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PREGNANCY AND
THE DIABETIC
PATIENT
PRECONCEPIONAL
COUNSELING
Dr Mona Fouda Neel
MBBS,MRCP(UK),FRCPE
Consultant Endocrinologist
Associate Professor of Medicine
College of Medicine
King Saud University
Introduction:
GESTATIONAL DIABETES MELLITUS
Gestational Diabetes Mellitus is carbohydrate intolerance
with onset or first recognition during pregnancy,
It has been recognized for decades but the potential
significance of the condition as well as criteria for screening
and diagnosis remain controversial.
It affects up to 14% of the pregnant population.
The main pathogenic factor is insulin resistance, which
occurs to some degree in all pregnancies, but those who are
unable to compensate develop GDM.
Women at greater risk of developing GDM are those
who are:
 Obese
 Older than 25 years
 Have a previous history of abnormal glucose
metabolism
 Have prior poor obstetric outcome
 Have first-degree relatives with diabetes
 Are members of ethnic groups with high
prevalence of DM
At the fourth International Workshop Conference on
Gestational Diabetes Mellitus sponsored by the ADA,
the glucose concentrations considered diagnostic of
GDM was lowered.
This was based on data suggesting that lower
degrees of glucose intolerance were associated with
increased risk of adverse perinatal outcome.
The recommendation to test all pregnant women
was changed and women who appear to be at a low
risk of GDM will no longer be screened with a
glucose load test
•Members of ethnic groups with a low
prevalence of GDM
•No known DM in first-degree relatives
•Those younger than 25 years
•Not obese before pregnancy
•No history of abnormal glucose metabolism
•No history of poor obstetric outcome
*
In an identified low-risk group the risk of GDM is
less than 2%.
Women within the high-risk group should undergo
glucose testing as soon as feasible.
Women of average risk or found negative on initial
screening should undergo the testing at 24-28 weeks of
gestation.
A FBS > 7 mmo1 or causal plasma glucose > 11.1 meets
the threshold for diagnosis of DM and if confirmed on a
subsequent day there is no need to do any glucose
challenge.
ON-STEP APPROACH
An OGTT is performed without prior screening. It is
cost effective in high-risk patients or populations.
TWO-STEP APPROACH
An initial screening test using 50gm glucose load and
during 1hr blood sugar level and of higher than a
certain threshold do OGTT.
A glucose threshold value > 7.8 mmo1/L identifies
approximately 80% of women with GMD and the
yield is further increased to 90% if the threshold is
lowered to 7.2.
Table 1: Criteria for the Diagnosis of Gestational Diabetes
Mellitus
__________________________________________________________________________________________________________________________________________
____
WHO
National
Diabetes Data
Group
American
Diabetes
Association
Impaired
Glucose
Diabetes
Tolerance
___________________________________________________________________________________________________________________________________________
___
Glucose load for oral
Glucose tolerance
Glucose level fating
100
100 + 75
75
105
95
95
Time, h 1
190
180
180
NA
NA
2
165
155
155
140
200
3
145
140
NA
NA
NA
NA
75
140
___________________________________________________________________________________________________________________________________________
__
Since many women do not recognize their pregnancies
until they are will into the first trimester, and since it
usually takes several weeks of effort to attain good
glycaemic control, preconception control must be
the goal for women with diabetes. In their
reproductive years, they must be educated and
impressed with the fact that they must plan their
pregnancies and make concerted effort to maximize
control before conception.
Diabetes mellitus should be monitored carefully in
pregnancy. If left untreated, whether it is pregnancy
associated (Gestational Diabetes Mellitus) or preexisting before pregnancy, increases the risk of
material and fetal/neonatal mortality and morbidity.
Before the era of insulin, maternal mortality was
a high as 30% and perinatal mortality varied
from 66-90%
Till the mid 1970s physicians were still advising
diabetic women to avoid pregnancies.
Maternal Complications In Diabetic Pregnancy
 Hyperglycaemic ketoacidosis
 Pregnancy induced hypertension
 Pyelonephritis and other infections
 Polyhydramnios
 Preterm labour
 Worsening of chronic complications, e.g., Retinopathy Nephropathy,
Neuropathy, Cardiac Diseases.
