Diabetes in pregnancy is still considered a high-risk condition for both mother and baby. Even in the best centres, malformation and mortality rates are reportedly twofold to fivefold higher than in the background population, and pregnancy planning rates remain obstinately poor. Increasing global rates of type 2 diabetes are now extending into pregnancy, with similarly poor outcomes to type 1 diabetes, and excess maternal weight is adding to the complexity of management. Over the last 5–10 years, several randomised trials have offered new insight into the role of oral hypoglycaemic drugs and insulin analogues in pregnancy, while continuous subcutaneous insulin infusion (CSII) pumps and continuous glucose monitors (CGMs) are under scrutiny. The relevance of minor degrees of hyperglycaemia to adverse pregnancy outcome was clearly demonstrated by the Hyperglycaemia and Adverse Pregnancy Outcome (HAPO) study, but translation of these data into clinical practice has proved challenging because of the continuum of risk. Long-term metabolic and cardiovascular implications of hyperglycaemia during pregnancy for mother and child are now generally recognised with major implications for public health.
Epidemiology
Globally, 21.4 million (16.9%) of 127.1 million live births to women aged 20–49 years are affected by hyperglycaemia in pregnancy . Approximately 16% of the 21.4 million may be caused by diabetes in pregnancy (including known and previously undiagnosed diabetes). These statistics reflect the growing prevalence of the type 2 diabetes epidemic on pregnancy, and they vary significantly with ethnicity and location. 91.6% of cases are reported in low- and middle-income countries where access to maternal care is often limited . A UK survey in 2003 estimated the frequency of type 1 diabetes as one in 364 (0.27%) and type 2 as one in 955 (0.10%) births . The increase in hyperglycaemia in pregnancy is compounded by overweight/obesity, which now affects about half of women who give birth .
Adverse perinatal outcomes
A review of 12 population-based studies published within the last 10 years compared 14,099 women with type 1 diabetes with 4,035,373 women from the background population reported a twofold to fivefold increased risk of adverse pregnancy outcomes as follows:
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Congenital malformations, 5.0% versus 2.1% (relative risk (RR): 2.4)
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Perinatal mortality, 2.7% versus 0.72% (RR: 3.7)
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Preterm delivery, 25.2% versus 6.0% (RR: 4.2)
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Large for gestational age (LGA) infants, 54.2% versus 10.0% (RR: 4.5)
In the UK Confidential Enquiry into Maternal and Child Health (CEMACH), 4% of foetuses had at least one major congenital anomaly (twice that of the general population). The most common anomalies were congenital heart disease (1.7%; three times that of the general population) and musculoskeletal (0.7%) . At least one in two infants of mothers with type 1 diabetes has complications related to glucose control .
Adverse perinatal outcomes
A review of 12 population-based studies published within the last 10 years compared 14,099 women with type 1 diabetes with 4,035,373 women from the background population reported a twofold to fivefold increased risk of adverse pregnancy outcomes as follows:
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Congenital malformations, 5.0% versus 2.1% (relative risk (RR): 2.4)
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Perinatal mortality, 2.7% versus 0.72% (RR: 3.7)
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Preterm delivery, 25.2% versus 6.0% (RR: 4.2)
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Large for gestational age (LGA) infants, 54.2% versus 10.0% (RR: 4.5)
In the UK Confidential Enquiry into Maternal and Child Health (CEMACH), 4% of foetuses had at least one major congenital anomaly (twice that of the general population). The most common anomalies were congenital heart disease (1.7%; three times that of the general population) and musculoskeletal (0.7%) . At least one in two infants of mothers with type 1 diabetes has complications related to glucose control .
Type of diabetes and outcomes
The outcomes of women with type 1 and type 2 diabetes are equally poor . A recent meta-analysis of 33 studies involving 7966 type 1 and 3781 type 2 pregnancies showed that women with type 2 diabetes had a significantly higher risk of perinatal mortality but no difference in rates of malformation .
