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ETHICS FOCUS
SA JOURNAL OF DIABETES & VASCULAR DISEASE
74
VOLUME 8 NUMBER 2 • JUNE 2011
Diabetes in pregnancy: ethical considerations
MJ TITUS
Introduction
G
estational diabetes mellitus (GDM) is a form of diabetes that
occurs in pregnancy and results in significant adverse effects
for mother and child, both in the short and long term.
1
It
is associated with an increased rate of foetal malformations as
well as risks for foetal macrosomia, birth trauma and neonatal
hypoglycaemia. Women with a previous history of unexplained
stillbirth have a high incidence of GDM.
In addition to these risks, there is evidence that children of
diabetic mothers have a predisposition to a number of diseases
later in life but there have been no intervention studies to show
that these can be prevented.
2
On the other hand, pregnancy may
worsen the progression and prognosis of the condition as GDM
includes women with pre-existing but previously unrecognised
diabetes.
3
It is therefore imperative that a woman who presents
with GDM is counselled extensively during pregnancy in order that
that she can make an informed choice in the management of her
pregnancy.
Management of a diabetic woman has two main objectives,
namely to maintain maternal well-being by tight metabolic control
and prevention of complications in the woman, and to prevent the
adverse effects of the disease on the foetus. When an ill foetus
needs to be delivered prematurely, one may need to consider the
allocation of scarce resources. This article will discuss the fiduciary
duties and ethical obligations of the healthcare practitioner with
emphasis on the management of a diabetic woman where there
is conflict between the well-being of the woman and that of the
foetus.
Prevention of GDM
The recurrence of GDM in subsequent pregnancies is low. While
the reason for this is not known, it may be related to variations
in placental hormone production or an alteration in the maternal
lifestyle before conception. Glueck
et al.
4
have demonstrated a
10-fold reduction in the development of GDM in women with
polycystic ovarian syndrome treated with metformin, compared to
no treatment.
Management of GDM has implications for the child both in the
immediate postpartum short term and in the long term. Failure
to prevent development of GDM may lead to macrosomia and
adverse outcomes of pregnancy, as discussed below, and this may
have ethical implications for the mother, the foetus and the child.
Recent studies on children of both type 1 and type 2 diabetic
mothers have shown that there is an increased risk of glucose
intolerance, childhood obesity and other metabolic disturbances in
adolescence.
5
Macrosomia
This is associated with an increased incidence of operative and
traumatic delivery andwith childhood and adult obesity. An informed
woman may request delivery by caesarean section (CS) to avoid a
difficult and traumatic delivery. While the healthcare practitioner
should respect the woman’s autonomy, he/she would also be
ethically bound to inform the woman about the risks of delivery by
CS, and weigh the potential harm to the woman against potential
benefits to the foetus. DM
per se
is not an indication for CS and
where there is no medical reason for CS, maternal request for CS is
not advisable.
6
A report by the National Institute of Clinical Excellence
(NICE) stated that the relative risk of maternal death was 4.9 (95%
CI: 3.0–8.0) for CS. This amounted to 0.82 maternal deaths/1 0000
CSs, as opposed to 0.17 maternal deaths/10 000 vaginal births.
7
There is no evidence that good glycaemic control reduced the CS
rate or the risk of shoulder dystocia.
8
Therefore it may be difficult
to decline to do a CS when a woman requests it for fear of labour
and a potentially difficult labour and birth trauma. Under these
circumstances, it would be advisable to offer counselling to help
her address her fears in a supportive manner because this helps
reduce her fears of labour pains and results in a shorter labour.
9
A policy of induction of labour at 38 weeks reduces the incidence
of large-for-gestational-age babies, neurological injuries from birth
trauma and probably unexplained late stillbirths.
10
Congenital abnormalities
The overall rate of congenital abnormalities is double the
background rate and there is a three-fold increase in the rates of
neural tube defects, skeletal abnormalities and congenital heart
defects. In women with poor glycaemic control, the risk is as high
as 25%.
11
The patient has a right to know what the implication of
a positive screening test is, and her right to decide outweighs what
the healthcare practitioner may advise.
Before undertaking any screening test, the patient should be
properly counselled by presenting her with all available relevant
information and what consequent action is available in case of an
abnormal test. Effective counselling should be done before and
after the test, providing sufficient information to enable rational
decision-making.
12
Screening for genetic diseases with possibly
invasive tests on the woman should be discussed early in pregnancy
so that the woman can exercise her options.
Where the diagnosis of a genetic abnormality is made, the
woman may want to terminate the pregnancy and the attending
physician should not impose his/her beliefs on the patient. While the
physician may be obliged to exercise beneficence-based obligations
to the foetus by opting for a chance at life, the woman may also
have an obligation not to bring a child into the world that may
not lead a normal life, and may therefore opt for a termination of
pregnancy. In so doing she will be exercising her autonomy, which
should be respected at all times.
Correspondence to: MJ Titus
Head of Clinical Department, Obstetrics and Gynaecology, Grey’s Hospital,
Pietermaritzburg, South Africa
e-mail: titusmj@telkomsa.net; Joseph.Titus@kznhealth.gov.za
S Afr J Diabetes Vasc Dis
2011;
8
: 74–75.
For ethics CPD points, go to www.diabetesjournal.co.za
