![]()
SA JOURNAL OF DIABETES & VASCULAR DISEASE
ETHICS FOCUS
VOLUME 8 NUMBER 2 • JUNE 2011
75
Sudden intrauterine death
Foetuses of diabetic mothers are prone to sudden, unexplained
intrauterine death (IUD) and this is related to the degree of
glycaemic control. The incidence of IUD is highest after 36 weeks’
gestation and is more commonly found in macrosomic babies.
13
It may be tempting to deliver these babies prematurely in order
to avoid this eventuality. While this may be beneficial to both
the mother and the foetus because glycaemic control may be
enhanced in the mother and the foetus may be removed from an
unfavourable environment, the principle of beneficence to both
the mother and the foetus may be negated by the harm that early
delivery may bring to the newborn baby. The baby may need to
have assisted ventilation in a neonatal intensive care unit, which
is not the best place for a premature baby because of potential
nosocomial infection. In addition, beds in neonatal intensive care
units are a scarce resource, which should be allocated to the most
needy.
14
Diabetic ketoacidosis
Diabetes accounts for approximately 3 to 5% of all maternal
mortality, andapproximately 15%of deaths are secondary todiabetic
ketoacidosis (DKA).
15
DKA may be precipitated by hyperemesis
gravidarum, infection, tocolytic therapy with
b
-sympathomimetics
and corticosteroid therapy. Deterioration and development of DKA
may also result from autonomic neuropathy and gastro-paresis.
16
Even though the risk of maternal death from an episode of DKA
is now less than 1% with prompt recognition and treatment, the
foetus does not fare well.
17
In spite of aggressive treatment of the
mother and improvements in neonatal care, studies suggest a 10 to
25% rate of foetal loss for a single episode of DKA.
18,19
Ethical dilemmas arise when the mother is in a coma following
an episode of DKA. The pregnancy may have to be terminated in
maternal interest and in order to give the foetus a chance of survival
at a time when the mother is not in a position to give informed
consent. This act of beneficence to both the mother and baby could
be viewed as unethical on two fronts: the foetus may have suffered
irreversible damage and the mother may also be in an irreversible
coma such that an act of beneficence to both mother and baby
may not be beneficial to either of the parties. Should the healthcare
worker not do anything in anticipation of an unfavourable outcome
to the mother and the baby, this may also create a dilemma.
A brain-dead mother with a premature, viable foetus may also
pose an ethical dilemma. The mother may have to be kept in an
intensive care unit until the baby can be delivered at a reasonable
gestational age. This has ethical implications in that a decision
needs to be made on allocation of scarce resources, and a multi-
disciplinary team comprising an obstetrician, a neonatologist and
an intensivist should take a decision such as this.
Diabetic nephropathy
Pregnancies in women with diabetes may be complicated by
nephropathy with severe proteinuria, hypoalbuminaemia and
normochromic anaemia. This in turn may be worsened by pre-
eclampsia, which increases up to four-fold in diabetic women. The
presence of proteinuria and a reduced glomerular filtration rate are
significant risk factors for nephrotic syndrome, hypertension, pre-
eclampsia, placental insufficiency, pre-term delivery, and neonatal
morbidity and mortality. These pose significant ethical dilemmas
because of competing interests of the mother and foetus.
20
Diabetic retinopathy
There is a two-fold increase in progression of diabetic retinopathy
during pregnancy, and women with diabetes may develop
retinopathy for the first time during pregnancy. The worsening
retinopathy is often related to the rapid improvement in glycaemic
control, which is a feature of early pregnancy, and to the increase in
retinal blood flow. The risk is increased with poor metabolic control,
diastolic hypertension, renal disease, anaemia and the severity of
baseline retinopathy.
20
Conclusion
Healthcare professionals who treat pregnant women have a
fiduciary duty and an ethical obligation to prevent the adverse
effects of maternal disease on the foetus, and to prevent worsening
of the disease or the development of complications in the mother.
