There is an epidemic of diabetes in the United States. In the last ten years, the number of American diagnosed with diabetes has increased 40 percent. The number has risen from 4.9% to 6.9%. It is estimated that the number will increase buy another 16.5% by 2050. A woman born in 2000 has a 39% risk of developing diabetes. The epidemic of obesity is responsible for the current epidemic of diabetes in pregnancy. The incidence of diabetes complicating pregnancy has increased 40% between 1989 and 2004.
When a fetus in utero is exposed to maternal elevated blood glucose, it causes an increase in fat cells leading to insulin resistance & obesity in childhood. This leads to diabetes in adulthood. Fetal exposure to a diabetic mother often lead to childhood obesity and later adult diabetes*.
The increasing incidence of diabetes in pregnancy translates into more women who have diabetes during pregnancy being treated by generalist obstetricians.
The management errors during the prenatal period for diabetic women include the following:
1. The failure to have the patient maintain a daily log of her fasting and two hour postprandial blood glucose each day after each meal.
2. The failure of physician to review the daily blood glucose values each day.
3. The failure to have the patient see a nutritionist and keep a daily log of her food choices to be reviewed by the physician during the patient’s weekly office visit.
4. The failure to start the patient on insulin or an oral hypoglycemic agent when the fasting glucose rises to 105-110 mg%.
5. The failure to recognize that allowing another physician to manage the diabetes results in a disconnect wherein the obstetrician most often doesn’t know if the blood glucose levels are really adequately well controlled.
6. The failure to recognize the substantially increased risk of shoulder dystocia at the time of delivery as fetal weight increases:
|Birthweight Group||# of Births||Shoulder Dystocia # (%)|
|< 3,000 g||2,953|
|3,001 – 3,500 g||4,309||14 (0.3)|
|3,501 – 4,000 g||2,839||28 (1.0)|
|4,001 – 4,500 g||38 (5.4)|
|> 4,500g||17 (19.0)|
|All Weights||10,896||97 (0.9)|
Incidence of Shoulder Dystocia according to birthweight grouping in Singleton Neonates delivered vaginally in 1994 at Parkland Hospital
7. The position of the American College of Obstetricians and Gynecologists that Caesarean section to avoid shoulder dystocia should only be performed if the fetus weighs more than 5,000 grams (11 pounds) directly results in large babies being trapped by severe shoulder dystocias at the time of vaginal delivery**.
Adding to the risk of injury to the large fetus at delivery are the following:
a) Most generalist obstetricians have little to no experience in delivering a large fetus with a severe shoulder dystocia without neurologic injury resulting.
b) Most obstetricians waste time performing maneuvers that have no efficiency in freeing the trapped shoulder dystocia; only rotational maneuvers will decisively unlock the shoulder from behind the pubic bone in a severe shoulder dystocia.
c) Most obstetricians still believe that once suprapubic pressure and the McRoberts maneuvers are applied, that traction should be applied to the baby’s head and neck while the anterior shoulder is still trapped. Even gentle traction applied to the head and neck before the trapped shoulder is freed will result in neurologic damage to the stretched brachial plexus.
In summary, the inexorable demographic changes will result in more diabetic pregnancies, larger babies with increased shoulder diameters, an increased incidence of shoulder dystocia and neurologic injury at the time of birth. The reliance on failed conventional wisdom and old management styles by obstetricians and their educational resources will result in more babies with cardiac damage from elevated maternal blood glucose and brachial plexus injuries from shoulder dystocia.
* Williams Obstetrics, 23rd Ed, 2010 Cunningham, p. 1104-1105
** A.C.O.G., 2002
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