Risks and risk factors
These are well established for both mother and baby, and are modified to some extent by the type and duration of diabetes, glycaemic control and diabetes-related vascular complications . Fifty per cent of babies may need admission to neonatal care (10% intensive care) , and the following are the risk factors:
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General risk factors: age, parity, weight, hypertension, smoking and drug abuse
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Obstetric risk factors: previous miscarriage, multiple pregnancy, nutritional deficiency, late booking and poor obstetric history
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Maternal risk: miscarriage, accelerated retinopathy and nephropathy, hypoglycaemia and hypoglycaemic unawareness, diabetic ketoacidosis (DKA), pre-eclampsia, hydramnios, operative delivery and infection
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Foetal risk: stillbirth, perinatal mortality, congenital anomalies, small/large for gestational age (SGA/LGA), preterm delivery, operative delivery, shoulder dystocia and birth injury, neonatal hypoglycaemia, polycythaemia, hypocalcaemia and respiratory distress syndrome
Pathophysiology
Adaptation of maternal metabolism during pregnancy involves a greater fall in plasma glucose and amino acids, and a greater rise in free fatty acids to overnight fasting than in the non-pregnant state (‘accelerated starvation’) associated with hepatic insulin resistance. In later pregnancy, a progressive rise in postprandial glucose and its associated insulin response, associated with decreased insulin sensitivity, parallels the growth of the foetal placental unit, and it rapidly reverses after delivery. This ‘facilitated anabolism’ brings about appropriate changes in carbohydrate, amino acid and lipid metabolism, and ensures adequate nutrients for the developing foetus.
Deficient β-cell reserve, either absolutely, as in type 1 diabetes, or relatively, as in type 2 diabetes or gestational diabetes mellitus (GDM), will result in the abnormal adaptation of carbohydrate, protein and fat metabolism. In type 1 diabetes, sufficient insulin is required to compensate for increasing caloric needs, increasing adiposity, decreasing exercise and increasing anti-insulin hormones. The insulin dose to maintain normoglycaemia and prevent maternal ketosis may increase up to threefold in the course of pregnancy in type 1 diabetes, and women with type 2 diabetes will usually require insulin treatment, often at high doses, because of obesity and physical inactivity.
The Pedersen hypothesis (proposed over 50 years ago) that maternal hyperglycaemia accelerates foetal growth through foetal hyperinsulinaemia is supported by animal and epidemiological data, and has provided a basis for the concept of foetal programming. Other maternal fuels are also likely to be implicated.
Type 1 and type 2 diabetes preceding pregnancy
Provision of care
A multidisciplinary team operating in a secondary- or tertiary-care setting is a commonly adopted model for the care of pregnant women with diabetes . Essential team members include an obstetrician, a diabetes physician, a specialist nurse, a dedicated dietician and a diabetes-trained midwife. Review is usually done fortnightly and initially focussed on diabetic rather than on obstetric issues. Women are reviewed weekly as term approaches. Ideally, there should be an open-access pregnancy-planning clinic with a seamless interface with the joint antenatal diabetes clinic.
Rationale for pre-pregnancy care
Recognition that congenital malformations were increased in infants of diabetic mothers was first observed >40 years ago, and quickly linked with maternal periconceptional hyperglycaemia. Most abnormalities occur in the teratologically sensitive period up till the seventh gestational week. A UK population registry-based study between 1996 and 2008 involving 401,149 singleton pregnancies (1677 in women with diabetes) showed that the odds of a malformation increased by 30% for each percentage (11 mmol/mol) increase in booking HbA1c . Periconception HbA1c was the most important predictor of malformations with a linear risk between 6.3% and 11% (45–97 mmol/mol). A meta-analysis of 14 studies of pre-pregnancy care showed a threefold reduction in the risk of major congenital malformations among 1192 offspring who received such care compared with 1459 offspring of mothers who did not . It is important, however, for the mother to realise that these risks are reduced with any improvement in HbA1c .
Pre-pregnancy counselling/pre-pregnancy care
Distinction is needed between the two major components of pregnancy planning.
