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Pregnancy is associated with increased tissue resistance to insulin, resulting in increased levels of blood insulin as well as glucose and triglycerides These changes are due to placental lactogen and elevated circulating estrogens and progesterone Although pregnancy does not appear to alter the long-term consequences of diabetes, retinopathy and nephropathy may first appear or become worse during pregnancy Debate continues over whether gestational diabetics are women whose glucose intolerance is solely a function of their pregnancy compared with their nonpregnant state Alternatively, pregnancy may merely serve to unmask an underlying propensity for glucose intolerance, which will be evident even in the nonpregnant state at some time in the future if not in the immediate postpartum period However, goals for glycemic control during pregnancy are the same whether the diagnosis is made before or during the pregnancy Prepregnancy counseling and evaluation of diabetic women should include a complete chemistry panel, HbA1c determination, 24-hour urine collection for total protein and creatinine clearance, funduscopic examination, and an ECG Any medical problems should be addressed, and HbA1c levels of 6% should be achieved before pregnancy Euglycemia should be established before conception and maintained during pregnancy with daily home glucose monitoring by the patient A well-planned dietary program is a key component, with an intake of 1800 2200 kcal/d divided into three meals and three snacks Insulin is given subcutaneously in a split-dose regimen with frequent dosage adjustments Patients taking some oral agents prior to pregnancy should be switched to insulin However, limited information suggests that agents such as glyburide may be safe and effective in pregnancy The use of continuous insulin pump therapy has been found to be very useful during pregnancy in women with type 1 diabetes mellitus Congenital anomalies result from hyperglycemia during the first 4 8 weeks of pregnancy They occur in 4 10% of diabetic pregnancies (two to three times the rate in nondiabetic pregnancies) Euglycemia in the early weeks of pregnancy, when organogenesis is occurring, reduces the rate of anomalies to near-normal levels Even so, because few women with diabetes begin a rigorous program to achieve euglycemia until well after they have become pregnant, congenital anomalies are the principal cause of perinatal fetal deaths in diabetic pregnancies All women with diabetes should receive counseling about pregnancy and, when the decision has been made to start a family, should receive prepregnancy management by providers experienced in diabetic pregnancies Fasting and preprandial glucose values are lower during pregnancy in both diabetic and nondiabetic women Euglycemia is considered to be 60 80 mg/dL while fasting and 30 45 minutes before meals and < 120 mg/dL 2 hours after meals This is the target for good diabetic control during pregnancy Glycated hemoglobin levels help determine the quality of glucose control both before and during pregnancy While perinatal problems for mother and baby are decreased by fastidious diabetic control, the incidence of
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4 AIDS during Pregnancy
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Heterosexual acquisition (45%) and injection drug use (17%) are the principal identified modes of HIV infection in women Asymptomatic infection is associated with a normal pregnancy rate and no increased risk of adverse pregnancy outcomes There is no evidence that pregnancy causes AIDS progression Although some fetuses appear to acquire HIV infection antenatally by transplacental transmission, approximately two-thirds are infected close to or during the time of delivery Zidovudine (500 mg/d orally) given to the mother antenatally starting at 14 weeks of gestation and during labor (1 mg/kg/h intravenously) and then to the infant (2 mg/kg orally four times daily) for the first 6 weeks of life reduces the transmission rate from 25% to 8% HIVpositive pregnant women should be assessed by CD4 count, plasma RNA levels, and prior or current antiretroviral use In general, pregnant HIV-positive women should receive at least zidovudine but also highly active antiretroviral therapy (HAART) appropriate for their HIV disease status after counseling regarding the potential impact of therapy on the fetus and infant after delivery Although information is limited, zidovudine has been associated with mild anemia in infants at birth but only efavirenz has been clearly linked with anomalies (myelomeningocele) The use of prophylactic elective cesarean section before the onset of labor or rupture of the membranes to prevent vertical transmission of HIV infection from mother to fetus has been shown to reduce the transmission rate to 2% in infants of mothers taking zidovudine There is limited information on the impact of elective cesarean section on transmission rates in infants of mothers on HAART or with viral loads less than 1000 copies/mL However, with HAART therapy and undetectable viral loads (< 50 copies/ mL), there may be no additional benefit of cesarean delivery HIV-infected women should be advised not to breastfeed their infants
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Centers for Disease Control and Prevention (CDC) Achievements in public health Reduction in perinatal transmission of HIV infection United States, 1985-2005 MMWR Morb Mortal Wkly Rep 2006 Jun 2;55(21):592 7 [PMID: 16741495] Public Health Service Task Force Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1 Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV1 Transmission in the United States, October, 2006 http:// wwwhivatisorg
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