Diabetes Mellitus in Pregnancy

The Challenge

The challenge is to diagnose and manage disturbances of glucose metabolism to minimize the risk associated with diabetes in mothers and fetuses. Diabetes and pregnancy have profound effects on each other, making a familiarity with the interactions between mother, fetus, and the diabetic process a requirement to provide optimal care.

• Scope of the Problem: Diabetes mellitus is the most common medical complication of pregnancy, affecting 2%–7% of patients (varying in direct proportion to the prevalence of type 2 diabetes in a given population or ethnic group). Between 80% and 90% of these patients have gestational diabetes. Patients who had gestational diabetes in a previous pregnancy have a 33%–50% likelihood of recurrence in a subsequent pregnancy. Patients with type 1 diabetes are at greater risk for maternal complications (diabetic ketoacidosis, glucosuria, hyperglycemia, polyhydramnios, pre-eclampsia, pregnancy-induced hypertension, preterm labor, retinopathy, urinary tract infections, postpartum uterine atony). The offspring of women with diabetes have a 3-fold greater risk for congenital anomalies (3%–6%) than children of mothers without diabetes (1%–2%). Most common among these anomalies are cardiac and limb deformities. Other fetal complications include fetal demise, polyhydramnios, hyperbilirubinemia, hypocalcemia, hypoglycemia, macrosomia, polycythemia, prematurity, respiratory distress syndrome, and spontaneous abortion.

• Objectives of Management: To return serum glucose levels to as close to normal as possible through a combination of diet, exercise, oral hypoglycemic agents, and insulin (for selected patients). Optimal management of diabetes begins before pregnancy. Optimal management also requires patient and family education and involvement. For the established patient with diabetes, this teaching is directed to the need for tighter control and more frequent monitoring. The woman with newly diagnosed diabetes requires general instruction about her disease and the unique aspects of diabetes during pregnancy. With respect to the fetus, the goal of treatment is to reduce the likelihood of macrosomia and its consequences. Neonatal hypoglycemia may also be reduced.