Hyperosmolar Non-Ketotic Coma, MODY and Gestational diabetes

Question 1

Patient demographics

Answer 1

Usually T2DM, often new presentation Usually older Long hx (e.g. 1wk)

Question 2

Diagnosis

Answer 2

Hyperosmolar hyperglycaemic state (HHS) is confirmed by: Dehydration Osmolality >320mosmol/kg Hyperglycaemia >30 mmol/L with pH >7.3, bicarbonate >15mmolL and no significant ketonenaemia <3mmol/L

Question 3

Metabolic derangement

Answer 3

Marked dehydration and glucose >35mM No acidosis (no ketogenesis) Osmolality >340mosmol/kg

Question 4

Complications

Answer 4

Occlusive events are common: DVT, stroke Give LMWH

Question 5

Management (3)

Answer 5

Rehydrate ̄c 0.9% NS over 48h May need ~9L Wait 1h before starting insulin It may not be needed Start low to avoid rapid changes in osmolality E.g. 1-3u/hr Look for precipitant MI Infection Bowel infarct

Question 6

What is MODY

Answer 6

Maturity-onset diabetes of the young (MODY) is characterised by the development of type 2 diabetes mellitus in patients < 25 years old. It is typically inherited as an autosomal dominant condition. Over six different genetic mutations have so far been identified as leading to MODY.

Question 7

What is Mody 3 vs 2

Answer 7

MODY 2

20% of cases

due to a defect in the glucokinase gene

MODY 3

60% of cases

due to a defect in the HNF-1 alpha gene

Question 8

Features of MODY

Answer 8

Features of MODY

typically develops in patients < 25 years

a family history of early onset diabetes is often present

ketosis is not a feature at presentation

patients with the most common form are very sensitive to sulfonylureas, insulin is not usually necessary

Question 9

Risks to mother and foetus

Answer 9

miscarriage, pre-term labour, pre-eclampsia, congenital malformations, macrosomia, and a worsening of diabetic complications, eg retinopathy, nephropathy

Question 10

Risks of GDM

Answer 10

aged over 25; family history; +ve; weight↑; non-Caucasian; hiv+ve; previous gestational DM

Question 11

Pre-conception advice

Answer 11

Control/reduce weight, aim for good glucose control, offer folic acid 5mg/d until 12 weeks.

Question 12

Screening

Answer 12

OGTT if risk factors at booking (16–18 weeks if previous gdm)

Question 13

Mx of GDM

Answer 13

• Oral hypoglycaemics other than metformin should be discontinued. Metformin may be used as an adjunct or alternative to insulin in type 2 dm or gdm.

Question 14

Post-partum Mx

Answer 14

6wks postpartum, do a fasting glucose