ABSTRACT
Background: Coronavirus disease 2019 (COVLD-19), the global pandemic that has spread throughout the world, is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Given the limited scientific evidence on the manifestations and potential impact of this virus on pregnancy, we decided to report this case. Case presentation: The patient was a 38 year-old Iranian woman with a triplet pregnancy and a history of primary infertility, as well as hypothyroidism and gestational diabetes. She was hospitalized at 29 weeks and 2 days gestational age due to elevated liver enzymes, and finally, based on a probable diagnosis of gestational cholestasis, she was treated with ursodeoxycholic acid. On the first day of hospitalization, sonography was performed, which showed that biophysical scores and amniotic fluid were normal in all three fetuses, with normal Doppler findings in two fetuses and increased umbilical artery resistance (pulsatility index [PI] > 95%) in one fetus. On day 4 of hospitalization, she developed fever, cough and myalgia, and her COVID-19 test was positive. Despite mild maternal symptoms, exacerbated placental insufficiency occurred in two of the fetuses leading to the rapid development of absent umbilical artery end-diastolic flow. Finally, 6 days later, the patient underwent cesarean section due to rapid exacerbation of placental insufficiency and declining biophysical score in two of the fetuses. Nasopharyngeal swab COVID-19 tests were negative for the first and third babies and positive for the second baby. The first and third babies died 3 and 13 days after birth, respectively, due to collapsed white lung and sepsis. The second baby was discharged in good general condition. The mother was discharged 3 days after cesarean section. She had no fever at the time of discharge and was also in good general condition. Conclusion(s): This was a complicated triplet pregnancy, in which, after maternal infection with COVID-19, despite mild maternal symptoms, exacerbated placental insufficiency occurred in two of the fetuses, and the third fetus had a positive COVID-19 test after birth. Therefore, in cases of pregnancy with COVID-19 infection, in addition to managing the mother, it seems that physicians would be wise to also give special attention to the possibility of acute placental insufficiency and subsequent fetal hypoxia, and also the probability of vertical transmission.Copyright © 2022 Goldstein and Associates. All rights reserved.
ABSTRACT
Introduction: Covid-19, a novel Coronavirus SARS-COV-2, has caused major morbidity and mortality worldwide most especially in the high-risk population. SARS-COV-2 has caused more unfavorable outcomes and increased insulin resistance in patients with diabetes mellitus. It has been observed that many of these patients require very high doses of insulin to manage hyperglycemia. This will discuss a case of a young male with newly diagnosed type 2 diabetes complicated with Covid-19 infection. Case Description: 38-year-old Hispanic male with no past medical history presented to the emergency department with shortness of breath, cough, and chest congestion. His only medication was azithromycin. He had no family history of diabetes mellitus. There was no acanthosis nigricans on examination and the patient's BMI was 26.7 kg/m 2 . The patient was admitted for severe acute respiratory syndrome and diabetic ketoacidosis. His hba1c level was 13.7%, c-peptide was inappropriately low with a value of 0.31 ng/mL and glucose of 153 mg/dL and GAD-65 and islet cell antibodies were negative. Endocrinology was consulted for diabetic management. The patient was started on basal insulin 5 units at bedtime;however, the dose was increased to 7 to 9 to 12 and then 20 units at bedtime due to uncontrolled sugar levels. The patient was started on short-acting insulin before meals because his glucose ranged from 156 mg/dL to 381 mg/dL. The patient clinically improved and was discharged on hospital day 12. He got discharged on insulin detemir 20 units at bedtime and insulin lispro 8 units before meals. On a visit to the clinic, the patient was weaned off of insulin due to better glycemic control. His hba1c level significantly dropped to 7.2% and his c-peptide level improved to 3.21 ng/mL. He is now been controlled only on metformin 1000mg twice a day. Discussion: There is no definite explanation for why SARS-COV- 2 infection causes new-onset diabetes and worsening insulin resistance. However, there have been some theories attributed to the effects of the SARS-COV-2 coronavirus on angiotensin-converting enzyme 2 (ACE2). ACE2 is present in metabolic organs and tissues including pancreatic beta cells. As a result, an infection with the SARS-COV-2 virus could affect the pathophysiology of glucose metabolism causing increase insulin resistance. Another theory explains that coronavirus could cause ketosis-prone diabetes causing diabetic ketoacidosis in patients with no known history of hyperglycemia. Therefore, Covid-19 has some association with diabetes mellitus management outcomes.
ABSTRACT
The ongoing global pandemic of the coronavirus disease 2019 (COVID-19) has placed a severe strain on the management of chronic conditions like diabetes. Optimal glycemic control is always important, but more so in the existing environment of COVID-19. In this context, timely insulinization to achieve optimal glycemic control assumes major significance. However, given the challenges associated with the pandemic like restrictions of movement and access to healthcare resources, a simple and easy way to initiate and optimize insulin therapy in people with uncontrolled diabetes is required. With this premise, a group of clinical experts comprising diabetologists and endocrinologists from India discussed the challenges and potential solutions for insulin initiation, titration, and optimization in type 2 diabetes mellitus (T2DM) during the COVID-19 pandemic and how basal insulin can be a good option in this situation owing to its unique set of advantages like lower risk of hypoglycemia, ease of training, need for less monitoring, better adherence, flexibility of using oral antidiabetic drugs, and improved quality of life compared to other insulin regimens. The panel agreed that the existing challenges should not be a reason to delay insulin initiation in people with uncontrolled T2DM and provided recommendations, which included potential solutions for initiating insulin in the absence or restriction of in-person consultations; the dose of insulin at initiation; the type of insulin preferred for simplified regimen and best practices for optimal titration to achieve glycemic targets during the pandemic. Practical and easily implementable tips for patients and involvement of stakeholders (caregivers and healthcare providers) to facilitate insulin acceptance were also outlined by the expert panel. Simplified and convenient insulin regimens like basal insulin analogues are advised during and following the pandemic in order to achieve glycemic control in people with uncontrolled T2DM.