Diabetes in pregnancy Timing and Mode of Delivery Tan Lay Kok Consultant Department of Obstetrics & Gynaecology Singapore General Hospital

Diabetic pregnancy & delivery Best outcomes for mother & baby

What are the concerns Stillbirth

What are the concerns Stillbirth Macrosmia

What are the concerns Stillbirth Macrosmia Shoulder Dystocia

What are the concerns Stillbirth Macrosmia Timing of delivery Shoulder Dystocia Timing of delivery Planned elective versus Expectant (spontaneous)

Literature Review Overall quality is POOR

Fetal concerns

NICE guidelines 2015

NICE recommendations Discuss the timing and mode of birth with pregnant women with diabetes during antenatal appointments, especially during the third trimester. [new 2015]

NICE recommendations Advise pregnant women with type 1 or type 2 diabetes and no other complications to have an elective birth by induction of labour, or by elective caesarean section if indicated, between 37+0 weeks and 38+6 weeks of pregnancy. [new 2015] 37 38 39 40 41 weeks

NICE recommnedations Consider elective birth before 37+0 weeks for women with type 1 or type 2 diabetes if there are metabolic or any other maternal or fetal complications. [new 2015] 37 38 39 40 41 weeks

NICE recommendations Advise women with gestational diabetes to give birth no later than 40+6 weeks, and offer elective birth (by induction of labour, or by caesarean section if indicated) to women who have not given birth by this time. [new 2015] NO LATER THAN 37 38 39 40 41 weeks

NICE recommendations BEFORE Consider elective birth before 40+6 weeks for women with gestational diabetes if there are maternal or fetal complications. [new 2015] BEFORE 37 38 39 40 41 weeks

NICE recommendations Diabetes should not in itself be considered a contraindication to attempting vaginal birth after a previous caesarean section. [2008]

NICE recommendations 37 38 39 40 41 weeks

NICE recommnedations Explain to pregnant women with diabetes who have an ultrasound‑diagnosed macrosomic fetus about the risks and benefits of vaginal birth, induction of labour and caesarean section. [2008]

Informed consent & the standard of care Patient autonomy & rights Move away from medical paternalism Patients are consumers making choices Bolam may be inapplicable Therapeutic exception may be inapplicable Risk counselling with what patient meaningfully requires to make informed decision Shoulder dystocia and sequelae are material risks the patient would want to know Ensure patient aware of material risks in any recommended treatment, and provide reasonable alternatives and treatments Inapposite Material risks – attach signficane to the risk

NICE recommnedations Explain to pregnant women with diabetes who have an ultrasound‑diagnosed macrosomic fetus about the risks and benefits of vaginal birth, induction of labour and caesarean section. [2008]

Conclusions Timing & Mode of delivery is an important part of antepartum management Factors to consider: EDM versus GDM Pharmacology versus diet/lifestyle alone Degree of control Concomitant maternal complications & risk factors Fetal growth, size Shared Decision Making Important part Devote time and energy Medicolegally relevant part of management Factos in timing Shared