gynecology and obstetrics
Risk Factors for Complications During Pregnancy
Diabetes
Preexisting Diabetes Mellitus in Pregnancy occurs in ≥ 6% of pregnancies, and gestational diabetes occurs in about 8.5% of pregnancies. Incidence is increasing as the incidence of obesity increases. Preexistinginsulin-dependent diabetesincreases the risk of the following: Urinary Tract Infection in Pregnancy None Metabolic Acidosis None Preeclampsia and Eclampsia None Fetal death Major fetal malformations Large-for-Gestational-Age (LGA) Infant (fetal weight > 4.5 kg) If vasculopathy is present, Small-for-Gestational-Age (SGA) Infant None The need for preterm, Cesarean Delivery or operative delivery The incidence of fetal macrosomia is about 50% higher in pregnant women with preexisting diabetes than in pregnant women in the general population. The incidence of perinatal mortality is also higher. Women with preexisting diabetes are more likely to require preterm delivery for obstetric or medical indications. Exercise during pregnancy (with judicious changes in diet) reduces the need for cesarean and operative deliveries in these women ( Diabetes references , Tight glucose control before conception and during early pregnancy is essential to prevent fetal malformations. Insulinrequirements usually increase during pregnancy. Gestational diabetesincreases the risk of the following: Hypertensive disorders Large-for-Gestational-Age (LGA) Infant None The need for Cesarean Delivery None Gestational diabetes is routinely screened for at 24 to 28 weeks and, if women have risk factors, during the 1st trimester. Risk factors include the following: Previous gestational diabetes A macrosomic infant in a previous pregnancy Unexplained fetal losses Prepregnancy body mass index (BMI) > 30 kg/m2 Maternal age > 40 years Family history of diabetes Some races or ethnicities associated with higher rates of diabetes (eg, people with Hispanic-American, African-American, American Indian, Asian, or Pacific Islander ancestry) Screening and confirmation of the diagnosis of gestational diabetes can be done in 1 or 2 steps: 1-step test: A fasting, 75-g glucose, 2-hour oral glucose tolerance test (GTT) 2-step test: A non-fasting, 50-g glucose, 1-hour GTT; if abnormal (≥ 135 mg/dL/7.5 mmol/L), then a fasting, 100-g, 3-hour GTT The diagnosis is best based on results of an oral glucose tolerance test (OGTT—see table Glucose Thresholds for Gestational Diabetes Using a 3-hour Oral Glucose Tolerance Test* ). The OGTT may be done in 1 or 2 steps. Based on a recommendation from the 2013 National Institutes of Health (NIH) consensus development conference, screening begins with a 1-hour 50-g glucose load test (GLT); if results are positive (plasma glucose > 130 to 140 mg/dL [7.2 to 7.8 mmol/L]), a 3-hour 100-g OGTT is done. Optimal Treatment (with dietary modification, exercise, and close monitoring of blood glucose levels and Women with gestational diabetes mellitus may have had undiagnosed diabetes mellitus before pregnancy. Thus, they should be Screening 6 to 12 weeks postpartum, using the same testing and criteria used for patients who are not pregnant. 1.Artal R: Exercise: The alternative therapeutic intervention for gestational diabetes.Clinical Obstetrics and Gynecology46 (2):479–487, 2003. 2.Artal R: The role of exercise in reducing the risks of gestational diabetes mellitus in obese women.Best Pract Res Clin Obstet Gynaecol29 (1):123–4132, 2015. 