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.

Conclusion

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
Blog: drsmrutihaval@blogspot.com
drsmrutimhaval.blogspot.com
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.

The silence of tired tongues

 

Brazilian "mate" at an Irish background

Mayara Floss

* Thoughts about one of my experiences as a Brazilian medical student in the countryside of Ireland

When I was leaving an elder’s home care in a rural area of Ireland, a doctor told me: "you know, one of the last things a person with dementia loses is the sensation of the touch on the skin, and this is the reason that touching your patients is so important in this stage of their lives."

 With these few words I started to realize how much this explains to us. One of our first sensations is the tact, and in the end everything is the same sensation. The knowledge to feel before speak. But, as we grow up, the tact becomes rarer. Sometimes the symbol of a friendship becomes a simple handshake. And we start to get used of how not to feel. We leave our parents’ laps and start “learning” that too much proximity often is invasive or not common. 

 However, the sensation of the touch continues to be important, even in our unconscious. People with dementia do not lose the capacity of having emotions or the recognition of a caress. Probably this is one of the sensations the doctors need to revive in their practicing. The tact is essential, even if just feeling the pulse. In the song “Casa no campo” (house at countryside), by Zé Rodrix, he speaks about “the silence of the tired tongues”, something not so common in our society nowadays. However, when the dementia process starts, this silence makes more sense. 

The care also changes its form, the silence of tired tongues makes us try to approach people in other ways. Sometimes, words lose their meaning, as well as communication (which seems to be many times attached to concept of speaking) with the patient becomes in body language. Although the person with dementia is most of times isolated from the conversation and loses the reference of the listening, what we learn is the importance of smiling, of giving hands and hug each other – be human without talking. Sometimes I think that words left the world more distant. Probably, the importance of the touch continues to everybody since his/her childhood, but masked by words. By finding a patient in the process of dementia, we have the chance to rediscover ourselves and our own tact. Due to this, tired tongues or not we still could say a lot of things touching.

The song about the house on the countryside and the "tired tongues"

Originally written in Portuguese: http://balsa10.blogspot.com.br/2014/05/silencio-das-linguas-cansadas.html?q=sil%C3%AAncio  

Diabetic foot real challenge of rural India

  Dr Smruti Mandar Haval  (Dr. Smruti Subhash Nikumbh)

About a man with gangrenous diabetic foot and his fight against amputation

 It was a lazy Saturday evening of my OPD. Suddenly one of my hospital attendant came & told me, “Madam,one OPD patient is waiting for you. Would you like to examine him? He has a bad pus filled, fowl smelling, dirty wound over his one of the foot.” She made a face. But I decided to help him. As I am a primary care physician and helping him is my duty.

I asked my attendant to send him to my OPD. This was my first encounter with Shintre family. I saw one 18 years old young boy was accompanying his 78 years old grandfather who was suffering from left diabetic foot.

It seems he was known diabetic and hypertensive since last many years and was taking treatment from CHC near by because he cannot afford a private physician. He was a poor, illiterate fellow, surviving with his wife in different house. His pension income was 500/- only. The treatment he received from CHC was theTb.metformin 500mg OD and Tb. atenolol 50 mg OD. (Not so preferred combination in old age diabetic person unless indicated).He also had some heart problem (? IHD) in past but no details were available.

The patient was having deteriorating wound day by day even after dressings by CHC staff. The family came to me as they overheard I am a diabetic educator and were hopeful that I will help them in this worsening situation.

This was a tricky call for me. As I have to decide to treat him in my OPD or refer him to surgeon. But family members were not ready for surgical intervention and requested me to do the most needful I can to my best capacity.

I made my mind to take the challenge & win this battle of diabetic foot. I was determined to save this foot as amputation is not the solution .A thorough patient education, family members counselling, appropriate BSL control and wound care is must as treatment.

 I carefully assessed the foot.It was full of pus, slough, dorsum of foot skin was destroyed. Tendons, even some part of metatarsals was visible. The third toe of foot had dry gangrene at distal phalanx and proximal phalanx has developed wet gangrene changes. He has no pain sensation; temperature sensation over the foot. Mild crude touch was intact.

