Pregnant Diabetic Patient Research Articles

Diabetes management in pregnancy

Diabetes in pregnancy is associated with significant morbidity and mortality and its prevalence is rising. The management of this condition involves the co-ordinated care of a multi-disciplinary team consisting of endocrinologists, obstetricians, midwives and dieticians. This review concentrates on the control of diabetes in pregnancy, by which both maternal and fetal complications can be minimised. The management of gestational diabetes centres on self-monitoring of blood glucose, diet control and if necessary, insulin treatment. Women with gestational diabetes have a high risk of developing type 2 diabetes later in life and should be counselled on the importance of lifestyle modification. In patients with pre-existing type 1 and 2 diabetes, pre-conception counselling is important to optimise pregnancy outcome. Such counselling also provides an opportunity to screen for pre-existing vascular complications such as retinopathy (which may worsen during pregnancy) and measure baseline markers of glycaemic control such as HbA 1C. Insulin requirements vary during pregnancy and hence daily assessment of blood glucose levels should be performed and the insulin dose adjusted accordingly. Conventional injections of insulin or insulin pumps are both effective in optimising glycaemic control, although the latter is generally used in patients for whom achieving normoglycaemia is challenging. Blood pressure should be regularly monitored and hypertension treated. The evidence for the efficacy of various treatment modalities has been examined in this review. By optimising diabetes management in pregnancy, it is hoped that the pregnant diabetic patient can look forward to a similar pregnancy outcome as that of a normal woman.

A spectrum of glucose thresholds may effectively prevent complications in the pregnant diabetic patient

This article outlines the probable positive relationship between levels of maternal glycemia and perinatal morbidity and mortality. A spectrum of different glucose thresholds can be established and used appropriately to prevent each complication. This article also outlines the concept of normality and what definitions of normality should be used to evaluate the relationship between the level of glycemia and perinatal outcome. Definitive conclusions are hampered by a lack of uniformity in definitions and interventions, and by a failure in some analyses to control for confounding variables. However, it is suggested that different levels of glycemia are required to prevent different diabetic complications. Thus, although it is not always possible to achieve targeted levels of glycemic control in all patients, any improvement will be beneficial because it will affect fetal complications associated with that glucose threshold.

Management of diabetic pregnancies in the United Kingdom

The aim of this postal questionnaire survey was to identify facilities currently available for the care of pregnant diabetic women in the United Kingdom and determine how closely these reflect the standards recommended by The St Vincent Declaration Action Programme. A questionnaire was sent to a physician and an obstetrician in each of the 255 obstetric hospitals in the UK. Two hundred and forty-five (96.1%) hospitals replied, with most of these managing 20 or less insulin dependent diabetics per year. Of the hospitals, 58.4%, had a special combined diabetic antenatal clinic; 86.6% of the units had a single physician responsible for diabetic care, whilst more than one obstetrician was involved in 50.6% of the units. Prepregnancy counselling was provided in 87.4% of the hospitals. Home blood glucose monitoring was used in 97.9% of the units. Ideal mean pre- and postprandial blood glucose concentrations were 6.0 mmol/1 (SD 0.82) and 7.9 mmol/l (SD 0.91), respectively. Ultrasound was routinely used to assess fetal growth in 98.7% of the units. The mean gestational age for elective caesarean section was 38.2 weeks (SD 0.55), compared with 39.0 weeks (SD 0.35) for planned vaginal delivery. During labour, 98% of the units used a dextrose and insulin infusion, but only 53.7% of the units maintained an intrapartum maternal blood glucose of between 4 and 6 mmol/l. We conclude that there is widespread variation in the management of the pregnant diabetic patient, and much practice is suboptimal. Many of the recommendations of the St Vincent Declaration are not being met by current UK practice.

