Book of Medical Disorders in Pregnancy - Tintash

e obese too and families eat together
and acquire similar attitudes to food. The
problem may simply be behavioral.
Advice after gestational diabetes: A
woman who has had GDM should be
given the following advice: You are at
risk of developing diabetes and so:
Achieve and maintain a satisfactory BMI
Take regular exercise Do not smoke Do
not have pregnancies in rapid
succession. Whereas combined oral contraceptives
and hormone replacement
therapy do not seem to increase the risk
of developing diabetes, further
pregnancy does a lower renal threshold
for glucose develops early in pregnancy
and some women have glucosuria with
levels of blood sugar below 100 mg%.
Diabetic as well as non diabetic patients
may show physiologic glucosuria, and
this must be considered in making the
diagnosis. It is generally accepted that
the renal threshold in pregnancy is
lowered partly due to the increased renal
plasma flow and increased glomerular
filtration rate. Partly due to decreased
reabsorption of glucose from the renal
tubules as a result of increased output of
adrenocorticotrophic and adrenocortical
hormones. There is no proof of the exact
incidence of the lowered renal threshold
in normal pregnancy, for it does not
always occur, even in the diabetic
patient. However, Fine claims that if
efficient methods are used, there is a
uniform finding of glucosuria in pregnancy.
An intravenous glucose
tolerance test may be a more reliable
index of islet cell function than the oral
test because of variations in gastrointestinal
absorption and motility during
pregnancy, but misleading results occur,
Welsh subjected a series of patients to
oral and intravenous tests and found that
approximately 3/4 of those showing
abnormal oral test had normal
26
intravenous test. The introduction of the
intravenous tolbutamide test and the
cortisone glucose tolerance test has been
added in addition to the venous
tolbutamide test because of its lack of
sensitivity. In any case these tests can
not be done in pregnancy.
Antenatal care - On the initial visit a
complete history is taken, a thorough
physical examination is performed, and
routine laboratory work scheduled. The
patient is then seen every two weeks
until the 26th week of gestation and
every week thereafter ideally, at each
subsequent visit, the patient is evaluated
both medically and obstetrically by an
obstetrician and an internist together.
The urine is examined at each visit for
glucose, acetone and albumin. Weight
and blood pressure are checked and the
patient examined for signs of edema and
polyhydramnios.
Hemoglobin determination is ca-rried
out monthly and the ocular fundus
examined frequently if the patient shows
evidence of fluctuating carbohydrate
tolerance, early toxemia or infection, she
is admi-tted to hospital for further
evaluation and strict diabetic control.
Fetal age assessment - The clinician
assesses fetal maturity with difficulty in
the diabetic mother. The menstrual cycle
is frequently irregular in diabetic
women, so the calculation may be
erroneous from the start. The fundal
height may be misleading due to the
large fetal size or the presence of
hydramnios. In mothers with
cardiovascular or renal disease the
infants may be smaller than average for
gestational age. A combina-tion of
gestational date estimation, fundal
height, and fetal size radiological
evidence of the presence of the distal