I was worried for changes of gas gangrene and maggots .But to our luck wound has no maggots or crepitus changes.I cleaned the wound and  then washed it properly with betadine, normal saline, spirit and gauze pad. While using gauze pad for dressing I follow one rule taught by my surgery teacher.”Not to use cotton straight on the wound. The small threads of cotton got stuck or attached to slough and margins which delays the wound healing.” Hence I used simple gauze made up of dressing bandage roll. I also immunized him with a tetanus toxoid injection.

I know sending pus culture was a must thing but due to limitations of both my reliability of resources and patient’s economic status I have to cancel that investigation. But I did other relevant investigations like CBC, Sr.creatinine, Sr.urea, lipid profile,BSL fasting & post prandial, ECG, X ray foot.

To my relief X ray has no changes of Charcot joint,osteomyelitis or gas gangrene. But his Hb was low, creatinine, urea, BSL were high.

After evaluation of investigations I switch him to pre-mix insulin, aspirin atorvastatin, oral haematemics and low dose ecitalopam as he was very depressed and anxious about the entire process. I used tramadol and paracetamol as analgesics as since the beginning I was worried for his renal function, hence don’t want to use NSAIDs group drugs (many doctors give diclofenac injection intramuscular quite often as routine without considering renal status.)I also stopped his CHC started metformin and atenolol which has no much role in his treatment now. His blood pressure was 130/80 mm Hg; hence we did not give any antihypertensive with relevant antibiotics.

Slowly he started showing improvement .His pus reduced, wound looks healthy and granulation development was visible. But the third toe was still a concern. It’s the gangrene changes were not resolving. One day during the dressing, the tendon holding the third toe rupture and by next visit the toe was unstable. This happened after 4 months of meticulous dressing.

In this situation I have to take a call of amputation– painful but important. I discussed the possibilities with family and the patient .they gave me the consent for same as by now it’s only a toe they were sacrificing and not the whole limb.:-)

With their permission I did the amputation with a pair of scissors .It bleed profusely post amputation as patient was on aspirin but later after giving a good pressure bandage, stump started healing fast and appropriately.

Initially for almost 2 months we did twice a week dressing.Once wound started healing well we reduced it to once a week. During this treatment anemia correction and use of aspirin works like magic wand. The patient has zero pain, temperature sensation minimal touch sensation over the limb on day one. But as we started regular supervised dressing series he resumed his pain, touch sensation to almost normal level. At times he used to scream, beg and yell for euthanasia .But this pain was worth bearing because birth of new foot has started in his life.Now Mr.Janaba Shintre is doing well. The diabetic foot is almost healed now. He has resumed his day today activities well.


Conclusion
This journey with this patient as primary care physician and diabetic educator taught me a lot. This experience underline few important aspects of patient centered care like good compliance to treatment ,faith in treating physician, role of good patient and family’s education etc.Every diabetic foot does not require amputation. With systematic and periodic care we can save limb from horror of amputation and followed disability.

At the end I thank Almighty for giving me transient healing hands of a physician. Thank you. :-).

_________
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
Blog: drsmrutihaval@blogspot.com
          drsmrutimhaval.blogspot.com
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.

When Arthritis becomes a challenge

On 19th of May, we celebrated the World Family Doctor Day. Thank you all those who are working tirelessly and maintaing integrity and ethical values of our noble profession. Time to remember and celebrate our contribution towards a healthier world. This year smoking cessation was the  theme. Preventive, curative and promoting health are the core areas of primary care physician. We are working to help everyone who wants to quit smoking and to educate all those who are still ignorant about its ill effects. You can quit smoking if you just think to quit. Have a better life..A smoke free life!!! 

Please enjoy the story by Dr. Sumana Datta.

Dr.Sumana Datta

A 30 year old married house wife, lean and thin, belonging to a lower middle class family,residing at a nearby village,came to my clinic an early morning.On entering my clinic before I could offer her a seat, she started explaining her symptoms to me.She was anxious.

