Diseases of the exocrine pancreas-pancreatitis, cystic fibrosis Endocrinopathies-Cushing syndrome, pheochromocytoma, others
Drug or chemical induced-glucocorticosteroids, thiazides, �-adrenergic agonists, others Infections-congenital rubella, cytomegalovirus, coxsackievirus
MODY = maturit I-onset diabetes of the young. Data from Powers, 21n2.
Diabetes is the most common medical complication of pregnancy. Women can be separated into those who were known to have diabetes before pregnancy-pregestationalior overt, and those diagnosed during pregnancy-gestational diabetes. The proportion of pregnancies complicated by diabetes more than doubled between 1994 and 2008, after which rates seem to have stabilized Oovanovic, 2015). Almost 258,000-6.5 percent-of gravidas in the United States had pregnancies coexistent with some form of diabetes in 2015 (Martin, 2017). Prevalence of diabetes is highest among non-Hispanic blacks, Mexican-Americans, Puerto Rican-Americans, and Native Americans (Golden, 2012). he incidence of gestational diabetes during the past 20 years, shown in Figure 57-1, is reminiscent of similar statistics for obesity (Chap. 48, p. 936).
I:u
FIGURE 57-1 Increasing prevalence of type 2 diabetes in the United States from 1995 to 2015. (Reproduced with permission from Centers for Disease Control and Prevention, 201o7.)
Until the mid-1990s, the classification by Priscilla White (1978) for diabetic pregnant women was the linchpin of management. Today, the White classiication is used less frequently but still provides simple and useful information on pregnancy risks and prognosis (Bennett, 2015). And, because most currently cited literature also contains data from these older classifications, the one previously recommended by the American College of Obstetricians and Gynecologists (1986) is provided in Table 57-2.
Beginning several years ago, the American College of Obstetricians and Gynecologists no longer recommended the White classification. Instead, the current focus is whether diabetes antedates pregnancy or is irst diagnosed during pregnancy. Many now recommend adoption of the classiication proposed by the American Diabetes Association (ADA), which is shown in Table 57-3.
he rising prevalence of type 2 diabetes, particularly in younger people, has led to an increasing number of afected pregnancies. For example, the CDC (2015) estimates that more than 5000 new cases of type 2 diabetes are diagnosed each year in youths before the age of 20 years. Feig and coworkers (2014) reported that the incidence of pregestational diabetes doubled from 7 per 1000 women in 1996 to 15 per 1000 in 2010. When considering the previously mentioned high percentage of diabetes that is undiagnosed, then many women identified to have gestational diabetes likely have type 2 diabetes previously unrecognized. In fact,rS to 10 percent of women with gestational diabetes are found to have diabetes immediately after pregnancy.
Women with high plasma glucose levels, glucosuria, and ketoacidosis present no diagnostic challenge. Women with a
TABLE 57-2. Classification Scheme Used from 1986 through 1994 for Diabetes
Age of Onset (yr) 10 to 19 10 to 19 aWhen diagnosed during pregnancy: proteinuria :500 mg/24 hr before 20 weeks' gestation.