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By J. Kerth. Roanoke College.

Lurie and Wolf also argue that the trials contravene existing guide- lines – in particular buy discount benadryl 25 mg on line, the Declaration of Helsinki (World Medical Association purchase 25 mg benadryl with amex, 1996) and the international ethical guidelines for biomedical research involv- ing human subjects of the Council for International Organizations of Medi- cal Sciences (1993) benadryl 25mg cheap. They also question the scientiWc rationale for placebo controls discount 25mg benadryl, and suggest equivalency trials, using the best known regimen compared against another: ‘We believe that such equivalency studies of alternative antiretroviral regimens will provide even more useful results than placebo-controlled trials, without the deaths of hundreds of newborns that are inevitable if placebo groups are used’ (Lurie and Wolf, 1997: p. Marcia Angell (1997) takes an even more critical stance, comparing some of the placebo-controlled trials to the infamous Tuskegee syphilis experiment (Anonymous, 1992). She maintains, as do Lurie and Wolf, that researchers have an obligation to provide the controls with the best current treatment, rather than the best locally available one. To do otherwise, she argues, is to adopt a double standard in research, or an ethical relativism that ‘could result in widespread exploita- tion of vulnerable third world populations for research programmes that could not be carried out in the sponsoring countries’ (Angell, 1997: p. Even informed consent is insuYcient protection, she argues, ‘because of the asymmetry of knowledge and authority between researchers and their subjects’ (Angell, 1997: p. The NuYeld Council on Bioethics, in their discussion paper, proposed an interpretation of principle 11–3 of the Helsinki Declaration (World Medical Association, 1996) such that ‘the best proven diagnostic and therapeutic method’ is interpreted as meaning ‘the best locally available diagnostic and therapeutic method’ (NuYeld Council on Bioethics, 1999: p. This sits uncomfortably with Article One of the Declaration, which deWnes the researcher’s duty ‘to remain the protector of the life and health of that person on whom biomedical research is being carried out’. In conclusion, research into the prevention of vertical transmission has engendered a public and acrimonious debate and a schism in the medical profession. Perhaps we are witnessing the clash between an ethic of science Wrmly rooted in the mechanistic-reductionist or modernist paradigm, and an ethic based on a more humanistic, postmodern worldview. It can provide us with useful evidence for the beneWt of interventions, but, in order to achieve this, it eschews individual concerns, needs and relationships. The postmodern ethic, on the other hand, allows for the individual voice to be heard and tolerates uncertainty (Bauman, 1993; Hodgkin, 1996; Laugharne, 1999). One response to the criticisms – a revision of the research guidelines – may lead to a dangerous shift in the ethical require- ments for research, such that research subjects from poor countries could be more readily exploited. Furthermore, the justiWcations do not satisfactorily address the importance of trust, intrinsic to the relationship between the health professional and the woman seeking antenatal care. Amended by the 29th World Medical Assembly, Tokyo, Japan, October 1975; 35th World Medical Assembly, Venice, Italy, October 1983; 41st World Medical Assembly, Hong Kong, September 1989 and the 48th World Medical Assembly, Somerset West, Republic of South Africa, October 1996. It is already possible to test embryos for several conditions at the pre-implanta- tion stage (through pre-embryo biopsy) and to test fetuses for even more conditions during the course of their gestation (through amniocentesis, chorionic villus sampling and umbilical cord blood sampling) (Robertson, 1994: pp. In the near future, however, there will be increased ability to test for mild diseases, late-onset diseases, treatable diseases, propensities for common diseases, and even non-disease characteristics such as longevity, height and body-build (Strong, 1997: p. Although genetic knowledge of this type may strike us as an unalloyed blessing, ethicists worry that such information might fuel parents’ increasing desire for perfect progeny. At most, if their moral views permitted, they could discard a pre-embryo or abort a fetus that tested positive for a relatively small range of genetic maladies, such as Tay–Sachs disease, Down’s syndrome and Fragile X (Robertson, 1996). However, as soon as safe, eVective and beneWcial genetic therapies for embryos and fetuses are developed, parents will have the option of repairing or changing rather than destroying their progeny, an option bound to please those who believe that human life should be protected from the moment of conception on- wards (Mehlman and Botkin, 1998: pp. Assuming the successful development of a wide range of safe and eYcacious genetic therapies, should parents be encouraged to perfect their children through genetic means – as well as traditional environmental means such as education? In particular, pregnant women