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Caroline was 29 when she first came to my office in October 1994 for evaluation of her type 1 diabetes. Just over 5 feet tall and weighing 122 pounds, she was a petite and vivacious woman, happily married with one child, and working part-time.
Caroline was a very charming patient. She would bribe us with delicious goodies, such as home-baked sugar-coated cinnamon buns, which, she explained, were not for her personal consumption. It was also apparent from the start that she was going to do what she wanted to do, when she wanted to do it. She generally knew how to control her diabetes, but was not always motivated to do so.
Caroline was tentatively planning another pregnancy and was not using any contraception. She had been diagnosed with diabetes at age 16 and had been pregnant four times, but had three miscarriages. Her only child was a healthy seven-year-old son. She recognized that her loose blood glucose control had been partly responsible for the miscarriages.
She had seen several endocrinologists over the years, and had been hospitalized recently with diabetic ketoacidosis in July 1994. Thereafter, she had been under the care of an endocrinologist who had switched her to a program of regular insulin before meals and bedtime intermediate-acting insulin (NPH). But she switched back to twice-daily mixtures of intermediate and regular on her own. She subsequently began having episodes of hypoglycemia several times weekly.
Caroline 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 one and four times daily. Caroline's initial glycohemoglobin was markedly elevated at 9.7 (a normal range is between 4.2 and 6.3) , indicating that the changes she made to her diabetes program were not working too well.
To help in setting priorities for her pregnancy, I gave her a written treatment plan. The first item on the plan instructed her to test her sugar four or more times daily, and to plan to increase the frequency of testing to eight or more when she became pregnant. I also advised her to resume using contraception immediately, until her diabetes control was reasonable for pregnancy.
We also discussed improving the coordination of her medical care. She had a primary doctor in one suburb of our metropolitan area, an obstetrician in another, and now an endocrinologist, myself, in a third suburb. None of us practiced at the same hospitals, meaning that any hospitalization would involve only one of her three doctors.
We discussed temporary targets for her diabetes control. She felt she could keep her blood sugars below 200 (with an average sugar of 140 or less) avoid gaining weight, and control insulin reactions. She agreed to later increase the targets, to a maximal blood sugar of 140 after eating and an average blood sugar of 85, in preparation for her pregnancy. I informed her that she could expect occasional insulin reactions while on the very tight control program.
Caroline also chose to start an insulin pump, hoping that it would give her better control than the injections. She began pumping after her third office visit, in December. Her glycohemoglobin slowly declined as she learned how to use the pump-to 8.7 in April of the following year, and then to 7.2 by September. She remained under our care, as well as that of 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 in late October, and it remained normal throughout the rest of her pregnancy. Despite problems with hypertension and edema, she delivered a healthy baby daughter on March 25, 1996. At delivery, she was admitted to the hospital and self-controlled while hospitalized, with backup hospital staff.
She had remained on her insulin pump throughout the pregnancy. She had two visits with me after her childbirth, but I then lost track of her for over a year. When she returned to my office in August 1997, she was still using her pump. Her glycohemoglobin was back up to 9.7, exactly where it had been when I first met her. A year later, it continues to remain elevated at 9.3. She has been checking her blood sugar levels only sporadically, despite our warnings that pumps require frequent monitoring.
She was recently hospitalized with another episode of diabetic ketoacidosis, which was apparently due to a digestive problem (gastroenteritis). Her eyes have had progressive retinopathy, and she has been treated with laser therapy in both eyes to prevent loss of vision. Her weight has increased to 150 pounds, which she admitted was due to overeating.
She also admits that she has not been paying as much attention to her diabetes control now as she had been during her pregnancy. She explained that she now has a full-time job in a beauty salon, and cares for her two kids and husband. She has hinted at getting off the pump, and I have told her that she could quit using it anytime and resume insulin injections.
When I first met Caroline, I made a calculated guess that she would respond to an approach that emphasized intensive control in preparation for her much-desired pregnancy. And this approach worked for a while, as long as she was motivated to have a successful pregnancy. Using an insulin pump may have helped Caroline to focus her attention, but it clearly did not result in any long-term improvement in her control as measured by the glycohemoglobin testing or the other diabetes problems she has experienced since her pregnancy.
It is sometimes mistakenly assumed that using an insulin pump will automatically result in tighter diabetes control (as measured by lower glycohemoglobin values). However, as is amply indicated in Caroline's case, the pump is only a tool that can allow better control if and when the patient is driven to do what it takes to get there.
This case illustrates something that we all should always recognize: diabetes control is up to the patient, and nothing we health professionals can do can force he or she to do more than they are willing to try. Motivation is key.
Would I have recommended a pump had I known that Caroline's glycohemoglobin would only temporarily improve during pregnancy? Definitely! After all, the pump seems to have helped her to have a successful pregnancy despite her previous poor track record, and it now allows her the flexibility to be 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 been worthwhile.
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