Hippokratia 2012, 16, 4: 385
Tsakalis AV1, Harizopoulou VC2, Goulis DG2, Savopoulos C3, Limenopoulos V1, Hatzitolios AI3
1Department of Internal Medicine, “G. Gennimatas” Hospital, 2Unit of Reproductive Endocrinology, First Department of Obstetrics and Gynaecology, 3First Propedeutic Medical Department, AHEPA Hospital, Aristotle University, Thessaloniki, Greece
Keywords: gestational diabetes mellitus, type 2 diabetes, diabetic ketoacidosis
Gestational diabetes mellitus (GDM) is defined as glucose intolerance with onset or first recognition during pregnancy. Pregnancies diagnosed with GDM are in increased risk of adverse perinatal, maternal and neonatal outcomes as well as recurrence of GDM in future pregnancies and subsequent development of type 2 diabetes (DM2)1.
A 30-year-old woman presented at the emergency department with anorexia, polyuria, polydipsia and abdominal pain accompanied by vomiting during the last four days. She lost eight kg of weight during last month. Her obstetric history included a pregnancy, two years before her presentation, complicated with GDM and terminated by caesarian section in the 39th week of gestation. Her infant was male, healthy and weighted 2450 g. Personal and family history was free. Blood tests revealed: plasma glucose concentration 543 mg/dl, glycated hemoglobin 9.7%, pH 7.122. A diagnosis of diabetic ketoacidosis was set and given the history of GDM, the diagnosis of DM2 was obvious as well.
The patient was admitted to the Department of Internal Medicine. Rehydration by intravenous administration of fluids, potassium and regular insulin was applied. She responded soon and well and her glucose concentrations were gradually normalized. She received information on issues of diabetes, diet and physical activity. She was discharged seven days after her admission, receiving a prescription of an intensive insulin basal bolus scheme. The suggested follow-up included a scheduled monthly visit at the diabetologic outpatient clinic.
Despite the diagnosis of GDM, the only information given to the patient by her obstetrician concerned just diet adjustments during pregnancy. She was not given any information on the risk of developing DM2 in the future, neither on the ways to prevent it. She failed to detect the early symptoms of hyperglycaemia, which resulted in the life-threatening complication of diabetic ketoacidosis.
Lack of uniform diagnostic criteria for GDM has often led to misconceptions and undertreatment of GDM2. The responsibility of providing the patient with optimal treatment belongs to health care providers as well as the health care system. The management should be focused on glucose surveillance and establishement of healthy lifestyle changes (diet, physical activity). The success of the therapeutic approach depends on the individualized approach and the active participation of the patient in the decision-making3. Health care providers should establish a close and longitudinal relationship with the patient, stressing the importance of postnatal metabolic assessment, according to clinical practice guidelines, in order to attain the important goals of diabetes prevention and early diagnosis of overt diabetes.
1. Bellamy L, Casas JP, Hinqorani AD, Williams D. Type 2 diabetes mellitus after gestational diabetes: a systematic review and meta-analysis. Lancet. 2009; 373: 1773–1779.
2. Karagiannis T, Bekiari E, Manolopoulos K, Paletas K, Tsapas A. Gestational diabetes mellitus: why to screen and how to diagnose. Hippokratia. 2010; 14: 151-154
3. Ferrara A, Ehrich SF. Strategies for diabetes prevention before and after pregnancy in women with GDM. Curr Diabetes Rev. 2011; 7: 75-83.