should refrain from drinking alcohol, smoking tobacco and ingesting a wide range of illicit and licit drugs during pregnancy (Matthieu, 1996: pp. As prenatal gene therapies develop, pregnant women should also permit physicians to penetrate their bodies, more or less invasively, in order to treat their fetuses’ genetic maladies or simply to improve upon their genetic endowments. Finally, parents should provide their children with as many safe, eVective and beneWcial postnatal genetic and environmental enhance- ment therapies as they can reasonably aVord. In this chapter, I will argue that although parents have a limited right to enhance their already normal children geneti- cally, and, conceivably, also a limited duty to do so, they should not be encouraged to do so. It should do so, however, not through legal bans or prohibitions on the development of genetic therapies, but through: (1) the development of practice guidelines for health care researchers and practitioners specializing in genetic screening, testing, diag- nosis, counselling and therapy; and, even more importantly, (2) the creation of democratic fora designed to achieve some sort of public consensus about the extent of parents’ procreative and rearing rights. As Rober- tson sees it, the speciWc right to select oVspring characteristics is linked to two more general rights: (1) a parent’s right not to procreate children because of the more or less burdensome aspects (physical, psychological and social) of Genetic screening 89 reproduction; and (2) a parent’s right to procreate a child with particular characteristics (e. This second right derives from ‘the great importance to individuals of having biologic oVspring – personal meaning in one’s life, connection with future generations, and the pleasures of child rearing’ (Robertson, 1994: p. Since negative selection activities (carrier screening, pre-implanta- tion screening, prenatal screening and abortion) and positive selection activ- ities (therapeutic ex utero or in utero genetic manipulation) enable parents to select oVspring traits, Robert-son views these activities as protected by a person’s procreative liberty. Actions that aim to produce oVspring who are supernormal (enhan- cement), subnormal (intentional diminution) or clones, says Robertson, ‘deviate too far from the experiences that make reproduction a valued experience’ to be protected by procreation liberty rights. However, some of these non-therapeutic actions – those aimed at enhancement – might be viewed as part of ‘parental discretion in rearing oVspring’ (Robertson, 1994: p. In the name of ‘bettering’ their children, parents submit their children to sex-alignment operations, certain cosmetic surgeries, growth-hormone treatments, Ritalin therapy and multiple doses of Prozac. So long as parents can show that such interventions are safe, eVective and beneWcial, state authorities will not interfere with parents’ child-rearing activities. Given that this is the case, Robertson reasons that state authorities are not likely to interfere with genetic enhancement interventions, although they would be likely to interfere with genetic dimin- ution interventions. Robertson’s ideas about what constitutes a harm seem to be roughly equivalent to those of Norman Daniels, who views as harmful any actions that detract from so- called species-typical functioning (Daniels, 1986: p. If it is typical for the human species that its members be able to hear and see, for example, deliberately deafening or blinding a fetus is harmful to the fetus. So long as every member of the species can do what is typical for the species reasonably well, it matters not that some members of the species can do it 90 R. Given the reasonability of Robertson’s and Daniels’s implied positions on enhancement, it is diYcult to identify what might, in the end, be harmful about enhancing one’s progeny. Interestingly, in the course of explaining why it would be wrong for deaf parents, who view deafness as a valuable culture rather than a disability, to use genetic therapy prenatally to ensure deaf children for themselves, the lawyer Dena Davis (1997) provides some clues. Davis concedes that since people have diVerent ideas about what counts as an enhancement and what counts as a diminution, deaf parents, wishing to ensure deaf children for themselves, might reasonably argue that the lifestyle in the deaf community is a good one for children – indeed, according to Lennard Davis (1995), a better one than the lifestyle for children in the non-deaf community. In essence, deaf parents might argue in the manner Amish parents argue when they defend their practice of limiting their children to an elementary school education on the grounds that further formal education interferes with the Amish system of home-based vocational training – i. Davis notes that by depriving their children of the opportun- ity to secure a high-school diploma, Amish parents virtually ensure ‘that their children will remain housewives and agricultural laborers’ (Davis, D. An Amish child who rebels against the Amish way of life for one reason or another will Wnd himself or herself without the basic education he or she needs to be anything other than an agricultural