Obstetrical management of the pregnant diabetic

Pregnancy outcome in gestational diabetes with preconceptional diabetes counselling

One hundred and thirty-six women with known previous gestational diabetes and normal glucose tolerance between pregnancies attended a preconceptional clinic at least 2 months before conception, and were regularly consulted by a diabetological team. Evaluation consisted of oral glucose tolerance test (OGTT), mean blood glucose, glycosylated haemoglobin and management by self-blood-glucose monitoring (SBGM) and nutritional counselling. When these patients were compared to a group of 154 patients with gestational diabetes who attended our clinic at different stages of pregnancy, the former had improved glucose homeostasis whereas the latter had more frequent elevations of fasting and postprandial glucose levels throughout pregnancy. This group had also more maternal complications and higher Caesarean section rates. Congenital anomalies were 0.65% among offspring of nonattenders, while none occurred in those with preconceptional counselling. Macrosomia and hypoglycaemia were significant neonatal complications in infants of nonattending mothers. We concur with the recommendation that preconceptional counselling in gestational diabetics is required to improve glucose homeostasis throughout pregnancy, and that appropriate evaluation of glucose intolerance should be included as part of prospective family planning.

Alcoholic ketoacidosis in a pregnant woman

A case of alcoholic ketoacidosis in a 23-year-old chronic alcoholic, gravada V, para IV, is reported. Symptoms were constant, severe, nonradiating pain with crampy exacerbations, anorexia, nausea and vomiting. The patient had a tender and irritable full-term uterus. She was treated inhospital with vigorous fluid therapy and 5% dextrose in normal saline, sodium bicarbonate, glucose and insulin and showed improvement overnight. Alcoholic ketoacidosis has not been reported in pregnant women. Metabolic derangements combine to produce ketoacidosis more readily in the pregnant alcoholic. Differentiation of alcoholic ketoacidosis and diabetic ketoacidosis is important since treatment varies. For alcoholic ketoacidosis, treatment is vigorous rehydration with dextrose-saline while diabetic ketoacidosis usually requires multiple therapeutic modalities.

A review of the significance of gestational diabetes

One hundred and ninety-six pregnancies complicated by gestational diabetes in a referred private practice over an 18-year period have been reviewed. Initially they were managed as true diabetics and the pregnancies terminated before the 38th week. More recently, pregnancies have been managed on an outpatient basis and allowed to proceed to term, with a higher percentage of vaginal deliveries and no increase in perinatal mortality or morbidity. A high incidence of neonatal jaundice was noted, but no explanation emerged. Differences between true diabetes and gestational diabetes, with particular reference to perinatal mortality are discussed and the good prognosis for the gestational form emphasised. Follow-up suggests that a continuation of the rapport established between physician, obstetrician and patient during pregnancy may be important in delaying or preventing the subsequent onset of diabetes.

Gestational and pregestational diabetes: an approach to therapy

The objective of management in the pregnant diabetic patient is to achieve physiologic glucose homeostasis through the use of diet and insulin. As outlined, the numerous ancillary tests developed during the past 15 years to assist the clinician in determining impending fetal death have left much to be desired, especially where metabolic homeostasis has not been achieved prior to the thirty-sixth week of gestation. The statistics from this institution indicate that the maintenance of the plasma glucose concentration below 100 mg. per cent throughout gestation, regardless of the severity of the diabetes, all but removes the risk of maternal-fetal complications due to diabetes. The management is uniform for all patients exhibiting an abnormality of carbohydrate metabolism, and, although it is rather difficult to accept, there have been minimal neonatal complications when the protocol outlined in this presentation has been followed.