Chapter 94

Maternal diabetic control is a key factor in determining fetal outcome. Data indicate that perinatal morbidity and mortality rates in the offspring of women with diabetes mellitus have improved with dietary management and insulin therapy. The use of oral hypoglycemic agents is controversial, and there is some concern about worse maternal and neonatal outcomes as compared to treatment with insulin. However, complications may still arise in the infant, including hypoglycemia, hypocalcemia, hypomagnesemia, perinatal asphyxia, respiratory distress syndrome (RDS), other respiratory illnesses, hypertrophic cardiomyopathy, hyperbilirubinemia, polycythemia, renal vein thrombosis, macrosomia, birth injuries, and congenital malformations. Because of a better current understanding of the pathophysiology of diabetic pregnancies, these complications can be recognized and treated.

1. I. Definition

1. A. White's classification. White's classification system is based on the age at onset, duration of the disorder, and complications and is predictive of perinatal mortality. It is currently used to group women with diabetes during pregnancy and provide a method to compare groups of infants. The original table was produced in 1949 and was most recently revised in the 1980's (see Revised White's Classification, Table 94–1). A major change was placing gestational diabetes in its own category. Newer classifications have been suggested but none are widely adopted.

1. B. The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus.Table 94–2 presents the nomenclature of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus (American Diabetes Association, Alexandria, VA). This classification defines the illness based on the etiology of the disease. It discourages the use of terms such as insulin-dependent diabetes (IDDM) and the use of roman numerals type I and type II. Preferred terms are Type 1 diabetes mellitus, Type 2 diabetes mellitus, other types, and gestational diabetes mellitus. It is important to note that any type of diabetes can progress through clinical phases of being normoglycemic to hyperglycemic, being asymptomatic and symptomatic during their clinical history.

2. II. Incidence. It is estimated that 3–10% of all pregnancies are complicated by diabetes, and 90% of these are women with gestational diabetes. Women with a family history of type 2 diabetes mellitus, Asian, Native American, Middle eastern, African and Hispanic women, or obesity are at higher risk.

3. III. Pathophysiology

1. A. Macrosomia. Macrosomia is the classic presentation of the infant of a poorly controlled diabetic mother (IDM). It is the result of biochemical events along the maternal hyperglycemia-fetal hyperinsulinemia pathway, as described by Pedersen. Macrosomia occurs in 15–45% of diabetic pregnancies and plays a role in both birth injuries, including shoulder dystocia, brachial plexus injuries, subdural hemorrhage, cephalohematoma, and the increased rate of asphyxia seen in infants of diabetic mothers. Hispanic diabetic women have higher rates of macrosomia than other ethnic groups.

1. B. Small for gestational age. Mothers with renal, retinal, or cardiac diseases are more likely to have small for gestational age or premature infants, poor fetal outcome, fetal distress, or fetal death.

1. C. Specific disorders frequently encountered in IDMs

1. 1. Metabolic disorders

1. a. Hypoglycemia is ...

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