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READERS RESPOND
A 40-Year-Old Woman With Diabetes Contemplating Pregnancy After Gastric Bypass Surgery
Risa B. Burns, MD
JAMA. 2008;299(17):(doi:10.1001/jama.299.17.jrr80003).
The patient described and interviewed below faces a crossroads in medical care. Consider the patient's history and the patient's perspective, expressed in her own words. Then review the questions posed and imagine you are caring for this patient. How would you approach this crossroads? Using evidence from the literature and your own experience, respond by using the link to the right. Responses will be selected for posting online based on their timeliness and quality including use of the available evidence, weighing the issues, and addressing the patient's concerns. The discussion of this Clinical Crossroads case, authored by Dr Donald R. Coustan, will be published in the June 4, 2008, issue of JAMA; responses must be received by May 28, 2008, to be considered for online posting.
CASE PRESENTATION
Mrs T is a 40-year-old gravida 2 para 1 woman with type 2 diabetes and hypertension who is trying to conceive. In July 2003, Mrs T had a clomiphene-conceived pregnancy. She was given maintainence insulin during her pregnancy and was treated with nifedipine for her hypertension after developing a warm antibody response to methyldopa. Her pregnancy was otherwise uncomplicated and she delivered a healthy boy at 40 weeks by low transverse cesarean delivery because of a herpes simplex virus outbreak at the time of delivery. Her gynecologic history is significant for herpes simplex virus. She had a normal Papanicolaou test result in November 2005. She has a distant history of polycystic ovary syndrome but has been menstruating regularly since losing weight following a gastric bypass procedure.
Her medical history is significant for type 2 diabetes, diagnosed in 1999, for which she is currently taking metformin, and for hypertension, diagnosed in 1996, which has been well controlled with valsartan, though her gynecologist is planning to switch her back to nifedipine in anticipation of a pregnancy. She has a history of anticardiolipin antibodies and was treated with enoxaparin during her previous pregnancy. The antibodies were detected during routine screening; her sister has anticardiolipin antibodies and there is a strong family history of thromboses, although Mrs T has never had any.
Her surgical history is significant for a roux-en-Y gastric bypass operation in 2004. She subsequently lost 45 kg (100 lb) over the course of a year, though she has now developed iron deficiency anemia. She is intolerant of oral iron and will shortly undergo a course of intravenous iron.
At an office visit in September 2006, her blood pressure was 122/70 mm Hg and her body mass index was 30. Her examination was otherwise unremarkable. Laboratory studies revealed a glucose level of 70 mg/dL and a hemoglobin A1c level of 5.4%. Her hemoglobin level was 8.8 g/dL, with an iron level of 19 µg/dL and a ferritin level of 1.8 ng/mL.
Her current medications include valsartan, 160 mg/d, and slow-release metformin, 500 mg/d. She is allergic to labetalol with development of lichen planus, codeine with development of hives, and latex; angiotensin-converting enzyme inhibitor therapy was complicated by a cough, and methyldopa was associated with warm antibody production.
She is married and lives with her husband and son. She works as a midwife. She has no history of tobacco, alcohol, or drug use.
MRS T: HER VIEW
With my first pregnancy, I knew that I was at high risk, not only because of the diabetes but I also had high blood pressure. My hemoglobin A1c was in the 7 range. So they decided to bring my sugar down quickly and started me on insulin. They also switched me from glipizide to metformin. The metformin was stopped in the early first trimester and then I continued with the insulin shots, which were about 6 times a day. There were no complications in the pregnancy from the diabetes; it was well controlled by medication and diet.
A year after I had my son, I decided to really do something about my health. So I ended up having gastric bypass, as was recommended by my endocrinologist and my internist, which helped me lose 100 lb. I went off the insulin and now I’m only taking 500 mg of metformin.
I understand that the next pregnancy is going to be a lot of work. I have reduced a lot of my high-risk symptoms, but I have added another risk, because I had the gastric bypass and now I’m severely anemic. As far as diabetes, I know that my hemoglobin A1c being in the normal range puts my risk at about the same as the rest of the population. I know that probably during the pregnancy I will need insulin again, as my blood glucose will probably get higher and my blood pressure is still an issue.
I do have concerns with a future pregnancy. For me, the first pregnancy was really tedious because I had to be on the insulin. I was on it for the 10 months of the pregnancy, and then a year after that because I was breastfeeding. But I knew about the benefits for the baby of breastfeeding, including for diabetes, and I just thought it was worth it.
I don't understand why infertility patients can take the metformin until 15 or 16 weeks but if you're diabetic, as soon as you get a positive pregnancy test you have to stop the metformin and continue with the insulin. I’m not so sure the insulin is completely necessary, even through the pregnancy, because you could also give oral medication during the pregnancy.
AT THE CROSSROADS: QUESTIONS FOR READERS
How should Mrs T's case be managed preconception? What should be the goals of her therapy and what are the preferred treatments? What are the preconception risks and benefits of gastric bypass surgery for an obese woman with type 2 diabetes? What is the evidence that intensive antidiabetic therapy improves pregnancy outcome? How is type 2 diabetes best managed in pregnancy, what are the goals of therapy, and what are the preferred agents?
AUTHOR INFORMATION
We thank the patient for sharing her story and for providing permission to publish it.
Author Affiliation: Dr Burns is from the Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
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