Preconception counselling
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Preconception counselling is the education of, and discussion with, women of reproductive age about pregnancy and contraception, and it should be delivered annually in a primary and/or a specialist care to all women of reproductive age
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Discussion includes future pregnancy plans, importance of pre-pregnancy care, relationship of optimal glycaemic control to improved outcomes, possible need for revised treatment (e.g., substitution of insulin in type 2 diabetes), efficient contraception, how diabetic complications may affect future pregnancy, high-dose folic acid, teratogenic drugs (e.g., angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs) and statins) and urgent referral details if pregnant
Pre-pregnancy care
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Pre-pregnancy care is the additional care needed to prepare a woman with diabetes for pregnancy, and involves a close partnership between the woman and health-care professional. Ideally, it should begin at least 6 months before she embarks on a pregnancy.
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Discussion includes the use of contraception until optimal glycaemic control is achieved, relevant maternal and foetal risks, individualised and realistic glycaemic targets, revision of drug therapy, prescription of 5-mg folic acid daily, screening for and treatment of complications, nutritional and lifestyle advice, smoking and alcohol cessation.
A regional UK pre-pregnancy care programme was associated with improved outcomes but only 27% of eligible women attended, and there was no improvement among women with type 1 diabetes (50% access to preconception care) . A similar lack of improvement was reported from Sweden and Finland , but in Germany considerable improvements have been achieved with lower HbA1c levels and reductions in preterm delivery and macrosomia/LGA, possibly associated with an increased use of continuous glucose monitoring (CGMS) and continuous subcutaneous insulin infusion (CSII) .
The UK CEMACH survey reported that women with type 2 compared with type 1 diabetes were less likely to have received pre-pregnancy care (62% vs. 75%), to be taking folic acid preconception and to have microvascular complications, but more likely to be ethnically diverse, to suffer from socio-economic deprivation, to be hypertensive and overweight, and to have better glycaemic control both at booking and during pregnancy.
Health-care provision is likely to differ for women with type 1 and type 2 diabetes, and hence the need to promote awareness in whatever setting women are receiving routine diabetes care. Using content analysis of transcribed groups, we have recently produced a DVD and an online resource tool ( www.womanwithdiabetes.net ) aimed at improving the reproductive knowledge of diabetes among women of childbearing age. Significantly improved pregnancy planning was observed following regional distribution of this resource to all eligible women .
Maternal obesity and pregnancy
Obesity now affects one in five women who give birth, and it may be one of the greatest threats to childbearing women. In the UK survey, more than half of maternal deaths were in either overweight or obese women (15% in women with a body mass index (BMI) above 35). Pregnancy may cause or worsen obesity through excessive weight gain, and obesity may complicate pregnancy by increasing the risk of fertility problems, LGA and maternal hypertensive and diabetic disorders. Maternal obesity has been linked with a twofold to threefold increase in rates of malformation, perinatal mortality, caesarean section and macrosomia, although in a recent meta-analysis, BMI was not a significant independent predictor of poor outcome in women with type 1 and type 2 diabetes .
The American Institute of Medicine (2009) recommends gestational weight gain of:
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10–12.5 kg for normal weight women
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12.5–18 kg for underweight women (BMI <19.8 kg/m 2 )
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5–9.1 kg for obese women (BMI >30 kg/m 2 )
Cedergren suggested that obese women should gain <6 kg to reduce the risk of adverse pregnancy outcomes. Current UK guidelines recommend that women with a pre-pregnancy BMI >27 kg/m 2 should restrict their calorie intake to 25 kcal/kg/day in the second trimester. High maternal gestational weight gain in non-diabetic women increases the risk of LGA . Concern remains that a low maternal gestational weight gain is associated with SGA and preterm birth . Preventive measures by supporting women to lose weight and achieve a near-normal BMI before conception remain the ideal, and practically the most feasible strategy.
