Pregnancy complicating ambulatory patient management of diabetes

Surveillance of pregnant diabetics--comparison between outpatient and inpatient management

From 1982 to 1993 67 diabetic women attended the University Women's Hospital obstetric clinic at Würzburg. These women were separated into two groups: group 1 (inpatient group) delivered between 1/82 and 7/87, group 2 (outpatient group) delivered between 8/87 and 4/93. Between 1982 and 1987 we used extensive inpatient care. But did not so after 1987. The fetus was monitored by ultrasound scans, cardiotocography, oxytocin stress test and doppler measurements. Nearly all patients used home blood glucose monitoring. We compared blood glucose levels, mode of delivery and fetal outcome for the two groups. There was no significant difference in the average blood glucose levels between the two groups. Cesarean section rates (37%) and gestational age at delivery (37 weeks) were similar in both groups. Fetal macrosomia (birth weight > 4000 g) occured more frequently in the outpatient group (group 1: 4%, group 2: 25%, P < 0.01). This fact did not effect perinatal morbidity. Postnatal metabolic disorders did not increase. Fetal anomalies occurred less frequently in the outpatient group (group 1: 7%, group 2: 2%, P < 0.05).

Gestational diabetes mellitus among African-American women

Gestational diabetes mellitus (GDM) is associated with increased risk of poor outcomes for the pregnancy. It is a strong risk factor for subsequent diabetes. The epidemiology of GDM in African-American women is not well known. It has not been demonstrated that their risk factors are similar in character and weight to those among White women. There is considerable multicollinearity among GDM risk factors such as age, parity, obesity, hypertension, and family history of diabetes, and this needs to be sorted out. This review is based on the results of a nested case-control study to evaluate the frequency of, and the relationships of the known risk factors with, the onset of GDM among African-American women. All cases of GDM within a cohort of women seen at any of the county health department clinics in Jefferson County, Alabama from 1981 to 1987 were identified. The cohort represents approximately 63% of all African-American pregnancies in the county during the period. With few exceptions (5.1% based on fasting plasma glucose greater than or equal to 120 mg/dl), potential GDM cases (7.1%) were selected on the basis of a 2 h post 100 g carbohydrate meal screening plasma glucose measure at their second prenatal visit and again at 28-32 weeks greater than or equal to 115 mg/dl and diagnosed on the basis of the results of an oral glucose tolerance test (OGTT) using the criteria of O'Sullivan and Mahan. Women with any prior history of diabetes (even in pregnancy), 1.6%, were excluded. The frequency of the new diagnosis of GDM among African-American women in this pregnancy in the cohort was 2.5% of pregnancies and 3.4% of women, which is similar to the values reported in the other studies. Controls were selected from women with negative screening tests who delivered after a GDM subject. The results reported in this paper reflect 358 cases (86% of all eligible GDM cases identified) and 273 controls. Cases were significantly older (28.3 vs. 21.7 years), of higher gravidity (2.7 vs. 1.9), more obese (76.7 vs. 61.7 kg), gained weight more rapidly (0.34 vs. 0.28 kg/week), had more hypertension in this pregnancy (28.2 vs. 2.6%), and there was a higher proportion with a family history of diabetes (41.3 vs. 16.5%) (p less than 0.001 for all comparisons). Because there were significant correlations among the risk factors in both cases and controls, multivariable logistic regression analyses were performed.(ABSTRACT TRUNCATED AT 400 WORDS)

Outpatient obstetric management of women with type I diabetes

Conventional obstetric management of diabetic women has frequently incurred extensive hospitalization. Although this approach improved perinatal results for these women and their infants, it is costly and cumbersome. The 3-year experience of an outpatient diabetic obstetric clinic is compared with the results obtained at the same facility during 5 previous years when hospitalization was used more extensively. Perinatal mortality and morbidity were not different in 51 type I diabetic women managed almost entirely as outpatients when compared with 58 similarly complicated diabetic patients receiving more conventional management. Mean prenatal admissions (1 vs 2, p = less than 0.01), mean prenatal hospital days (6 vs 12, p = 0.05), and prolonged delivery admissions of greater than 7 days (31% vs 69%, p = less than 0.01) were significantly less. Outpatient obstetric management of diabetic women efficiently decreases maternal morbidity without increasing infant morbidity and mortality.

Placental lactogen, progesterone, total estriol and prolactin plasma levels in pregnant women with insulin-dependent diabetes mellitus

Fifteen insulin-dependent diabetic (White's class B-C) and 10 healthy pregnant women were examined from the 12th to the 36th wk. Every 4 wk, a blood sample was drawn to determine total estriol, progesterone, placental lactogen and prolactin. Throughout the pregnancy, total estriol and progesterone in diabetic and non-diabetic women are very similar. On the contrary, the PRL levels are constantly lower in diabetic pregnant women, even though the difference is statistically significant only for the 24th wk determination. The hPL level is instead significantly lower in diabetic pregnant women at the 12th, 20th, 24th, 32nd and 36th wk. A negative correlation exists between the hPL value and the mean blood glucose level, performed the same day as the hormonal test. This correlation is statistically significant at the 12th, 16th, 20th, 28th and 36th wk. No significant difference is found between the two groups examined for the delivery week, the placental weight, the birth weight and the fetal body weight index. To conclude, while estriol and progesterone are not affected by the higher variability of glucose levels during pregnancy in diabetics, compared to normals, hPL and perhaps also PRL may be influenced by the mild hyperglycemia consequent to diabetes.

Nursing care of the pregnant woman with diabetes mellitus

The woman with diabetes who becomes pregnant faces increased risk of morbidity, urinary tract infections, vaginitis, difficult delivery, hemorrhage, cesarean section, preeclampsia, and hydramnios. Chronic disease alone produces emotional tension. Added to this she has increased general life stresses such as added financial responsibility, increases time commitments, and changes in lifestyle demands. The infant of the diabetic is often large for dates, faces respiratory distress syndrome with early delivery, may experience hypoglycemia, and may have fetal anomalies. Clinical specialists of nursing, consulting and working together, can develop a plan of nursing care for the pregnant woman with diabetes. Because the pregnant diabetic woman faces the usual adjustments to pregnancy plus problems dealing with a chronic condition of diabetes, nursing care should combine consideration of the physical, emotional and educational needs. In view of the many health team members providing care to the pregnant diabetic, one central figure with continued interaction can decrease fragmentation and provide continuity of care.