Skip to main content
  • More from ADA
    • Diabetes
    • Diabetes Care
    • Diabetes Spectrum
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
    • ADA Scientific Sessions Abstracts
    • BMJ Open Diabetes Research & Care
  • Subscribe
  • Log in
  • Log out
  • My Cart
  • Follow ada on Twitter
  • RSS
  • Visit ada on Facebook
Clinical Diabetes

Advanced Search

Main menu

  • Home
  • Current
    • Current Issue
    • Online Ahead of Print
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
  • Browse
    • Issue Archive
    • Saved Searches
    • COVID-19 Article Collection
    • Quality Improvement Sucess Stories
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
  • Info
    • About the Journal
    • About the Editors
    • ADA Journal Policies
    • Instructions for Authors
  • Advertising
  • Reprints/Reuse
  • Subscriptions
    • Individual Subscriptions
    • Institutional Subscriptions and Site Licenses
    • Access Institutional Usage Reports
    • Purchase Single Issues
  • Alerts
    • E­mail Alerts
    • RSS Feeds
  • Podcasts
    • Diabetes Core Update
    • Special Podcast Series: Therapeutic Inertia
    • Special Podcast Series: Influenza Podcasts
    • Special Podcast Series: SGLT2 Inhibitors
    • Special Podcast Series: COVID-19
  • Submit
    • Submit a Manuscript
    • Submit Cover Art
    • Instructions for Authors
    • ADA Journal Policies
  • More from ADA
    • Diabetes
    • Diabetes Care
    • Diabetes Spectrum
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
    • ADA Scientific Sessions Abstracts
    • BMJ Open Diabetes Research & Care

User menu

  • Subscribe
  • Log in
  • Log out
  • My Cart

Search

  • Advanced search
Clinical Diabetes
  • Home
  • Current
    • Current Issue
    • Online Ahead of Print
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
  • Browse
    • Issue Archive
    • Saved Searches
    • COVID-19 Article Collection
    • Quality Improvement Sucess Stories
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
  • Info
    • About the Journal
    • About the Editors
    • ADA Journal Policies
    • Instructions for Authors
  • Advertising
  • Reprints/Reuse
  • Subscriptions
    • Individual Subscriptions
    • Institutional Subscriptions and Site Licenses
    • Access Institutional Usage Reports
    • Purchase Single Issues
  • Alerts
    • E­mail Alerts
    • RSS Feeds
  • Podcasts
    • Diabetes Core Update
    • Special Podcast Series: Therapeutic Inertia
    • Special Podcast Series: Influenza Podcasts
    • Special Podcast Series: SGLT2 Inhibitors
    • Special Podcast Series: COVID-19
  • Submit
    • Submit a Manuscript
    • Submit Cover Art
    • Instructions for Authors
    • ADA Journal Policies
Departments

Case Study: Type 1 Diabetes With Subacute Presentation During Pregnancy

  1. Michelle L. Griffith, MD and
  2. Shubhada M. Jagasia, MD
    Clinical Diabetes 2009 Apr; 27(2): 86-87. https://doi.org/10.2337/diaclin.27.2.86
    PreviousNext
    • Article
    • Info & Metrics
    • PDF
    Loading

    PRESENTATION

    T.S. presented at age 17 with apparent gestational diabetes mellitus (GDM) in her first pregnancy. Her past medical history included allergic rhinitis and acne vulgaris; she had no history of polycystic ovarian syndrome, impaired glucose tolerance, or impaired fasting glucose. She also had no complaints of hirsutism, prior menstrual irregularity, or weight gain. Her family history was notable for diabetes in both parents. Her prepregnancy BMI was 26.2 kg/m2.

    At diagnosis of pregnancy at ~ 5 weeks gestational age, a fingerstick glucose was 224 mg/dl; home testing at ~ 10 weeks revealed continued elevated glucose levels in the 200 mg/dl range, and the patient also had polyuria and polydipsia. She subsequently had a 50-g oral glucose tolerance test with a result of 262 mg/dl. She was diagnosed with GDM and started on nutritional therapy and glyburide once daily.