PREGNANCY IN DIABETES

For patients with preconception diabetes, the most important aspect is the need for good glycemic control pre conception to lessen the risk of congenital malformations. Careful assessment of diabetes complications is essential prepregnancy. In the absence of major complications, good glycemic control gives the pregnant diabetic patient the same chance for a healthy baby as the rest of the population. Pregnancy alters carbohydrate tolerance, and thus gestational diabetes should be screened for and, when found, treated aggressively with dietary intervention, glucose monitoring, and insulin if good glycemic control has not been attained. These patients are at greatly increased risk for diabetes in the long term.

Telemedicine in the treatment of diabetic pregnancy

AbstractGood diabetic patient control requires that treatment be continuously adapted to the patient's behaviour and the control achieved, in order to get the glucose level within a predetermined target range. Several approaches have been documented. Self‐monitoring of blood glucose (SMBG) has become a major element in the care of individuals with diabetes mellitus. In managing the pregnant diabetic patient it must be considered that two patients are being treated: the mother and the fetus. It appears that the strict maintenance of euglycaemia before conception and during the prenatal period may favourably influence perinatal mortality and morbidity. Assuming that easy access to diabetes care providers would allow patients to make appropriate adjustments to their management and thus improve their metabolic control, a controlled trial comparing customary management with continuous diabetes care providing access to patients' self‐monitored glucose data, was undertaken in diabetic pregnancy. In the study, two groups were compared. The Dianet group (7 diabetic pregnant women) used a Diva System: they stored their data in blood glucose meters (ROMEO) with memory to store and transmit data when inserted into JULIET, and this data was directly carried through a telephone modem (JULIET + BOXTEL) to our service every week, and they came to the clinic every two weeks. The control group (10 pregnant diabetic women) recorded their data in a diary and came to the diabetes clinic every week. The use of the telphone modem (DIANET system) stimulated both the patient and the diabetes specialist to keep closer control of blood glucose levels. This might be especially useful in the treatment of diabetes in pregnancy because the patients are usually highly motivated to achieve better metabolic control, as was shown by (a) faster optimisation of blood glucose profiles, (b) better pre‐breakfast and pre‐lunch blood glucose concentration, (c) fewer hypoglycaemic episodes, in the DIANET versus the control group.

Diabetic Retinopathy During Pregnancy

This article outlines the pathophysiology of diabetic retinopathy, its epidemiology, and its diagnosis. Recommendations for management of the pregnant diabetic patient through the team approach has resulted in a dramatic improvement in maternal and fetal complications during pregnancy. By including a retinal specialist in the team during each trimester, the effects of pregnancy on the progression of diabetic retinopathy should be nearly identical to that of the non-pregnant patient.

Outcome of Pregnancy in Diabetic Patients in Dar es Salaam, Tanzania

Between 1 June 1986 and 31 August 1987 all 47 pregnant diabetic Tanzanian women attending Muhimbili Medical Centre, Dar es Salaam were seen and managed by a small team of interested physicians and obstetricians. Of the 50 pregnancies there were 44 (88%) live births, five (10%) perinatal deaths, and one (2%) spontaneous abortion. One child was born with a serious congenital abnormality. All five perinatal deaths were seen in women who presented late in pregnancy (three) or had poor blood glucose control (two). In 10 (36%) of the 28 pregnancies in the 25 patients with insulin-requiring diabetes, insulin requirements decreased greater than 8 U during the course of pregnancy. The present study suggests that with close supervision of the pregnant diabetic patient in Africa perinatal mortality rates approaching those seen in developed countries can be achieved, despite the lack of home blood glucose monitoring. Rates could be further reduced if medical services were more widely available, and if all patients were educated on the importance of early presentation in pregnancy.

Accelerated retinopathy and nephropathy in diabetic pregnancy

We report a case of severe deterioration in sight despite good metabolic control in a pregnant diabetic patient which has not recovered at two years post-delivery. This was accompanied by a deterioration in renal function which similarly has not improved.

Management of the pregnant diabetic patient.

