Diabetes in pregnancy has been increasing in incidence in recent years.
This is because not only is the incidence of diabetes in the general population itself increasing, but women nowadays are getting pregnant at a later age when diabetes is more common.
Two groups of patients are considered under this heading:
- Diabetic patients who get pregnant.
- Pregnant patients who develop diabetes during the course of their pregnancy-Gestational Diabetes.
The complications, treatment and management of both the groups however are almost the same, so they will be described together.
Women at risk of developing Diabetes:
- Women with a family history of diabetes.
- Very obese patients.
- Excessive weight gain.
- Elderly patients - women above the age of 35 years.
- Women with a bad obstetric history :
- Women who have previously delivered a stillborn baby.
- Have had an unexplained intrauterine foetal death.
- Neonatal death.
- Recurrent pregnancy loss.
- Premature labour in an earlier pregnancy.
- Congenital malformed baby.
- Difficult delivery of a grossly overweight baby.
Signs and Symptoms of Diabetes in Pregnancy:
- Symptomless: Most women who develop diabetes during their pregnancy are diagnosed only at the routine blood and urine tests for blood sugar (random) at the first antenatal visit. The random blood sugar test is repeated at the 28th week of pregnancy, as very often diabetes develops at or around this period.
In women who are at risk of developing diabetes, fasting and post-prandial (after meals) blood is tested for blood sugar levels. An oral glucose tolerance test (GTT) may also be needed in some cases.
Women at risk of developing gestational diabetes can also use home test kits regular monitoring of the blood glucose level.
- Excessive weight gain: Women with gestational diabetes frequently put on excess weight.
- Hydramnios: Excessive liquor in the amniotic cavity can occur in diabetic patients.
- Recurrent infections: Women who complain of recurrent urinary tract infections, vaginitis or vaginal itching that do not respond to standard antibiotics must always be investigated for gestational diabetes.
- Pressure symptoms: Breathlessness, edema and other signs of pressure from the enlarged uterus may be more than in normal pregnancies.
Complications of Diabetes in Pregnancy:
- Abortion, specially recurrent abortions.
- Pre-eclamptic toxaemia (PET) is more common in pregnancy with diabetes than in a normal pregnancy.
- Premature labour.
- Hydramnios can develop.
- Maternal infections especially urinary tract infections and vaginitis
- Intra-uterine foetal death.
- Intra-uterine growth retardation of the foetus
- Difficult labour due to big size of the baby
Complications in the foetus:
- Foetal defects like macrosomia (large size of the baby).
- Intra-uterine foetal death
- Intra-uterine growth retardation of the foetus
- Birth injuries due to large size of the baby
- Shoulder Dystocia of the baby.
- Neonatal deaths – death of the baby within 5-7 days of birth
- Delayed maturation of the foetal lungs
- Congenital maformations of the foetus, mainly skeletal defects, cardiac and kidney anomalies. A lethal congenital anomaly is anencaphaly or absence of the foetal skull.
Treatment of Diabetes in Pregnancy:
- Proper regulation of diet.
- Regulated doses of Insulin when diet alone cannot control diabetes.
- Regular monitoring of the blood glucose level, either by home test kits or by testing at a laboratory. Urine can be tested for the level of sugar everyday by the patient herself at home with the help of multistix strips. Both home test kits and multistix strips are available online.
- Intensive antenatal care to prevent abortion, PET, premature labor.
- Repeated USG to diagnose foetal congenital defects and appropriate management.
Time of Delivery :
- Labor is induced in cases of controlled diabetes at 38 weeks of pregnancy with careful foetal monitoring - maturity scoring, foetal heart rate, cervical scoring for induction of labour.
- Cesarian Section should be done where baby or mother is at risk due to complications like large fetus and PET and in cases of uncontrolled diabetes.
- The patient is kept under careful surveillance in the postpartum period as she is at the risk of having postpartum haemorrhage and developing postpartum infections.
Foetal Monitoring : The baby should be closely monitored after birth as there is a risk of development of neonatal hypoglycaemia. The baby receives increased blood sugar from the mother while in the uterus.
After birth, when this source of sugar disappears, there may be a sudden drop of blood sugar level. Regular blood samples are taken from the baby to test for the blood sugar level.
Glucose may be needed to be given to the baby by IV drip immediately after birth, and then the dose gradually tapered off as she adjusts to the changed environment.
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