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Complications Delivery information by


Our aim is to alleviate human suffering related to diabetes and its complications among those least able to withstand the burden of the disease. From 2002 to March 2017, the World Diabetes Foundation provided USD 130 million in funding to 511 projects in 115 countries. For every dollar spent, the Foundation raises approximately 2 dollars in cash or as in-kind donations from other sources. The total value of the WDF project portfolio reached USD 377 million, excluding WDF’s own advocacy and strategic platforms. – PowerPoint PPT presentation

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Title: Complications Delivery information by

  • Hypoglycemia
  • Premature Labour
  • Preeclampsia

  • Discuss causes, prevention strategies and
    treatment of hypoglycemia for those women on
  • Discuss premature labour, recognizing
    contractions, and action to take
  • Discuss diagnosis and treatment of preeclampsia

Definition of hypoglycemia
  • The development of autonomic or neuroglycopenic
  • Low plasma glucose (less than 4.0 mmol/L or 72
  • Symptoms resolved by administration of
  • Cryer, Davis, Shamoon, 2003

Risk of hypoglycemia (1 of 3)
  • Only those taking glucose-lowering medicines or
    insulin are at risk
  • Risk increases with
  • Not enough carbohydrate consumption
  • Late or missed meal
  • Fasting or malnourishment
  • Too much insulin
  • Prolonged or unplanned activity

Risk of hypoglycaemia (2 of 3)
Symptoms of hypoglycaemia
Canadian Diabetes Association, 2013
Possible consequences of hypoglycaemia
Effect Of Hypoglycemia On Fetus
Fetal heart rate, as well as fetal movements and
placental perfusion appear to be unchanged during
conditions of maternal hypoglycemia in the range
of 2.5 3.0 mmol/L (4555 mg/dL)
Coustan, 2009 Diamond, Reece et al, 1992 Nisell,
Persson, et al1994 Reece, Hagav, et al 1995
Treatment (1 of 2)
Canadian Diabetes Association, 2013
Treatment (2 of 2)
  • Severe
  • 20 g glucose
  • Glucagon 1ml SC or IM increases BG by 3 -12
    mmol/L (54-216 mg/dl) over 60 min
  • IV dextrose- 20 to 50 ml of 50 dextrose over 2
    to 3 minutes immediate response is seen
  • Manage seizure- place person on their side if not
    too agitated

Follow-up management
Follow-up management
  • Meal or snack (15 to 20 g carbohydrate a
    protein source)
  • Next dose of insulin taken as usual if cause is
    known and hypo was mild
  • Consider reducing next dose of insulin if hypo
    was severe
  • Assess cause and prevent recurrence
  • Avoid BG levels lt 4 mmol/L (72 mg/dL)

Premature Labour
  • Preterm labour in GDM can use steroids and
    tocolysis as for other pregnancies
  • Preferably avoid betamimetic as tocolytics
  • Nifidepine is a good choice
  • Both steroids / tocolytics can push glucose up so
    need to monitor closely and cover with insulin /
    increasing dose of insulin
  • Rule out UTI as a risk factor for preterm labour

  • Women with GDM are at increased risk of
    preeclampsia this is partly due to the increased
    insulin resistance
  • It is possible that this increase could be
    accounted for by the fact that their age and BMI
    predispose them to GDM as well as hypertension.
  • Monitor BP urine albumin every visit

Hollander 2007
  • Discuss when to deliver infant
  • Discuss options for inducing labour
  • Discuss implications of Caesarian section

Timing of delivery the same for all?
  • Women with diabetes before pregnancy are at
    increased risk
  • In GDM perinatal mortality rates lower
  • If insulin requiring, best to use approach
    similar to pregestational DM
  • GDM managed on diet and exercise alone possibly
    not at any greater risk from baseline
  • Depends on severity and duration of diabetes as
    well as co morbidities

Timing of delivery
  • Gestational specific risks for still birth
    continue to fall up to 38 weeks but increase
    slightly over 40 weeks
  • In insulin dependent women most would plan
    delivery 38 - 39 weeks
  • Between 38 and 39 weeks
  • No difference in incidence of cesareans
  • More larger babies in one study
  • There is as yet not enough evidence that
    induction in diabetic pregnancies prevents fetal

  • In diet controlled GDM women most would be
    comfortable to 40 weeks
  • With good control and reassuring tests of well
    being some centres go on to 41 weeks

Patel, Steer, Doyle et al. 2003
Mode of delivery
  • Matter of choice
  • High section rates 30 80 averaging 50 in
    many centres
  • Vaginal delivery is possible and safe
  • Previous obstetric history
  • EFW
  • Other clinical factors
  • Induction of labour is a safe option

Monitoring labour
  • Labour is a time of unpredictable glucose and
    insulin demands risk of hypoglycemia
  • Sliding scale / infusion
  • Maintain plasma glucose below 110 mg/dl to avoid
    maternal hyperglycemia and subsequent foetal
  • Careful intrapartum FHR monitoring
  • Pay attention to second stage slow progress is
    a red flag
  • Caution with instrumental delivery
  • Be prepared for shoulder dystocia

Jovanovic L. 2005
  • Canadian Diabetes Association Expert Committee.
    Canadian Diabetes Association 2013 Clinical
    Practice Guidelines for the Prevention and
    Management of Diabetes in Canada. Can J Diab
    201337(suppl 1)S69-71
  • Coustan, D, Glob. libr. women's med., (ISSN
    1756-2228) 2009 DOI 10.3843/GLOWM.10162
  • Cryer P.E. Davis, S.N. Shamoon, H. Hypoglycemia
    in diabetes. Diabetes Care, 200326(6)1902-1912
  • Diamond MP, Reece EA, Caprio S et al Impairment
    of counterregulatory hormone responses to
    hypoglycemia in pregnant women with
    insulin-dependent diabetes mellitus. Am J Obstet
    Gynecol 199216670-77
  • Hollander M, Paarlberg KM, Huisjes AJM, 2007
    Gestational Diabetes A Review of the Current
    Literature and Guidelines Volume 62, Number 2
    Obstetrical and Gynecological Survey
  • Nisell H, Persson B, Hanson U, et al Hormonal,
    metabolic and circulatory responses to
    insulin-induced hypoglycemia in pregnant and
    nonpregnant women with insulin-dependent
    diabetes. Am J Perinatol 199411231-236
  • Reece EA, Hagay Z, Roberts AB et al Fetal
    Doppler and behavioral responses during
    hypoglycemia induced with the insulin clamp
    technique in pregnant diabetic women. Am J Obstet
    Gynecol 1995172151-155.
  • Saleh M., Grunberger, G. Hypoglycemia A cause
    for poor glycemic control. Clinical Diabetes,
  • Jovanovic L, Knopp RH, Kim H, et al. Elevated
    pregnancy losses at high and low extremes of
    maternal glucose in early normal and diabetic
    pregnancy evidence for a protective adaptation
    in diabetes. Diabetes Care 2005 281113.
  • Patel RR, Steer P, Doyle P, Little MP, Elliot P.
    Does gestation vary by ethnic group? A
    London-based study of over 122000 pregnancies
    with spontaneous onset of labour. Int J of Epid.
    200333107-113.DOI 10.1093/ijc/dyg238.