Nutritional recommendations in diabetes
Few evidence-based dietary guidelines exist for women with diabetes with or without obesity. A healthy lifestyle consisting of a well-balanced diet and moderate physical activity should be encouraged for all women during pregnancy. The aim is to reduce postprandial hyperglycaemia and to prevent hypoglycaemia between meals and nocturnally. Low glycaemic index foods may help to reduce postprandial hyperglycaemia, but randomised trial evidence is lacking which shows that these foods reduce adverse maternal/foetal outcomes .
As with a healthy non-pregnant diet, approximately 50% of the total energy is provided by carbohydrate and <35% from fat. Individual advice around appropriate carbohydrate intake and the adjustment of insulin prior to exercise to avoid hypoglycaemia is necessary especially early in pregnancy. For women with type 2 and GDM, 30 min of walking once or twice a day after meals is realistic and easily achievable, and this can lower fasting and postprandial blood glucose values as well as reduce the need for insulin.
There are no specific weight recommendations, but minimising unnecessary weight gain in obese women with type 2 diabetes and GDM women can improve maternal glycaemic control, reduce the risk of macrosomia and improve pregnancy outcomes .
Glycaemic control
The importance of optimal glucose control for healthy infant outcomes is unquestioned. Recommendations are broadly similar across international bodies and in the UK, and these include the following :
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Target capillary glucose levels of below 5.3 mmol/l fasting and 1 hour after meals: 7.8 mmol/l or 2 hours after meals : 6.4 mmol/l
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Blood glucose should be measured up to eight times daily (before and after each meal, at bedtime and, intermittently, in the middle of the night)
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If feasible, women planning pregnancy should aim for HbA1c below 6.5% (48 mmol/mol)
In a large multicentre UK cohort, <10% of UK women with type 1 diabetes had HbA1c <6.1% at first antenatal visit, increasing to around 25% at 26 and 34 weeks. At 34 weeks, 22% of women had an HbA1c ≥ 7% . We recently demonstrated a linear trend between increasing second and third trimester HbA1c values (independent of first trimester HbA1c) and adverse outcomes, supporting the utility of HbA1c measurement in later pregnancy to indicate high-risk pregnancies, which need intensive supervision ( Fig. 1 ).
There is a significant risk of hypoglycaemia with intensification of insulin therapy, especially during the first trimester, and glycaemic targets should be individualised. Severe hypoglycaemia, affecting up to 40% of women, causes substantial morbidity (seizures, fractures and road-traffic accidents), and it is the leading cause of death in type 1 diabetic pregnancy .
Diabetic complications
Retinopathy
Ideally, all diabetic patients should have a detailed eye examination prior to pregnancy. This permits relevant treatment (including photocoagulation) before optimisation of glycaemic control, and is essential to reduce the risk of retinopathy progression during pregnancy. Risk factors for progression include pre-existing retinopathy, poor blood glucose control preconception, longer diabetes duration, rapid improvement of diabetes control during the first trimester and previous or pregnancy-induced hypertension. UK guidelines recommend retinal assessment at the first antenatal appointment (if not performed in the previous 12 months), at 28 weeks, if the first assessment is normal, and additionally at 16–20 weeks if any retinopathy is present.
Nephropathy
The term includes microalbuminuria or proteinuria, with or without maternal hypertension, or significant impairment in the renal function. While recent retrospective data have reported perinatal survival rates of 95%, these vary with the stage of nephropathy, and they are accompanied by high rates of pre-eclampsia (32–65%), preterm delivery (57–91%) and foetal growth restriction (12–45%) . Tight blood glucose and blood pressure control before and during pregnancy, close foetal surveillance and timely delivery are needed to optimise pregnancy outcome. ACEIs/ARBs are teratogenic, and they should be discontinued before or possibly at conception in patients with more severe nephropathy pre pregnancy. Methyldopa and labetolol are alternative agents. Screening for microalbuminuria should take place at booking (if not performed in the previous 12 months), and referral to a nephrologist should be considered if serum creatinine >120 μmol/l or protein excretion >2 g/day . Microalbuminuria in early pregnancy is associated with a fourfold increased risk of pre-eclampsia in type 1 diabetic pregnancy. Women with increasing proteinuria during pregnancy need to be closely monitored particularly in late pregnancy.
