Essay 308 - IDDM

(a)

I would ask about her glycemic control and any past or recent acute diabetic complications, e.g hypoglycemia, and ketoacidosis. Chronic complications like retinopathy, nephropathy and neuropathy should also be assessed. I would review her current medication and compliance. Insulin and metformin can be safely continued throughout pregnancy, whereas ACE inhibitor and angiotensin-II receptor blocker should be stopped. She should start folic acid 5mg daily if not yet. 

I would enquire about her obstetric history, including parity, and complications in previous pregnancies if any. 

Other concomitant medical issues, e.g. hypertension, should also be enquired. Smoking, alcohol or drug use should be advised to stop.

On physical examination, blood pressure, pulse rate and body mass index should be documented. Urine dipstick should be done to detect proteinuria.

HbA1c would help to assess her glycemic control in the immediate pre-pregnancy period and is related to the risk of congenital anomaly. I would perform serum creatinine, creatinine clearance and 24 hour urine total protein to assess her kidney function. Fundoscopy should be performed if no assessment for retinopathy was done during the last 12 months. A viability and dating ultrasound would be necessary.

(b)

I would explain to her a good glycemic control is of essential role to improve pregnancy outcome. She would be advised to test blood glucose level when fasting, 1 hour after every meal and before bed time. If can be safely achieved, the target should keep fasting glucose between 3.5 - 5.9 mmol/L and 1-hour post-prandial less than 7.8 mmol/L. She should be reviewed by diabetes care team to assess the glycemia control every 1 -2 weeks. She should be offered ketone testing strips and advised to test for ketonuria if she becomes hyperglycaemic or unwell.

She should be advised about the increased risk of hypoglycemia during pregnancy, possibly due to a tighter control. Especially during the first trimester with nausea and vomiting, she may require more frequent testing and alteration/reduction of insulin regime. 

HbA1c should not be used in second and third trimester as it may underestimate due to hemodilution.

(c)

For well-controlled diabetes and a normally grown fetus, elective delivery should be offered after completed 38 weeks. Aim is for vaginal delivery, but it also depends on the woman’s wish and whether there is any previous history of Caesarean delivery, shoulder dystocia or birth trauma. If estimated fetal weight more than 4.5kg, elective Caesarean section should be offered with a course of antenatal steroid, to reduce risk of shoulder dystocia. If the woman declines elective delivery and opts for spontaneous labour, then more frequent fetal monitoring is required (weekly fetal cardiotocography and amniotic fluid volume).

Clinical assessment and additional investigations

Glycaemic control and recent complications like ketoacidosis or frequent episodes of hypoglycaemia should be noted as should long term complications such as nephropathy, hypertension, retinopathy. The date of last retinal screening should be noted and arranged if not performed in the last 12 months.

Drug therapy should be reviewed. ACE inhibitors and statins should be discontinued. Type and method of insulin administration should be recorded. It is likely that this woman has type 1 DM but this should be clarified as oral hypoglycaemic agents other than metformin should be discontinued. High dose folic acid use should be confirmed and recommended if not currently in use.

Previous Obstetric history, timing and mode of delivery should be asked, detailing obstetric complications and neonatal problems.

Other medical comorbidities should be excluded. This should include risk assessment for VTE. Gynaecological history should include presence of uterine scars or cervical treatments.

The patient’s weight, height and BMI should be recorded. Diet should be enquired about (complex carbohydrates) to help tailor dietary advice. Urinalysis will identify pre-existing proteinuria. Blood pressure and pulse rated should be recorded. This will help distinguish pre-existing renal disease from Pre-eclampsia presenting later in pregnancy. Social factors such as smoking status, alcohol intake and cannabis use are risk factors that should be asked about.

Fundoscopy should be performed in the absence of retinopathy screening in the last year.

Fetal viability should be confirmed on pelvic ultrasound. The woman’s attitude towards aneuploidy screening should be discussed and offered appropriately (from 11-14wks).  An anomaly scan with 4 chamber view and imaging of the outflow tracts should be arranged for 18-20 weeks.

Baseline U&Es, FBC should be performed. Hb 1AC may be used as an estimate for glycaemic control in the first trimester but should not be routinely used in the 2^ndor 3 rd trimesters.

Routine screening for syphilis, HIV, Hepatitis B should be offered as should Blood type and antibody screening.

Advice regarding Monitoring of blood glucose concentrations

Her advice should individualised to the patient and be given as part of a multidisciplinary team including diabetologists, dieticians, Diabetic specialist midwives and obstetricians. Her plan should be individualised, emphasising strict control of Blood sugars between 2.4-5.0 fasting and less than 7.8 1 hours post prandial.

She should understand that well controlled diabetes is not associated with increased risks of fetal malformation and will help prevent poor perinatal outcome and stillbirth.

She should be advised to perform her blood sugar prior to every meal, 1 hour after and before bed time. She should be advised about the symptoms and signs of hypoglycaemia and be instructed, along with family members, on how to use a glucagon pen.

