Fillers A memorable patient

Home glucose monitoring, who started it?

BMJ 1998; 316 doi: (Published 09 May 1998) Cite this as: BMJ 1998;316:1467
  1. Clara Lowy, reader in medicine
  1. London

    In 1975 there was compelling evidence that glycaemic control in pregnancy was critical for a successful outcome for mother and baby. However, diabetic control could be monitored only by the women testing the urine for reducing substances. The renal threshold for glucose not uncommonly falls in pregnancy with resultant glycosia when the blood glucose values are still in the normal range. The instruction to diabetic pregnant women was to keep “the urine blue” (clinitest tablets were still in use and when five drops of urine and 10 drops of water were added to the clinic test tablet the mixture would remain blue if free of reducing substances). My patient had obeyed this instruction, but unfortunately for her, and perhaps fortunately for the diabetic fraternity, she developed a drastic reduction in her renal threshold for glucose, which resulted in a prolonged hypoglycaemic episode. So at 26 weeks of pregnancy I advised her to come into hospital to be monitored. Her response to this request was, “What are you going to do in hospital that I cannot do at home?” My reply was, “Measure your blood glucose.” Her response to this was, “Why can't I do this at home?”

    The dextrostix together with the Eyetone reflectance metre had been on the market for 10 years but was largely discredited. However, if correctly used (20 minute warm up time, calibration with standards, adequate drop of blood applied to the dextrostix, accurate timing of the reaction, and careful washing of strip and blotting) blood glucose values could be achieved with a plus or minus 10% accuracy. The incentive for my patient to get to grips with the technology was overriding. It would mean that she would not be incarcerated in hospital. She learnt very fast. I still have her records. She made about three measurements a day and was not admitted until term. From then on every established pregnant woman in our unit has monitored her blood glucose. Two years later my patient was pregnant again. By then blood glucose measurements were made before most meals and at bedtime. I used to show her records at meetings because two days before delivery she was attending a wedding rather than in an antenatal bed, the accepted practice at the time. Home glucose monitoring is now universal for all insulin dependent diabetic patients and no pregnant diabetic woman is routinely kept in hospital for the entire third trimester of her pregnancy. But 23 years ago my colleagues considered this a dangerous practice. Patients may contribute more to advances in medicine than is recognised.

    We welcome articles up to 600 words on topics such as A memorable patient, A paper that changed my practice, My most unfortunate mistake, or any other piece conveying instruction, pathos, or humour. If possible the article should be supplied on a disk. Permission is needed from the patient or a relative if an identifiable patient is referred to. We also welcome contributions for “Endpieces,” consisting of quotations of up to 80 words (but most are considerably shorter) from any source, ancient or modern, which have appealed to the reader.

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