Diabetic ketoacidosis
DKA presents a serious threat to maternal health and foetal viability. Precipitating factors include hyperemesis, beta-mimetic drugs, failure to continue regular insulin therapy and infection. Every mother should be taught how to monitor urinary ketones, and they should be given emergency contact numbers. If unwell, with reduced oral intake/vomiting with hyperglycaemia and ketonuria, urgent admission should be arranged especially if adequate hydration cannot be maintained.
Management
Insulin regimens
Most patients with diabetes before pregnancy are now using a multiple dose insulin (MDI) regimen comprising a short-acting preprandial insulin and an intermediate-acting insulin up to three times daily. Women with type 2 diabetes controlled on a twice-daily fixed mixture insulin regimen before pregnancy are often changed to an MDI regimen during pregnancy.
Rapid-acting analogue insulins, for example, aspart, lispro and glulisine, are frequently used as they reduce postprandial hyperglycaemia, are less prone to cause hypoglycaemia and can be taken immediately prior to meals. Data on their safety and efficacy have largely come from observational data, but a large randomised controlled trial (RCT) of insulin aspart versus regular soluble insulin in type 1 diabetes showed similar efficacy, with a tendency to lower rates of hypoglycaemia and without apparent toxicity . Insulin aspart and lispro are licensed for use during pregnancy (Food and Drug Administration (FDA) category B and European Medicines Agency (EMA) approved); glulisine is FDA category C. Basal analogue insulins include insulin detemir and glargine. An RCT of 310 women with type 1 diabetes randomised to insulin detemir or neutral protamine hagedorn (NPH) insulin (both with mealtime insulin aspart) revealed non-inferior HbA1c values, lower fasting plasma glucose values with detemir in later pregnancy and similar perinatal outcomes . Levemir is approved by the FDA (category B) and the EMA for use in pregnancy. No large RCT data for insulin glargine are available, but a review of observational studies did not show any excess of adverse outcomes.
Continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring (CGMS)
There is little evidence supporting the routine use of CSII in pregnancy. A meta-analysis of six studies (107 CSII vs. 106 MDI) showed comparable glucose control and pregnancy outcomes , although these studies were in the pre-analogue era and lacked power to detect differences in neonatal outcomes. Observational data (CSII vs. MDI) are conflicting, mostly retrospective and with striking selection biases. It seems likely that capillary glucose monitoring reveals only a minor fraction of hyperglycaemic excursions and day-to-day variability , and this may be relevant to adverse foetal outcome.
An RCT, which compared continuous glucose monitoring system (CGMS) with or without conventional glucose monitoring every 4–6 weeks between 8–32 weeks of gestation in 46 type 1 and 25 type 2 women, showed an improvement in the mean HbA1c in late pregnancy (5.8% vs. 6.4%; p = 0.0007) with lower LGA rates (35% vs. 60%) compared with conventional monitoring . A subsequent Danish RCT of intermittent real-time CGMS (RT-CGMS) versus self-monitored plasma glucose seven times daily showed no improvement in glycaemic control, or pregnancy outcome in women with pre-gestational diabetes , although women were tightly controlled at conception (HbA1c 6.6% vs. 6.8% (49 vs. 51 mmol/mol)). A multicentre trial is currently underway to determine if RT-CGMS can improve HbA1c in women with type 1 diabetes who are pregnant or are planning pregnancy without excessive hypoglycaemia (CONCEPTT). Future trials in pregnancy are likely to focus on sensor-augmented pump therapy (CSII + RT − CGMS) compared with optimal conventional regimens given a meta-analysis reporting benefit outside pregnancy . However, the cost of this technology is likely to limit the use to highly selected, educated, motivated women in experienced centres.