The prognosis in diabetic pregnancy has greatly improved as a result of patient education and the availability of home blood glucose monitoring techniques enabling the implementation of good metabolic control pre-pregnancy, antenatal and intrapartum. These in turn have made possible the benefits to the offspring of vaginal delivery at term. Screening for gestational diabetes is important and the prognosis is also good where maternal normoglycaemia is achieved. All diabetic pregnancies should be cared for in specialist units under the supervision of an integrated team comprising an obstetrician, diabetologist and paediatrician, and for optimal results care should start prior to conception.

Recto-vaginal colonization and urinary tract infection by group B Streptococcus in the pregnant diabetic patient.

The influence of maternal diabetes on Group B Streptococcus (GBS) colonization and GBS urinary infection was investigated. The population under study comprised 1,050 pregnant women (70 of them diabetics, the remaining 980 non-diabetics). A higher prevalence of GBS colonization was found among diabetics (20% versus 10.9%) (p less than 0.05). The rate of colonization was not correlated to the severity of the diabetes condition. Urinary infection was diagnosed on 8.6% of diabetic patients, versus 7.1% of non-diabetics (p greater than 0.05). Urinary infection by GBS occurred with similar frequency in both groups (0% in diabetics and 1% in non-diabetics). The possible etiological implications are commented on, and vaginal and rectal cultures are recommended for GBS screening in the pregnant diabetic patient.

Reassessment of White's classification and Pedersen's prognostically bad signs of diabetic pregnancies in insulin-dependent diabetic pregnancies

The classification systems developed over 20 years ago by White and Pedersen identified diabetic pregnancies at increased risk for perinatal mortality. To assess whether these same criteria would currently be valid, 199 diabetic pregnancies with deliveries from 1977 to 1983 were reviewed. Perinatal mortality rates for White's Classes B gestational (n = 72), B (n = 27), C (n = 67), and D + F + R (n = 33) were 2.9%, 11.1%, 14.9%, and 21.1%, respectively (p < 0.05). White's classes were also predictive of pulmonary morbidity (12.5%, 18.5%, 22.4%, and 42.4%, respectively). The presence of one or more of the prognostically bad signs of pregnancy (n = 76) increased the perinatal mortality rate to 17.1% versus 7.3% among insulin-dependent diabetic pregnancies without prognostically bad signs (p < 0.05). The presence of any prognostically bad signs of pregnancy was also predictive of pulmonary morbidity in general (31.6% versus 16.3%, respectively) and hyaline membrane disease in particular (13.2% versus 4.1%, respectively). Thus with use of modern obstetric management and medical care of the pregnant diabetic patient, both White's classification and Pedersen's prognostically bad signs of pregnancy continue to be predictive of perinatal mortality.

Continuous insulin delivery systems for the pregnant diabetic patient

In highly unstable diabetes (brittle diabetes) the degree of metabolic control called for today in managing the pregnant diabetic patient is not achievable by intensified conventional insulin therapy. These cases have been markedly improved by continuous insulin delivery systems. In the course of 2 years, 6 diabetic pregnant patients (8%) were treated with insulin pumps for a total of 910 days, using the intravenous route once, the intraperitoneal route twice and the subcutaneous route three times. The group consisted of one White C, one White D and four White R diabetic patients. Metabolic control was achieved by 5,916 blood sugar measurements, 42 determinations of glycosylated hemoglobin (HbA1) and 19 determinations of amniotic fluid insulin. The intravenous and the subcutaneous route showed about the same rate of hypoglycemia as intensified conventional insulin therapy. Hypoglycemia did not appear, however, under intraperitoneal insulin administration. Mean blood glucose in patients on the pump dropped from 121.0 to 97.4 mg/dl. The standard deviation of the blood glucose values during one week dropped from 64.5 to 35.2 mg/dl, the mean amplitude of glycemic excursions (MAGE) from 100 to 43 mg/dl and the mean of daily differences (MODD) from 72 to 29 mg/dl. The concentration of glycosylated hemoglobin sank from 10.5 to 6.8%. The metabolic condition improved significantly. On average, the patients were hospitalized for 7.5 (1.7-12.8) weeks. Fetal hyperinsulinism developed in 2 patients on the pump and was reversible by closer metabolic management. Neonatal weight was in the normal range and there were no signs of diabetogenic fetopathy.

