eMedicine Specialties > Endocrinology > Diabetes Mellitus

Diabetes Mellitus and Pregnancy: Follow-up

Author: Thomas R Moore, MD, Chairman, Professor, Department of Reproductive Medicine, University of California at San Diego School of Medicine
Contributor Information and Disclosures

Updated: May 21, 2009

Follow-up

Further Inpatient Care

  • Avoiding shoulder dystocia
    • Although ultrasonographic measurements of the fetus have proven to be poor predictors of the risk of shoulder dystocia, this technique continues to be the mainstay for assessing risk in pregnancy for women with diabetes. The commonly used formulas derived from a multivariate regression multiply multiple coefficients together, with the resultant product (estimated fetal weight) typically having an accuracy that is seldom less than within 15%. Fetuses predicted to weigh 4000 grams and 4500 grams based on ultrasonographic findings actually weigh that much only 50% of the time.
    • In a study involving more than 300 fetuses who weighed more than 4000 grams at birth, ultrasonography was found to have a sensitivity of only 65% in identifying macrosomic fetuses. However, a sensitivity of approximately 80% is typically associated with a specificity of 50-60%. This means a false-positive rate of 30-50% occurs even with the more predictive formula, possibly requiring an unnecessary cesarean delivery of more than 100 fetuses in order to prevent one from having permanent Erb palsy.
    • Thus, current data do not support a policy of early induction of labor in cases of possible fetal macrosomia. If one accepts that 8-20% of infants of diabetic mothers born weighing 4500 grams or more will experience shoulder dystocia, 15-30% of these will have recognizable brachial plexus injury, and 5% of these injuries will result in permanent deficit, approximately 333-1667 cesarean deliveries would have to be performed for possible macrosomia to prevent one case of permanent injury due to shoulder dystocia.
    • However, if fetal weight is estimated to be 4500 grams or more, the risks and benefits of cesarean delivery should be discussed with the patient. 
  • Intrapartum glycemic management
    • Maintenance of intrapartum metabolic homeostasis optimizes postnatal infant transition by reducing neonatal hyperinsulinemia and subsequent hypoglycemia.
    • The use of a combined insulin and glucose infusion during labor to maintain maternal blood sugars in a narrow range (80-110 mg/dL) during labor is a common and clinically efficient practice. Typical infusion rates are 5% dextrose in Ringer lactate solution at 100 mL/h and regular insulin at 0.5-1.0 U/h. Capillary blood sugar levels are monitored hourly in these patients.
    • For patients with diet-controlled gestational diabetes mellitus or mild type 2 diabetes, avoiding dextrose in intravenous fluids normally maintains excellent blood glucose control. After 1-2 hours of monitoring, no further assessments of capillary blood sugar typically are necessary.
  • Management of the neonate
    • The most critical metabolic problem that affects infants of diabetic mothers is hypoglycemia. Unmonitored and uncorrected hypoglycemia can lead to neonatal seizures, brain damage, and death. The strongest predictor of neonatal hypoglycemia is maternal mean blood glucose level during labor.  Infants of diabetic mothers also appear to have disorders of both catecholamine and glucagon metabolism and have a diminished capability to mount normal compensatory responses to hypoglycemia.
    • Thus, current recommendations specify frequent blood glucose checks and early oral feeding when possible (ideally from the breast), with infusion of intravenous glucose if oral measures prove insufficient. Most neonatologists maintain strict monitoring of the glucose levels of newborn infants of diabetic mothers for at least 4-6 hours (frequently 24 h), often necessitating admission to a newborn special care unit.
    • Current evidence indicates that with proper encouragement, sustained breastfeeding is possible for a significant proportion of patients with overt diabetes. In fact, evidence indicates that breast-fed infants have a much lower risk of developing diabetes that those exposed to cow's milk proteins.
    • Studies of breastfeeding women with diabetes indicate that lactation, even for a short duration, also has a beneficial effect on overall maternal glucose and lipid metabolism. For postpartum women who had gestational diabetes mellitus during their pregnancies, breastfeeding may offer a practical low-cost intervention that helps reduce or delay the risk of subsequent diabetes in women with prior gestational diabetes mellitus.
    • Webster et al longitudinally compared breastfeeding habits among women with diabetes and without diabetes. At discharge, 63% of diabetic mothers and 78% of mothers without diabetes were breastfeeding. At 8 weeks, the proportions of each were nearly identical (58% and 56%, respectively). At 3 months, 47% percent of mothers with diabetes and 33% mothers without diabetes continued to breastfeed.53
Intensive management of women with glucose intolerance during pregnancy has resulted in markedly improved outcomes in recent years. Despite these advances, care of the infant of a mother with diabetes continues to require vigilance and meticulous monitoring with a full understanding of the quality of glycemic milieu in which it developed.

Deterrence/Prevention

Prevention of gestational diabetes is an attractive concept, but no progress has been made, despite attempts in smaller studies. Because body fat and diet contribute to the risk of gestational diabetes mellitus, patients who lose weight prior to pregnancy and follow an appropriate diet may lower their risk of gestational diabetes mellitus. However, the pregnancy hormones impose such a high degree of insulin resistance, in very susceptible individuals, even marked weight loss and attention to diet are not likely to be successful.

