Breaking all the rules: A case report of Type 1 Diabetes in pregnancy — ASN Events
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Breaking all the rules: A case report of Type 1 Diabetes in pregnancy (#58)

Anna Krelle 1 , Nicole Bloom 1 , Alison Nankervis 1 2 , Sarah Price 1 2 3
  1. Department of Obstetric Medicine, Royal Women's Hospital, North Melbourne, Victoria, Australia
  2. Diabetes and Endocrinology, Royal Melbourne Hospital, Parkville, Victoria, Australia
  3. Department of Medicine, University of Melbourne, Parkville, Victoria, Australia

A 33-year G8P7M1 woman of Jewish ancestry presented for maternity care at 8 weeks gestation. Her history was significant for long-standing Type 1 Diabetes diagnosed at 9 years of age. T1D was managed with a Medtronic 640G insulin pump and Freestyle Libre flash glucose monitoring. She had sub-optimal diabetes control with a first trimester HbA1c of 7.7%. There was no evidence of microvascular or macrovascular diabetes complications. She had normal hypoglycemic awareness and had no admissions for diabetic ketoacidosis in the past decade. Her other history was significant for obesity (112kg; BMI 40.3kg/m2). Thyroid function and coeliac serology were normal.

The woman’s partner was a man of Jewish ancestry who also had Type 1 Diabetes. She also had a sister and maternal niece with rheumatoid arthritis. Five of her seven offspring had developed Type 1 Diabetes before 8 years of age. The obstetric outcome of each pregnancy is listed in Table 1. The age of development of Type 1 Diabetes and the antibody status of each child is listed in Table 2.

648555ef50c44-Table+1.PNG

648555ef50c44-Table+2.PNG

At the time of abstract submission, this woman is 24 weeks gestation. Her TIR is 82% and HbA1c 6.5%. Blood pressure is 120/80mmHg. Morphology scan is unremarkable.  

Discussion:

This case is remarkable. Firstly, the predicted risk of an offspring developing T1D if one parent has T1D is around 3% if the index case is the mother, around 6% if the index case is the father and around 10% if both parents have T1D1,2. In this case, 5/7 (70%) of children have T1D this far, demonstrating the strong genetic drive for the development of T1D in this family. Although the family history may suggest monogenic diabetes, each child is antibody positive and has classic T1D. Despite this, the offspring of the index case have no other autoimmune diseases including no coeliac disease or thyroid disease.

Secondly, it is highly atypical to see a grand multipara with long standing T1D given the high rates of pregnancy complications and the usual progression of diabetes complications. Thirdly, although three offspring were born with macrosomia, this woman did not develop preeclampsia (PET) in any pregnancy despite relatively prolonged pregnancies3. This suggests that there may be genetic factors which protect against the development of PET and endothelial dysfunction during and after pregnancy.

  1. Parkkola A, Laine AP, Karhunen M, et al. HLA and non-HLA genes and familial predisposition to autoimmune diseases in families with a child affected by type 1 diabetes. PLoS One. 2017;12(11):e0188402. doi:10.1371/journal.pone.0188402
  2. Parkkola A, Härkönen T, Ryhänen SJ, Ilonen J, Knip M, Register FPD. Extended family history of type 1 diabetes and phenotype and genotype of newly diagnosed children. Diabetes Care. Feb 2013;36(2):348-54. doi:10.2337/dc12-0445
  3. Lemaitre M, Ternynck C, Bourry J, Baudoux F, Subtil D, Vambergue A. Association Between HbA1c Levels on Adverse Pregnancy Outcomes During Pregnancy in Patients With Type 1 Diabetes. J Clin Endocrinol Metab. Feb 17 2022;107(3):e1117-e1125. doi:10.1210/clinem/dgab769
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