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Maternal complications in diabetic pregnancy

https://doi.org/10.1016/j.bpobgyn.2010.10.015Get rights and content

Pregnant women with diabetes have to manage both the effect of pregnancy on glucose control and its effect on pre-existing diabetic complications. Most women experience hypoglycaemia as a consequence of tightened glycaemic control and this impacts on daily living. Less commonly, diabetic ketoacidosis, a serious metabolic decompensation of diabetic control and a medical emergency, can cause foetal and maternal mortality.

Microvascular complications of diabetes include retinopathy and nephropathy. Retinopathy can deteriorate during pregnancy; hence, regular routine examination is required and, if indicated, ophthalmological input. Diabetic nephropathy significantly increases the risk of obstetric complications and impacts on foetal outcomes. Pregnancy outcome is closely related to pre-pregnancy renal function.

Diabetic pregnancy is contraindicated if the maternal complications of ischaemic heart disease or diabetic gastropathy are known to be present before pregnancy as there is a significant maternal mortality associated with both of these conditions.

Section snippets

Hypoglycaemia

There is sound evidence that optimal glucose control periconception reduces the risk of congenital malformations in the offspring and the risks of stillbirth, macrosomia and pre-eclampsia during pregnancy. The target set for optimal glucose control is a fasting glucose of 3.5–5.9 mmol l−1 with 1-h post prandial blood glucose of 7.8 mmol l−1.2 The target for glycosylated haemoglobin (HbA1c) at preconception and in the first trimester is recommended as close to 6.1% as can be achieved without the

DKA

This is a serious metabolic complication of diabetes and a medical emergency. Fortunately, the prevalence of DKA in diabetic pregnancy is low at 1–2%.12 It most commonly occurs in the second or third trimester or in pregnant women with new-onset type 1 diabetes, although it may affect women with type 2 diabetes or, more rarely, gestational diabetes.*12, 13 There is an increased risk of DKA developing in pregnancy, as, in pregnancy, there is a marked increase in insulin resistance and enhanced

Gastroparesis diabeticorum

Gastroparesis is one of the few complications in which pregnancy is contraindicated. Women should be advised at preconception counselling that there is a significant risk of morbidity and a poor perinatal outcome if pregnancy is pursued.3

Gastroparesis occurs in people with long-standing diabetes, who have microvascular complications including retinopathy, nephropathy and neuropathy. It is the presence of delayed gastric emptying in the absence of mechanical obstruction.19, 20 Until recently,

Implications for pregnancy

Women known to have gastropathy before pregnancy should be counselled that it will likely worsen during pregnancy. They may expect difficulties with nutrition and might require parenteral nutrition during pregnancy. Gastroparesis poses an extreme risk to maternal health, second only to coronary heart disease.*2, 22

Diabetic retinopathy

Diabetic retinopathy is the major cause of blindness in those of working age in the UK and USA.25, 26 It is characterised as non-proliferative retinopathy and proliferative retinopathy,27, 28 and its presence can only be determined by examining the retina through dilated pupils, preferably using digital retinal photography. The earliest clinical signs of non-proliferative retinopathy are microaneurysms and dot intra-retinal haemorrhages. These lesions may increase with progression of the

Risk factors

Risk factors for the development of diabetic retinopathy include the duration of diabetes, glycaemic control and blood pressure control and are discussed below:

  • The duration of diabetes is the most closely linked to an increasing incidence of retinopathy;

  • Tight glycaemic control has been demonstrated to protect against the development and progression of retinopathy4, 30; and

  • Tight blood pressure control is protective against the development and progression of retinopathy.31

Diabetic retinopathy in pregnancy

There are no RCTs on the management of diabetic retinopathy in pregnancy. All evidence has been derived from cohort studies.

Although it is unusual for diabetic retinopathy to develop de novo in the eyes of women with diabetes during pregnancy,32 those women known to have diabetic retinopathy pre-pregnancy are at an increased risk of progression of this condition.32, 33, 34, 35, 36 Factors that increase the risk of progression of retinopathy include longer duration of diabetes (>10 years) and

Glycaemic control

It is well known from the Diabetes Control and Complications Trial (DCCT) trial4 that diabetic retinopathy may progress when glycaemic control is tightened. Despite this, all diabetic women need to have good glycaemic control at and around the time of conception; hence, rapid optimisation of glucose control is recommended, even in the presence of diabetic retinopathy.

Examination for diabetic retinopathy- NICE Guidance2

  • At the first antenatal clinic visit all pregnant women with pre-existing

Diabetic nephropathy

Diabetic nephropathy is a long-term microvascular complication of diabetes.40 It is a progressive disease that is categorised as:

  • Microalbuminuria (incipient nephropathy). This occurs when small amounts of albumin (30–300 mg 24 h) are excreted in the urine, but, at this stage, the glomerular filtration rate (GFR) is normal. Microalbuminuria may increase over the years. The rate of increase in microalbuminuria excretion is linked to blood pressure and glycaemic control.

  • Macroalbuminuria or

Medical management

Maternal and foetal outcomes for women with diabetic nephropathy can be optimised using a multidisciplinary team approach.

Coronary artery disease

Coronary artery disease is a macrovascular complication of diabetes. Until recently, this has been rarely associated with diabetic pregnancy, as it has been unusual to diagnose coronary heart disease in younger type 1 diabetic women but demographics are changing. The number of pregnant women with type 2 diabetes has risen 11-fold in 10 years in northern England, 59 and, within England, women with type 2 diabetes make up 25–30% of the pregnant diabetic population.1 In some areas, this proportion

Treatment

Women with diabetes and known ischaemic heart disease should be counselled against pregnancy.62

During pregnancy, if myocardial infarction is confirmed, management is similar to that in non-pregnant women. There should be a low threshold for emergency coronary intervention, and treatment with angioplasty with or without stenting is recommended. Thrombolysis should not be withheld in either pregnancy or post-partum.

Delivery should take place in a centre with adequate facilities and staff to deal

Summary

Maternal diabetes and its complications have implications for the successful outcome of pregnancy. Women with diabetes should be aware of their individual risks prior to pregnancy and, in most instances, good preconception care and management of the diabetes and pregnancy by a skilled multidisciplinary team will ensure a good outcome for mother and baby.

All pregnant diabetic women on insulin therapy should be equipped with the skills and knowledge to deal with hypoglycaemia and hyperglycaemia

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