Diabetic implications – The overall implications for diabetes should be also considered for gestational diabetes.

Insulin pump – If the patient is using a continuous insulin pump, preoperative interviews and timeouts should include a plan to handle insulin requirements during labor or cesarean delivery.

Insulin requirements – Insulin requirements change based on the stage of labor:
1st stage – Increase in insulin requirements
2nd stage – Decrease in insulin requirements (with epidural/spinal anesthesia)
3rd stage – Insulin requirements stabilize
4th stage – Decrease in insulin requirements

Watch for hypoglycemia in the neonate – neonates born to mothers with pregestational diabetes are very susceptible to hypoglycemia in the postpartum period.

Glycemic control – both maternal and perinatal outcomes are improved when glycemic control during pregnancy approaches levels observed in normal pregnancies (60 – 100 mg/dL).

Document neuropathies – Diabetes may worsen existing neuropathies during pregnancy

Beta agonists contraindicated – tocolytic agents are contraindicated in the patient with poorly controlled diabetes.

Changes in hormones during pregnancy naturally creates a degree of insulin resistance in the peripheral tissues of the parturient during the second and third trimesters. Basal insulin requirements double by term. Gestational diabetes occurs in patients that are unable to mount an adequate response to these basal requirements. If the patient had diabetes prior to conception, it is commonly referred to as pregestational diabetes

Diabetes is considered a teratogenic (metabolic imbalance)

Diabetes is one of the causes of intrauterine fetal demise, decreased uteroplacental perfusion, preterm labor and delivery, shoulder distocia, fetal structural malformations/defects, neonatal respiratory distress syndrome, neonatal hypoglycemia, neonatal hyperbilirubinemia.

Diabetes is thought to be one of the contributing factors to the development of cerebral palsy in the baby, inhibiting lung maturity of the neonate, uterine atony, gestational hypertension, polyhydraminos, and cesarean delivery.

Diabetes is one of the risk factors for development of preeclampsia, shoulder dystocia, and epidural abscess

Nonstress tests are indicated twice a week in the patient with pregestational diabetes. This starts at 32 weeks gestation.

Strict glycemic control prior to conception has been shown to potentially reduce congenital anomolies by 90% AND a three-fold decrease in spontaneous abortion in parturients with pregestational diabetes