labourer or housewife. In Davis’s estimation, the parents of this child will have harmed him or her by substantially limiting their child’s presumed right to control the course of his or her own destiny. Davis then reasons that if Amish parents harm their children by denying them educational opportunities, the lack of which will set them back considerably in the larger, non-Amish community should they decide to enter it, deaf parents would even more egregiously harm their children by using genetic diminution therapies to deprive them permanently of their ability to hear. All parenthood exists as a balance between fulWlment of parental hopes and values and the individual Xowering of the actual child Genetic screening 91 in his or her own direction. Although Davis’s arguments are directed against the practice of genetic diminution, the crucial question to ask for our purposes is whether geneti- cally enhancing a child ‘closes’ or ‘opens’ doors for him or her. For example, a person with exceptional intellectual capabili- ties has the opportunity to pursue a much wider range of career options than a person with minimal intellectual capabilities. On the other hand, an enhanced child might have a future more closed than a ‘normal’ child if, for example, his parents enhanced his intellectual and rational capacities to such a degree that his physical and emotional capacities shrivelled.

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In 2005 buy 25mg benadryl, the Dutch euthanasia assessment committee reported that a doctor lawfully complied with a request for euthanasia from a patient with Alzheimer’s disease cheap 25 mg benadryl visa. Beyond the death of the individual person and its immediate legal/moral implications buy benadryl 25mg, the major problem with active euthanasia is that its social acceptance removes any ‘principled objection’ to involuntary euthanasia discount benadryl 25 mg on line. The relation between relgion and risk for depression is complex and simple explanations may be 573 misleading. The strongest opposition came from specialists in palliative care, followed by those charged with looking after the elderly. Spirituality is a strong sense of connection that enables a person to feel that his/her life contributes to a greater and valued whole, that we are not meaningless within the Universe. People who do not have religious beliefs may describe themselves as such or as humanist, agnostic or atheist. In-patients with this status should not be made to feel embarrassed during hospital-based religious services. Non-religious funeral ceremonies can be organised by the Humanist Association of Ireland (www. Many religious and cultural groups have their own herbal remedies (which may interact with orthodox prescriptions) and washing rituals. Where medicines contain animal products forbidden by a particular religion the adherent will want to decide on whether to take them or not. Traditions requiring candles to be lit near the deceased should be accommodated if it is safe to do so. Those traditions mandating multiple visitors to the sickroom may be requested to rotate visitors or may be asked to leave a few visitors with the patient while others pray in a prayer room. Coroners should be advised where religion mandates early burial so that a Death Certificate is not unduly delayed. Some traditions have beliefs that may clash with those of the majority of the population but they must nevertheless be respected, e. There is some degree of pastoral cross- cover among the major non-Catholic Christian traditions but this will require clarification in each case. The tradition of the Irish Traveller Community (who are mostly Roman Catholic) held that pregnant women should avoid dead bodies and this practice may still pertain. Some traditional Roma women may want their menfolk to talk on their behalf but this cannot be assumed. The Roma often visit the sick in large numbers and they usually want to bring a deceased member’s remains home as quickly as possible where the body will be displayed for two nights. Baptism in the Orthodox Church is normally conducted when the baby is 40 days old, unless the baby is dying in which case the Orthodox priest or the parents can conduct the rite. Orthodox Christians believe that the deceased should be buried whole and undamaged. Baptists do not baptise infants even when death is imminent; a minister of that faith may perform a Naming Ceremony if the child dies (including miscarriage/stillbirth) before it can be baptised. Lutherans baptise during infancy and any Christian can perform this ritual in an emergency; a blessing may be offered in the case of miscarriage. Methodists do not have a formal death rite but they usually want a dying baby to be baptised. Presbyterians may want a minister of their faith to be called in cases of death in order to help them pray but the dead, including a child, are deemed to be in God’s hands so a chaplain need not be called after death as such; non-ordained adherents may pray for and name a deceased newborn child but they cannot baptise the baby. Pentecostalists (belonging to many different Churches) receive 146 phenomenon dated to Charcot and Freud. Important concepts in sociobiology include