The closed-loop artificial pancreas, by which glucose is sensed continuously and insulin delivered by a computer algorithm, continues to evolve, and it has been shown to be successful in a laboratory setting and preliminary clinical studies. Such methodology is undoubtedly attractive but perhaps most feasible nocturnally given the variable insulin resistance and glucose absorption during pregnancy.
Oral hypoglycaemic agents
Metformin is an insulin sensitiser, which inhibits gluconeogenesis and hepatic glucose output while increasing muscle glucose uptake. Increasing numbers of women have conceived while taking metformin for type 2 diabetes or polycystic ovary syndrome (PCOS). The drug crosses the placenta, but no teratogenicity in animals has been reported. Human data on metformin in the first trimester are confined to small and often retrospective studies . An RCT of 40 PCOS women suggested better outcomes with metformin, while a cohort study of 214 women with type 2 diabetes showed no evidence of adverse outcomes with metformin. A small RCT in PCOS women showed a ninefold reduction in GDM in those who continued metformin during pregnancy compared with those who stopped treatment. An RCT of 360 women with PCOS showed that treatment with metformin from conception to 12 weeks of gestation resulted in a higher pregnancy rate (53.6% vs. 40.4%; p = 0.06) and live birth rate (41.9% vs. 28.8%; p = 0.014) compared with placebo. A Canadian study (MITY) involving randomisation of women with type 2 diabetes to insulin with or without metformin is currently in progress. Follow-up data on longer-term neonatal outcomes are also required.
In the UK, metformin is recommended for use in the preconception period , but in the US, substitution of insulin is still recommended as the most effective and preferred agent to control hyperglycaemia .
Obstetric surveillance
Accurate dating of the pregnancy is imperative, and is best achieved by an ultrasound examination at 8–10 weeks. The goal of obstetric surveillance is to identify the foetus at risk, in order to intervene in a timely and appropriate fashion to reduce perinatal morbidity and mortality. Given the limitations of the available tests and lack of rigorous scientific trials, all protocols used for foetal surveillance are empiric and all have limitations.
Foetal monitoring in women with diabetes is as per routine antenatal care, and includes a 20-week anomaly scan and a foetal cardiac scan. The UK guideline recommends ultrasound monitoring of foetal growth and amniotic fluid volume every 4 weeks from 28 to 36 weeks, and individualised monitoring of foetal well-being for women at risk of intrauterine growth restriction (IUGR) and for those with macrovascular disease or nephropathy. Tests of foetal well-being before 38 weeks are not recommended unless there is a risk of IUGR.
Labour and delivery
The primary objectives are to avoid foetal death in utero and the hazards of obstructed labour or shoulder dystocia associated with foetal macrosomia. As a consequence, caesarean section rates for women with pre-gestational diabetes in most parts of the world are >50% (67% in the UK CEMACH survey vs. 24% in the background population) . Iatrogenic prematurity has resulted in high rates of admission to neonatal intensive care unit (NICU) in type 1 diabetes.
The indications for caesarean section are often multiple and vary with individual hospital policy. The rate tends to be lower in women with type 2, many of whom have had previous pregnancies at a time when glucose tolerance was normal. For the obstetrician, the major consideration influencing the mode of delivery remains the risk of birth injury. Current UK guidelines advise that women with diabetes should be offered elective delivery after 38 weeks assuming that no other significant factors have developed before this time. An individualised approach to the timing and mode of delivery is essential. This is particularly so in pre-gestational and insulin-requiring GDM where many factors need to be considered including glycaemic control, diabetes complications, past obstetric history, foetal growth (macrosomia or IUGR) and the availability of health-care resources in labour. Preterm labour can be particularly hazardous for the infant of the diabetic mother. Beta-sympathomimetic agents used to suppress uterine contractions, and corticosteroids used to accelerate foetal lung maturation, may result in significant and prolonged maternal hyperglycaemia, and even ketoacidosis, and the need for supplementary insulin must be anticipated. A number of algorithms to guide glycaemic management during steroid therapy have been developed . Admission to hospital and close supervision are essential.