    At the time of initial consultation with endocrinology, she was at 23 weeks gestational age. She had continued polyuria and polydipsia. Exam revealed a gravid young woman with stable vital signs. She had normal thyroid and cardiac exams and no acanthosis nigricans.

    Because of her young age, relatively low BMI, and lack of stigmata of insulin resistance, labs were sent to look for evidence of autoimmune diabetes. Laboratory data included an A1C of 6.5%, C-peptide of 2.3 ng/ml (reference range 0.9-7.1 ng/ml), and GAD antibody of < 1.00 (reference range < 1.46).

    Review of her glucose meter download showed poor control with persistent hyperglycemia and average blood glucose of 155 mg/dl. Because her diabetes was not adequately controlled with glyburide, it was discontinued at the first endocrinology visit, and she was started on an insulin regimen of glargine and aspart with carbohydrate counting for her mealtime doses.

    The rest of the pregnancy was complicated by poor adherence, difficulty with carbohydrate counting, and continued hyperglycemia, with occasional hypoglycemia. Her regimen was adjusted several times. At the time of delivery at 39 and 3/7 weeks of pregnancy, however, she had not returned for follow-up in the prior 8 weeks, nor had she sent blood glucose data to the clinic. She delivered a healthy 10 lb, 3 oz infant. She had also developed pregnancy-induced hypertension.

    At ~ 6 weeks postpartum, she presented to an internist to establish care. She had stopped insulin therapy but continued to have nocturia. At that visit, labs included a random glucose of 492 mg/dl, A1C of 11.7%, and C-peptide of 0.7 ng/ml. Insulin antibodies were not checked. She was diagnosed with type 1 diabetes and started back on intensive insulin therapy.

    The patient returned for follow-up with endocrinology ~ 4 weeks later. On repeat labs, C-peptide was 0.4 ng/ml, islet cell IgG antibody was < 1:4, and GAD antibody was positive at 1.75. Insulin doses were increased to improve her glycemic control; however, adherence remained a problem. Although 2-week follow-up was scheduled, the patient did not keep this appointment and presented to the hospital with altered mentation in diabetic ketoacidosis within a month.

    QUESTIONS

    1. What proportion of patients presenting with diabetes during gestation will subsequently be diagnosed with type 1 or type 2 diabetes?

    2. What clinical features are suggestive of type 1 diabetes or latent autoimmune diabetes in adults (LADA)?

    3. What antibodies should be tested when autoimmune diabetes is suspected?

    COMMENTARY

    GDM, defined as carbohydrate intolerance that begins or is first recognized during pregnancy, affects ~ 7% of pregnancies annually, with a higher incidence in some ethnic groups.1 Even normal pregnancy is a state of increased insulin resistance induced by weight gain and placental hormone secretion, including human placental lactogen and growth hormone variant. By the third trimester, insulin sensitivity is about 50% less.2 In a normal pregnancy, insulin secretion increases by ~ 30% to compensate for this defect. Thus, GDM results from a combination of increased resistance and lack of sufficient compensatory insulin increase, leading to relative insulin deficiency.

    Some patients with GDM may still have relatively normal insulin resistance in the nonpregnant state. Other patients who are diagnosed with GDM may also have underlying impaired glucose tolerance that is exacerbated by pregnancy. More rarely, type 1 diabetes may be first detected in pregnancy, when the prodromal phase of the disease is present in the pregestastional time period.3 The physiological stressor of pregnancy may then unmask the disease.

    Fewer than 1 in 10,000 women may become pregnant during the prodromal phase of type 1 diabetes.1 More frequently, type 2 diabetes may be first detected in pregnancy when the pregnancy exacerbates hyperglycemia or as a result of patients receiving routine medical care while pregnant. Among patients with GDM in the United States, it has been estimated that 50% will develop overt diabetes within 10 years after delivery.2 In Finland, where the 6-year risk for diabetes after GDM is estimated at 10%, 4.6% of patients developed type 1 diabetes after GDM, and 5.3% eventually developed type 2 diabetes.4

    Among patients with a new diagnosis of diabetes, be it during gestation or not, several clinical features may suggest an underlying diagnosis of type 1 diabetes or LADA. LADA is considered by some to be a distinct disease state and by others to be on the continuum of type 1 diabetes, but a characteristic feature is antibody positivity; disease onset is often insidious. Features that may raise suspicion include age < 50 years; presentation with acute symptoms such as weight loss, polyuria, or polydipsia; personal history of autoimmune disease; family history of autoimmune disease; and BMI < 25 kg/m2.

