129)
10.1 (183)
7.2
Metformin BD 19
5.3 (97)
9.6 (173)
Metformin BD
5.8 (105)
8.7 (157)
6.5
Discussion on choice of insulin _ metformin –can be insulin alone - type of premix (analogue or regular insulin) and how to arrive at a dose – critical discussion on this management of dosing
Should the metformin be continued?
Disadvantages of premix insulin vs advantages of rapid acting and detemir (less ability to adjust, less flexibility vs higher cost) or regular and NPH
How to deal with woman not following the meal plan or checking BG
Patient felt giddy on 26 in am and so cut back to 22 – 0 20 – how to adjust dosing to achieve better control

17. Mrs M 29 week scan Ask to comment
To identify that AC is on the 90th centile - discuss implications and when to rescan

18. Mrs M
She comes in with c/o discomfort and abdominal pain at 30 weeks How will you manage her now? Uterus is irritable with some tightening on and off
Watch for regularity of contractions – and check a vaginal exam
If uncertain – a TV scan and a normal cervical length ( > 2.5 cm) will help rule out Preterm labour
Send of a MSU for routine and C/S
Check BP
Once uterus is noted to contract – tocolysis and steroids

19. Mrs M
Tocolytic – which drug and dose Steroids – dose / concerns in GDM
Nifidepine preferred – tocolytic
Betamethasone 12 mg 24 hours apart
Check glucose and adjust insulin – usually effect lasts 3-4 days then can taper back to earlier dosing – emphasize that even if not on insulin earlier, GDM many need insulin to cover steroids.

20. Mrs M
Uterine contractions settle. UTI picked up and treated with appropriate antibiotics She is now 37 weeks FBS 5.5mmol/L (100mg/dL) 1 hr PPBS 8.3 mmol/L (150 mg.dL) on Regular (soluble) NPH Comes in with decreased movements What would your approach be?
First examination document FH and then run a CTG – if normal Scan to assess liqour and EFW
Discuss and consider induction of labour / delivery
should we insert a CTG trace here and give them a little bit about what to look for?

21. Case Study #4 Mrs. C, a 32 year old primigravida
Reports for the first antenatal checkup.
She is obese with a body mass index of 35 kg/m2, both her parents have diabetes.
Her OGTT results are as follows.
Her HbA1c is 9.2%.
What type of diabetes does this patient have?
What is the ideal line of treatment?
What is the prognosis for the pregnancy and for future resolution of diabetes?
Time
0 hr (Fasting)
1 hour
2 hour
Glucose mmol/L(mg/dL)
10.6 (192)
16.0 (288)
14.6 (263)
This patient has pregestational diabetes. GDM does not usually present this early in pregnancy, and HbA1c will not be so high.
The patient will need lifestyle modification and insulin.
It is also unlikely that the diabetes will resolve after delivery.
Anomaly scans and fetal echocardiograms should be done to rule out congenital anomalies .
NOTE only one slide here as woman is not GDM but DM