DIABETES AND PREGNANCY


1. Screening for diabetes during pregnancy

A substantial proportion of women of child bearing age develop gestational diabetes mellitus (GDM). GDM is defined as diabetes which is first detected during pregnancy. In order to prevent maternal and prenatal complications of diabetes, early detection of glucose tolerance abnormalities during pregnancy is important. Another advantage is screening for GDM is the fact that women who develop glucose intolerance during pregnancy will run higher risk of developing diabetes in the future; thus, detection of this abnormality provides the possibility of preventive intervention.

Screening is recommended at two stages during pregnancy: All pregnant women should be screened for diabetes during the first antenatal visit by testing for glycosuria. A positive test is an indication for further assessment by a 75 g oral glucose tolerance test.
At 24-28 weeks of gestation, women at high risk of developing GDM  or IGT should be screened by means of an oral glucose tolerance test, using 75 g glucose load.
Those at high risk include women with:
Previous GDM or IGT
A family history of diabetes
Obesity
Adverse obstetric history
History of giving birth to a big baby
History of congenital malformation affecting the newborn in previous pregnancy
The WHO criteria for the diagnosis of glucose tolerance abnormalities can be used during the pregnancy.

Management

Good glycaemia control has special importance during pregnancy. Maternal and prenatal complications can be reduced if good control is achieved before and during conception. Good biochemical control before pregnancy is important since hyperglycaemia seems to be a major factor in the development of congenital malformations and the risk of these malformations is highest during the first eight weeks of gestation.
Guidelines for the management of diabetes during pregnancy

Intensive education and management of the woman with diabetes should start several months before conception to ensure strict control during the early weeks of pregnancy.
Pregnancy may have to be deferred until optimal control is achieved.
Women well controlled on oral hypoglycemic drugs should be changed over to insulin and achieve optimal blood glucose control before conception.
Those controlled on diet alone may continue on such therapy as long as they are carefully monitored to assess the need for insulin.
Therapy targets, prior to conception, should be achieved. Treatment should aim at having pre-prandial and postprandial glucose levels which are close to normal as well as normal or near normal glycated hemoglobin levels (i.e., A1C, if such measurement is available).
Full clinical assessment is needed. Renal and retinal complications should be looked for.
During pregnancy frequent follow-up is needed to insure that therapy target is meet without significant hypoglycaemia. Review every two or four weeks is generally recommended but should be more frequent if required.
Early morning urine should be tested for ketones, if indicated, to rule out starvation. Urine glucose measurement, however, is no longer reliable during pregnancy because of change in the renal threshold Insulin is preferably given three to four times per day. Some patient may be  controlled with two daily injections of a mixture of short- and intermediate- acting insulin.
Delivery should be planned jointly by the physician and the obstetrician. It can take place at term without surgical intervention but earlier induction of caesarean section may be needed for obstetric reasons.
Following delivery, frequent blood glucose monitoring is needed to avoid hypoglycaemia and to adjust the insulin dose which diminishes dramatically at this stage.
Postpartum follow-up and counseling will be needed in all cases.


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