Gestational Diabetes Mellitus Complicated by Hemolysis, Elevated Liver Enzymes, and Low Platelet Count After Decreased Need for Insulin: 2 Cases

Abstract

Case series Patient:— Final Diagnosis: Acute fatty liver of pregnancy • HELLP syndrome Symptoms: Decrease in insulin dosage for gestational diabetes mellitus Medication: — Clinical Procedure:— Specialty: Obstetrics and Gynecology Objective: Unusual clinical course Background: When a woman becomes pregnant, the placenta produces human placental lactogen (hPL). The anti-insulin effect of hPL raises maternal blood glucose levels, allowing the fetus to use glucose as a nutrient. Because hPL is produced by the placenta until delivery, insulin requirements in patients with gestational diabetes mellitus (GDM) typically increase, but in some cases, they may decrease. We retrospectively examined data from women with GDM who received insulin and delivered at our hospital. Case Reports: From April 2019 to March 2020, we targeted patients who were diagnosed with GDM, received insulin, and delivered at our hospital. GDM was diagnosed based on the guidelines from the Japanese Society of Obstetrics and Gynecology. The rate of change in insulin dosage was calculated as: (insulin dosage at delivery – insulin dosage 14 days before delivery) divided by 14. Two patients whose insulin dosage was significantly reduced developed a syndrome of hemolysis, elevated liver enzymes, and low platelet count or acute fatty liver of pregnancy and underwent emergency cesarean section. Conclusions: The present case report suggests that a decrease in insulin requirement in pregnant patients with GDM can predict maternal abnormalities due to placental dysfunction.

Updates on Gestational Diabetes

“…As hPL is produced by the placenta until delivery, insulin requirements in patients with GDM generally increase, but in exceptional situations, some cases may lead to a decrease in this insulin requirement. Kawarai et al 6 retrospectively examined data from patients with GDM who received insulin and gave birth between April 2019 and March 2020.…”

“…In some patients, insulin dosage is decreased, but no studies to date have reported perinatal prognosis in the context of reduced insulin requirements during pregnancy. 6 Some recent findings allow us to better explain the pathophysiology of GDM. Chemerin is one such example.…”

Atualidades no Diabetes gestacional

“…Como o hPL é produzida pela placenta até o parto, as necessidades de insulina em pacientes com DMG geralmente aumenta, mas em situações de excessão, alguns casos podem cursar com uma diminuição desta necessidade insulínica. Kawarai et al 6 examinaram, retrospectivamente, dados de pacientes com DMG que receberam insulina e deram à luz entre abril de 2019 a março de 2020.…”

“…Em alguns pacientes, a dosagem de insulina é diminuída, mas nenhum estudo até o momento, relatou o prognóstico perinatal no contexto de necessidades reduzidas de insulina durante a gravidez. 6 Algumas descobertas recentes permitem explicar melhor a fisiopatologia do DMG. A quemerina é um destes exemplos.…”