Signs and symptoms of ketoacidosis should be given as should ketine testing strips and advice to attend the unit if ketoacidosis is developing. Verbal and written information should be given in the patient’s own language if necessary.

Discuss factors influencing decision and timing and mode of delivery.

Elective delivery should be offered from 38 weeks in the absence of complications. If macrosomia is present (4.5kg) the additional risks of intrapartum complications (shoulder dystocia, secondary arrest) should be discussed and caesarean section offered. Other obstetric indications such as Fetal distress, abnormal lie may necessitate caesarean delivery. VBAC is not a contraindication in the presence of diabetes but the additional risks of induction, uterine rupture and success should be clearly discussed.

The development of complications like PET, IUGR or sudden decrease in insulin requirements often indicates earlier delivery. Steroids are not contraindicated if caesarean delivery is planned before 39 weeks or if delivery occurs before 35 completed weeks but should be given with sliding scale insulin.  

Clinical assessment would include type and dose of insulin she is taking,her most recent blood sugar levels ,if any recent episodes of ketoacidosis or hypoglycaemia. History of associated conditions like hypertension,nephropathy,retinopathy or autonomic neuropathy.Review her medications if on ACE/ARB inhibitors or statins as they are contraindicated in pregnancy.History of smoking,alcohol abuse should be taken.Obstetrical history taken to note number of children and mode of delivery.Examination would include BMI and blood pressure. Additional investigations would include renal function tests,HbA1c,Blood sugar fasting and post prandial, Thyroid profile, urine microscopy for protein and bacteruria.   If retinal assessment offered if not done within past one year .Dating scan should be advised alongwith combined test for down syndrome screening.

Woman is advised that good control of sugars associated with good pregnancy outcome and would be associated with decreased chances of abortions ,congenital malformations ,unexplained stillbirth and macrosomia.Blood sugar control would require frequent visits to hospital (1-2 weekly) and would be seen by a multidisciplinary team including dietician,diabetologist,midwife and obstetrician.Maintaining blood sugar between 3.5 -5.9 mmol/l (fasting) and <7.8 mmol/l (postprandial 1 hour) is advised. Woman and her partner are educated regarding episodes of hypoglycaemia  ,symptoms include fainting and excessive sweating and advised on the use of glucose solution and injection glucagon.Woman advised that she may have to do blood sugar upto 7 times in a day including fasting and postprandial1 hour after major meals and one night time ,she would be provided blood glucose monitor.Admission may be required at times for sugar control.

Diabetic pregnancies are complicated by unexplained stillbirth therefore induction at 38 weeks is advisable, however ,if complicated with macrosomia,i.e,birth weight of >4.5 kg then caesarean is advisable to avoid difficult delivery and shoulder dystocia. If complicated with fetal growth restriction delivery planned according to growth scan and Doppler studies.Worsening of hypertension,renal function tests ,would prompt an earlier delivery.

Pregnancy with preexistent diabetes is not uncommon and is associated with increased maternal & fetal morbidity & mortality, although in standard setup of  medical practice complications are minimising.

a)

Initial assessment should begin with obtaining detail history of both - medical condition & pregnancy itself. While assesing the course of IDDM, focus should be on the control of sugar levels at the time of conception as it may lead to congenital anomalies of the fetal cardiovascular, neural & other anomalies.History of any complications like renal damage, retinal damage, neurological problems etc, should be asked, as these are indicators of poor prognosis. Also, periconceptional medications should be explored as some of oral hypoglycemics- thiaglitazone groups are teratogenic, however Metformin & Insulin preparations are safe.

Previous obstetric history, if any, should be asked with detail outcome, for example miscarriages, pregnancy with intrauterine fetal demise/stillbirth, polyhydramnios/ macrosomic/IUGR or abnormal baby/ difficult deliveries - shoulder dystocia, as these will itself reflect the extent of glycemic control in the past pregnancies and will alert us for the management of current pregnancy.

Further, any co-existent medical disorder like Hypertesion, should be looked for, as these increase further morbidities.

She should be asked about present course of pregnancy, as she is likely to get complicated by hyperemesis or urinary tract infections. Folic acid & multivitamins supplentations, Insulin doses adjusted according to blood sugar monitoring, should be confirmed. It is often noted that Insulin requirement increases during pregnancy.

Her detail physical examination should be done - height, baseline weight & BMI, BP to assess general health status. Urine should be examined for infection / glycosurea/ proteinurea. Baseline blood tests like FBC for anaemia, Fasting & Postprandial sugar levels, Glycosylated Hb to note the glycemic control over past 2-3 months, renal function teststo rule out renal complication, should be done. Fundoscopy should be done to rule out proliferative retinopathy.

First trimester dating ultrasound should be arranged as soon as possible and then NT scan between 11 to 13.6 weeks of gestation, should be offered along with double marker screeing.

She should be reffered to a diabetic clinic and a multidisciplinary team involving Consultant obstetrician, specialist diabetes care nurse, physician for further assessment & care.

B)

She should be monitored in the diabetic clinic, although she can monitor her sugar levels at home using capillary blood glucometer.