the following: Fitness, the highest measure of evolutionary success has been reached in that the best genes are past down through the baptism when an adherent is ready to receive this sacrament and infant baptism is not a requirement of this tradition. The Religious Society of Friends (‘Friends’, Quakers) have no clergy but may want a visit from a fellow adherent such as an elder during times of distress; baptism is not necessary for infants who are dying; funerals are silent apart from apart from acknowledging manifestations of God’s goodness in the deceased and requests for comfort for the bereaved. Seventh-day Adventists, who have the same Sabbath as do Jews, must not eat ‘unclean’ food. Alcohol, including during Holy Communion (pure grape juice is allowed), is avoided. Baptism by full immersion only takes place when the ‘age of accountability’ is reached. Church of Jesus Christ of Latter-day Saints should be referred to as Latter-day Saints rather than as Mormons; home teachers visit their sick and elders perform religious ceremonies; blessing of the sick involves anointing with oil and laying on of hands; burial is preferred to cremation; and baptisms (normally conducted at age 8 years) of infants who are dying is not deemed to be necessary. Jehovah’s Witnesses have Hospital Liaison Committees that provide support, mediation, and information when medical interventions are proposed; blood, blood cells and plasma (including in foods such as black pudding) are not allowed (adherents vary in relation to use of the patient’s own blood or the use of albumin, clotting factors and immunoglobulins; organ donation/transplantation is based on personal choice); baptism of the newborn is not practiced (baptism occurs when the person understands its implications). First Church of Christ, Scientist (Christian Science) adherents may only be in hospital for childbirth, following an accident or secondary to family pressure and members should be allowed to discuss the level of care they will accept (children can be treated in accordance with State Law); a time to pray may be requested before a medical intervention; females should handle deceased female Christian Scientists; post-mortem examination requires compelling reasons; cremation is more common than burial; and baptism is not part of Christian Scientist ritual. Bahá’í adherents customarily put a ring on the finger of the deceased and this should never be removed. The Bahá’í forbid cremation and insist that the deceased is interred as near as possible to the place of death. Orthodox Jews do not use electrical appliances such as telephones on the Sabbath; neither do they travel during that period so visitors may need assistance with somewhere to rest; and women may want to light candles at the onset of Sabbath. Males over 13 years of age may wish to pray wearing religious garments such as a shawl. Islam (Muslims) is divided into the Sunni and Shi’a traditions; the left hand should where possible be left free for washing; when a child is born the parent, usually the father, recites a prayer into each ear in turn; patients should eat halal food (pork and alcohol are forbidden); during Ramadan food and liquid are avoided from dawn to dusk, although pregnant women, the ill and children are not subject to this rule; just before death the person should be turned toward Mecca; the body of the deceased should not be washed by healthcare staff and touching the body is a task for same-sexed staff; the dead, who should be modestly covered, are believed to retain awareness; essential post-mortems should end with restoration of removed organs; full ritual is carried out after death for foetuses that have developed; burial (in shroud and facing Mecca; cremation is forbidden) should be as soon as possible. Hinduism (Hindus) is often associated with Ayurveda, a traditional medical system involving herbs, exercise and diet. Beef (sometimes pork) and its derivatives are disallowed (if these are in prescription medicines the patient has a choice to make). If family are not available then healthcare staff can clean and wash deceased Hindu adherents; a lighted candle is left near the head of the body; and cremation takes place within 24 hours of death with the ashes then scattered into a river, followed by 13 days of mourning. Sikhs have strict dietary practices and will want to know if medicines contain proscribed agents such as alcohol. They have a strict dress code (including a strapped miniature sword and a turban – when necessary for examination or treatment purposes, patients should be asked to remove their own turban). A dead child should be wrapped in a clean white cloth before being handed over to the family. Buddhists believe that consciousness is retained for about 4 hours after death and they wish for a peaceful and private environment, unaffected by mind-altering medication, during their last hours so that the spirit (i. The body should not be laid out for at least 4 hours, the head should remain untouched, and only essential cleaning (e. Sacred symbols (Prayer Mandalas) may be placed on the deceased and these should be left in situ. Post-mortem examination should be delayed for a minimum of 4 hours and preferably for some days.

