Diabetes mellitus in pregnancy: antenatal management

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Management of diabetes mellitus in pregnancy can be divided into phases:

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These are the crucial components in the management of diabetes mellitus in pregnancy during antenatal period:

1. Dating
2. Glucose level assessment
3. Glucose control
4. Management of complications
5. Determination of mode and timing of delivery

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Dating

Accuracy of gestational age is really important for the management of diabetes mellitus in pregnancy, especially for determination of timing of delivery. The earlier dating is done, which is done by using ultrasound, the more accurate the estimated gestational age of the fetus.

There is some special cases in which early dating is not done, and the dates are not certain. In such cases, amniocentesis might need to be done, to check for lecithine syringomyeline (L:S) ratio, to assess for fetal lung maturity.

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Glucose level assessment

Blood sugar profile (venous blood sugar) is usually done monthly or every 2 weeks, aim to achieve blood sugar level of 4 - 6 mmol/L. It reflects the recent blood sugar control.

Meanwhile, HbA1c is done once in each trimester, with target of HbA1c <6 - 7%. It reflects the glucose control for the previous 2 - 3 months, hence, also reflects the adequacy of BSP testing schedule.

Blood sugar home monitoring (capillary blood sugar) is recommended for all patients.

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Glucose control

Blood sugar level is controlled either by diet control or by using subcutaneous insulin. Oral anti-diabetic agents are not recommended because of the teratogenic risk.

If sugar control is not achieve by diet control only, then the use of subcutaneous insulin is initiated.

Different consultant might prefer different regimen of insulin. Common regimen used is a regimen of three premeal injections of short acting insulin. There are also other regimen that can be used such as a twice daily regimen of short and intermediate acting insulin. See also Diabetes mellitus in pregnancy: insulin therapy during antenatal phase

The aim of premeal blood sugar level range from 4 to 6 mmol/L.

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Management of complications

Early detection of complications is important, either maternal complications or fetal complications.

See also Diabetes mellitus in pregnancy: ultrasound work up during antenatal phase

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Determination of mode and timing of delivery

Optimally controlled of the diabetes, the pregnancy should be allowed to at least 38 - 39 weeks, but not to go beyond the expected date of delivery.

Poorly controlled diabetes might need earlier delivery, usually because of the complication, such as macrosomic baby.

Vaginal delivery is the mode of delivery if there is no other obstetric complications such as dysfunctional labour, which may call for emergency caesarean section.

Elective caesarean section should be considered in women with:

• Bad obstetric history
• History of subfertility
• Poor diabetic control
• Vascular complications
• Macrosomia

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*Antenatal visit frequency

Antenatal visits should be done every 2 weeks until 32 - 34weeks and then weekly thereafter.