Managing Gestational Diabetes in a Developing Country

Latino women are up to two times more likely than white women to have gestational diabetes (GD). The Lewis E Braverman Endocrine Fellow in Training Educational Grant sponsored one USA clinical fellow to do an away rotation focused on gestational diabetes at a tertiary hospital specialized in maternal health. The experience included a prospective case series with the objective of using real-time continuous glucose monitoring (CGM) for the educational training of patients and local providers. To our knowledge, this is the first report of CGM in pregnancy in Peru as CGM technology is not commercially available there.


Methods:

Prospective case series. After informed consent was signed, patients with GD participated in this study. The Hospital Nacional Docente San Bartolome (HSB) is a tertiary public hospital specialized in maternal health located in Lima, Peru. HSB has ~200 beds, and delivers ~6,000 newborns annually, most of them from low income families. Due to limitations in access to glucometers and glucose strips, serum glucose levels (fasting and 1h postprandially) typically guide therapy. Patients > 18yo with GD diagnosed between weeks 24-28 of gestational age (one step glucose tolerance test or with fasting serum glucose ≥92mg/dL in two occasions or postprandially of ≥125mg/dL in any trimester) received a Libre 2 CGM sensor for 14 days to aid with the glucose monitoring and nutritional education. Management of GD consisted of weekly educational sessions x 2, an individualized dietary plan with close follow up by nutritionist. Insulin therapy was initiated when time above range ( >140 mg/dl) exceeded 20% for 5-7 days.


Results:

Three patients were enrolled, each of them worn the CGM for 14 days. Their ages ranged between 28 and 41 years old. Two patients started insulin therapy while wearing the CGM due to hyperglycemia. The diet-controlled patient had a pre-term delivery. Both insulin-treated patients had scheduled cesareans, one of them had a macrosomic baby, whereas the other baby had normal weight.  All three patients described the CGM as a positive experience as it allowed them to monitor their glucose levels constantly without the need for fingerpricks, which is difficult to obtain in Peru. It also gave them real-time feedback on the glycemic effect of specific food items. Although worn only for 14 days, the use of CGM allowed the endocrinologist to promptly start and adjust insulin therapy.


Discussion/Conclusion:

The use of CGM allowed to effectively adjust insulin therapy in patients with GD, from an ethnic minority group with low income. CGM helps bridge gaps in health care delivery and promote positive behavior change.