Patient Education

  • Education is the cornerstone of effective metabolic management of the patient with diabetes during pregnancy. The American Diabetes Association offers educational curricula specific to each type of diabetes encountered during pregnancy (IDDM, NIDDM, GDM), specifically organized around each phase of pregnancy. This information can be transmitted to the patient by office staff and labor/delivery nurses. However, specially trained and certified nurses and dietitians (ie, certified diabetes educators) are the most effective in this regard. Most large programs treating women with diabetes during pregnancy assist the patient with a staff that includes a registered nurse, a certified diabetes educator, a dietitian knowledgeable about pregnancy, and a social worker. Successful management of diabetic pregnancy is optimized when this type of team care is available.
  • The diabetes-in-pregnancy team is also able to help the patient during the puerperal period with the challenges of lactation, diet, sleep, and glycemic control. This team is also most effective in providing a smooth return to nonpregnant metabolic management.

Miscellaneous

Medicolegal Pitfalls

Two main issues present medicolegal pitfalls for the clinician treating patients with diabetes in pregnancy.

  • First is the occurrence of a severe, debilitating congenital anomaly in the infant of a mother with diabetes.
    • Structural defects occur in 3-8% of offspring of diabetic pregnancy, but this rate drops 3- to 4-fold if excellent glycemic control is maintained during the period of embryogenesis.
    • Thus, it is incumbent upon the medical provider, when discussing pregnancy plans with a woman with preexisting diabetes, to mention the preventability of these birth defects with good periconceptional glycemic control
    • The patient should be advised to use a reliable method of contraception until she has achieved an HbA1c level within the reference range preconceptionally. This counseling should be recorded in the patient’s medical record.
  • A second risk is birth injury, which may include perinatal asphyxia, clavicle or humerus fracture, brachial plexus disruption, or, less commonly, direct cerebral or cervical spine trauma.
    • Permanent palsy of the arm and hand after a difficult delivery of an obese fetus usually leads to litigation and, in some cases, large judgments. Although current scientific data establishing the foreseeability and preventability of these injuries remains inadequate, defending obviously high-risk cases can be difficult.
    • The obstetrician managing the patient’s third-trimester prenatal care and labor may be judged at fault should an injury occur during delivery if an ultrasonogram suggests that fetal weight exceeds 10 pounds, labor proceeds slowly, or a difficult forceps or vacuum procedure is necessary to deliver the fetal head. Thus, obtaining an ultrasonogram-based estimation of fetal weight in the last 2-3 weeks prior to delivery and offering cesarean delivery to a patient with an estimated fetal weight of more than 4500 grams or a labor course that is protracted such that she is unable to expel the fetal head spontaneously after 2-3 hours of pushing effort are prudent.

 
Acknowledgments

We wish to thank Carri Warshak, MD, Assistant Professor, Department of Reproductive Medicine, University of California at San Diego School of Medicine, for her previous contributions to this entry.



More on Diabetes Mellitus and Pregnancy

Overview: Diabetes Mellitus and Pregnancy
Differential Diagnoses & Workup: Diabetes Mellitus and Pregnancy
Treatment & Medication: Diabetes Mellitus and Pregnancy
Follow-up: Diabetes Mellitus and Pregnancy
References
Further Reading
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Keywords

gestational diabetes mellitus, gestational diabetes, diabetes mellitus, diabetes, insulin, glucose, blood sugar, metformin, diabetes type 2, diabetic, diabetes 2, hyperglycemia, hypoglycemia, diabetes diet, diabetes treatment, mellitus, diabetes mellitus type 2, diabetes symptoms, diabetes diagnosis, high blood sugar, type 2 diabetes mellitus, type II diabetes mellitus, DM, DM type 2, adult-onset diabetes mellitus, infants of diabetic mothers, IDMs, infant of diabetic mother, IDM, maternal hyperglycemia, fetal hyperglycemia, diabetes inpregnancy,diabetes-associatedbirth defects, diabeticbirth defects, gestational DM, macrosomia, macrosomic infant, macrosomic fetus, diabetic pregnancy, fetal macrosomia

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Contributor Information and Disclosures

Author

Thomas R Moore, MD, Chairman, Professor, Department of Reproductive Medicine, University of California at San Diego School of Medicine
Disclosure: Nothing to disclose.

Medical Editor

Robert K Zurawin, MD, Associate Professor, Director of Baylor College of Medicine Program for Minimally Invasive Gynecology, Director of Fellowship Program, Minimally Invasive Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine
Robert K Zurawin, MD is a member of the following medical societies: American Association of Gynecologic Laparoscopists, American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, Association of Professors of Gynecology and Obstetrics, Central Association of Obstetricians and Gynecologists, Harris County Medical Society, North American Society for Pediatric and Adolescent Gynecology, and Texas Medical Association
Disclosure: Johnson and Johnson Honoraria Speaking and teaching; Conceptus Honoraria Speaking and teaching; Biosphere Medical Honoraria Speaking and teaching; Eli Lilly Honoraria Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Romesh Khardori, MD, Chief, Division of Endocrinology, Metabolism and Molecular Medicine, Professor, Department of Internal Medicine, Southern Illinois University School of Medicine
Romesh Khardori, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Medical Association, American Society of Andrology, Endocrine Society, and Illinois State Medical Society
Disclosure: Nothing to disclose.

CME Editor

Mark Cooper, MBBS, PhD, FRACP, Head, Diabetes & Metabolism Division, Baker Heart Research Institute, Professor of Medicine, Monash University
Disclosure: Nothing to disclose.

Chief Editor

Carl V Smith, MD, The Distinguished Chris J and Marie A Olson Chair of Obstetrics and Gynecology, Professor, Department of Obstetrics and Gynecology, University of Nebraska Medical Center
Carl V Smith, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Medical Association, Arkansas Medical Society, Association of Professors of Gynecology and Obstetrics, Central Association of Obstetricians and Gynecologists, Council of University Chairs of Obstetrics and Gynecology, Nebraska Medical Association, and Society for Maternal-Fetal Medicine
Disclosure: Nothing to disclose.

 
 
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