This is the story of Mrs. Chandni (name changed), a 35 year old lady who had a spontaneous conception and a smooth journey in her pregnancy till 24 weeks gestation, when her test for glucose tolerance came positive during a routine screening test. Her risk factors were a family history of diabetes, late age at pregnancy and being overweight (high BMI). After further investigations and workup, she was advised to be on a diabetic diet and regular exercise with prenatal yoga. As gestation advanced, her sugar control could not be achieved with diet alone and had to be started on insulin till delivery. At full term, the fetal size was more than normal and mildly disproportionate to the size of bony pelvis of the mother. On clinical and ultrasound estimation of fetal weight, a decision was taken to give her a short trial of labour. The estimated fetal weight was nearly 4 Kg and keeping in mind the risk associated with vaginal birth, delivery was planned in a tertiary care centre with blood bank and ICU facilities along with neonatal ICU care. She went in spontaneous labour at 38 weeks gestation and delivered a healthy female weighing 3.8 Kg.

Carbohydrate intolerance is the most common metabolic complication of pregnancy. Gestational Diabetes Mellitus (GDM) affecting nearly 5 to 10% of the population poses numerous problems for both mother and fetus. The incidence of diabetes during pregnancy is increasing worldwide and India is expected to be the diabetic capital of the world by 2025. Seventy-five percent of women with gestational diabetes respond to diet therapy alone. When glycemia is not achieved by diet alone, insulin therapy is recommended. Complications during pregnancy present according to the classification of diabetes and its severity: there are variations in pregnancy outcomes. One of the most common complications of gestational diabetes is macrosomia (overweight babies), which is associated with shoulder dystocia and brachial plexus injury during vaginal normal delivery. So before finalising the mode of delivery all the investigations including fetal and maternal status should be taken into consideration.

Complications that may affect the baby: Babies born to women with diabetes have an increased chance of having breathing difficulties, low blood sugar (hypoglycemia) and jaundice (yellowish skin) at birth. The maternal variables: gestational age at the time of delivery, onset of labor, mode of delivery, pregnancy complications and blood loss during pregnancy are contributing factors to NICU (Neonatal Intensive Care Unit) admission of the newborn.

• Excessive birth weight. Extra glucose in the bloodstream crosses the placenta, which triggers baby’s pancreas to produce more insulin. This can cause the baby to grow too large (macrosomia). Very large babies — those that weigh 4 to 4.5 Kg or more — are more likely to become wedged in the birth canal, sustain birth injuries or require a C-section birth.
•  Early (preterm) birth and respiratory distress syndrome. A mother’s high blood sugar may increase her risk of early labor and delivering her baby before its due date, or her doctor may recommend early delivery because the baby is large.

Babies born early may experience respiratory distress syndrome — a condition that makes breathing difficult. Babies with this syndrome may need help breathing until their lungs mature and become stronger. Babies of mothers with GDM may experience respiratory distress syndrome even if they’re not born early.

• Low blood sugar (hypoglycemia). Sometimes babies of mothers with gestational diabetes develop low blood sugar (hypoglycemia) shortly after birth because their own insulin production is high. Severe episodes of hypoglycemia may provoke seizures in the baby. Early feedings and sometimes an intravenous glucose solution can return the baby’s blood sugar level to normal.
• Type 2 diabetes later in life. Babies of mothers who have gestational diabetes have a higher risk of developing obesity and type 2 diabetes later in life.

Untreated gestational diabetes can result in a baby’s death either before or shortly after birth.

COMPLICATIONS THAT MAY AFFECT MOTHER

Gestational diabetes (GDM) increases the chances of certain pregnancy complications. So close antepartum care and follow up is needed. Possible risks include higher chances of needing a C-section, miscarriage, preterm birth, high blood pressure and future diabetes.

• High blood pressure and preeclampsia. Gestational diabetes raises the risk of high blood pressure, as well as, preeclampsia, a serious complication of pregnancy that causes high blood pressure and other symptoms that can threaten the lives of both mother and baby.
• Future diabetes. If one has GDM, there are more chances to get it again during a future pregnancy. Chances of developing type 2 diabetes become higher as one gets older. However, making healthy lifestyle choices such as eating healthy foods and exercising can help reduce the risk of future type 2 diabetes.

Of those women with a history of GDM who reach their ideal body weight after delivery, fewer than 1 in 4 eventually develop type 2 diabetes.

Factors determining mode of delivery in a diabetic mother are estimated fetal weight (clinical and by ultrasound), duration of pregnancy and blood sugar control. The aim is to achieve the most desirable results for both the mother and her offspring.

Management options include expectant management, induction of labor and Caesarean delivery. There are many variations in practice, since patients and providers have different perceptions of the potential benefits and risks of management approaches. Most women who have GDM deliver healthy babies. However, gestational diabetes that’s not carefully managed can lead to uncontrolled blood sugar levels and cause problems for both mother and baby, including an increased likelihood of needing a C-section to deliver. Labor and delivery management of women with GDM can affect neonatal and maternal outcomes in millions of women.

Elective Caesarean delivery or planned Caesarean delivery is one of the suggested options for a suspected macrosomic (large) fetus. Although there is a greater chance of needing a C-section, many women with GDM have regular vaginal births.

Doctors know that there is a higher rate of maternal morbidity and mortality with caesarean as compared with vaginal delivery. Also, it has been observed that women delivering a macrosomic infant by prelabor caesarean section have a 3 times greater risk of postpartum infection and an 11 times greater risk of wound complications.

But sometimes there’s no other option than surgery. Reasons for a C-section vary from the development of pre-eclampsia (high blood pressure and excess protein in the urine after 20 weeks of pregnancy), to a previous C-section, failed induction, obstructed labor, excessive fetal growth and malpresentation.

The diabetes and pregnancy expert Dr. Lois Jovanovic says, that independent of type of diabetes, glucose control or complications, the women with diabetes have poorer myometrial contractions than the women with normal glucose tolerance. The authors’ conclusion that each pregnant diabetic women should thus be treated uniquely during labor and delivery proves that women with diabetes truly are special.

At the same time, if macrosomic babies (4 to 4.5Kg) are given a trial of vaginal delivery, they are likely to suffer from shoulder dystocia and brachial plexus injury.

Some questions that the pregnant mother or her family can ask when your Gynecologist is planning for a C-section –

• Why does my baby need a C-section?
• How accurate is estimation of birth weight? Could the baby be smaller than expected?
• What are the risks to the baby if C-section is not performed?
• What are the risks if a C-section is performed?

Normal Vaginal Delivery (Natural Birth)

Vaginal deliveries are the best mode of delivery for any mom: there’s a better recovery. A  C-section is a major surgery with increased blood loss and risk of surgical complications.

It has been recently observed by the researchers at Liverpool, UK that women with diabetes have poor uterine contraction ability i.e. even if they push for hours will never succeed. These women had a higher chance of induction, instrumental deliveries (forceps, vacuum) and C-sections.

Doctors tend to induce women with diabetes (pre-gestational or gestational) on medications (whether insulin or oral medication) around 39 weeks gestation. The reason for this is that women with diabetes are at a greater risk for stillbirth, and 39 weeks has been shown to be the time when the fetus is fully developed. The downside of induced labor is that it may double the odds of a C-section birth.

To conclude, the more you learn about your bodies, the better you can work with what you’ve got, and feel empowered about your birthing experience. Optimizing outcomes for women with gestational diabetes mellitus treatment (GDM) and their fetuses requires not only careful metabolic management, but also appropriately applied fetal surveillance techniques and thoughtful selection of the most advantageous timing and route of delivery.