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Potential Perinatal Morbidity/Mortality in Infants of Diabetic Mothers
______________________________________________________________________________________________________________________________________
- Asphyxia
Increased blood volume
- Birth injury
Intra uterine growth retardation
- Cardiac hypertrophy
Macrosomia
- Congenital anomalies
- Erythema and hyperviscosity
Neurological instability and
irritability
Organomegally
- Heart failure
Respiratory distress syndrom
- Hyperbilirubinaemia
Small left colon
- Hhypocalcaemia
Still birth
- Hypoglycaemia
Transient haematuria
- Hypomagnesaemia
______________________________________________________________________________________________________________________________
________
In spite of all the advances achieved so far in the care of
the pregnant diabetic woman, many problems remain.
High incidence of congenital anomalies and
spontaneous abortion in infants of
diabetic mothers (IDMs).
The true incidence of SAB in diabetic pregnancies is
not known, but has been reported to be as high as
30%, double that of the general population.
The increased risk of congenital anomalies in IDMs
ranges from 6-12%, a two-five-fold increase over the
general population and accounts for around 40% of
perinatal loss in IDMs
Table III:
Congenital Malformations in Infants of Diabetic Mother (IDMs)
•
252
•
•
•
•
Anomaly
* Ratio
Caudal regression
Spina bifida, hydrocephalus and others CNS defects
2
Anencephalus
3
Heart anomalies
4
Anal/Rectal Atresia
Renal anomalies
- Agenesis
- Cystic Kidney
- Ureter Duplex
Situs inversion
48
Ratio of incidence is in comparison to the general population.
The etiology of this increased incidence of
congenital anomalies in IDMs is not yet clearly
defined. Some have shown that hyperglycaemia
and other metabolic abnormalities are teratogenic
singly or in combination.
3
5
6
4
23
It is very important to understand that
fetal organogenesis is largely completed by
eight weeks after the last menstrual period (six
weeks past conception) and therefore, poorly
controlled diabetes during the early weeks of
pregnancy, in many cases before the woman
even know that she is pregnant, significantly
increases the rise of a first trimester SAB or
delivering an infant with a major anomaly.
The association between HbA1c, which expresses
roughly the control of blood glucose over the preceding
4-6 weeks before its measurement, and increased risk
of congenital anomalies of SABs has made it a useful
tool in assessing the metabolic control in early
pregnancy during the critical period of organogenesis
(< 13 weeks) and therefore predicting such
complications early on. Therefore, normalizing blood
glucose levels before and during the early weeks of
pregnancy can reduce dramatically the risk of major
anomalies as well and the occurrence of SABs to almost
near that of the non-diabetic population.
Care of the difficult patient who often
presents late for antenatal care and/or
is non compliant.
Care of the woman with severe diabetic
complications.
Therefore, pre-pregnancy counseling has emerged
as a vital component in the woman with diabetes.
The major component of a pre-pregnancy
counseling include:
- Contraceptive advice.
- Risks of pregnancy, maternal and fetal/neonatal.
- Importance of maintaining normal blood glucose levels.
- Genetics counseling.
- Personal commitment by the woman.
Goals of Pregnancy Planning Program
-
Assessment of patient’s fitness for pregnancy
Obstetric evaluation
Intensive education of patient and partner
Attainment of optimum Diabetic control
Timing and planning of pregnancy
A planned pregnancy is a major objective of a
preconception counseling
Blood glucose should be normalized as possible
before and throughout pregnancy to reduce the
risk of developing complications.
The woman should understand fully the increased
risk of complications both for her and for her
diabetes is not properly controlled before and
during the early weeks of pregnancy, but should
also be reassured that with continual optimal
glucose control throughout pregnancy, she can
effectively reduce the reduce the risk of
complications.
She will also need to know that diabetic chronic
complications can worsen during pregnancy, e.g.
retinopathy and nephropathy, and preconception
evaluations of such complication must be
emphasized.
Deep, personal commitment can never be
overemphasized. The woman has to understand that she will be
seen frequently by her physician and may need to be hospitalized if
problems arise. Personal involvement in maintaining normal blood
glucose throughout pregnancy is mandatory and the pregnant woman
has to understand the importance of such deep personal commitment on
the outcome of her pregnancy.
