Saturday, 11 June 2016

The Dual Challenge Pregnancy with Hypothyroidism and GDM

About a young lady and her journey with hypothyroidism and GDM
Dr Smruti Mandar Haval  (Dr. Smruti Subhash Nikumbh)

This story I have pen down today is about Mrs.P a young lady of mid-twenties age. She is a known case as hypothyroidism and on regular treatment. In fact her hypothyroidism got diagnosed during her work up of infertility. With meticulous follow up and treatment she managed to conceive.(It is a painful journey so far as she meet me every month with blood report - poor lady is tired of same).But now she is a pioneer member of Project Kamal and inspiring many more for a good fight against hypothyroidism).

All was good till one fine day her husband called me and asked for an appointment .Her 7 th month was running and she was suffering from sore throat, joint pain, fever with chills, pedal edema etc. The joint pain was so severe that it was refraining her from doing her day to day activity. I ask him to see me earliest. It’s been an slightly emotional call as I know this couple last 18 months and have seen their struggle quit closely. They are very humble, obedient and compliant with whatever treatment has been offered to them.

As per schedule she came to my OPD and I did her assessment. Clinically she was suffering from acute pharyngitis with viral fever. She told me these symptoms are there from 4-6 days and she seek treatment for same from a nearby doctor who gave her two injections (?) followed by which she had dark colored urine for 2 days with little relief. We advise her few basic investigations to work up fever cause.

She came back after 2 hours with them and to our surprise her urine was showing 3 + glucose, her RBS was 348 mg/dl, Hb has dropped and urine was showing few pus cells. This was a big news as all her last investigations were absolutely normal. To confirm the findings we probed her more on family details and we got to know that her father was a diabetic and died few years back because of diabetic complications. Her paternal aunt and elder sister are diabetic. So a strong history of diabetes support current results.

She got nervous, anxious, emotional all at same time and started crying as she smell that something is wrong with her investigations. The husband and I somehow counseled her that no need to worry lets fight the battle. I told her that she is on verge of a disease name Gestational diabetes mellitus a type of diabetes appears during pregnancy and there is treatment for it if she cooperates as she always do. She somehow manage to balance her emotions and told me please go ahead and confirm whether it’s really there in her as she was really tired of fighting this pricking & draw blood business!

I did her Hba1c in my OPD and that reading too came 8.4 %.I was not so convinced with that result as her Hb was also low so there were higher chances of bias or increased reading. We also cross check her urine sample for glycosuria as on dip stick we got 3 + glucose but on Benedict's test also the urine colour came brick red the same colour I have seen in my biochemistry classes!

We admit her control her sugars with MNT and insulin therapy. Her infection has been controlled with intravenous antibiotics. Throughout the process pedal edema remains with fluctuations but her BP was normal and no investigations suggesting HELLP syndrome. Now things are under control, she underwent caesarian section and delivered healthy girl child Macrosomic but cute.


The lesson I learnt from this case is importance of detail history taking, screening high risk pregnancy and MOGTT in second trimester. Tests like MOGTT are bit costly, time consuming hence not so popular test or investigation in most of the parts of rural India.

But the primary care physician and obstetricians can use simple tests like 50 gm oral glucose challenge test which is less time consuming and good screening tool along with random RBS. This may help to pick up the DM early in pregnancy as India is one of the capital of diabetes and diabetes is fast treading disease.

Many guidelines have shown that South Asian females are more at risk of developing GDM hence there early screening is very important. HbA1c can also act as a good tool but in Indian rural scenario under lying Anaemia is a hurdle. Through Diabetic Mitra project we are trying to improve this situation and hopeful that Almighty will give us healing hands. Thank you.

Suggestions for strengthening rural healthcare and Role of WoRSA

To create database or educational materials this will help primary care physician in rural area all over the world in awareness about GDM. Some researches papers can be done and published which can later be used as reference or guidelines suitable to need of south Asia.

Dr Smruti Mandar Haval (Dr. Smruti Subhash Nikumbh)
M.B.B.S.D.N.B. (Family Med),M.N.A.M.S.,P.G.D. Diabetology & Geriatric Med.
Certified International Diabetic Educator by Project Hope & International Diabetes Federation (IDF) USA
Consulting Physician in Family medicine, Diabetology, Preventive Cardiology, Thyroid disorders & Geriatric Medicine
C.E.O. Sukarmayogi Publishers, Sankeshwar Dist: Belgaum, Karnataka
Assistant Professor, Department Family Medicine, USM-KLE IMP,Belgaum
Area of practice- Sankeshwar, Dist – Belgaum ,Karnataka

Epidemiology of your area in brief:
It’s an semi rural area covering more than 50 km radius including many villages. Its USP is it’s an border area connecting borders of Maharashtra and Karnataka which makes it an multiethnic area. Common chronic health diseases are diabetes,hypertension,asthma ,hypothyroidism etc.

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