I asked her to be calm, take a deep breath,offered her a seat near to me and asked my assistant to give her a glass of water to drink.There were patients waiting outside my clinic but I decided to take my time listening to her with patience.

What I came to know was that This lady had been suffering for the last 1 and half years from generalised weakness,generalised body ache , low back ache and pain in multiple big and small joints including the small joints of hands, occassional episodes of low grade fever.The symptoms were proggressive in nature associated with deterioration of  her general well being.At present she could not eat well, sleep well, remained tensed and depressed.The worst part of the story was that her husband had left her due to her illness.She had no child.She was staying at her parents house.She had been treated by local doctors posted in their rural hospitals with several multivitamins and pain killers providing brief episodes of relief but followed by recurrence.Her blood investigation showed raised ESR.

The lady broke into tears while narrating her story to me.

On examination I found out that she was having  pallor, tachycardia (may be due to anxiousness, may also be due to anaemia and her disease process) and polyarthritis affecting the small joints of hands.The DIP was not tender or swollent at that time but she was telling that she had suffered pain in the DIP s also.A startling finding was that she had dry hypopigmented plaques with white scaling , central clearing and severe itching affecting the lateral aspect of her right cheek extending more laterally to involve the right ear and right side of her neck.When asked about these skin lesions, she said that this was present for long duration,and showed me that there were similar lesions in the anterior aspect of abdomen, lateral aspect of right thigh too.There was no such lesion in the extensor aspects of limbs or near pressure points.Nails were spared.Scalp was also not involved.She was insisting that those were diagnosed to be Tinea Corporis (local language : Daad) and she had been applying several antifungal topical ointments.

To me it clinically appeared to be a typical lesion of DLE (Discoid Lupus Erythematosis) and I suspected that she might have been sufferring from Lupus Arthritis.

I asked her to do a blood test for ANA , Biopsy from the lesion.But thess tests were not available locally and the lady could not afford the price of the tests too.

Based on my clinical suspicion I started her on Hydroxychloroquine 400mg /day along with TCA and Clonazepam, Oral iron supplementation and a Sunscreen lotion.I asked her to protect herself and the lesions from exposure to sunlight.

She came to me for a follow up after 14 days.Luckily,She responded well to Hydroxychloroquine and was symptomatically better.She was happy.

I explained to her what I suspected, what an autoimmune disease is,that it is a multisystem disorder and that ideally she should visit a Rheumatoligist and should undergo regular monitoring.

But she is reluctant to visit any other doctor.

Till now she is doing fine with marked improvement of her generalised well being.Her parents came to me and thanked me a several times.She has started a new life.She is now providing  home tution to toddlers.

What I am trying next is to contact a local NGO and arrange for her treatment in a Govt Tertiary Care centre in Kolkata at least for once where she will be able to undergo a consultation with a rheumatologist and undergo the other necessary investigations free of cost to exclude other underlying systemic complications of the Disease.

I have assured the lady and her family that her continuous care, monitoring and screening for other systemic complications with the locally available cheap baseline investigations will be totally taken care of by me.

Suggestions for strengthening Rural Health Care:

This case has taught me the importance of dermatologic manifestations of systemic diseases. The primary care physicians should be trained well regarding the Dermatological Manifestations of Systemic diseases preferrably with Audio Visual Educational materials which will help them in early diagnosis and treatment of several systemic illnesses based on clinical suspicion where the resource is  limited.

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Area of Practice:

Gangarampur (Sub divisional town) Dist: South Dinajpur, State:WB, Country: India. Epidemiology of the area: It's a small town of about 10km2 diameter with apprx. 50, 000 population.It is located very near to Indo-Bangladesh border.There is  huge inflow of patients not only  from nearby rural areas of South Dinajpur , North Dinajpur, Malda district but also from the rural areas of Bangladesh.Population comprises of people from  both Hindu and Muslim communities.There is also prevalance of the Tribal communities.

Dr.Sumana Datta,

MBBS, DNB; Specialist Family Physician;

Life member, AFPI

President,

Academy of Family Physicians of India (WB Chapter)

Ph: 9232610964