________________________________________________________________________________________
Pregnancy Assessment for Diabetic Women
________________________________________________________________________________________
-
-
-
Gynaecological evaluation
Laboratory evaluation
•
HbA1c level
•
Urinalysis and culture
•
24-h Urine for creatinine clearance and total protein
Thyroid panel (Type I Diabetic Women)
Special studies
ECG or treadmill
Neuropathy testing if indicated
POTENTIAL CONTRAINDICATIONS TO PREGNANCY
1. Ischaemic heart diseases
2. Active proliferative retinopathy, untreated
3. Renal insufficiency: Cr. C1 < 50 m1/min or serum
creatinine > 2mg/d1 or heavy protein > 2g/24hr or
hypertension (BP > 140/90 despite treatment)
4. Severe gastroneuropathy: nausea, vomiting, and diarrhea
PRE-PREGNACY MANAGEMENT
Once the woman has undergone the pre-pregnancy counseling
and found fit to get pregnant, then a plan should
be outlined for pre-pregnancy management, with the goal of
normalizing the blood glucose level before
conception and maintaining of euglycaemia throughout the
pregnancy
Ideally, the Diabetes care team should include:
- The primary care physician or an endocrinologist
- The obstetrician
- A nurse educator (preferably a certified Diabetes
educator)
- A registered dietitian
- A paediatrician or neonatologist
Then she can be placed on an intensive human insulin
regimen with adequate coverage of premeal insulin as
well as basal insulin need. She could be taught selfmonitoring of blood glucose and she should do it
frequently before and after meals.
Preconception goals for premeal glucose levels should be 7090 mg/d1 (3.8-5 mmo1/L) and the 1-2 hours postmeal
blood glucose levels should fall at or below 130mg/d1
(7.2 mmol/L).
Adjustment in insulin doses according to blood glucose
levels can then be done by the patient\s team, or of she is
quite motivated and apt, she can do it herself at home. She
should also be warned about the symptoms and signs of
hypoglycaemia and taught how to mange it. Her partner or
a relative should also be instructed in the use of glucagons.
Serial HbAlc can be drawn monthly to confirm
normalization of blood glucose level in the preconceptional
period to affirm the safety of pursuing pregnancy form the
metabolic standpoint.
When maternal glucose levels are used, insulin therapy
is recommended when MNT fails to maintain selfmonitored glucose at the following levels:
Fasting whole blood glucose
 95mg/d1 (5.3 mmo1)
Fasting plasma glucose
 105mg/d1 (5.8 mmo1/L/1)
or
1-h postprandial whole blood glucose
 140mg/d1 (7.8 mmo1/L1)
1-h postprandial plasma level
 155mg/d1 (7.2 mmo1/1)
2-h postprandial whole blood glucose
 120mg/d1 (6.7 nni1/1)
2-h postprandial plasma level
 130mg/d1 (7.2 mmo1/1
The most important tool in reducing perinatal morbidity
and mortality owing to major malformation attributed to
uncontrolled diabetes mellitus remains prevention.
Glycaemic control in the first trimester is not only relevant
it is critical.
PREGNANCY AND THE DIABETIC PATIENT
MONITORING AND CLINIC VISITS
The cornerstone of management of Diabetes in pregnancy is
a team approach with frequent visits to the clinic by the
pregnant woman as well as the daily home blood glucose
monitoring.
SMBG reduces hospital admissions and hospital stay in days if
required and it has been the single most important advance in
the management of diabetes in pregnancy in the last decade
because of its ability to provide intensive management of
diabetes without the need for frequent admissions.
Achieving euglycaemia in pregnancy can promise an
outcome that shows no deleterious effect of diabetes.
Pre-existing diabetes has its own complications, which
should be carefully monitored during pregnancy.
“Controlled Diabetes is essential to fetal welfare”.
This statement made by Dr. Priscilla White in
1928 is as pertinent now as it was then.
*The major diabetogenic hormones of placenta are human
placental lactogen hPL, estrogen and progesterone. Also
serum cortisol is increased during pregnancy and prolactin
being elevated during gestation has a diabetogenic effect as
well.
*Degradation of insulin is increased during
pregnancy because of certain placental enzymes
comparable to liver insulinases, and the function of
the placental membrane, which has an insulin
degrading activity.
The normal pancreas compensate by increasing
insulin secretion. If the pancreas doesn’t respond
adequately to these changes or of the clearance of
glucose is defective then gestational diabetes occurs.
