Diabetes in Pregnancy – The Need for Early Detection

Dear Friends,

I am re-sharing here an article I wrote along with my wife Dr K Harrini on the eve of the World Diabetes Day 2010, for promoting public awareness on Diabetes in Pregnancy. I hope you find it interesting and informative.

Please do have a look at the link http://www.ktvr.com/hospital/NewsLetters/KtvrNewsLetter1210201010202PM.html - it gives a coverage on our activities for World Diabetes Day 2010. Comments and suggestions are most welcome.

With thanks & regards,

Vijay.

Diabetes in Pregnancy – The Need for Early Detection

by

Dr. K. Harrini, MD (O & G) and Dr. J. Vijay Venkatraman, MBBS, F. Diab.

Diab-at-ease Clinik and Women & Child Care Clinic, KTVR Group Hospital

Narayana Guru Road, Saibaba Colony, Coimbatore – 641 011.

Phone: 0422 – 2445311, 2445451. Mobile: +91-94421-55511

E-mail: hospital@ktvr.com Web: www.ktvr.com

World Diabetes Day (WDD) is celebrated every year on November 14. World Diabetes Day was created in 1991 by the International Diabetes Federation and the World Health Organization in response to growing concerns about the escalating health threat that diabetes now poses. Interestingly, this day is also celebrated as Children’s day in India. It is very appropriate that these two occasions fall on the same day because children are becoming more susceptible to diabetes nowadays and the best gift we can give our children and ourselves alike is awareness on the implications of diabetes and stress on its prevention.

The World Health Organization’s estimation of the prevalence of diabetes in adults indicates an expected total rise of more than 120% from 135 million in 1995 to 300 million in 2025. This includes Gestational Diabetes Mellitus (GDM) which is defined as ‘carbohydrate intolerance with first recognition or onset during pregnancy’ and Pre-GDM, a term that denotes known diabetic subjects who become pregnant.

The prevalence of diabetes in India is growing tremendously and so is its awareness. While knowing about diabetes in general is very important, we need to also focus on diabetes in pregnancy with more seriousness, as two generations are at risk and because prevention of diabetes starts from there. Women with GDM are at increased risk of future diabetes and their children are at risk of childhood obesity and diabetes later in life. This fact should warn the physicians and general public alike to the necessity to devote special attention to this problem.

GDM is associated with obstetric, maternal and neonatal complications. Uncontrolled diabetes in pregnancy leads to spontaneous abortions, birth defects - especially heart problems in the baby, preterm labour, big baby, hypertension, sudden in-utero death, delayed & difficult labour and consequently more bleeding during delivery. Mothers are at increased risk of urinary tract and vaginal infections and Type 2 Diabetes in future. Babies have immediate problems of respiratory distress, hypoglycaemia (low sugar) and electrolyte imbalance and long term complications of obesity and diabetes. Hence, it is essential to screen all the pregnant women for glucose intolerance by oral glucose test. It is usually done between 24 -28 weeks of gestation and in selected high risk women even earlier.

A team approach is needed in management of Pregnancy in Diabetes with the obstetrician, diabetologist, dietician and paediatrician working in concert. Intensive monitoring, diet and insulin therapy are cornerstones for management. The importance of educating pregnant women with diabetes (and their partners) about the condition and its management cannot be overemphasized.

All pregnant women must be aware of when to screen for GDM and GDM mothers must know about its implications for herself and her baby, diet, lifestyle changes, self-glucose monitoring and insulin therapy. Foetal growth must be evaluated with ultrasound and foetal echo done to rule out cardiac problems. Maintenance of mean Plasma Glucose level ~105 mg% is ideal for good foetal outcome. This is possible if Fasting and Post prandial levels are around 90 mg/dl and 120 mg/dl respectively. Insulin is essential if medical nutrition therapy fails to achieve normal glucose levels.

Prevention of adverse maternal and perinatal outcomes in GDM is based on achieving maternal blood glucose as close to normal as possible. Gestational diabetic women require follow up. Glucose tolerance test with 75g oral glucose is performed after 6 weeks of delivery and if necessary repeated after 6 months and every year to determine whether the glucose tolerance has returned to normal or progressed. Diabetes in Pregnancy needs holistic care for good health of women and her child.

The theme for World Diabetes Day is “Diabetes Education and Prevention” and the campaign slogan for 2010 is “Let’s take control of diabetes. Now.”

The slogan for this year's World Diabetes Day Walk is “Understand diabetes and take control”. Let us remember all these key points and commit to the well-being of ourselves and our children, in our dedication to the cause of preventing diabetes.

Hypoglycemia in patients with Diabetes Mellitus

Diabetes mellitus is a common health disorder characterized by a myriad of clinical features that share the common denominator of increased blood sugar levels known as hyperglycemia. The term hypoglycemia refers to the state in which the blood sugar level drops below the acceptable lower limit of the normal value. In this article, we shall see how hypoglycemia, stands out as an important topic that every diabetic patient should be aware of, in lieu of the significant toll it could take on their health.

Normal blood sugar levels in human beings usually range from 70 to 140 mg/dL depending on various factors throughout the day. Hypoglycemia is generally experienced when blood sugar levels drop lower than 60 mg/dL. It is almost always seen only in diabetic subjects on treatment with insulin or with some types of oral anti-diabetic medications. It is seldom encountered in a normal non-diabetic person or a diabetic subject who is not on any drug treatment for diabetes. Exceptions may be times of starvation or unusually intense physical activity, which occur more often in children than adults.

