21. Diabetes Mellitus

Summary

As more women with diabetes are contemplating pregnancy and more women are delaying pregnancy, healthcare providers should expect to see more pregnant women with pregestational as well as gestational diabetes. Management of these women should follow accepted guidelines in order to decrease maternal and perinatal morbidity and mortality. To that effect, the central goal is to decrease the risk for congenital anomalies secondary to preconception hyperglycemia, as well as to shepherd the pregnant woman through pregnancy in order to reach term without maternal complications such as preeclampsia or fetal complications such as uteroplacental insufficiency, antepartum stillbirth, macrosomia, birth injury, and postnatal hypoglycemia. This can be achieved by a combination of frequent glucose monitoring, dietary and pharmacologic interventions, diligent fetal surveillance, appropriate timing of delivery, and judicious choice of delivery route. In most cases, diabetic patients can be brought to term, and perinatal mortality from stillbirth, prematurity, and birth injury can be markedly reduced. It is important that the obstetrician who occasionally manages diabetic patients is familiar with the uses and limitations of established treatments. This chapter concentrates on the pregestational diabetic patient. For discussion of gestational diabetes, see Chapter 20.