Diabetes and Pregnancy

Research has found that approximately 50,000 to 150,000 infants are born to diabetic mothers each year. Of those infants, the ones who will experience the greatest complications are those who are born to mothers with pre-existing diabetes or who have had a delayed diagnosis of gestational diabetes (GDM).

• Pre-Existing Diabetes
  Women who have been diagnosed with diabetes before becoming pregnant need to be counseled on the importance of maintaining a consistent, within normal limits blood glucose level prior to even becoming pregnant. Glycosylated hemoglobin levels or HbA1c is a lab test used to determine the percents of HbA1c in the blood stream. If the HbA1c level is greater than seven to nine percent of the total hemoglobin, then there is a greater risk of anomalies for a period of six to twelve months before conception and during the first trimester.
  
  
• Gestational Diabetes
  Most women who develop gestational diabetes do not have a prior history of carbohydrate intolerance. Most often screening occurs between 24 to 28 weeks. Those who have risk factors for gestational diabetes should be tested prior to 24 to 28 weeks. Those risk factors include; obesity, glycosuria, over the age of thirty, hypertension, polyhydramnios, family history of diabetes, previous macrosomic neonate, previous history of gestational diabetes, and previous fetal death of unknown etiology.

MATERNAL COMPLICATIONS

• Infections
  Infections can be more common especially urinary tract and vaginal infections. If the urine infections affect the kidneys (pyelonephritis), the patient is then predisposed to preterm labor and birth.
  
  
• Hypertension
  Chronic hypertension and pregnancy induced hypertension are more likely in both type I and type II diabetes. This is typically due to underlying renal disease. Essential hypertension and pregnancy induced hypertension tends to occur more frequently with gestational diabetic mothers. Most often this is true when the diagnosis of gestational diabetes is made prior to 24 weeks.
  
  
• Hypoglycemia
  Severe hypoglycemia that compromises maternal cardiac function can lead to decreased uteroplacental function and result in fetal distress.
  
  
• Diabetic Ketoacidosis
  Increased hyperglycemia (blood glucose higher than 350 mg/dL) can lead to ketonemia, acidosis signs and other clinical symptoms. This accumulation of symptoms can lead to hypovolemic shock, serious electrolyte imbalance (secondary to dehydration) and maternal death.
  
  
• Other Intrapartum Complications
  Other complications that can be seen in the pregnant diabetic include; hypotonic contractions, prolapsed umbilical cord (a birth emergency), amniotic fluid embolism, uterine atony and postpartum hemorrhage.

TREATMENT OPTIONS

Treatment for those women who have type I or type II diabetes really needs to begin at least three to six months prior to pregnancy. Treatment for these women should aim at strictly controlling the woman’s plasma glucose levels. This can be accomplished through diet, physical activity, blood glucose monitoring and appropriate insulin administration when indicated.

OB visits for the pregnant diabetic need to include evaluation for possible renal disease, identification of chronic hypertension, neuropathies, and eye problems. Ultrasounds should include evaluation of fetal macrosomia. Non-stress tests and biophysical profiles should be included in the plan of care in the third trimester. Aside from regular OB visits, a registered dietitian and diabetes educator are an essential component to the healthcare team of a pregnant diabetic for the purposes of patient education and diet guidance.

• Labor
  The need for induction of labor is often a consideration for the pregnant diabetic. Most often this is thought of due to the size of the fetus. Other indications for induction which are common for these mothers include a gestational age of 40 weeks or greater, severe pregnancy induced hypertension, and decreased fetal well-being (as noted by biophysical profile results and/or non-stress tests).
  
  
• Indications for Caesarean Section
  Pregnant diabetics also have an increased incidence of cesarean section. This is often due to at least one of the following; cephalopelvic disproportion, fetal macrosomia, fetal malpresentation and complications associated with diabetes.

If your client had diabetes during their pregnancy, contact our office at Medical Jurisprudence, Inc. for case analysis and assistance.