In managing women in this situation, healthcare professionals
frequently apply the ethical principles of autonomy, beneficence and
non-maleficence. Where premature delivery becomes imperative,
as in life-threatening complications in the mother, the principle
of justice and fairness of the allocation of scarce resources should
be applied, and autonomy supersedes all other ethical principles,
provided the woman has been given sufficient information to
enable her to make a decision of her own free will.
References
1.
Tieu J, Crowther CA, Middleton P. Dietary advice in pregnancy for preventing
gestational diabetes mellitus.
Cochrane Database Syst Rev
2008;
2
: CD006674.
2.
Studd JW.
Progress in Obstetrics and Gynaecology
, vol 16. Oxford: Elsevier, 2005.
3.
Nelson-Piercy C (ed).
Handbook of Obstetric Medicine
, 4th edn. New York:
Informa Healthcare, 2010: 89.
4.
Glueck CJ, Wang P, Kobayashi S, Phillips H, Steve-Smith L. Metformin therapy
throughout pregnancy reduces the development of gestational diabetes in
women with polycystic ovary syndrome.
Fertil Steril
2002;
77
: 520–525.
5.
Weiss PA, Scholz HS, Haas J, Tamussino KF, Seissler J, Borkenstein MH. Long-
term follow-up of infants of diabetic mothers with type 1 diabetes: evidence of
hereditary and non-hereditary transmission of diabetes and precursors.
Diabetes
Care
2002;
23
: 905–911.
6.
FIGO Committee for the Study of Ethical Aspects of Human Reproduction and
Health.
Ethical Issues in Obstetrics and Gynecology.
November 2006.
7.
National Collaborating Centre for Womens’ and Childrens’ Health commissioned
by the National Institute for Clinical Excellence. Caesarean Section.www.rcog.
org.uk
(accessed 01/04/2011).
8.
Jarrett RJ. Gestational diabetes: a non-entity.
Br Med J
1993;
306
: 37–38.
9.
Steyn W. Elective caesarean section on request – the scientific evidence is lacking.
Obstet Gynae Forum
: 6–11.
10. Coetzee EJ. Gestational diabetes – the emerging picture.
Obstet Gynae Forum
:
17–20.
11. Nelson-Piercy C (ed).
Handbook of Obstetric Medicine
, 4th edn. New York:
Informa Healthcare, 2010: 83.
12. Van Gelderen CJ, Nicolau E. Ultrasound, ethics and the law:
Obstet Gynae Forum
:
11–14.
13. Confidential Enquiry into Maternal and Child Health. Improving the Health of
Mothers, Babies and Children: A Report on Pregnancies in Women with Type 1
and Type 2 Diabetes 2002–2003: England, Wales and Northern Ireland. London,
England: CEMACH 2003.
14. Moodley K (ed).
Medical Ethics, Law and Human
. Pretoria: Van Schaik.
15. Gabbe SG, Mestman JH, Hibbard LT. Maternal mortality in diabetes mellitus: an
18-year survey.
Obstet Gynecol
1976;
48
: 549–551.
16. Edmonds DK (ed).
Dewhurst’s Textbook of Obstetrics and Gynaecology
, 7th edn;
Oxford: Blackwell, 2007: 248.
17. Drury MI, Greene AT, Stronge JM. Pregnancy complicated by clinical diabetes
mellitus: a study of 600 pregnancies.
Obstet Gynecol
1977;
49
: 519–522.
18. Kilvert JA, Nicholson HO, Wright AD. Ketoacidosis in diabetic pregnancy.
Diabetic
Med
1993;
10
: 278–281.
19. Montoro MN, Myers VP, Mestman JH,
et al
. Outcome of pregnancy in diabetic
ketoacidosis.
Am J Perinatol
1993;
10
: 17–20.
20. Nelson-Piercy C (ed).
Handbook of Obstetric Medicine
, 4th edn. New York:
Informa Healthcare, 2010: 82.
