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THIS BOOK IS DEDICATED TO THE MANY MOTHERS
WITH DIABETES
WHO HAVE ALLOWED US TO PARTICIPATE IN THEIR
CARE OVER THE YEARS,
BEING INVOLVED IN THE MOST IMPORTANT EVENTS IN
THEIR FAMILIES’ LIVES.
WE CONTINUE TO LEARN FROM EACH OF YOU,
AND APPLYING THOSE LESSONS HAS ADVANCED OUR
ABILITY
TO CARE FOR WOMEN WITH DIABETES DURING THEIR
PREGNANCIES.
Contents
Foreword
Acknowledgments
List of Contributors
Prepregnancy Counseling, Assessment, and Management of Women with
Preexisting Diabetes or Previous Gestational Diabetes
Highlights
Preexisting Diabetes
Prepregnancy Counseling
Prepregnancy Assessment
Prepregnancy Management
Previous GDM
Contraception in Women with Diabetes and Prediabetes: Options and
Assessing Risk and Benefits
Highlights
Intrauterine Devices
Hormonal Contraceptives
Permanent Sterilization
Selected Readings
Psychological Impact of Diabetes and Pregnancy
Highlights
Response to Pregnancy in Women with Preexisting Diabetes
Response to the Diagnosis of Gestational Diabetes
Long-Term Adaptation
Personality Types and Individualizing Treatment
Dealing with Crises
The Importance of a Team Approach
The Importance of a Support System
Selected Readings
Assessment of Glycemic Control
Highlights
Normoglycemia During Pregnancy
Self-Monitoring of Capillary Blood Glucose
Other Measures of Metabolic Control
Recommendations
Selected Readings
Management of Morning Sickness
Highlights
Nonpharmacologic Treatment
Insulin Adjustments
Medical Management
Selected Reading
Nutrition Management of Preexisting Diabetes During Pregnancy
Highlights
Medical Nutrition Therapy
Weight Gain Recommendations
Macronutrients
Micronutrients
Meal Planning
Other Substances
Food Safety
Postpartum Nutrition Management
Lactation Nutrition Management
Selected Readings
Use of Insulin During Pregnancy in Preexisting Diabetes
Highlights
Metabolic Alterations during Normal Gestation
Therapeutic Insulin Use
Dosage Adjustment
Insulin During Labor and Delivery
Postpartum Insulin Requirements
Oral Antidiabetes Agents
Diagnostic Testing and Fetal Surveillance
Highlights
Diagnostic Testing with Ultrasound
α-Fetoprotein Testing
Genetic Testing
Fetal Surveillance with Ultrasound
Fetal Activity Determinations
Antepartum Fetal Monitoring
Amniocentesis for Fetal Lung Maturity Determination
Timing and Mode of Delivery
Fetal Surveillance During Labor
Diabetic Ketoacidosis
Preterm Labor
Selected Readings
Gestational Diabetes Mellitus
Highlights
Diagnosis
Epidemiology
Nutritional Management
Exercise as a Treatment Modality
Metabolic Management During Pregnancy
Obstetric Management
Selected Readings
Neonatal Care of Infants of Mothers with Diabetes
Highlights
Perinatal Mortality and Morbidity
Resuscitation
Nursery Care
Long-Term Follow-Up
Selected Readings
Foreword
T
his fifth edition is intended to provide up-to-date guidance on all
aspects of the care of pregnant women with preexisting diabetes,
whether she has type 1 or type 2 diabetes, and with gestational
diabetes. The care of pregnant women with diabetes and gestational
diabetes requires a committed health-care team and considerable resources.
It is our hope that the information in this book will be helpful in enabling
the various health-care professionals who make up that team to have access
to practical advice and carry out their mission. Each of the contributors is
engaged actively in providing care to pregnant women with preexisting
diabetes and gestational diabetes. Although there are many reasonable
approaches to providing that care, we have outlined herein those that we
find to be effective.
Acknowledgments
T
he editor is indebted to Dr. Lois Jovanovic, who lovingly edited the
first four editions of this book. She has set a high standard for this fifth
edition. Her contributions to our understanding of diabetes in
pregnancy and its treatment have been seminal.