Deleterious effect of sustained or intermittent
hyperglycaemia on the fetus:
1. During orgaqnogenesis (weeks 2-8), an increased risk
of malformation
2. Premature stimulation of fetal insulin secretion leads
to;
macrosomia
inhibition of pulmonary surfactant maturation
leading to fetal respiratory distress
neonatal hypoglycaemia leading to permanent
neurological damage
Achieving optimal control of diabetes requires balancing
the meal, insulin dosage, an activity level with strong
commitment form all those involved in the care of the
diabetic pregnant woman, with the pregnant woman
herself being the most important member of the team.
Working with the pregnant population is a rewarding
experience as they are strongly motivated in the care of
their disease. The best chance for success comes when
the pregnancy is planned, as good metabolic control is
desired before conception.
Risk factors for developing GDM e.g. family
history, obesity, and poor obstetric history
identify only 50% of women at risk.
GOALS IN THE DIABETIC PREGNANCY
The target range for blood glucose during pregnancy is
patterned after maternal plasma glucose levels in normal
pregnancies.
Mean plasma glucose level is about 20% lower in
pregnancy then pre-pregnancy level and the HbA1c
follows suit.
Blood Glucose Goals
In Diabetic Pregnancy
-
-
Fasting
Pre-meal
1 hr post prandial
2 hr post prandial
02.00 – 06.00 AM
60 – 90mg/dl (3.3 – 5.0 mmol)
60 – 105mg/dl (3.3 – 5.8 mmol)
110 – 130mg/dl (6.1 – 7.3 mmol)
90 – 120mg/dl (5.0 –6.7 mmol)
60 – 120mG/dl (3.3 – 6.7 mmol)
To achieve this, frequent SMBG readings are necessary.
Ideally, eight tests should be done; one before each meal
and one 1-2 hours after each meal; one at bedtime and
one in the middle of the night.
*Pre-meal tests assess presence of asymptomatic
hypoglycaemic and establish the pre-meal short-acting
insulin doses.
*Post-meal tests are used to evaluate the effect of the
particular meal and insulin doses on the blood glucose.
*Bedtime testing is necessary to rule out any hypo or
hyperglycaemia, which requires attention before
retiring to bed and also determines the quantity and
quality of the bedtime snack.
*03:00 testing is important in detecting hypoglycaemia
if nocturnal hypoglycaemia is suspected.
These tests provide feedback about the match between
food and insulin and the effect of dietary changes.
Although eight tests per day is ideal, this can be
impractical for many patients and some centers
recommend four tests each day –fasting 1-2 hours after
each meal.
Patients on more than two injections per day or
receiving continuous subcutaneous insulin injection
therapy will need to perform at least seven tests a daybefore each meal, after each meal, and at bedtime.
Results should be recorded in an organized manner so
that the glycaemic pattern is recognized and steps made
appropriately, according to blood glucose levels.
SMBG is one of the most important tools for maintaining
euglycaemia during pregnancy. It provides day-to-day
information on which treatment recommendations can be
based, but it has the inherent potential for gross inaccuracies
and therefore education and periodic reevaluation and
reeducation are vitally important for its success.
HOME MONITORING
Blood glucose should be maintained in the normal range
throughout the day, throughout pregnancy. This can
only be achieved by self-monitoring of blood glucose be
the patient at home. It should be taught at the initial
visit to the clinic to allow for immediate monitoring on a
daily basis.
There are two methods currently available for SWMBG:
i. visual comparison of reacted reagent strips
ii.The use of reflectance or enzyme electrode blood
glucose meters.
Both methods depend on a glucose oxidase reaction
The members of the health care team looking after the
pregnant diabetic mother should verify that the patient
is monitoring her blood glucose accurately by frequent
check-ups in the clinics.
PROBLEMS WITH SMBG
i.Objectivity
Errors in judgment, especially when patients are highly
motivated to keep their blood glucose readings in the normal
range, is not uncommon, especially with the visually read strips.
The meters are less likely to invite errors in judgment.
ii.Accuracy
Improper technique can lead to variability in results and
this can be minimized if patients are adequately trained
and carefully monitored. Some systems are more
dependent upon user skills than others.
Others factors affecting accuracy include defective strips,
instrument malfunction, severe hypo or hyperglycaemia,
and haematocrite value. With current systems, SMBG
measurements should be within 15% of the results of a
reference measurement using the same blood sample.
