Introduction

Diabetes mellitus, a clinical syndrome characterized by deficiency of or insensitivity to

insulin and exposure of organs to chronic hyperglycemia, is the most common medical
complication of pregnancy. Over 3 million persons in the United States are sufficiently
affected bydiabetes mellitusto warrant treatment with insulin or oral hyperglycemics.
Another 3 million are treated with diet alone in addition to a possible 4 or more million with
varying degrees of asymptomatic glucose intolerance.
Preexisting diabetes (ie, diabetes diagnosed prior to pregnancy) affects approximately 1-3
pregnancies per 1000 births. In spite of the goal of preconception counseling for women with
preexisting diabetes, many women will present for medical care for the first time during
pregnancy. In this light, pregnancy affords a unique opportunity for diabetes screening and
may well be the best opportunity in a woman's life to discover or prevent her diabetes.
Gestational diabetesmellitus (GDM) is defined as any degree of glucose intolerance with
first recognition during pregnancy. GDM complicates approximately 4% of pregnancies
(135,000 cases in the United States annually).
Hyperglycemia around the time of conception and early organogenesis results in the
developing embryo having a 6-fold increase in midline birth defects. Ketoacidosis is an
immediate threat to life and is the leading cause of perinatal morbidity in diabetic
pregnancies today, accounting for 40% of perinatal mortality.
Complications of GDM include fetal macrosomia, which is associated with increased rates
of secondary complications such as operative delivery, shoulder dystocia, and birth trauma.
In addition, neonatal complications attributed togestational diabetesinclude respiratory
distress syndrome (RDS), hypocalcemia, hyperbilirubinemia, and hypoglycemia.
Before the introduction of insulin in 1922, patients often died during the course of their
pregnancy. Twenty years ago it was not uncommon to deliver an unexplained stillbirth from
a mother withtype 1 diabetesmellitus. In an effort to prevent fetal death, deliveries were
often performed early.
Today, this tragedy is rare, and over the last decade associated perinatal morbidity and
mortality have been reduced from 60% to less than 5%. With therapy beginning prior to
conception and continuing throughout pregnancy, including nutrition therapy, insulin when
necessary, and eventual antepartum fetal surveillance, there is a marked decline in overall
morbidity and mortality. Two decades ago, most diabetics required prolonged
hospitalization, but today the majority is managed with only brief hospitalizations. This is
partly due to the technologic improvements in home reflectance glucose monitors and the
beneficial impact they have had in management of the diabetic during pregnancy.
Currently, the major challenges of caring for diabetics in pregnancy are first, to enhance
preconceptual glucose control and reduce the risk of associated congenital malformations,
second to adequately screen pregnant women, and third, to detail the full impact of milder
glucose elevations, not only on maternal risk for developing diabetes, but also on immediate
and long-term consequences to the fetus/child.

What
risks
does
pregestational
diabetespose
to
the
baby?
Poorly controlled pregestational diabetesposes a number of risks to the baby. These risks
can be greatly reduced with good blood sugar control starting before pregnancy.

Birth defects: Women with poorly controlled diabetes in the early weeks of
pregnancy are 3 to 4 times more likely than nondiabetic women to have a baby with a
serious birth defect. These include heart defects or neural tube defects (NTDs), birth
defects of the brain or spinal cord (1).
Miscarriage: High blood sugar levels around the time of conception may increase the
risk of miscarriage (1).

Premature birth(before 37 completed weeks of pregnancy) (1): Premature babies are

at increased risk of health problems in the newborn period as well as lasting disabilities.

Macrosomia: Women with poorly controlled diabetes are at increased risk of having a
very large baby (10 pounds or more). Macrosomia is the medical term for this. These
babies grow so large because some of the extra sugar in the mother's blood crosses the
placenta and goes to the fetus. The fetus then produces extra insulin, which helps it process
the sugar and store it as fat. The fat tends to accumulate around the shoulders and trunk,
sometimes making these babies difficult to deliver vaginally and putting them at risk for
injuries during delivery.

Stillbirth: Though stillbirth is rare, the risk is increased with poorly controlled
diabetes (3).

Newborn complications: These include breathing problems, low blood sugar levels
and jaundice (yellowing of the skin). These complications can be treated, but it's better to
prevent them by controlling blood sugar levels during pregnancy.

Obesity and diabetes: Babies of women with poorly controlled diabetes may be at
increased risk of developing obesity and diabetes as young adults (1).
What
risks
doesgestational
diabetespose
to
the
baby?
Babies of women withgestational diabetesusually face fewer risks than those of women
with pregestational diabetes. Babies of women withgestational diabetesusually do not
have an increased risk of birth defects (4). However, some women withgestational
diabetesmay have had unrecognized diabetes that began before pregnancy. These women
may have had high blood sugar in the early weeks of pregnancy, which increases the risk of
birth defects.
Like pregestational diabetes, poorly controlledgestational diabetesincreases the risk of
macrosomia, stillbirth and newborn complications, as well as obesity and diabetes in young
adulthood (5, 6).
Does
diabetes
cause
other
pregnancy
complications?
Women with diabetes (pregestational and gestational) are likely to have an uncomplicated
pregnancy and a healthy baby, as long as blood sugar levels are well controlled. However,
women with poorly controlled diabetes are at increased risk of certain pregnancy
complications. These include:

Preeclampsia: This disorder is characterized byHigh Blood Pressureand protein in

the urine. Severe cases can cause seizures and other problems in the mother and poor
growth and premature birth in the baby.
Polyhydramnios: Too much amniotic fluid (polyhydramnios) can increase the risk of
preterm labor and delivery (1, 3).
Cesarean delivery: When the baby grows too large, a cesarean delivery often is
recommended (5).
What
causesgestational
diabetes?
Gestational diabetesoccurs when pregnancy hormones or other factors interfere with the
body's ability to use its insulin. An affected woman usually has no symptoms. This form of
diabetes usually develops during the second half of pregnancy and goes away after delivery.
Who
is
at
risk
ofgestational
diabetes?
Women with certain risk factors are more likely to developgestational diabetes. These risk
factors include (5, 7):

Hadgestational diabetesin a previous pregnancy

Age over 30

Overweight and/or excessive weight gain during pregnancy

Had a very large (over 91/2 pounds) or stillborn baby in a previous pregnancy

African-American, Native American, Asian, Hispanic, Pacific Island ancestry

However, even women who don't have any risk factors can developgestational diabetes. For
this reason, health care providers screen most pregnant women for the disorder. According to
the American Diabetes Association (ADA), women under age 25 who have no other risk
factors may not require screening because they have a very low risk of the disorder (8).