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Diabetes in pregnancy

Outcomes and complications

Identifying key intervention opportunities during a pregnancy complicated by diabetes: A review of acute complications of diabetes during pregnancy

A clinical overview of common complications in diabetes during pregnancy and strategies for implementing interventional patient care.

Summary points
  • Diabetes during pregnancy automatically categorizes a pregnancy as a high risk.
  • Current guidelines recommend testing women for overt diabetes (type 1, type 2, or pre-diabetes) at the first prenatal visit.
  • Diabetic retinopathy and nephropathy are well known to progress during pregnancy and should be followed closely.
  • Complications such as preeclampsia and hypertension have a strong association with diabetes during pregnancy, and other rare but acute complications including venous thromboembolism, cardiovascular disease (CVD), sepsis, and diabetic ketoacidosis can also occur.
  • Diabetes during pregnancy also increases the risk of labor and delivery complications such as induction of labor and cesarean section.
  • Post-partum changes and stress have the ability to exacerbate diabetes complications and may lead to unexpected challenges such as delayed onset of lactation.
  • Post-partum care should include the development of a life plan, as patients with diabetes during pregnancy may be at greatest risk of developing CVD, and those with gestational diabetes are more likely to go on to develop type 2 diabetes.

Bradley PK et al. Curr Diab Rep 2016; 16: 17. doi: 10.1007/s11892-015-0710-6

Quantification of the type 2 diabetes risk in women with gestational diabetes: A systematic review and meta-analysis of 95,750 women

A systemic review of the factors that increase the risk of developing type 2 diabetes in women with gestational diabetes.

Summary points
  • Up to half of women with gestational diabetes mellitus (GDM) go on to develop type 2 diabetes.
  • The objective of this systematic review was to quantify the risk of progression to type 2 diabetes for women with GDM.
  • The future risk of diabetes appears to be mainly influenced by the gestational glycemic status, as women with increased fasting blood glucose level and those who required insulin to manage GDM were more likely to develop type 2 diabetes.
  • Hypertensive disorders in pregnancy and preterm delivery in GDM pregnancies are associated with future onset of type 2 diabetes.
  • Factors specific to pregnancy such as gestational age at onset of GDM and general maternal characteristics such as body mass index, ethnicity and family history are also associated with future onset of type 2 diabetes.
  • Postnatal counseling of women with GDM should be individualized to reduce the risk of developing type 2 diabetes later in life.

Rayanagoudar G et al. Diabetologia 2016; 59: 1403–1411. doi: 10.1007/s00125-016-3927-2

Long-term health outcomes in offspring born to women with diabetes in pregnancy

This review critically assesses the existence of a direct causal relationship between diabetes during pregnancy and long-term offspring health outcomes.

Summary points
  • Diabetes in pregnancy includes pre-existing type 1 diabetes (present before pregnancy), pre-existing type 2 diabetes, or gestational diabetes (ie, diabetes with onset or first diagnosis in pregnancy).
  • Intra-uterine mechanisms make an important contribution to the link between gestational diabetes and offspring greater adiposity, insulin resistance, and type 2 diabetes.
  • The role of maternal diabetes and cognitive abilities of offspring remains unclear, as some studies report an adverse effect, while others found that maternal pregnancy diabetes may result in a ‘protective’ effect and greater offspring IQ in childhood.
  • The putative role of DNA methylation as a mediator in associations of pregnancy diabetes and offspring long-term health is promising but still novel.
  • Current evidence supports a direct causal role for exposure to maternal diabetes in utero in determining offspring long-term greater adiposity and adverse cardiometabolic health.

Fraser A, Lawlor DA. Curr Diab Rep 2014; 14: 489. doi: 10.1007/s11892-014-0489-x

Stillbirth in the pregnancy complicated by diabetes

A review of the epidemiology, pathophysiology, prevention, and ongoing research into diabetes-associated perinatal mortality.

Summary points
  • Despite improvements in screening and patient care, approximately 4% of all stillbirths are attributable to diabetes, and diabetic pregnancies are at increased risk for perinatal mortality.
  • Recent studies have shown that patients with type 1 and type 2 diabetes have a greater risk of stillbirth, while gestational diabetes as a risk factor is still debatable.
  • Practitioners often find no clear etiology for stillbirth, as the pathophysiology of stillbirth in diabetic pregnancies is complex and appears to be multifactorial.
  • In terms of achieving pregnancy outcomes in women with diabetes that approximate those of women without diabetes, strict glycemic control is the single most important goal for women with diabetes attempting pregnancy.
  • Women with pre-existing vascular complications (eg, hypertension) should be appropriately treated with medications that are considered acceptable for pregnancy.
  • In general, women with well-controlled diabetes can be delivered at 39 weeks, while women with poorly controlled diabetes can be delivered at any time from 34 to 39 weeks.

Starikov R et al. Curr Diab Rep 2015; 15: 11. doi: 10.1007/s11892-015-0580-y