Coordinated metabolic and obstetric management of diabetic pregnancy.

Diabetes during pregnancy is associated with insulin resistance, an increase in insulin requirement, and a greater tendency to ketosis and ketoacidosis. Increased perinatal mortality is related to maternal hyperglycemia and can be decreased dramatically with strict control of plasma glucose during pregnancy and a smooth-working obstetrician-internist-neonatologist team. Bad prognostic signs include pyelonephritis, ketoacidosis, toxemia, and poor prenatal care. Timing of delivery is no longer arbitrary at 36 or 37 weeks, but is based upon signs of fetal lung maturation and estimates of fetal risk. Abnormalities in the infant, including congenital abnormalities, biochemical abnormalities, respiratory distress syndrome, and large body weight must be managed in a well-equipped newborn intensive care unit under the care of experienced neonatologists. Strict attention to these principles has resulted in viable infants in the last 36 pregnant diabetic patients delivered at Vanderbilt University Hospital. Therefore, close medical supervision, use of modern obstetric technics, and the availability of a well-equipped and staffed neonatal intensive care unit can result in a good outcome in this group of patients. Finally, the decision for pregnancy must be carefully considered by the diabetic patient, her husband, and her physician long before pregnancy occurs.