Book of Medical Disorders in Pregnancy - Tintash

femoral epiphyses can help in
assessment of fetal maturity.
In the multiparous patient, with the fetal
head dipping in the pelvis and the cervix
favorable, induction of labour with
oxytocin may be used. If the patient is
primiparous, cesarean section is usually
chosen. The best perinatal results, are
obtained when cesarean section is done
for gigantic size baby. Difficult and
prolonged labors only make diabetic
control difficult.
The availability of serial urinary estriol
measurement can provide the clinician
with an objective assessment of the
integrity of the fetoplacental unit. In the
non-pregnant female, the ratio of
estriol/estrone/estradiol is 3/3/1 respectively.
In pregnancy the ratio is 30/2/1,
illustrating very considerable increase in
the estriol fraction during pregnancy.
Estriol is produced in the placenta, but
production is dependent on an adequate
supply of precursors from the fetal
adrenal glands.
In normal pregnancy urinary secretion
levels of estriol exceed 12 mg/24 hours.
Values less than 10 mg/24 hours signify
impending fetal jeopardy, while values
below 4 mg/24 hours are compatible
with fetal death. These values are less
significant in the earlier weeks of
gestation, but absolutely true in the last
four week and relatively true in the last
eight to ten weeks. As there is individual
variation, plus a 25% range of error,
single laboratory determinations maybe
inconclusive. Significance should be
attached to the trend with repeat estriol
determinations and not to a single high
or low value.
Self monitoring:
Pre existing diabetes and GDM:
27
4 times/day: before breakfast and 2
hours post meal Pre-meal monitoring
may also be necessary in many patients
Nocturnal monitoring (»3 AM) may be
necessary on intermittent basis Fasting
urine ketones. In the diabetic patient,
daily estriol levels can give an index for
predicting impending intrauterine death.
Diabetes monitoring and visits:
The only diabetes medication currently
used during pregnancy is insulin.
Endocrinology visits every 1-4 weeks.
At each visit, review results of urine
analyses perform blood pressure, urine
protein and ketones by dipstick. Hb A1C
level every 4-8 weeks. Education by
counseling as needed. Ophthalmology
exam early in first trimester; follow up
depending on findings of this exam.
Measurement of Biparietal diameter by
ultrasonography can be very helpful, diameter
measuring 9.1 to 9.2 cm implies
that the fetus is greater than 36 weeks.
Amniotic fluid analysis for orange cells
percentages, creatinine and lecithin
sphingomyelin ratio can also provide an
index of fetal maturity and help
physician in close follow up of his
patient.
Greater than 20 per cent orange
cells implies fetal maturity, similarly
greater than 2 mgm per cent creatinine
implies maturation of fetal kidneys while
lecithin sphingomyelin ratio of greater
than 2:1 indicates fetal lung maturity.
None of these values should be singly
used to decide about the time for interruption
of pregnancy.
There is con-siderable variation
in absolute values of these substances in
diabetic mothers. It is the total progress
of pregnancy which the clinician must
consider in conjunction with these