Pregnancy and Childbirth in Diabetic Mothers

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Expert Says
(Page 1 of 20)
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Pregnancy and Childbirth in Diabetic
Mothers (Pre-gestational and
Gestational Diabetes)
This is the story of Mrs. Chandni (name
changed), a 35 year old lady who had a
spontaneous conception and a smooth
journey in her pregnancy till 24 weeks
gestation, when her test for glucose tolerance
came positive during a routine screening test.
Her risk factors were a family history of diabetes,
late age at pregnancy and being overweight (high
BMI). After further investigations and workup, she
was advised to be on a diabetic diet and regular
exercise with prenatal yoga.

(Page 2 of 20)
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Expert Says
As gestation advanced, her sugar control could
not be achieved with diet alone and had to be
started on insulin till delivery. At full term, the fetal
size was more than normal and mildly
disproportionate to the size of bony pelvis of the
mother. On clinical and ultrasound estimation of
fetal weight, a decision was taken to give her a
short trial of labour. The estimated fetal weight
was nearly 4 Kg and keeping in mind the risk
associated with vaginal birth, delivery was planned
in a tertiary care centre with blood bank and ICU
facilities along with neonatal ICU care. She went in
spontaneous labour at 38 weeks gestation and
delivered a healthy female weighing 3.8 Kg.

Today’s Article
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Expert Says
Carbohydrate intolerance is the most common
metabolic complication of pregnancy. Gestational
Diabetes Mellitus (GDM) affecting nearly 5 to
10% of the population poses numerous problems
for both mother and fetus. The incidence of
diabetes during pregnancy is increasing worldwide
and India is expected to be the diabetic capital of
the world by 2025. Seventy-ﬁve percent of women
with gestational diabetes respond to diet therapy
alone. When glycemia is not achieved by diet
alone, insulin therapy is recommended.
Complications during pregnancy present
according to the classiﬁcation of diabetes and its
severity: there are variations in pregnancy
outcomes.

Today’s Article
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Today’s ArticleToday’s ArticleExpert Says
One of the most common complications of
gestational diabetes is macrosomia (overweight
babies), which is associated with shoulder dystocia
and brachial plexus injury during vaginal normal
delivery. So before ﬁnalising the mode of delivery
all the investigations including fetal and maternal
status should be taken into consideration.

Today’s Article
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Today’s ArticleToday’s ArticleToday’s ArticleExpert Says
Complications that may affect the baby: Babies
born to women with diabetes have an increased
chance of having breathing difﬁculties, low blood
sugar (hypoglycemia) and jaundice (yellowish
skin) at birth. The maternal variables: gestational
age at the time of delivery, onset of labor, mode of
delivery, pregnancy complications and blood loss
during pregnancy are contributing factors to NICU
(Neonatal Intensive Care Unit) admission of the
newborn.

Today’s Article
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Today’s ArticleToday’s ArticleToday’s ArticleToday’s ArticleExpert Says
• Excessive birth weight. Extra glucose in the
bloodstream crosses the placenta, which
triggers baby’s pancreas to produce more
insulin. This can cause the baby to grow too
large (macrosomia). Very large babies — those
that weigh 4 to 4.5 Kg or more — are more likely
to become wedged in the birth canal, sustain
birth injuries or require a C-section birth.
• Early (preterm) birth and respiratory distress
syndrome. A mother’s high blood sugar may
increase her risk of early labor and delivering her
baby before its due date, or her doctor may
recommend early delivery because the baby is
large.

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Expert Says
Babies born early may experience respiratory
distress syndrome — a condition that makes
breathing difﬁcult. Babies with this syndrome
may need help breathing until their lungs mature
and become stronger. Babies of mothers with
GDM may experience respiratory distress
syndrome even if they’re not born early.
• Low blood sugar
(hypoglycemia). Sometimes babies of
mothers with gestational diabetes develop low
blood sugar (hypoglycemia) shortly after birth
because their own insulin production is high.

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Expert Says
Severe episodes of hypoglycemia may provoke
seizures in the baby. Early feedings and
sometimes an intravenous glucose solution can
return the baby’s blood sugar level to normal.
• Type 2 diabetes later in life. Babies of mothers
who have gestational diabetes have a higher
risk of developing obesity and type 2 diabetes
later in life.
Untreated gestational diabetes can result in a
baby’s death either before or shortly after birth.

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Expert Says
COMPLICATIONS THAT MAY AFFECT MOTHER
Gestational diabetes (GDM) increases the chances
of certain pregnancy complications. So close
antepartum care and follow up is needed. Possible
risks include higher chances of needing a C-
section, miscarriage, preterm birth, high blood
pressure and future diabetes.

