Endocrine Disorders in Pregnancy

Diabetes Mellitus

See Table 8-1.

■ Pregestational diabetes—patient had DM before pregnancy

■ Gestational diabetes—patient develops diabetes only during pregnancy. Gestational diabetes is classified as type A according to White classification.

■ White classification A1—controlled with diet

■ White classification A2—requires insulin

Screening

Screening is controversial, but tests often used are:

1. Glucose challenge test—at 26 to 28 weeks:

■ Give 50-mg glucose load (nonfasting state).

■ Draw glucose blood level 1 hour later.

Pregnancy testing is recommended before prescribing hormonal medications in patients with anovulatory symptoms and menstrual irregularities.

TABLE 8-1. Diabetes Classifications

Class

Onset

Postprandial

Glucose

Duration (yrs)

Vascular Disease

Therapy

A!

Gestational

< 95 mg/dL

< 120 mg/dL

Diet and exercise

Az

Gestational

< 95 mg/dL

> 120 mg/dL

Insulin

Class

Onset

Duration (yrs)

Vascular Disease

Therapy

B

> 20 yrs old

< 10

None

Insulin

C

10-19 yrs old

10-19

None

Insulin

D

Before age 10

> 20

Benign retinopathy

Insulin

F

Any

Any

Nephropathy (pronounced "neFropathy")

Insulin

R

Any

Any

Proliferative Retinopathy

Insulin

H

Any

Any

Heart

Insulin

Diabetes is the most common medical complication of pregnancy.

Gestational diabetes probably results from placental lactogen secreted during pregnancy, which has large glucagon-like effects.

Thirty percent of women with gestational diabetes develop other diabetes later.

The CNS anomaly most specific to DM is caudal regression.

■ > 140 is high (a 3-hour glucose tolerance test is then required to diagnose GDM).

■ If > 200, patient is diagnosed with GDM type A1 and a diabetic diet is initiated.

2. 3-Hour glucose tolerance test—if glucose challenge test is > 140 and

■ Draw glucose levels at 1 hour (n < 180), at 2 hours (n < 155), and at 3 hours (n < 140).

■ Positive for gestational diabetes if 2/4 high values

Risk Factors

■ Previous or family history of gestational diabetes

■ History of large babies

■ History of full-term stillbirth or child with cardiac defects

Effects of Gestational Diabetes

Maternal Effects

■ Four times increased risk of preeclampsia

■ Increased risk of bacterial infections

■ Higher rate of C-section

■ Increased risk of polyhydramnios

■ Increased risk of birth injury

Fetal Effects

■ Increased risk of perinatal death

■ Three times increased risk of fetal anomalies (renal, cardiac, and CNS)

■ Two to three times increased risk of preterm delivery

■ Fetal macrosomia increases risk of birth injury.

■ Metabolic derangements (hypoglycemia, hypocalcemia)

Management

The key factors involved in successful management of these high-risk pregnancies include:

■ Good glucose control:

■ Prepregnancy glucose levels should be maintained during pregnancy with insulin.

■ Glucose control should be checked at each prenatal visit.

Starting at 32 to 34 weeks:

■ Fetal monitoring:

■ Ultrasonography to evaluate fetal growth, estimated weight, amniotic fluid volume, and fetal anatomy at 16 to 20 weeks' GA

■ Nonstress test and amniotic fluid index testing weekly to biweekly depending on disease severity

■ Biophysical profile

■ Contraction stress test (oxytocin challenge test)

■ Early elective delivery:

■ Fetal macrosomia must be ruled out with ultrasonography.

If fetal weight is > 4,500 g, elective cesarean section should be considered to avoid shoulder dystocia. Unless there is an obstetric complication, induction of labor and vaginal delivery are done.

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