History
A 20-year-old woman is pregnant for the first time. The pregnancy is unplanned and the partner has left but she is supported by her mother and has decided to continue.
She was diagnosed with type 1 diabetes aged 15 years. She has been taking long-acting and short-acting insulin under the care of her general practitioner (GP), but the referral letter suggests that she has not always been compliant.
She had a positive pregnancy test 2 weeks ago and her GP has referred her urgently to the antenatal clinic for review in view of the diabetes. By her dates she is now 7 weeks and 5 days’ gestation. She has no other significant gynaecological or medical history.
Examination
The woman has a body mass index of 29 kg/m2. Blood pressure is 131/68 mmHg and pulse is 81/min.
Questions
• What further investigations need to be arranged?
• Outline the principles of management of the pregnancy.
Medicine
The investigations can be divided into those for maternal and for fetal wellbeing:
• maternal wellbeing:
• baseline urea and electrolytes
• pre- and post-prandial capillary blood glucose measurements
• fetal wellbeing:
• viability scan (increased risk of miscarriage in diabetic women)
• fetal echocardiography (increased risk of all fetal abnormalities in diabetic offspring)
• detailed anomaly ultrasound examination at 20 weeks.
Diabetic (type 1) pregnancies may be affected by an increase in a range of complications as well as fetal abnormalities. However optimal control of blood sugar is thought to reduce the complication risk to near that of a non-diabetic pregnancy, so a large propor-tion of management is aimed at maintaining very tight blood glucose control. In this par-ticular case, the history, HbA1c and presence of glycosuria suggest that the woman has generally poor control, providing a particular challenge to management of this pregnancy.
KEY POINTS
• Type 1 diabetes pregnancies are high risk for mother and fetus and need specialist diabetes and obstetric input. Very close blood glucose control should reduce the complication rate to near that of a non-diabetic mother.
• Fetal complications include miscarriage, congenital abnormality, macrosomia, stillbirth and shoulder dystocia.
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