James K. Rone, MD, FACP, FACE

Gestational Diabetes in a Previously Healthy, Thin Woman

October 25, 2012

Tags: Gestational diabetes mellitus

THIS WAS MY REPLY TO MY WIFE'S OLDEST, DEAREST FRIEND, SEEKING INFORMATION WHEN HER DAUGHTER-IN-LAW WAS DIAGNOSED LATE IN PREGNANCY WITH DIABETES.

As your research suggests, gestational diabetes (GDM) usually occurs in mothers who are already predisposed to diabetes (obesity, family history, poor lifestyle habits, irregular periods and infertility). Your daughter-in-law’s lack of these features is unusual and I don’t know enough about the situation to explain it. Pregnancy is an insulin-resistant state which can tip someone on the verge of diabetes over the edge, and the fact that it’s taken 7 months to show up suggests that she had to be “tipped” further than average.

Your genetic background is of no importance—this is a maternal issue—not one the baby’s genes causes. Poor control of the GDM though can affect the baby—at this late stage probably no birth defects, but GDM babies tend to be bigger and harder to deliver.

Not sure what the acne has to do with anything—if she had it pre-pregnancy that would be a sign of insulin resistance though.

I can speculate about 2 possibilities—she either does have some occult genetic predisposition that hasn’t obviously manifested up till now, or this is the onset of type 1 diabetes (“juvenile onset diabetes”) which young healthy thin people without family history certainly can get.

Usual treatment is insulin, but the pills glyburide and metformin have been used more lately. My personal preference, if this is not type 1 diabetes which has to have insulin, is metformin, but that must be the obstetrician’s decision.

Good luck.

jkr

Possible Hypothyroidism Despite "Normal" Thyroid Function Tests

October 10, 2012

Tags: Thyroid

THIS IS A LADY, WHO I AM PLEASED TO REPORT, READ THE BLOG AND CONTACTED ME THROUGH THE WEBSITE. SHE LIVES WITHIN DRIVING DISTANCE OF MY OFFICE AND WAS WONDERING IF IT WOULD BE WORTH MAKING AN APPT. HER STORY IS THE SAME OL' ONE--LOTS OF SYMPTOMS SUGGESTIVE OF HYPOTHYROIDISM, BUT HER THYROID FUNCTION TESTS (TFT'S) ARE "NORMAL" AND SHE KEEPS BEING TOLD IT'S NOT HER THYROID:

Good to know somebody out there is reading the blog.

If you have your lab reports available, what is your lab’s normal range for FT4? The values you documented certainly sound low-normal, I was just wondering how close to the lower normal limit they are.

The TSHs are obviously “normal” by any standard, but the question is might you have hypothyroidism due to or in addition to a defect in TSH production from the pituitary.

Any history of head injury, even something minor like knocked unconscious in an auto accident or fall?

Also, let me know all the meds you are on now.

You have enough symptoms that could be due to hypothyroidism, coupled with the lowish FT4’s and family history, that I do think a trial of thyroid replacement would be reasonable. It baffles me why “antidepressants, bcp, adhd medications” and the like are so often considered preferable to thyroid hormone, which is at least a substance that God/Mother Nature intended for us to have in our systems.

Please answer the ?’s I’ve underlined and I’ll get back to you.

***

--the 0.5 lower normal limit for FT4 is a little lower than I’m accustomed to thinking in terms of—meaning that your levels aren’t as low as I was thinking, but they are nevertheless still in the lower half of the relevant reference range. In other words I haven’t changed my mind about the possibility thyroid hormone replacement would help.
--the head injuries increase the possibility that there is a pituitary defect explaining the inappropriately normal TSHs in the face of the hypothyroidism we are postulating.
--I can’t prove this, but my feeling based on seeing a lot of patients with stories similar to yours, is that chronic pain (your headaches), narcotic use for the chronic pain, and various CNS-acting drugs, many different ones of which you are or have been on, contribute to a “soup” that hobbles TSH release—creating a central hypothyroidism-type pathophysiology.
--So, no guarantees as to our success, but I think it would be you coming to see me.

jkr

Fiction: Mystery
PI Sherry Russell vs. the reigning "Miss Nazi" in 1968 Huntsville, during the run-up to the Apollo moon landings
Dr. Rone's 1st Southern Noir novel
Hate crimes in 1967 Alabama; unflinching follow up to 'No Nice Girls'
Nonfiction: Health & Medicine
"A really good read for those that have been told they don't have a thyroid problem."

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