Management of the pregnant diabetic patient--are the pundits right?

Many authorities are currently suggesting specific strategies for optimal obstetrical management of pregnant diabetic patients which involve early admission, frequent monitoring and a high Caesarean section rate. The author suggests that a more conservative approach may be indicated. In support of this contention, he cites from his personal experience of managing over 1,000 diabetic pregnancies during the past 34 years. As there were no therapeutic abortions, the series is consecutive and unmodified. There were no maternal deaths, and the perinatal loss during the 34-year period was 7.4%. In the years 1979-1984 the perinatal loss in 285 viables was 4.5%, and the Caesarean section rate was 25.9%. In 87 primigravidae, the Caesarean rate was 31%.

Elevated maternal glycohemoglobin in early pregnancy and spontaneous abortion among insulin-dependent diabetic women

Insulin-dependent diabetic women without adequate glucose control have a higher rate of spontaneous abortions than does the general population of pregnant women. The present study examined whether insulin-dependent diabetic women who experienced spontaneous abortions had higher levels of glycohemoglobin in the first trimester than did insulin-dependent diabetic women who had normal pregnancy outcomes. Measurement of glycohemoglobin during the first trimester provides an integrated, retrospective index of glucose control during the phase of organogenesis. This study evaluated 116 pregnancies in 75 insulin-dependent diabetic women. Ninety pregnancies progressed beyond 20 weeks, with normal outcome. Twenty-six pregnancies terminated in spontaneous abortions before 20 weeks. The mean gestational ages for sampling of glycohemoglobin for the women who experienced spontaneous abortion and those for the women with pregnancies of more than 20 weeks were not significantly different. The mean level of glycohemoglobin for the women who experienced spontaneous abortions was significantly greater than that for the women with pregnancies of more than 20 weeks (p < 0.05). Individual levels of glycohemoglobin of less than 12% at 8 to 9 weeks' gestation were associated with favorable outcomes, whereas levels of glycohemoglobin of more than 12% were predictive of a greater incidence of spontaneous abortions (p < 0.05). These data suggest that the poorly controlled pregnant diabetic patient, as reflected by high levels of glycohemoglobin early in pregnancy, has an increased risk of spontaneous abortion.

Glucose monitoring and insulin administration in the pregnant diabetic patient.

Over the past decade, it has been apparent that the degree of glycemic control achieved in the pregnant patient with diabetes mellitus significantly affects perinatal outcome. While several studies have documented excellent perinatal outcome with good glucose control, the incidence of neonatal morbidity still remains substantially greater than that observed in the general population. Physiologic or "tight" control appears to further reduce the incidence of macrosomia, hypoglycemia, and other indices of neonatal morbidity. The application of home glucose-monitoring techniques to pregnancies complicated by diabetes can result in optimal glucose control. While one small comparative series did not document improvement in perinatal morbidity, fewer admissions for diabetic control and decreased patient expense were observed in the group using home monitoring. After pregnancy, most patients continued to use home monitoring. This probably reflects the degree of patient enthusiasm and interest generated by self-care. Programs using home blood glucose monitoring and individualized insulin regimens in the management of diabetes may have their greatest impact if implemented prior to conception. The degree of glucose control during early embryogenesis appears to determine the incidence of congenital malformations in the offspring of insulin-dependent diabetic women. Continued careful assessment of the degree of glycemic control may enable the patient and her physician to plan the optimal time for attempting a pregnancy.

Needle and catheter colonization in pregnant diabetic patients using the continuous subcutaneous insulin infusion pump.

The incidence of bacterial colonization and risk of infection associated with the use of continuous insulin infusion pump (CIIP) was examined in 11 pregnant diabetic patients. All patients received instruction on specific aspects of CIIP and needle insertion technique according to the protocol used in our institution. A total of 220 cultures was performed on the subcutaneous needle and connective tubing. There was no clinical evidence of infection. In conclusion, the risk of infectious cutaneous complications in the pregnant diabetic patient using CIIP is not increased over the nonpregnant diabetic population.