HbA1c MEASUREMENT IN PREGNANCY
I.Pre-existing Diabetes
It is useful in evaluation of the degree of diabetic control over
the period of 4-6 weeks before its measured and it is
therefore very useful in the critical early weeks of pregnancy.
Its level has been directly correlated with the increased
incidence of congenital malformation in infants of diabetic
mothers. The risks of congenital anomalies when the HbA1c
is higher than the man value of the non-diabetic women in
the first 8 weeks of gestation reached 28%. Therefore, it is
important to measure the HbA1c level when the diabetic
woman first presents with plans for pregnancy. This should
be advised to be as early as possible and continue with serial
measurements every 4-6 weeks until the pre-pregnancy goal
of near normal HbA1c value is achieved.
Once pregnant, the HbA1c should be checked every 4-6 weeks
to assess the degree of glycaemic control throughout the
pregnancy and should be maintained within or near the nondiabetic range.
II.Gestational Diabetes Mellitus
An initial HbAlc measurement is helpful
i. If it is in the non-diabetic range, which is usually the case. It
reassures the woman the GDM was diagnosed at the
appropriate time and was probably not present earlier in
gestation.
ii. If is elevated: then it warns that glucose intolerance or even
overt DM may have been present earlier in the pregnancy or
even predated the pregnancy.
iii. It serves as a baseline value in pregnancy
It should be measured every 4-6 weeks to monitor the control
and help in adjustment of the insulin doses.
URINARY KETONE TESTING
Ketonaemia during pregnancy has been associated with
changes in the developing nervous system of the fetus and
with decreased intelligence. It may also signal development
of maternal ketoacidosis, which is associated with 50-90%
mortality rate in the fetus.
Starvation ketosis commonly occurs after an overnight fast;
so it is best to test for urinary ketones in a first monitoring
urine sample.
If ketonuria occurs despite good glucose control and is
repeatedly seen at a particular tome of the day, then
the patient may need the addition of a snack before
that particular time. Urinary ketones need also to be
checked if a meal is delayed or missed, with any
illness, and with any blood glucose > 200mg/dl.
Persistent ketonuria not responding to dietary change
will require adjustment in the insulin doses.
In pregnant women with pre-existing diabetes,
certain tests may be required in addition:
- Thyroid function test (type IDDM).
- A clear catch dipstick urine analysis should be evaluated
for protein, ketones and WBC each visits to R/O occult
UTI or incipient toxamia.
- A finger stick blood glucose measurement should be done
each visit to verify self-testing results.
- Serial HbAlc levels every 4-6 weeks to assess overall
glycaemic control
Surveillance of diabetes related complications are
also vital:
- A 24-hour urinary sample for creatinine clearance and
protein should be collected each trimester with referral to
a nephrologist if nephropathy is present.
- A baseline retinal examination done by an opthalogist
with the necessary follow up examinations.
- Careful attention to cardiac status with referral to a
cardiologist
_______________________________________________________________________________
Frequency of Testing Maternal Status During Pregnancy for
Women with Pr-existing Diabetes
_______________________________________________________________________________
Test
HbAlc
Glucose
visits in the clinic
Fastin ketones
Urinalysis
clinic visits
Kidney function
Thyroid function
Eye status
as necessary
Frequency
Every 4-6 weeks
During weekly or bi-weekly
SMBG 4-8 times daily
Daily
During weekly or bi-weekly
Each trimester
Baseline & repeated as needed
First trimester and repeated
________________________________________________________________________________
FOLLOW UP VISITS
The pregnant woman with diabetes should be seen
every 1-2 week with fasting and/or random blood
glucose collected at each visit to document control and
assess how this value compares with SMBG at home.
MSU analysis and HbAlc should be followed up as
stated in the above table.
_________________________________________________________________________
Pregnancy Diet Calculation
_______________________________________________________________________________________________________________
_
Determination of desirable body weight:
100 lbs for first 5 ft of height + 5 lb/inch for each l inch over 5 ft ±
10% for large/small frame.
Determination of daily calorie requirement:
30 kcal/kg (2.2 lb) current body weight for active woman
25 kcal/kg (2.2 lb) current body weight for sedentary, obese women
to lose l lb/week, subtract 500 kcal from daily requirement or
increase exercise.