In addition to the contributors to this current fifth edition, the editor
would like to acknowledge the important contributions of the many health
professionals who have contributed to previous editions of this book; the
current edition is built on a very strong foundation:
Richard M. Cowett, MD
Stephanie Dunbar, MPH, RD
Donna Jornsay, RN, BSN, CPNP, MSS, ACSW
Sue Kirkman, MD
John L. Kitzmiller, MD
Lisa Marasco, MA, IBCLC, FILCA
Noreen Hall Papatheodorou, MSS, ACSW
Anne M. Patterson, RD, MPH
List of Contributors
EDITOR-IN-CHIEF
Donald R. Coustan, MD
Maternal-Fetal Medicine Specialist
Women & Infants Hospital of Rhode Island
Providence, RI
Professor of Obstetrics and Gynecology
Warren Alpert Medical School of Brown University
Providence, RI
Susan Biastre, RD, LDN, CDE
Clinical Nutrition Specialist
Women & Infants Hospital of
Rhode Island
Providence, RI
Julie M. Daley, RN, MS, CDE
Teaching Associate in Obstetrics and Gynecology
Warren Alpert Medical School of Brown University
Senior Diabetes Nurse Clinician
Division of Maternal-Fetal Medicine
Women & Infants Hospital of
Rhode Island
Providence, RI
Carol J. Homko, RN, PhD, CDE
Associate Research Professor,
Departments of Medicine (Section of Endocrinology) and Obstetrics &
Gynecology
Temple University School of Medicine
Philadelphia, PA
Siri Kjos, MD, MSEd
Professor
Department of Obstetrics and Gynecology
Harbor UCLA Medical Center
Torrance, CA
Abbot R. Laptook, MD
Medical Director, Neonatal Intensive Care Unit
Women & Infants Hospital of Rhode Island
Providence, RI
Professor of Pediatrics
Warren Alpert Medical School of Brown University
Providence, RI
Prepregnancy Counseling, Assessment, and
Management of Women with Preexisting Diabetes
or Previous Gestational Diabetes
Highlights
Preexisting Diabetes
Prepregnancy Counseling
Prepregnancy Assessment
Prepregnancy Management
Previous GDM
References
Highlights
Prepregnancy Counseling, Assessment, and
Management of Women with Preexisting Diabetes
or Previous Gestational Diabetes
• With proper counseling and management by the health-care team, the
outcome of most pregnancies complicated by diabetes can approach
that for the general population.
• General guidelines for prepregnancy counseling and management of
women with preexisting diabetes are as follows:
« Ensure that pregnancy is planned; counsel the woman about
contraception methods.
« Clearly identify for the woman and her partner the risks of
congenital anomalies and spontaneous abortions and their
relation to glucose control.
« Provide realistic information about chronic complications of
type 1 diabetes (T1D) and type 2 diabetes (T2D), their
potential impact on pregnancy and childbearing, and the
effect of pregnancy on chronic complications.
« Assess the woman’s fitness for pregnancy, paying special
attention to retinopathy, nephropathy, hypertension,
neuropathy, and ischemic heart disease.
« Identify any gynecologic abnormalities before conception,
and treat infertility as early as possible in view of the risk to
pregnancy associated with increasing duration of diabetes
and advancing maternal age. Social, financial, and marital
factors permitting, pregnancy should not be discouraged.
« Provide genetic counseling, including the risks of advanced
maternal age, if applicable.
« Provide realistic information about additional medical costs
associated with a pregnancy complicated by diabetes, such
as extra office visits, possible hospitalization, special tests,
and possible intensive neonatal care.
« Achieve optimum control of blood glucose levels before
conception. Ideally, A1C should be normal or near normal
before discontinuing contraception.
« Encourage good general principles of health, nutrition, and
hygiene, including cessation of smoking and alcohol
consumption. Prescribe a prenatal vitamin with folate as part
of the preconception treatment plan.
« Identify any problems requiring psychosocial consultation.
« Once the decision is made to attempt pregnancy, provide
appropriate optimism that careful glycemic control and
meticulous obstetric care results in an excellent outcome in
the vast majority of patients.
« Diagnose pregnancy as early as possible and document
conception date.
• Counseling and management of women with previous gestational
diabetes should include the following:
« Testing for diabetes or prediabetes, measuring glucose levels,
and assessing the need for treatment if diabetes or
prediabetes is found.
« Evaluating weight status and advising weight reduction if
appropriate.
« Reviewing risks:
* Gestational diabetes in future pregnancy (~60–70% risk).
* T2D (~50–75% risk if woman is obese).
« Advising careful family planning with use of effective
contraception until pregnancy is desired.
• Problems remaining in the care of pregnant women with diabetes are as
follows:
« Higher incidence of congenital anomalies and spontaneous
abortions than in the nondiabetic population.
« The woman with severe complications of diabetes.
« The “difficult” or nonadherent patient.
« Education of health-care professionals and women with
diabetes of childbearing age regarding the importance of
preconception planning and care.
