The case of a patient, her pump, and her pregnancy
This case, from a few years ago, describes a scenario that is equally likely to
occur today.
Caroline Snow was a 29-year-old woman when she first came to my office in October, 1994, for evaluation of her insulin-dependent diabetes. She was happily married, had one child, was working part-time, and planned to return to college soon. She was tentatively planning another pregnancy, but realized she'd be facing issues of balancing her responsibilities for her family, job, finances, and tackling better diabetes control. She was not using any contraception.
She had been diagnosed at age 16, and she had been pregnant four times, but had miscarried three times; her only child was a healthy 7-year-old son. She recognized that part of the reason for the miscarriages was her "loose control" of her diabetes. Medically, she described having seen several endocrinologists over the years; she had been hospitalized recently
with
diabetic ketoacidosis
in July, 1994. Thereafter, she had been under the care of yet another endocrinologist who had switched her to a program of Regular insulin before meals and bedtime NPH, but she switched back to twice-daily mixtures of NPH and Regular on her own. On her program, she was having episodes of
hypoglycemia
several times weekly. She viewed these hypoglycemic episodes as transient interruptions to her usual daily activities, since they could be treated without needing assistance from other people. She was unaware of any diabetic complications to her eyes, kidneys, heart, or otherwise. She was testing her blood sugar levels between once and four times daily.
She was petite and vivacious. She was 5 foot, 1 inch tall and weighed 122 pounds. Vital signs and general physical examination were unremarkable. Her initial
glycohemoglobin
[A1c] was markedly elevated at 9.7 (with a normal range of 4.2-6.3) despite her insulin reactions, implying that her revisions to her diabetes program weren't working too well.
She was advised to set priorities in preparation for her next pregnancy, and was given a written treatment plan. The first item on the treatment plan was "Get your diabetes in shape (normal glycohemoglobin or way down from present level)." She was to test her sugar four or more times daily, and to plan to increase the frequency of testing to eight or more when pregnant. She was advised to resume using contraception immediately, until her diabetes control was reasonable for pregnancy.
Other issues that were discussed at that first visit included the need for coordination of her medical care: she had a primary doctor in one suburb of our metropolitan area, an obstetrician across town, and now an endocrinologist who was in a third suburb entirely: none of the three doctors practiced at the same hospitals, implying that any hospitalization would mean only one of her three doctors would be someone she knew (and who knew her!).
She also needed to "catch up" with evaluation of her eyes, kidneys, and general health soon.
Temporary targets for her diabetes control were negotiated with her during the first visit: she felt that she could keep her blood sugars below 200, with an average sugar of 140 or less; no weight gain; and without insulin reactions. It was pointed out to her that her targets would soon be tightened in preparation for the upcoming pregnancy, to a maximal blood sugar of 140 after eating; with an average blood sugar of 85; weight gain would be per recommendations by her obstetrician; and she should expect occasional insulin reactions while on the very tight control program that is recommended for pregnancy.
After discussion about what insulin program to use, she chose to start an
insulin pump, and she began pumping after her third office visit, on December 27, 1994. Her glycohemoglobin very slowly declined as she learned how to use the pump, to 8.7 in April, 1995, and then to 7.2 by September, 1995. She remained under our care, as well as seeing her obstetrician/gynecologist, her primary care physician, and an ophthalmologist.
On August 15, 1995, she proudly announced that she had had a positive pregnancy test. Soon after this, her control suddenly improved - her glycohemoglobin plummeted to 5.7 (normal!) on October 31, and it remained normal throughout the rest of her pregnancy. Despite problems with hypertension and edema, on March 25, 1996 she delivered a healthy baby daughter. At delivery, she was admitted to the hospital where her obstetrician practiced; her diabetes was largely self-controlled while hospitalized, with backup by the hospital's diabetes nurse educator and an endocrinologist on that hospital's medical staff.
She had remained on her insulin pump throughout the pregnancy, and since then. She had two visits to us after her childbirth, but we then lost track of her for over a year. When she returned to our office in August, 1997, she was still using her pump. A glycohemoglobin was checked, and it was back up to exactly where she was when we first met her: 9.7. We have continued to follow her since then; at the time of her most recent office visit (on June 16, 1998), it remains elevated at 9.3. She has been checking her blood sugar levels only sporadically, despite our warnings that pump patients should keep very close track of what's happening. She has been hospitalized with another episode of diabetic ketoacidosis, which was apparently due to an acute episode of gastroenteritis. Her eyes have had progressive retinopathy, and she has been "zapped" with laser therapy in both eyes. Her weight has increased to 150 pounds, which she readily admits is related to overeating.
She readily admits that she's not paying as much attention to her diabetes control now as she had been during her recent pregnancy, but gives several reasons why: she has taken a full-time job in a beauty salon, as well as caring for her two kids and hubby. She has occasionally hinted at thoughts of stopping the pump, and I have told her that she could quit using it anytime and resume insulin injections; as of her last visit, she has chosen to continue to use the pump as the way to deliver her insulin.
Comments
It was immediately obvious at her first visit that Mrs. Snow, soon to be known to all of us as "Caroline," could be a very charming patient. (She'd bribe us with delicious goodies, such as home-baked sugarcoated cinnamon buns, which she explained carefully were not for her personal consumption.) It also was apparent from the start that she was going to do what she wanted, when she wanted. She generally knew how to control her diabetes, but wasn't always motivated to do so.
Initially, I made a calculated guess: that she'd respond to an approach that emphasized intensive control in preparation for her much-desired pregnancy. The concept of intensive diabetes control worked for a while, for the reason that really mattered to her: to have a successful pregnancy. Using an insulin pump may have helped Caroline to focus her attention, but it clearly didn't result in any long-term improvement in her control as measured by the glycohemoglobin testing or the other diabetes problems she's experienced since her pregnancy.
It is sometimes mistakenly assumed that using an insulin pump will automatically result in "better" diabetes control (as measured by lower glycohemoglobin values). However, as is amply indicated in the case of Mrs. Snow, "the pump" really is only a tool that can allow better control, if and when the patient is in the mood to do so. This case reemphasizes something that we all should always recognize: diabetes control is in the mind of the beholder, and nothing we health professionals can do can force the patient to do more than they are willing to try. The patient can do everything we reasonably request - but only during the time that they are appropriately motivated!
Would I have recommended a pump in the first place, had I known that Caroline's glycohemoglobin would only temporarily improve during pregnancy, then go back up to where it started? Definitely! After all, the pump seems to have helped her to have a successful pregnancy despite her poor track record previously, and it now allows her to "do her thing" as a working wife and mother. When Caroline comes in, bringing her toddler, her pump, her cinnamon buns, and her big, big smile, we know it's all been worthwhile.
This case was originally published in Diabetes Interview in 1998.
In this case study, the patient's name has been changed, but the rest of the story is true.
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