Diabetes in pregnancy Timing and Mode of Delivery
Tan Lay Kok Consultant Department of Obstetrics & Gynaecology Singapore General Hospital Diabetic pregnancy & delivery
Best outcomes for mother & baby What are the concerns Stillbirth What are the concerns Stillbirth Macrosmia What are the concerns Stillbirth Macrosmia Shoulder Dystocia What are the concerns Stillbirth Macrosmia Timing of delivery
Shoulder Dystocia Timing of delivery Planned elective versus Expectant (spontaneous) Literature Review Overall quality is POOR Fetal concerns NICE guidelines 2015 NICE recommendations Discuss the timing and mode of birth withpregnant women with diabetes duringantenatal appointments, especially duringthe third trimester. [new 2015] NICE recommendations Advise pregnant women with type1 ortype2 diabetes and no other complicationsto have an elective birth by induction oflabour, or by elective caesarean section ifindicated, between 37+0weeksand38+6weeksof pregnancy. [new 2015] weeks NICE recommnedations Consider elective birth before weeksfor women with type1 or type2diabetes if there are metabolic or any othermaternal or fetal complications. [new 2015] weeks NICE recommendations Advise women with gestational diabetes togive birth no later than 40+6weeks, andoffer elective birth (by induction of labour,or by caesarean section if indicated) towomen who have not given birth by thistime. [new 2015] NO LATER THAN weeks NICE recommendations BEFORE
Consider elective birth before 40+6weeksfor women with gestational diabetes if thereare maternal or fetal complications. [new2015] BEFORE weeks NICE recommendations Diabetes should not in itself be considered acontraindication to attempting vaginal birthafter a previous caesarean section. [2008] NICE recommendations weeks NICE recommnedations Explain to pregnant women with diabeteswho have an ultrasounddiagnosedmacrosomic fetus about the risks andbenefits of vaginal birth, induction of labourand caesarean section. [2008] Informed consent & the standard of care
Patient autonomy & rights Move away from medicalpaternalism Patients are consumers makingchoices Bolam may be inapplicable Therapeutic exception may beinapplicable Risk counselling with what patientmeaningfully requires to makeinformed decision Shoulder dystocia and sequelaeare material risks the patientwould want to know Ensure patient aware of materialrisks in any recommendedtreatment, and providereasonable alternatives andtreatments Inapposite Material risks attach signficane to the risk NICE recommnedations Explain to pregnant women with diabeteswho have an ultrasounddiagnosedmacrosomic fetus about the risks andbenefits of vaginal birth, induction of labourand caesarean section. [2008] Conclusions Timing & Mode of delivery is an important part ofantepartum management Factors to consider: EDM versus GDM Pharmacology versus diet/lifestyle alone Degree of control Concomitant maternal complications & riskfactors Fetal growth, size Shared Decision Making Important part Devote time and energy Medicolegally relevant part of management Factos in timing Shared