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Medications such as acet- body’s ability to warm the air to body tem- aminophen and sodium salicylates are gener- perature prior to its reaching the distal air- Management of labor and delivery Respiratory infections are the most common ally well tolerated and typically do not act as ways order 25mg benadryl amex. Colonization of the upper respira- systemic steroids should receive stress dose tory tract by pathogens leads to cell-mediated Occupational triggers steroids at the time of delivery and for up infammatory processes buy benadryl 25mg without a prescription, which in turn lead to Environmental allergens to 24 hours postdelivery27 order benadryl 25mg amex,37 order 25mg benadryl visa. These changes infuence airway erbations as well as for patients with mild Environmental allergenic triggers frequently resistance by modifying smooth muscle con- intermittent disease. Short acting b agonists As with inhaled corticosteroids, systemic cor- 2 follow seasonal patterns and 75–85% of asth- tractions and respiratory secretions15. Although human data are scant, however, the asthmatic population experi- association between chronic systemic steroid class of drug, special considerations for use they lack any evidence of an increased risk of ences an exaggerated response to subtle atmo- use during pregnancy and adverse pregnancy during pregnancy, and specifc examples of congenital malformations. Inhaled corticosteroids counteract the infam- bidity and mortality associated with poorly duction, leading to bronchial relaxation and matory response that takes place during asthma controlled asthma, and the important role that dilation. In addition, inhaled cortico- mediators of immediate hypersensitivity from systemic steroids may provide in asthma con- Emotional stress steroids act to modify the immune response mast cells. They can be further classifed as trol, the American College of Obstetrics and by inhibiting the activation of numerous cell Asthmatic patients experience changes in short acting agents used for acute exacerba- Gynecology recommends that systemic ste- types including mast cells, eosinophils, neu- elastic recoil, ventilation distribution and tions, and long acting agents used for main- roids be used when clinically indicated and trophils, macrophages and lymphocytes. A traindicated in pregnancy and have not been A Negative Negative Use approved associated with an increased risk of con- select group of patients will require chronic B Negative None available Use approved genital malformation or adverse pregnancy use of systemic steroids to adequately manage 5,17,35,43 asthma symptoms5,9,23,35,36. Examples include: Examples include: C Positive None available Use approved C None available None available Use approved • Beclomethasone (category C) • Prednisone (category C) D Positive/negative Positive Use approved • Budesonide (category B) • Methylprednisone (category C) X Positive Positive Contraindicated • Fluticasone (category C) • Dexamethasone (category C). This reduction in acetylcho- on therapy to inhaled corticosteroids therapy Immunol 2007;120(5 Suppl):S94–138 line activity results in an inhibition of secre- regimens. Am J Obstet be used in patients with intractable asthma Examples include: who require them for adequate symptom con- Gynecol 2006;194:120–6 Cromoglycates block the activation of chloride trol. Environ Health Perspect 2000;108(Suppl scribed during pregnancy due to multiple drug sodium prior to pregnancy may be maintained 4):697–704 • Zileuton (category C – not recommended). Mild persistent 1st scheduled inhaled corticosteroids pregnancy and stage of pregnancy on asthma The relationship of asthma medication use 2nd scheduled inhaled cromolyn severity: A systematic review. J Allergy Clin Immunol Moderate persistent Scheduled inhaled corticosteroids Gynecol 2004;190:1201–10 2004;113:1040–5 plus theophylline or salmeterol 3. Effect of Birth defects after maternal exposure to corti- fetal sex on airway lability in pregnant women costeroids: prospective cohort study and meta- with asthma. Association tice bulletin: clinical management guidelines of asthma diagnosis, severity, symptoms, and for obstetrician-gynecologists number 90, treatment with risk of preeclampsia. Association of obesity with pul- inhaled corticosteroids during pregnancy and monary and nonpulmonary complications of risk of pregnancy induced hypertension: nested pregnancy in asthmatic women. In our own combined obstetric and diabetes clinic no • Complications of diabetes women