    One study using these criteria found that, among patients with two or more of these features, 75% had LADA, whereas 24% had type 2 diabetes.5 For patients meeting only one criterion, 98% did not have antibodies indicative of LADA. Despite a lower BMI being suggestive of an autoimmune process, most patients with LADA are overweight or obese. Similarly, a family history of type 2 diabetes did not predict against LADA.5 However, testing for antibodies and clinical suspicion for an autoimmune process should be considered in patients with two or more of these clinical features.

    Diabetes-associated antibodies include antibodies to GAD, islet cell antibodies, antibodies to the protein tyrosine-phosphatase-related protein 2 (IA2), and insulin antibodies.4,6 These autoantibodies have been studied in relatives of patients with type 1 diabetes, and their presence, in the absence of apparent metabolic abnormalities, has a high predictive value for diabetes in those relatives. Patients can develop diabetes in the setting of one or more antibodies being positive, although some studies have correlated increased numbers of antibodies as well as higher titers of antibodies with increased risk for frank diabetes.5 The insulin antibodies and IA2 are more likely to be positive in children with type 1 diabetes, whereas GAD antibodies are more frequently detected in adult patients. Among patients with diabetes who are not insulin-requiring at diagnosis, antibody positivity predicts requirement for insulin in 80% of cases.7 Other autoimmune diseases are also increased in frequency in these patients. Although at this point there is no definite way to prevent diabetes in patients with positive antibodies, animal and human studies are ongoing.

    CLINICAL PEARLS

    GDM affects ~ 7% of pregnancies. When it is diagnosed, clinicians should keep in mind the possibility of a new diagnosis of type 1 or type 2 diabetes.

    Clinical features can be used to assess risk of autoimmune diabetes in patients with a new diagnosis and to guide appropriate antibody testing.

    Although a lower BMI may suggest LADA or type 1 diabetes, the majority of patients with LADA are overweight, so an elevated BMI should not exclude consideration of this diagnosis.

    Footnotes

    • Michelle L. Griffith, MD, is a fellow, and Shubhada M. Jagasia, MD, is an attending physician in the Division of Diabetes, Endocrinology, and Metabolism at Vanderbilt University Medical Center, in Nashville, Tenn.

    • American Diabetes Association(R) Inc., 2009

    REFERENCES

    1. ↵
      1. Perkins J,
      2. Dunn J,
      3. Jagasia S
      : Perspectives in gestational diabetes mellitus: a review of screening, diagnosis, and treatment. Clin Diabetes 25:57-62, 2007
      OpenUrlAbstract/FREE Full Text
    2. ↵
      1. Galerneau F,
      2. Inzucchi S
      : Diabetes mellitus in pregnancy. Obstet Gynecol Clin North Am 31:907-933, 2004
      OpenUrlCrossRefPubMed
    3. ↵
      1. Maresh M
      : Screening for gestational diabetes mellitus. Sem Fetal Neonat Med 10:317-323, 2005
      OpenUrlCrossRef
    4. ↵
      1. Jarvela I,
      2. Juutinen J,
      3. Koskela P,
      4. Hartikainen AL,
      5. Kulmala P,
      6. Knip M,
      7. Tapanainen JS
      : Gestational diabetes identifies women at risk for permanent type 1 and type 2 diabetes in fertile age: predictive role of autoantibodies. Diabetes Care 29:607-612, 2006
      OpenUrlAbstract/FREE Full Text
    5. ↵
      1. Fourlanos S,
      2. Perry C,
      3. Stein MS,
      4. Stankovich J,
      5. Harrison LC,
      6. Colman PG
      : A clinical screening tool identifies autoimmune diabetes in adults. Diabetes Care 29:950-975, 2006
      OpenUrlFREE Full Text
    6. ↵
      1. van Deutekom AW,
      2. Heine RJ,
      3. Simsek S
      : The islet autoantibody titres: their clinical relevance in latent autoimmune diabetes in adults (LADA) and the classification of diabetes mellitus. Diabet Med 25:117-125, 2008
      OpenUrlCrossRefPubMed
    7. ↵
      1. Falorni A,
      2. Brozzetti A
      : Diabetes related antibodies in adult diabetic patients. Best Pract Res Clin Endocrinol Metab 19:119-133, 2005
      OpenUrlCrossRefPubMed
    View Abstract
    PreviousNext
    Back to top

