Suboptimally Controlled Diabetes in Pregnancy: A Review to Guide Antepartum and Delivery Management

Abstract

Importance Diabetes mellitus is one of the most common complications in pregnancy with adverse maternal and neonatal risks proportional to the degree of suboptimal glycemic control, which is not well defined. Literature guiding providers in identifying and managing patients at highest risk of complications from diabetes is lacking. Objective This article reviews the definition, epidemiology, and pathophysiology of suboptimal control of diabetes in pregnancy, including “diabetic fetopathy”; explores proposed methods of risk stratification for patients with diabetes; outlines existing antepartum management and delivery timing guidelines; and guides direction for future research. Evidence Acquisition Original research articles, review articles, and professional society guidelines on diabetes management in pregnancy were reviewed. Results The reviewed available studies demonstrate worsening maternal and neonatal outcomes associated with suboptimal control; however, the definition of suboptimal based on parameters followed in pregnancy such as blood glucose, hemoglobin A1c, and fetal growth varied from study to study. Studies demonstrating specific associations of adverse outcomes with defined suboptimal control were reviewed and synthesized. Professional society recommendations were also reviewed to summarize current guidelines on antepartum management and delivery planning with respect to diabetes in pregnancy. Conclusions The literature heterogeneously characterizes suboptimal glucose control and complications related to this during pregnancy in individuals with diabetes. Further research into antepartum management and delivery timing for patients with varying levels of glycemic control and at highest risk for diabetic complications is still needed. Target Audience Obstetricians and gynecologists, family physicians Learning Objectives After completing this activity, the learner will be better able to determine levels of glycemic control associated with adverse outcomes; discuss antepartum management and monitoring of patients with diabetes; and summarize recommendations for delivery timing for pregnancies with suboptimal glycemic control.