with type 2 diabetes were encountered • Effect of pregnancy on diabetes until 2003. The circum- stances in our institution refect the changes • Effect of diabetes on pregnancy taking place in the general population, as also • Effect of diabetes on the neonate. In an ideal world women with diabetes will For women with diabetes mellitus, an elevated have planned pregnancies and the opportunity glycated hemoglobin (HbA1C) is associated for appointments before stopping contracep- with increased risks of adverse pregnancy tion, and for preconception counseling and care outcome including miscarriage, congenital with a multidisciplinary team that includes a anomalies and stillbirth. This position is supported by the safety of insulin analogues has been studied mendations for care recommend a target HbA1C HbA1C in the frst trimester. Although the 1989 St hyperglycemia clearly improves pregnancy out- with a body mass index greater than 27kg/m2 parison with human insulin, with improved 1C Vincent Declaration aimed for ‘a pregnancy come15. Multiple daily blood glucose testing is should see a dietitian if they have not already satisfaction and potential benefts with respect outcome in the diabetic woman that approxi- essential to achieve the best possible glycemic received dietary advice8. A severe hypoglycemic episode is being used in gestational diabetes mellitus long-acting insulin analogues: insulin glargine being observed for types 1 and 21. Hypoglycemia treatment should be stopped prior to conception, includ- protamine Hagedorn) by the time of the frst indicated by an HbA of greater than 10%8. Long-acting insu- and colleagues reported a more than 12-fold in HbA1C achieved before conception is associ- unplanned pregnancy in a woman with type 2 lin analogues were designed to provide a lon- increased relative risk of a congenital anom- ated with improvements in outcome. Achiev- diabetes mellitus taking any of these agents, as ger duration of action with a less pronounced aly associated with an HbA1C of greater than ing an HbA1C of below 7% without driving it their safety has not been formally assessed in peak of action compared to isophane insulin. In the absence of safety data, some Insulin glargine and insulin detemir both have panying this, signifcantly higher rates of with longstanding diabetes, especially those people still use these agents. The need for The prevention of toxemia is a complex issue isophane insulin, especially nocturnal hypo- A recent American study also suggested a the preconception administration is because and is discussed elsewhere in this volume. Baseline measurements of renal and assessment should be assessed to determine dation that women with diabetes take the thyroid function should be taken. It is the authors’ practice anomalies in thyroid hormone levels can greater risk of developing pre-eclampsia than Women with diabetes often take a range of to continue all other antihypertensive medi- impact early fetal development, it is essential the general population (see below), a point medications prior to pregnancy. Unfortunately, the ideal plinary team allows these medications to be ing pregnancy depending on the blood pres- agent to accomplish this task has not yet been reviewed so that appropriate changes can be sure at that time. It is phylactic antiplatelet agents (mainly low-dose have clinically diagnosed hypertension prior dopa or labetalol for blood pressure control as essential for all women with diabetes to have aspirin) suggested a 10% decrease in relative to pregnancy and are taking antihypertensive these are the medications with which British a retinal assessment prior to conception to risk of developing pre-eclampsia38 and con- medication(s); many also have long-term dia- obstetricians have the most experience. If low-dose aspirin is to be used, it diabeticsareprescribedangiotensin-converting to provide long-term protection against car- ment also provides a baseline for further should be started once a woman has a positive monitoring during each trimester. However, the available evidence is far tial investigation of prophylactic high-dose tion of retinal disease, and sudden improve- or changed prior to pregnancy, or once it is from conclusive, but since statin use is preven- vitamins C and E (antioxidants) appeared to ment of glycemic control should therefore be confrmed. Calcium supple- cluded that there was no evidence of terato- drugs when they are planning to conceive and retinal changes require urgent referral for oph- genicity with methyldopa, beta-blockers, cal- to