Expert Says
(Page 10 of 20)
• High blood pressure and
preeclampsia. Gestational diabetes raises the
risk of high blood pressure, as well as,
preeclampsia, a serious complication of
pregnancy that causes high blood pressure and
other symptoms that can threaten the lives of
both mother and baby.
• Future diabetes. If one has GDM, there are
more chances to get it again during a future
pregnancy. Chances of developing type 2
diabetes become higher as one gets older.
However, making healthy lifestyle choices such
as eating healthy foods and exercising can help
reduce the risk of future type 2 diabetes.

Expert Says
(Page 11 of 20)
Of those women with a history of GDM who reach
their ideal body weight after delivery, fewer than 1
in 4 eventually develop type 2 diabetes.
Factors determining mode of delivery in a
diabetic mother are estimated fetal weight (clinical
and by ultrasound), duration of pregnancy and
blood sugar control. The aim is to achieve the most
desirable results for both the mother and her
offspring.

Expert Says
(Page 12 of 20)
Management options include expectant
management, induction of labor and Caesarean
delivery. There are many variations in practice,
since patients and providers have different
perceptions of the potential beneﬁts and risks of
management approaches.

Expert Says
(Page 13 of 20)
Most women who have GDM deliver healthy
babies. However, gestational diabetes that’s
not carefully managed can lead to
uncontrolled blood sugar levels and cause
problems for both mother and baby, including
an increased likelihood of needing a C-section
to deliver. Labor and delivery management
of women with GDM can affect neonatal
and maternal outcomes in millions of
women.

Expert Says
(Page 14 of 20)
Elective Caesarean delivery or planned
Caesarean delivery is one of the suggested
options for a suspected macrosomic (large) fetus.
Although there is a greater chance of needing a
C-section, many women with GDM have regular
vaginal births.
Doctors know that there is a higher rate of
maternal morbidity and mortality with
caesarean as compared with vaginal delivery.
Also, it has been observed that women delivering
a macrosomic infant by prelabor caesarean
section have a 3 times greater risk of postpartum
infection and an 11 times greater risk of wound
complications.

Expert Says
(Page 15 of 20)
But sometimes there’s no other option than
surgery. Reasons for a C-section vary from the
development of pre-eclampsia (high blood
pressure and excess protein in the urine after
20 weeks of pregnancy), to a previous C-section,
failed induction, obstructed labor, excessive fetal
growth and malpresentation.
The diabetes and pregnancy expert Dr. Lois
Jovanovic says, that independent of type of
diabetes, glucose control or complications, the
women with diabetes have poorer myometrial
contractions than the women with normal glucose
tolerance.

Expert Says
(Page 16 of 20)
The authors’ conclusion that each pregnant
diabetic women should thus be treated uniquely
during labor and delivery proves that women with
diabetes truly are special.
At the same time, if macrosomic babies (4 to
4.5Kg) are given a trial of vaginal delivery, they are
likely to suffer from shoulder dystocia and
brachial plexus injury.

Expert Says
(Page 17 of 20)
Some questions that the pregnant mother or
her family can ask when your Gynecologist is
planning for a C-section –
• Why does my baby need a C-section?
• How accurate is estimation of birth weight? Could
the baby be smaller than expected?
• What are the risks to the baby if C-section is not
performed?
• What are the risks if a C-section is performed?

Expert Says
(Page 18 of 20)
Normal Vaginal Delivery (Natural Birth)
Vaginal deliveries are the best mode of delivery for
any mom: there’s a better recovery. A C-section is
a major surgery with increased blood loss and risk
of surgical complications.
It has been recently observed by the researchers
at Liverpool, UK that women with diabetes have
poor uterine contraction ability i.e. even if they
push for hours will never succeed. These women
had a higher chance of induction, instrumental
deliveries (forceps, vacuum) and C-sections.

Expert Says
(Page 19 of 20)
Doctors tend to induce women with diabetes (pre-
gestational or gestational) on medications (whether
insulin or oral medication) around 39 weeks
gestation. The reason for this is that women with
diabetes are at a greater risk for stillbirth, and
39 weeks has been shown to be the time when the
fetus is fully developed. The downside of induced
labor is that it may double the odds of a C-section
birth.

Expert Says
(Page 20 of 20)
To conclude, the more you learn about your
bodies, the better you can work with what you’ve
got, and feel empowered about your birthing
experience. Optimizing outcomes for women with
gestational diabetes mellitus treatment (GDM) and
their fetuses requires not only careful metabolic
management, but also appropriately applied fetal
surveillance techniques and thoughtful selection of
the most advantageous timing and route of
delivery.

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