Abstract #1407760: Case Study: A Challenging Case of Management of Pre-existing Type 2 Diabetes Mellitus During Pregnancy in a Patient with Multiple Insulin Allergies

Abstract

Management of pre-existing Type 2 Diabetes Mellitus (T2DM) during pregnancy can present challenges. In such cases treatment of choice to avoid hyperglycemia is insulin therapy, with a need for frequent insulin dosage titration. Tight glycemic control is necessary for preventing preeclampsia, macrosomia, stillbirth and other complications related to hyperglycemia. In this case study we will present the treatment of pregestational diabetes using an insulin pump in a patient with a history of multiple insulin allergies. A 33-year-old female patient presented with uncontrolled T2DM and a known allergy to insulin detemir. At her first pre-pregnancy visit she presented with a Hemoglobin A1c of 9.5% and was already monitoring her blood glucose using a Continuous Glucose Monitor (CGM). She was prescribed Metformin as an initial therapy. Semaglutide was later prescribed to achieve glycemic targets. Eight months later we were informed she was 5 weeks pregnant with an unplanned pregnancy. Semaglutide and Metformin were discontinued at that time and intensive insulin therapy was started with insulin glargine and insulin lispro. As the need for frequent insulin adjustment became apparent, she was started on an insulin pump with the use of insulin lispro at 15 weeks for more precise control of her blood sugars. Five weeks later the patient developed an allergic reaction (hives and dyspnea) related to the insulin lispro, and was switched to regular insulin U-200. As the pregnancy progressed, both the basal rates and insulin to carbohydrate ratio had to be increased with an average total daily dose of 176 units per day in the third trimester. Prior to becoming pregnant, her estimated average glucose (eAG) reading was 238 and time in range (TIR), 70 mg/dL-180 mg/dL, was 11%. At the start of the pregnancy, the patient's eAG was 224 and TIR was 17%. At 11 weeks, the target blood sugar range was adjusted to 70mg/dL - 140mg/dL for tighter blood sugar control. Towards the end of the pregnancy, the eAG was 156 with a TIR of 42%. At the end of her pregnancy, on her best day her TIR was 86%. The pregnancy was further complicated with preeclampsia and resulted in a Cesarean section at 36 weeks with a birth weight of 6lbs 3oz. Glycemic control is imperative for a beneficial outcome of the maternofetal unit since glucose levels tend to be higher during pregnancy. In addition, a history of insulin allergies can further limit treatment options. Use of a pump can prove beneficial for management of uncontrolled T2DM during pregnancy. Considering cases such as this can improve overall glycemic control during the gestational period.