The management of labour should follow standard practice as for the non-diabetic woman. Given the desire not to prolong pregnancy unduly, the induction of labour is widely utilised, and usually involves a combination of first prostaglandins followed frequently by oxytocin. Careful monitoring of progress is facilitated by a partograph and continuous electronic foetal monitoring by cardiotocography. Management of diabetes during labour should follow an established protocol in a dedicated centre with a neonatal care unit equipped and staffed to deliver the most sophisticated level of care. UK guidelines recommend the maintenance of maternal blood glucose between 4 and 7 mmol/l during labour and delivery to reduce the incidence of both neonatal hypoglycaemia and foetal distress . Hourly capillary glucose measurements provide a ready guide to the success of management and the need for insulin adjustment. Commonly used regimens (in the absence of a consensus) include an intravenous glucose/insulin infusion supplemented by additional insulin doses and a constant glucose infusion with insulin being infused separately by an infusion pump .
Postnatal
In women with type 1 diabetes, the insulin dose is reduced approximately to half that pre-pregnancy as soon as the cord is cut, followed by subsequent active-dose titration. Regular capillary glucose monitoring and intravenous fluids are continued until the mother is able to eat normally. Breastfeeding should be supported, and additional carbohydrate intake or further reduction in insulin dosing to reduce the risk of hypoglycaemia may be needed. Glucose targets are relaxed to those prior to pregnancy (4–7 mmol/l pre-meals).
In type 2 diabetes, insulin can usually be stopped at delivery with regular monitoring of capillary blood glucose. UK guidelines recommend that women on metformin or on glibenclamide before pregnancy may continue to take these drugs post partum while breastfeeding, but each case should be reviewed on an individual basis . Arrangements should be made for early midwifery community follow-up and postnatal diabetes review at 6 weeks.
Care of the newborn
All neonates should receive feeding as soon as possible to minimise the risk of hypoglycaemia. Monitoring of neonatal blood glucose pre-feeds should commence around 3–4 h of age and continue for at most a few days until levels are persistently above 2 mmol/l. A low blood glucose associated with abnormal clinical signs is a medical emergency requiring complete clinical evaluation and transfer to a neonatal unit. Tube feeds may suffice in milder cases, but for a reduced level of consciousness or fits, intravenous glucose should be instituted rapidly (5 mg/kg/min of glucose equivalent to 3 ml/kg per hour of 10% dextrose increased as necessary). Blood sampling for hyperbilirubinaemia, polycythaemia, hypocalcaemia and hypomagnesaemia is dictated by clinical examination. NICU admission should be considered for symptomatic hypoglycaemia, jaundice, respiratory distress, cardiac failure, preterm birth and where there is a need for intravenous fluids, tube feeding or exchange transfusion for polycythaemia. A neonatal echocardiogram is indicated in the presence of a heart murmur or if there are symptoms and/or signs of congenital heart disease.
Contraception
Patient preference and health status are the two main factors that determine the choice of contraception for diabetic women. Intrauterine contraceptive methods (IUDs) are particularly suited to women who do not wish to become pregnant within the next year. In women without vascular disease who wish to conceive sooner, combined (oestrogen and progesterone) hormonal contraception is considered safe. The lowest dose (oestrogen ≤35 μg) and potency formulation should be used as here the absolute increase in arterial thromboembolism is very low (1/12,000) and comparable to that among healthy users and non-users. Women with long-standing diabetes, hypertension, microvascular or cardiovascular complications, those who are <6 weeks post partum, and probably also those who smoke and who have a BMI >35 kg/m 2 should not use oestrogen-containing contraceptives; progesterone-only methods (injections, implants or tablets) may be used. Barrier and natural family planning methods are less ideal because of high failure rates. Following completion of childbearing, vasectomy and female sterilisation are available. When faced with an unintended pregnancy, women with diabetes must receive additional guidance reflecting their increased risk of major congenital anomalies. Clinicians must understand the range of contraceptive options available and promote effective methods.
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