Guidelines for the management of insulin-dependent diabetes mellitus in pregnancy

The infant of an insulin-dependent diabetic mother is at increased risk of perinatal death, neonatal problems and major congenital malformations. Many of these problems are preventable. All young women with diabetes should receive contraceptive advice and information about pregnancy. The objects of pre-pregnancy care are to assess suitability for pregnancy, to optimise control in early pregnancy and to improve pregnancy outcome through the provision of individualised education and information. Pre-pregnancy care can reduce the congenital malformation rate to approximately that of the nondiabetic. In each area there should be one designated diabetologist and one designated obstetrician who, together with their team, should see all pregnant women in a combined clinic in a hospital with an intensive care baby unit. All pregnant women with diabetes should have 24-hour access to the specialist team. Tight glycaemic control during pregnancy can reduce complications of pregnancy greatly, improving infant mortality and morbidity. Insulin requirements usually change during pregnancy. Education about hypoglycaemia and avoidance of ketoacidosis is essential. Women should have regular examination of the fundi and renal function. They should have ultrasound scanning to assess gestation, to look for abnormalities and to assess fetal growth. Fetal monitoring should be used, particularly for those at high risk. Women with good diabetic control and no complications of diabetes or pregnancy may be delivered at 39 to 40 weeks but those at high risk earlier. During labour or caesarean section blood glucose should be normalised using intravenous glucose and insulin supervised by a specialist team. An experienced paediatrician should be available. Breast feeding should be encouraged.