Hypoglycemia occurs in a diabetic patient due to one or more of the following scenarios:

1. The patient takes the drug but does not have the meal at the right time in relation with the drug intake as advised by the doctor.
2. The patient chooses to fast or has very little food on any given day after taking the regular medications.
3. The patient delays any meal for long hours. For example, it is common for people having a late lunch after taking medications in the morning to experience hypoglycemic episodes at noon.
4. The dosage of the medication is high or the patient’s drug requirement has recently decreased due to improvement in their blood sugar control.
5. The patient is dehydrated due to vomiting or diarrhea.
6. The patient subjects themselves to unaccustomed physical exertion.
7. The patient has kidney problems leading to poor excretion of the anti-diabetic medications leading to repetitive low sugar episodes.

Sudden hunger, shivering, palpitation and sweating are the initial warning signals of a hypoglycemic episode. Left untreated, hypoglycemia can lead to loss of concentration, drowsiness, confusion, speech difficulty, incoordination, visual disturbance and even to loss of consciousness. Frequent hypoglycemic episodes can cause memory loss in the long-term. Hypoglycemic episodes occur more frequently and are more severe in intensity in type 1 diabetic subjects than those with type 2 diabetes.

The immediate treatment for a hypoglycemic episode is to administer oral glucose preferably in a liquid form, i.e., either to give normal table sugar or glucose powder mixed in any beverage or in the worst case, with water. This is advocated rather than just pouring solid sugar crystals into the patient’s mouth because as the hypoglycemia becomes severe, the saliva in the mouth dries up and so, it is difficult for the sugar crystals to get absorbed. If the patient comes back to normalcy within a few minutes, no other treatment is required. But once a patient becomes unconscious or reaches a stage wherein it becomes impossible to feed them orally or develops repetitive hypoglycemic episodes, emergency hospitalization is mandatory because glucose has to given through injections and the patient also needs to be evaluated for other causes for the coma.

In order not to risk becoming hypoglycemic in public, diabetic patients on drug treatment are requested to always carry chocolates with them whenever they go out of the house. This helps a lot because they can take a chocolate immediately after they sense the initial symptoms of their low blood sugar level instead of allowing it to progress into a full-blown hypoglycemic episode.

Hypoglycemic episodes pose a big challenge in patients having diabetes for a long time because they are more prone to develop a condition called Hypoglycemia Unawareness in which they do not experience the classical alert signals of the condition while their blood sugar level is already much lower than normal. This condition occurs due to the patient’s nerves being affected due to long-term diabetes. These patients need to be more careful than others in taking their medication and food at the right time, as they run a higher risk of developing severe and serious complications due to hypoglycemia.

To conclude, hypoglycemia is something like a necessary evil for one who is on drug treatment for diabetes. Best results of diabetes management are seen only with good sugar control but good sugar control always comes with a little risk of hypoglycemia. If we avoid medications for the fear of hypoglycemia, we are almost always sure to face the severe complications of diabetes. But, if we learn to tackle the episodes of hypoglycemia prudently, we can be sure that we are striking the right balance. Balanced diet and right lifestyle are significant factors that influence blood sugar control positively. Needless to say, due to the complicated medical issues involved with diabetes and its treatment, a patient must never self-medicate and should always make it a point to regularly review with their doctor so as to maintain the expected level of sugar control with negligibly minimal low sugar episodes.

My first publication in an international medical journal!

Dear Friends,

At the outset, let me wish you all a very Happy New Year for welcoming 2010!

At the fag end of 2009, I am very glad to share with you that my second medical article (first in an international journal) has been published in the January 2010 edition of the Journal of Diabetes Science and Technology.

The article is titled 'Epidemiology of Cardiovascular Disease in Type 2 Diabetes: The Indian Scenario'. At this moment, I thank my teacher Prof V Mohan for including me in the writing of this article. This article will be available only by paid download from the journal's site for a period of one year from the date of publication.

However, the abstract of this article is available free of cost. The direct link is http://www.journalofdst.org/January2010/Abstracts/VOL-4-1-ORG10-MOHAN-ABSTRACT.pdf. I would be happy if you could read the article and give me your valuable feedback. Comments are suggestions are welcome.

With thanks & regards,
Vijay.

My first medical article published in JAPI!

Dear Friends,

I am very happy to share with you all that my first medical article has now been published in the June 2008 edition of the Journal of the Association of Physicians of India (JAPI). The article is about challenges in diabetes care in India. I am glad to have been one of authors of this article which has three internationally acclaimed opinion leaders in medicine, Dr Shashank R Joshi, Dr Ashok Kumar Das and Dr V Mohan, as its lead authors. At this moment, I thank my professor Dr V Mohan for including me in the writing of this article. You can access the article at the JAPI website www.japi.org. The direct links are http://www.japi.org/june_2008/u-443.pdf (PDF format) and http://www.japi.org/june_2008/u_443.html (HTML format). I would be happy if you could read the article and give me your valuable feedback. Comments are suggestions are welcome.

Yours Always Musically,
Vijay.