Type 1 Diabetes in Pregnancy; Influences on Mother and Fetus

Abstract

Type 1 diabetes complicates around 1 in 200 to 300 pregnancies in the United Kingdom. Historically maternal type 1 diabetes carried very high risks for mother and child. Introduction of insulin led to an immediate, marked decline in the previously very high rates of maternal mortality; in contrast an improvement in perinatal outcomes occurred more slowly but was nevertheless dramatic. This is strikingly demonstrated by the temporal decline in perinatal mortality in offspring of mothers with type 1 diabetes which was virtually universal before use of insulin in the 1920's, likely remained in excess of 20% even in the 1960's and fell to under 4% by the 1990's. The reasons for this more gradual improvement in perinatal outcomes cannot be defined with precision but will have been influenced by improved glycaemic management with use of intensive, multiple dose insulin treatment and home glucose monitoring; improvements in obstetric and neonatal management, and better management of complications of diabetes before and during pregnancy. In 1989 the St Vincent declaration proposed that pregnancy outcomes in women with type 1 diabetes should approximate those of the non-diabetic population. While the long term improvements in fetal outcomes have been dramatic, contemporary surveys confirm a persistent doubling or more of rates of congenital anomaly and a three to four fold increase in perinatal mortality in the UK and other European countries which will require further clinical innovation to overcome.

The fetal cerebro-placental ratio in diabetic pregnancies is influenced more by the umbilical artery rather than middle cerebral artery pulsatility index

“…[1] There is now clear and unequivocal evidence that adverse pregnancy outcomes are strongly linked to maternal hyperglycaemia, both in the peri-conception period and throughout gestation. [2,3] Although strict glycemic control does improve outcomes [4], there is still a higher rate of complications in women with DM and poorer perinatal outcomes, as well as exacerbation of existing maternal comorbidities, including hypertension, thyroid disease, pre-eclampsia and eclampsia. [2,5] Given the increased risk of late pregnancy complications particularly stillbirth, some international guidelines [6] now recommend planned delivery (either caesarean birth or induction of labour) no later than 39+0 weeks gestation for pregnant women with type 1 or type 2 DM with no other complications and no later than 41+0 weeks for women with GDM.…”

Impact of ineffective oesophageal motility and wrap type on dysphagia after laparoscopic fundoplication

“…Maternal diabetes during pregnancy is often associated with increased neonatal morbidity and mortality1. The incidence of congenital cardiac malformations in the offspring of diabetic mothers (3–6%) is considerably higher than in the normal population2–4.…”