    In this Issue

    March 2009, 27(2)
    • Table of Contents
    • Index by Author
    Sign up to receive current issue alerts
    View Selected Citations (0)
    Print
    Download PDF
    Article Alerts
    Sign In to Email Alerts with your Email Address
    Email Article

    Thank you for your interest in spreading the word about Clinical Diabetes.

    NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

    Enter multiple addresses on separate lines or separate them with commas.
    Case Study: Type 1 Diabetes With Subacute Presentation During Pregnancy
    (Your Name) has forwarded a page to you from Clinical Diabetes
    (Your Name) thought you would like to see this page from the Clinical Diabetes web site.
    CAPTCHA
    This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
    Citation Tools
    Case Study: Type 1 Diabetes With Subacute Presentation During Pregnancy
    Michelle L. Griffith, Shubhada M. Jagasia
    Clinical Diabetes Apr 2009, 27 (2) 86-87; DOI: 10.2337/diaclin.27.2.86

    Citation Manager Formats

    • BibTeX
    • Bookends
    • EasyBib
    • EndNote (tagged)
    • EndNote 8 (xml)
    • Medlars
    • Mendeley
    • Papers
    • RefWorks Tagged
    • Ref Manager
    • RIS
    • Zotero
    Add to Selected Citations
    Share

    Case Study: Type 1 Diabetes With Subacute Presentation During Pregnancy
    Michelle L. Griffith, Shubhada M. Jagasia
    Clinical Diabetes Apr 2009, 27 (2) 86-87; DOI: 10.2337/diaclin.27.2.86
    del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
    • Tweet Widget
    • Facebook Like
    • Google Plus One

    Jump to section

    • Article
      • PRESENTATION
      • QUESTIONS
      • COMMENTARY
      • CLINICAL PEARLS
      • Footnotes
      • REFERENCES
    • Info & Metrics
    • PDF

    Related Articles

    Cited By...

    More in this TOC Section

    Departments

    • Community Primary Care Diabetes Pathway
    • Increasing Attendance at Scheduled Appointments for Group Classes at a Diabetes Education Center
    • Case Reports on Diabetes-Related Outcomes for Pregnant Women in the National Diabetes Prevention Program
    Show more Departments

    Case Study

    • Insulin Resistance in a Hospitalized COVID-19 Patient: A Case Review
    • A Case of Euglycemic Diabetic Ketoacidosis Triggered by a Ketogenic Diet in a Patient With Type 2 Diabetes Using a Sodium–Glucose Cotransporter 2 Inhibitor
    • Sodium–Glucose Cotransporter 2 Inhibitor–Associated Prolonged Euglycemic Diabetic Ketoacidosis in Type 2 Diabetes: A Case Report and Literature Review
    Show more Case Study

    Similar Articles

    Navigate

    • Current Issue
    • Papers in Press
    • Abridged Standards of Care
    • Archives
    • Submit
    • Subscribe
    • Email Alerts
    • RSS Feeds

    More Information

    • About the Journal
    • Instructions for Authors
    • Journal Policies
    • Reprints and Permissions
    • Advertising
    • Privacy Policy: ADA Journals
    • Copyright Notice/Public Access Policy
    • Contact Us

    Other ADA Resources

    • Diabetes
    • Diabetes Care
    • Diabetes Spectrum
    • Scientific Sessions Abstracts
    • Standards of Medical Care in Diabetes
    • BMJ Open - Diabetes Research & Care
    • Professional Books
    • Diabetes Forecast

     

    • DiabetesJournals.org
    • Diabetes Core Update
    • ADA's DiabetesPro
    • ADA Member Directory
    • Diabetes.org

    © 2021 by the American Diabetes Association. Clinical Diabetes Print ISSN: 0891-8929, Online ISSN: 1945-4953.