Amniotic fluid C-peptide and phosphatidyl glycerol in diabetic pregnancy.

The concentrations of C-peptide and phosphatidylglycerol in the amniotic fluid were determined in 36 pregnant diabetic women. Twenty-one patients who were being treated with insulin for gestational diabetes as well as 15 patients who were insulin dependent were studied. All patients were subjected to a program of strict metabolic control, and amniocentesis was performed at gestational week 36-37. Phosphatidyl glycerol was present in the amniotic fluid in 15 cases and absent in 21. The mean concentration of C-peptide did not differ whether phosphatidyl glycerol was present or absent. (C-peptide: 0.56 +/- 0.06 and 0.43 +/- 0.05 nmol/l respectively). Although the mean value for amniotic fluid C-peptide in both groups was close to that in diabetic pregnancies with an uneventful neonatal outcome, it was significantly higher than that in non-diabetic pregnancies, indicating minor fetal hyperinsulinemia. The level of C-peptide in the amniotic fluid showed a correlation to the subsequent birthweight of the infant (r = 0.50; p less than 0.01). It is concluded that with rigorous metabolic control of the pregnant diabetic patient, the presence or absence of phosphatidyl glycerol, as an index of fetal lung maturity, is apparently not related to the level of C-peptide in the amniotic fluid.

The effect of plasma glucose variability on neonatal outcome in the pregnant diabetic patient

Maternal glucose variability was studied in 154 pregnant diabetic patients hospitalized during the last month of their pregnancies. By means of several statistical analyses of the coefficient of variation for within-day plasma glucose variability, we found as follows. (1) There was a significant association between maternal glucose variability and neonatal outcome. (2) Patients with greater glucose variability had more episodes of hyperglycemia, but not hypoglycemia. (3) There was no correlation between maternal glucose variability and the birth weight of the infant. We are proposing the use of an index for glucose variability to monitor glucose control in pregnancy and predict neonatal outcome. Although absence of glucose variability will not ensure prevention of neonatal complications, there is a clear association between greater glucose variability and neonatal complications.

Cardiovascular and biochemical effects of infusion of beta hydroxybutyrate into the fetal lamb

Previous studies from our laboratory have shown that beta hydroxybutyrate crosses the ovine placenta in small amounts during maternal hyperketonemia and produces significant reductions in fetal PaO2 and increased fetal lactate levels. The present study evaluates the effects of fetal hyperketonemia on fetal and maternal cardiovascular and biochemical parameters. Pregnant ewes (110 to 120 days' gestation) were instrumented with catheters in the femoral artery, femoral vein, and uterine veins, and electromagnetic flow probes were placed on the middle uterine arteries. The fetal carotid artery and jugular vein were catheterized, and a catheter and balloon were placed in the amniotic fluid. Beta hydroxybutyrate (0.44 mmole/min) and antipyrine (0.03 mmole/min) were simultaneously infused directly into the fetal jugular vein for 90 minutes. The fetal beta hydroxybutyrate level increased from a baseline of 0.12 ± 0.08 to 6.80 ± 0.46 mmoles/L and was associated with a significant decrease in fetal PaO2 (23.7 ± 2.4 to 16.0 ± 0.4 mm Hg) and a large increase in the fetal lactate level (1.85 ± 0.27 to 5.43 ± 0.92 mmoles/L) at 90 minutes. The present results suggest that during fetal hyperketonemia fetal oxygenation is significantly reduced and may contribute to the increased perinatal mortality in the pregnant diabetic patient.

Anesthetic and Obstetric Management of Diabetic Pregnant Women

Anesthesia for the pregnant diabetic patient should be based on an understanding of the pathophysiology of diabetes. This article reviews the metabolic and hormonal adjustments in normal and diabetic pregnancy; discusses maternal, fetal, and neonatal complications; and presents modern modalities of treatment.