Distribution of calories:
55-60% of carbohydrate (preferably unrefined carbohydrate with
fiber)
12-20% protein
< 30% fat (composed of up to 10% polyunsaturated fats, < 10%
saturated fats,
and remainder from monounsaturated fats).
_______________________________________________________________________________________________________________
___
Table IX:
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Sample Pregnancy Daily Insulin Therapy
_________________________________________________________________________________________________________________________________
Goals for therapy
Fasting, premeal blood glucose < 150mg/dl (< 8.3-5.5 mM)
1-2 h postmeal blood glucose < 150mg/dl (8.3 mM)
HbAlc should be < 6.1%
Human insulin regiments
Combination of short-acting insulin with intermediate-acting or
Long-acting insulin in 1 2 to 4-injection routine
0.5-1.0 Ukg –1 day –1 (0.2-0.4 Ulb–1 day) -⅔ total dose in A.N,
⅓ total dose in P.M
Examples
Short-and intermediate-acting insulin prebreakfast and predinner*
Short-acting insulin before each meal + intermediate or long-acting
insulin at bedtime
Short-intermediate-action insulin before lunch
___________________________________________________________________________________________________________________________________
*
Most intensive insulin regimes will consist of > 2 injections/day to
maintatin euglycemia
__________________________________________________________________________________________________________________________________
Table IX:
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Sample Algorithms for Pregnancy
Insulin Adjustment
___________________________________________________________________________________________________________________________________
Adjustments for unexplained hyperglycemia: check for deviations in diet and/or
illness, then:
1-2U.
If prebreakfast blood glucose BG > 100mg/dl (5.5 mM) for 2-3 day,
increase P.M intermediate-acting insulin by 2U or long-acting insulin by
If prelunch BG > 100mg/dl (5.5 mM) for 2-3 day,
increase prebreakfast short-acting insulin by 2U or prelunch short-
acting
insulin by 1-2U.
If predinner BG > 100mg/dl (5.5 mM) for 2-3 days,
shout- increase prebreakfast intermediate-acting insulin by 2U or prelunch
acting insulin by 1-2U
If bedtime BG > 120mg/dl (6.6 mM) for 2-3 days,
increase predinner shot-acting insulin by 1-2U.
_______________________________________________________________________________________________________________________________________
__
Adjustments for unexplained hyperglycemia: review meal plan,
then:
If breakfast BG > 70mg/dl (3.8mM) twice during a week of is
symptoms of low BG overnight.
decrease evening intermediate-acting insulin by 2U or long actinginsulin by 1-2U.
If predinner BG > 70mg/dl (3.8mM) or reaction occurs between
breakfast and lunch,
decrease prebreakfast shot-acting insulin by 1-2U
If predinner BG > 70mg/dl (3.8mM) or reaction occurs between lunch
and dinner,
decrease prebreakfast intermediate-acting insulin by 2U or prelunch
short-acting insulin by 1-2U.
If prebedtime BP< 70mg/dl (3.8mM) or reaction occurs between
dinner and bedtime,
Decrease predinner short-acting insulin by 1-2U.
___________________________________________________________________________
Labour and Delivery:
Patients with documented good blood glucose control
do not need early delivery but if a fetus with
documented poor pulmonary maturity as assessed by
aminiocentesis and poor results on fetal surveillance
protocols (heart rate, kicks count etc….) then
immediate delivery is advised.
Maternal insulin requirements usually drop quickly
postpartum and gestational diabetic mother will require
no further insulin. Pre-gestational diabetic mother will
require resumption of insulin treatment but the
requirement will be less for 48-96 hours post
operatively.
Almost 98% of gestational diabetic women revert
to normoglycaemia postpartum.
An OGTT test should be performed 6 weeks
postpartum.
Diabetes Mellitus will recur in each subsequent
pregnancy in 90% of cases.
If they remain overweight 60% will have overt DM
within 20 years.
REFERENCES:
 Medical Management of Pregnancy complicated by
diabetes.
 Education
American
Diabetes
Association
Clinical

Series, June
1993.
 Diabetes Complicating Pregnancy. The Joslin Clinic
Method,

editor John W.

Hare, MD. Allan T. Liss, Inc. New York, 1989.
 Endocrinology and Metabolism Clinics of North
America Diabetes
Therapy, June 1992.
Mellitus,
Perspectives
on
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