Pragmatic approach and variations in the management of pregnant women with type 1 diabetes mellitus on insulin pump: a case series
-
Varuna Nargunan
,
Christopher A. Enakpene
,
Glen Bennion
Abstract
Background
According to a 2017 Centers for Disease Control and Prevention (CDC) report, there were 23.1 million Americans living with diagnosed diabetes. Diabetes-related complications in pregnancy are spontaneous abortion, preterm delivery, preeclampsia, fetal malformations, altered fetal growth, polyhydramnios, and unexplained fetal demise. Continuous insulin delivery through insulin pump is used for effective management of type 1 diabetes (T1DM).
Case presentation
We present case reports of four patients who were on insulin pump for at least 1 year prior to pregnancy and continued throughout their pregnancy. Although these case reports demonstrated overall good pregnancy outcomes, it did not show how well their blood glucose was controlled during pregnancy.
Conclusion
Standard of care in diabetic management during pregnancy using insulin pump in the presented case reports supports the American Association of Clinical Endocrinologists recommendation that insulin pump should be used for women with preexisting T1DM during pregnancy.
Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.
Research funding: None declared.
Employment or leadership: None declared.
Honorarium: None declared.
Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.
Ethical approval: The research related to human use has complied with all the relevant national regulations, institutional policies and has been conducted in accordance with the tenets of the Helsinki Declaration, and it has been approved by the authors’ Institutional Review Board or equivalent committee.
Conflict of interest: I hereby declare on behalf of all the authors of this manuscript that in accordance with DE GRUYTER policy and my ethical obligation as a researcher, none of the authors listed in this manuscript have financial and/or business interests in a company that may be affected by the information reported in these case reports. Moreover, all authors listed here have contributed in various capacities in the conceptualization, patient care, literature search, writing and editing the manuscript up to this format.
Appendix
Continuous subcutaneous insulin pump uses only rapid acting insulin (lispro, aspart, glulisine), and all the four patients used aspart (Novo Nordisk, Plainsboro, NJ, USA).
Basal rate: This is the fixed rate of insulin dose that is programmed by the healthcare provider in the pump to deliver to patient. The delivery is continuous, but it can be programmed to alter delivery in each hour as needed. These rates can be set in fractions, and the total basal rate is the sum of a 24-hour settings. Alterations to the basal rates are based on the occurrences of hypoglycemic or hyperglycemic episodes at different times of the day.
Bolus setting: These are also preprogrammed by the healthcare provider in the pump, but the patient has to enter their blood glucose readings and the total carbohydrate intake for the pump to calculate the amount of insulin to be delivered. Once that information is fed to the pump based on the preprogramming, the pump will give the calculated amount of insulin and ask the patient to confirm before giving the bolus.
Estimation of basal insulin setting, an example using the patient in case # 1
From 12 midnight to 3 am, the pump is set at 0.7 unit/hour, giving 2.1 units during that period.
From 3 am to 6 am, it is set at 1.3 units/hour = 3.9 units.
From 6 am to 12 noon, 1.0 unit/hour = 6 units.
From 12 noon to 5 pm, it is again set at 1.0 unit/hour = 5 units.
From 5 pm to 9 pm, it is set at 1.1 units/hour = 4.4 units
From 9 pm to 12 midnight, 0.7 unit/hour = 2.1 units.
The total basal rate insulin for a 24-hour period is: 2.1 + 3.9 + 6.0 + 5.0 + 4.4 + 2.1 = 23.5 units
Moreover, the basal rate setting is also programmed to increase at an individual setting so that it can give extra insulin dose. If it is set to give extra 0.1 unit/hour, that will be 0.1 unit × 24 = 2.4 units. Then, the overall 24 hours basal insulin amount expected to be delivered for that individual will be increased from 23.5 units to 25.9 units, [23.5 + 2.4]. If it is set to give another extra 0.2 unit/hour across, it will be 0.2 unit × 24 hours = 4.8 units. Then, the total insulin expected for that individual in a 24-hour period will increase from 25.9 to 30.7 units [25.9 + 4.8].
References
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- Cardiac implant and the risk of infective endocarditis in pregnancy
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