Endocrinology Fellow Cooper University Health Care Philadelphia, Pennsylvania, United States
Introduction : Postprandial Hyperinsulinemic hypoglycemia is a rare complication of Roux-en-Y gastric bypass, occurring in approximately 0.1 to 0.3 % of patients. This usually presents with adrenergic and neuroglycopenic symptoms one to three hours after ingesting a carbohydrate-rich meal. Its underlying pathophysiology remains poorly understood, but it is believed to involve increase in incretin serum concentration. The management primarily consists of dietary modifications consisting in limiting simple carbohydrates and replacing them with complex carbohydrates, fiber, and increased protein intake.
Case(s) Description : A 37-year-old woman was initially evaluated by endocrinology due to hypoglycemia three months after Roux-en-Y gastric bypass. During initial evaluation she was found to have an elevated insulin level of 68.5 uIU/mL with serum glucose of 61 mg/dl. Further evaluation showed normal cortisol level, normal c-peptide, and negative Sulfonylurea screen. She was initially managed with dietary modifications, but subsequently had repeated admissions for similar presentation. CT abdomen/pelvis with IV contrast and MRI pancreas with IV contrast showed no pancreatic abnormalities. She was started on a continuous glucose monitor to closely monitor her glucose at home. During these admissions she was treated with Acarbose, which resulting in diarrhea and mild nausea, Octreotide which provided minimal relief and significant nausea, and Diazoxide which also resulted in significant nausea. At the 9-month mark since her diagnosis, she started developing more frequent hypoglycemic episodes. At that time, she was found to be in the first trimester of pregnancy. Due to the possible teratogenicity most medications used for hypoglycemia; a discussion was held with the maternal-fetal medicine team regarding how to proceed. After this discussion, it was decided to continue Acarbose for now and to titrate dose as tolerated, hoping that by the 3rd trimester her hyperinsulinemic symptoms would subside. During her pregnancy, she required multiple admissions due to severe hypoglycemic episodes. Octreotide was initiated during one of these admissions as benefits outweighed risks, but she quickly developed severe nausea and vomiting. At the 3rd trimester mark, her symptoms improved, her pregnancy continues, and she has been able to be managed as outpatient with close follow up with endocrine and maternal-fetal medicine.
Discussion : This case illustrates the challenges of managing hyperinsulinemic hypoglycemia during pregnancy. Refractory cases are usually treated with medications that delay breakdown of carbohydrates such as Acarbose, or medications that reduce insulin secretion such as Octreotide or Diazoxide. However, this is severely limited during pregnancy as usually these have not been studied during pregnancy, are known teratogenic or its side effects result in limited usage. Our case highlights the complexities in balancing maternal glucose control and fetal safety, emphasizing the need for individualized approaches when conventional medications may be contraindicated or poorly tolerated during pregnancy.
