Managing Labor and Delivery of the Diabetic Mother

Authors and Disclosures

Hen Y. Sela, MD,^† Department of Obstetrics and Gynecology, Hadassah Hebrew University Medical Center, PO Box 12000, Jerusalem 91120, Israel. Tel.: +972 267 764 24, Fax: +972 264 333 37, henys@hadassah.org.il

Itamar Raz, MD, Diabetes Unit, Hadassah Hebrew University Medical Center, PO Box 12000, Jerusalem 91120, Israel. ntv502@netvision.net.il

Uriel Elchalal, MD, Department of Obstetrics and Gynecology, Hadassah Hebrew University Medical Center, PO Box 12000, Jerusalem 91120, Israel. elchalal@cc.huji.ac.il

^†Author for correspondence

Key Issues

• The incidence rates of gestational diabetes mellitus (GDM) are increasing worldwide, which may reflect the increased prevalence of Type 2 DM and obesity.

• Many fetal complications, such as intrauterine fetal death, neonatal hypoglycemia, congenital anomalies, macrosomia and increased prenatal mortality, are related to pre-GDM.

• In women diagnosed with GDM, one of the most commonly reported problems is fetal macrosomia (incidence: 16-29%).

• Macrosomic fetuses are at increased risk of prolonged labor, operative vaginal delivery, asphyxia, Caesarean delivery and birth trauma, including shoulder dystocia and brachial plexus injury.

• Obstetricians use a variety of factors in clinical decision-making for delivery management. Estimated fetal weight by both ultrasound and clinical evaluation, maternal glucose control and gestational age are all measures of particular importance in such pregnancies.

• The two most widely available means of estimating fetal weight-clinical assessment and ultrasound-have been shown to have roughly equivalent accuracy, even in macrosomic fetuses. Generally, in the USA, a positive test for macrosomia is more accurate for ruling in macrosomia than a negative test result for ruling it out.

• Management options include expectant management, induction of labor and Caesarean delivery.

• In macrosomic fetuses, elective Caesarean delivery will dramatically decrease the occurrence of shoulder dystocia and brachial plexus injury, while elective prelabor Caesarean delivery poses relatively minor risks to mothers.

• The choice between a policy of early elective delivery (by either induction of labor or Caesarean section) and expectant management in diabetic women should take into consideration increased perinatal mortality and morbidity related to prolongation of pregnancy beyond the 40th week, as opposed to the dangers of prematurity and respiratory morbidity.

• The American Diabetes Association recommends delivery during the 38th week unless obstetric considerations dictate otherwise. The American College of Obstetricians and Gynecologists states that optimal timing of delivery in pre-GDM women relies on balancing the risk of intrauterine fetal death with the risks of preterm birth. In poorly controlled DM pregnant patients, early delivery may be indicated and amniocentesis for fetal lung maturity is advised.