restart them once they have fnished breast- ments are currently being investigated, and thalmologic review and should receive treat- cium channel blockers and hydralazine27. Optimal control of blood glucose be considered a relative contraindication to by two- to three-fold during the frst trimes- nopathy in 5% of pregnancies and observed and hypertension protects against develop- pregnancy. Appropriate education diabetic nephropathy, both of which are betes that can lead to end stage renal failure more light on risk factors, including diabetes. In a retrospective analysis of still- optimal glycemic control preconception, but should be considered during the preconcep- births occurring in women with type 1 diabe- to have a negative impact on long-term renal tion assessment for all women with longstand- also in preparation for the early weeks of preg- tes, a six-fold higher incidence of nephropathy function in women with diabetic nephropathy ing type 1 diabetes and all women with type nancy. Assessment of renal function creatinine) in contrast to those with low cre- 47,48 should be considered if other risk factors are Due to the increased frequency of hypogly- with serum creatinine, estimated glomeru- atinine clearance before pregnancy. Prompt return to normogly- be performed in all diabetic women prior to Other complications of diabetes Eating disorders associated with diabetes cemia, after hypoglycemia, may help to reduce conception. Sensorimotor The possibility of disordered eating patterns, between hypoglycemia and congenital mal- neuropathy in women with diabetes rarely including binge eating and insulin restriction formations, but this has not been confrmed causes problems during pregnancy and does 53 to avoid weight gain should be considered dur- in human studies. Autonomic neuropathy is associ- First-line hypoglycemia treatment should be Normal Unknown ated with hypoglycemic unawareness, which Hypoglycemia, usually defned as blood glu- consumption of fast-acting carbohydrates such <30 mg/24 hours can be aggravated by pregnancy. Women need to be aware Once blood glucose levels have recovered, fur- 30–300 mg/24 hours who have developed gastroparesis as a compo- that the tight control required before con- ther hypoglycemia should be avoided by con- Macroalbuminuria Increased pre-eclampsia nent of autonomic neuropathy often have poor ception, and in pregnancy, may predispose sumption of longer-acting carbohydrates such >300 mg/24 hours 49,50 metabolic control and inadequate nutrition. Evers as a cereal bar, fruit, biscuits or the next meal Protein excretion Increased risk of This complication is subsequently associated and colleagues demonstrated that the fre- if it is due. Women should be clearly at the preconception appointment, not least appointment in the antenatal clinic, as each nancy with a general increase as pregnancy informed that if they have high blood sugar because many of these effects can be modifed 1% decrease in preconception HbA1C halves progresses, although this effect varies between levels with ketones, or evidence of urinary by improving diabetic control before concep- the rate of adverse pregnancy outcomes7. There appears to be a triphasic ketones with even moderate blood sugar eleva- tion and maintaining good control throughout Women with long-term diabetes are at pattern of insulin requirements, which remain tions, they should seek medical help urgently the pregnancy. Unfortunately both miscarriage greater risk of developing pre-eclampsia than steady in the frst trimester and increase there- rather than attempting to manage the situa- and fetal anomalies are much more common the background population, and this risk is after55. Unfortunately, since both proteinuria in a prospective study of women with type 1 recognized, and explained to women that both and hypertension are common in pregnan- diabetes, after initial increases in insulin doses Many women with diabetes are not aware that miscarriage and fetal anomalies are not exclu- cies with long-term diabetes, it can be diff- a fall in insulin requirements was observed there is no reason why they should not breast- sive to pregnancies in diabetics, or those with cult differentiating between this phenomenon between 7 and 15 weeks’ gestation56. Unfortunately, changes, in combination with the need to bal- aged, in the interests of both the mother and A comparison of miscarriage rates in 386 these complications cannot be prevented by ance near normal glycemic control with avoid- her baby.

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