Prepregnancy Counseling, Assessment and
Management of Women with Preexisting Diabetes
or Previous Gestational Diabetes
W
omen with diabetes in pregnancy are divided into two categories: 1)
those with diabetes that predates the pregnancy and 2) those whose
diabetes develops during the pregnancy, known as gestational
diabetes mellitus (GDM). In both categories, when left untreated, the
diabetes can significantly increase the risk of maternal and fetal or neonatal
morbidity and mortality. Prepregnancy care incorporated into the plan of
management for women with preexisting diabetes can result in improved
pregnancy outcomes. This chapter provides the rationale behind and
protocols for developing a prepregnancy program for women with diabetes
or who have had previous gestational diabetes.
PREEXISTING DIABETES
Women with preexisting diabetes (type 1 diabetes [T1D] or type 2 diabetes
[T2D]) who desire pregnancy present a broad array of challenging problems
for the health-care team. In the preinsulin era, maternal mortality was as
high as 44%, and perinatal mortality was 60% (Hare 1977). Children with
true T1D, however, seldom lived to childbearing ages. After the discovery
of insulin, maternal and fetal or neonatal survival improved dramatically.
During the past four decades, advances in the care of the individual with
diabetes in general, as well as advances in fetal surveillance and neonatal
care, have continued to improve outcomes in most diabetic pregnancies to
near that of the general population (Coustan 1980, Jovanovic 1982, Steel
1994). The most common maternal (Table 1.1) and fetal or neonatal (Table
1.2) complications have decreased dramatically.
Table 1.1 Examples of Maternal Complications in
Diabetic Pregnancy
• Hypoglycemia, ketoacidosis
• Pregnancy-induced hypertension and preeclampsia
• Pyelonephritis, other infections
• Polyhydramnios
• Preterm labor
• Worsening of chronic complications—retinopathy,
nephropathy, neuropathy, cardiac disease
Table 1.2 Examples of Potential Perinatal Morbidity or
Mortality in Infants of Mothers with Diabetes
• Asphyxia
• Birth injury
• Cardiac hypertrophy and heart failure
• Congenital anomalies
• Erythremia (increased red blood cells) and hyperviscosity
• Hyperbilirubinemia
• Hypocalcemia
• Hypoglycemia
• Hypomagnesemia
• Intrauterine growth restriction
• Macrosomia
• Neurological instability; irritability
• Organomegaly
• Respiratory distress syndrome
• Stillbirth
Despite the advances made in the care of the pregnant woman with
diabetes, several problems remain:
• A high prevalence of congenital anomalies and spontaneous abortions
(SABs) in infants of mothers with diabetes (IDMs)
• Care of the woman with severe complications of diabetes
• Care of the “difficult patient” who often presents late for antenatal care
or is nonadherent (Steel 1994)
Morbidity and mortality associated with major congenital anomalies and
SAB are of major concern. The magnitude of both appears to be related to
metabolic control. The true prevalence of SAB pregnancies is not known,
but it has been reported to be as high as 30–60%, depending on the degree
of hyperglycemia at the time of conception, which is double that of the
general population (Miodovnik 1984). The increased risk of congenital
anomalies in IDMs ranges from 6% to 12%, a two- to fivefold increase over
the 2–3% incidence observed in the general population (Kitzmiller 1978,
Reece 1988). This increased risk of congenital anomalies accounts for
~40% of the perinatal loss in IDMs (Reece 1986). The combined risk of
congenital anomalies and SAB in poorly controlled diabetes in early
pregnancy can approach 65% (Greene 1993). In a nationwide prospective
study, which included first-trimester questionnaires filled out by all
pregnant women with T1D in the Netherlands over a 1-year interval,
congenital malformations occurred in 4.2% of self-reported planned
pregnancies but in 12.2% of unplanned pregnancies (Evers 2004).
Congenital malformations also increased when the mother has T2D
(Macintosh 2006).
The types of congenital anomalies observed in IDMs are varied (Table
1.3). Most are of cardiac, neural tube, or skeletal origin; they are more
commonly multiple, more severe, and more often fatal than those found in
the general population.
Table 1.3 Congenital Malformations in Infants of Mothers
with Diabetes
Ratios of
Anomaly
Incidence*
Caudal regression 252
Spina bifida, hydrocephalus, or other central nervous
2
system defect
Anencephalus 3
Heart anomalies 4
Anal or rectal atresia 3
Renal anomalies 5
Agenesis 6
Cystic kidney 4
Ureter duplex 23
Situs inversus 84
* Ratio of incidence is in comparison to the general population. Heart
anomalies include transposition of the great vessels, ventricular
septal defect, and atrial septal defect.
