Effect of Diabetes on Pregnancy. Effect of Pregnancy on Diabetes

There are a lot of complications during pregnancy, delivery, and in postpartum period due to diabetes. Maternal complications are: abortions, prematurity, increased incidence of EPH-complex, more often in severe forms (severe preeclampsia, eclampsia). Hydramnios is one of the commonest complications, which is connected with fetal congenital abnormalities (incidence is 25-50%). Abruptio placentae, placental incompetence are not so rare.

During labor complications are: abnormalities of labor pains, obstructed delivering due to a big fetus, shoulder dystocia, perineal injuries, hemorrhages in the 3^rd stage of labor and in early postpartum period. In the late postpartum period more often endometritis occurs.

Fetal complications are very serious too. These are: fetal macrosomia, diabetic fetopathy, congenital malformations, birth injuries. After birth secondary asphyxia, respiratory distress syndrome, perinatal infections may occur, so the level of perinatal death is very high.

Effect of Pregnancy on Diabetes. Pregnancy is a metabolic stress test for diabetes leading to aggravation of diabetes in pregnancy. In the first trimester, after the 10^th week of gestation, the glucose tolerance increases due to action of HCG, so the insulin requirement decreases. The doses of insulin have to be diminished. In 24-28 wk of gestation the glucose tolerance decreases due to insulin antagonism, resulting in development of hyperglycemia, glucosuria, so the dose of insulin has to be increased. The insulin antagonism is probably due to the combined action of human placental lactogen, estrogen, progesterone, free cortisol and degradation of insulin by the placenta. During the 3^rd trimester the insulin requirement decreases, probably, due to the action of fetal pancreas.

Insulin requirement falls significantly in puerperium.

Vascular changes, specially retinitis aggravate during pregnancy. Diabetes in pregnant is compensated when the level of glucose is 4.4 mmol/l to 6.6 mmol/l.

Because of these complications pregnancy and delivery may be contraindicated for the following groups of patients with diabetes:
- patients with progressive vascular changes;
- insulin-resistant forms of diabetes;
- diabetes in both partners;
- combination of diabetes with active pulmonary tuberculosis;
- ketoacidosis;
- antenatal and intranatal mortality in previous history;
- some other states.

Management of Pregnancy at Diabetes Mellitus. Each pregnant with diabetes should be hospitalized in term before 12 weeks of gestation to be sure that there is no contraindications for pregnancy and delivery. The aims of this hospitalization are: to determine the term of gestation, to correct the dose of insulin, to evaluate contraindications to prolongation of pregnancy.

The next prophylactic hospitalization should be in term of 20-24 weeks. Apart from those undertaken during the first hospitalization, the following should be done: examination of the condition of fetal-placental complex, diagnostics of congenital anomalies of the fetus, if any, revealing the onset of obstetric complications, such as EPH-complex, and their treatment.

The third prophylactic hospitalization should be undertaken in the term of 30-34 weeks of pregnancy to prepare the patient for delivery.

The optimal term of delivery for patient with diabetes is from 36-37 weeks, because after this term the placental incompetence is more progressive due to “growing old” and fetus may die. Prior to this term the delivery is dangerous due to dismaturity of the baby.

It is much better for these patients to have labor via natural generative passages of delivery. Cesarean section is indicated in the following cases: vascular changes during pregnancy, neuroretinopathy, ketoacidosis during pregnancy or labor, acute renal incompetence, a big fetus, a severe form of EPH-complex, hemorrhages due to abruptio placentae, placenta previa, etc.

Diabetic Fetopathy of Newborn. The body weight of baby of 36 weeks of gestation is the same as of full-term child. There is a disproportion in sizes of head and shoulders (the circumference of shoulders is bigger than that of the head) which can lead to mechanical injuries to infant. Due to chronic hypoxia intracranial hemorrhages may happen during labor. In spite of big mass these infants usually have significant signs of prematurity — soft bones, enlarged fontanelles, respiratory distress syndrome are typical of them. So the prognosis is unfavourable for them.

Pyelonephritis in Pregnancy. The incidence of pyelinephritis during pregnancy is 6-10%. It is an infectious disease; the most frequent causative agents are E. coli, enterococci, staphilococci, streptococci, and mixed infection. Pregnancy may contribute to the development of pyelonephritis because of dilatation of ureters and renal pelves and stasis of urine in the bladder and ureters, which are more expressed in term after 20 weeks of gestation due to increase of progesterone level in blood. Therefore the term of 20-24 weeks of pregnancy is of high risk of occurrence or aggravation of pyelonephritis.

Acute pyelonephritis usually occurs after 16 weeks of pregnancy.

Its symptoms are the following: acute aching pain in the area of loin, often radiating to the groin, fever with chill and rigor, anorexia, nausea and vomiting occurring due to general intoxication. Micturition or dysuria is a typical symptom. Pasternatsky’s symptom is positive. Blood analysis usually reveals bacteriuria, leukocyturia, proteinuria.

Chronic pyelonephritis may have a chronic course from the onset, or may develop as a result of ineffective treatment of acute or recurrent pyelonephritis. Asymptomatic bacteriuria may alternate with the periods of exacerbation at chronic pyelonephritis.

Diagnostics may be difficult due to long asymptomatic period when neither proteins nor pus cells are detected in the urine. Chronic pyelonephritis is frequently accompanied by chronic hypertension. Maternal and fetal prognosis depends on degree of renal damage.

Effect of Pyelonephritis on Pregnancy. The most common complication of pregnancy at pyelonephritis is preeclampsia and eclampsia, prematurity, intrauterine damage of the fetus. The incidence of EPH-complex in pregnants with pyelonephritis is about 40%, thus severe forms develop more often. The incidence of premature labor is about 30%, perinatal mortality is about 25%. The occurrence of asphyxia of newborn, hypotrophy, dismaturity, infections may take place.

Effect of Pregnancy on Pyelonephritis. The course of pyelonephritis exacerbates during pregnancy. Chronic pyelonephritis becomes acute during pregnancy, and, if not treated, it may occur twice or thrice during gestation.