She should be provided with the information & instructions about how to perform this test. She should be educated about the relation of calories intake - timing & amount with the result of the test. Fasting sugar test should be performed from 6 am to 8 am. then postprandial glucose levels 2 hrs of each, breakfast, lunch and dinner and then early morning sugar level at 2 am to 4 am, these are initial monitorings, which are also essential if there is change in the dose / type of insulin or if there is poor glycemic control / insulin resistance or any complication.

She should be provided with the reference range and should be advised to contact healthcare professional if abnormal values are noted.

She should be made aware of danger signs of hypoglycemia like sweating, light headedness, tremors, giddiness & fainting and if so, should check sugar levels and to take glucose orally, immediately.

She should be reviewed in the diabetic clinic at frequent intervals 2-4 weekly, to review glycemic control in relation with insulin. She should be advised that doses and site and type of insulin may need to alter, for better bioavailabiliy.

She should be counselled that inspite of good glycemic control, she remains high risk of developing fetal complications like stillbirth/ IUGR / congenital anomalies.

c)

Timing & mode of delivery depend upon the impact of disease on pregnancy and vice-versa.

Poor glycemic control at conception / teratogenic oral hypoglycemic drugs / womans wish may lead to early termination of pregnancy.

Detection of fetal anomolies/complications like fetal demise may also lead to late termination of pregnancy.

Late intrauterine death may be induced & delivered vaginally after detection & counselling of woman.

If there is worsening maternal complications like retinopathy / nephropathy or fetal complications like severe fetal growth restriction with abnormal doppler studies, then benefits of iatrogenic preterm delivery are weighed against the risk of continuing the pregnancy, and discussed with the woman and the decision is made according to the level of facility of NICU. in this situation caeserean delivery is safer to both mother & baby. If facilities are not available, then ex-utero transfer to tertiary level, is preferred if its for maternal indication or in-utero transfer if the indication is fetal compramise. Role of steroids for enhancing the fetal lung maturity is taken into account, if there is no urgent indication delivery.

If the disease is well controlled & no complications are evident, then induction of labour at 38-39 weeks of gestation should be advised, aiming for vaginal birth with continous fetal monitoring & sliding scale for glucose monitoring. Caeserian section should be done for obstetric indication, although womans concerns should be taken into account.

Women wishing for continuing pregnancy after 39 weeks, should be warned that there is significant increase in the chance of sillbirth after 39 weeks. If, inspite of careful senior consultation, woman is opting for continuing pregnancy, then clear documentation should be made and she should be offered more frequent monitoring, 2-3 times/week for fetal reason. 

a)

Take a history about her diabetes mellitus, asking about the duration, blood sugar control and screen for complications such as retinopathy, nephropathy, neuropathy and peripheral vascular disease. Ascertain current dose and regimen of insulin. Ask about hypoglycemic episodes, especially if there is concurrent hyperemesis gravidarum in the first trimester. Take a drug history for use of ACE inhibitors as these will have to be stopped due to the teratogenic risk in pregnancy. Ensure she is on high dose folic acid of 5mg/day and start aspirin 75mg/day if not already started. Take an obstetric history, in particular previous complications in pregnancy such as macrosomia and stillbirth and previous mode of deliveries. Take a social history to assess social support and smoking, alcohol and recreational drug use. Also ask about cervical smear history. On examination, take height and weight and calculate body mass index. Check blood pressure for hypertension and urine dipstick for proteinuria and ketonuria. Do an abodminal examination. Check fundoscopy for retinopathy if not done in the last 12 months. Do a neurological examination to assess for peripheral neuropathy. Do a full blood count to look for anaemia. Check urea, electrolytes and creatinine for baseline renal function. Consider referral to nephrologist if creatinine above 120mmol/l. Check HbA1c which will indicate diabetic control over the last 3 months. 

b)

Advise her to monitor and record 7-point blood glucose readings pre-meal, 1hr post-meal and at bedtime. The targets for premeal readings should be less than 5.9mmol/l and that for postmeal readings should be less than 7.8mmol/l. Emphasize the importance of good control of blood glucose levels in reducing the risk of pregnancy complications such as fetal macrosomia and stillbirth. Good control however does not eliminate these risks. Provide her with ketone reagent strips to detect ketonuria, and advise her to use them when she is hyperglycemic or feeling unwell. Presence of ketonuria suggests diabetic ketoacidosis and she will need to seek urgent medical attention. Inform her of the risk of hypoglycemia in pregnancy and advise her to carry sweets, a sweet drink or a glucagon pen with her. She and her family should be educated on the use of a glucagon pen. Advise her to contact the specialist midwife or seek medical attention if any problems arise, particularly if blood glucose levels are persistently below 3.5mmol/l or above the target range set, as insulin regime may need to be adjusted. Provide written information and contact information to support groups and emergency helplines. 

c)

Patients with insulin-dependent diabetes mellitus with a normally grown fetus are offered induction of labour at 38 weeks gestation in view of the risk of sudden intrauterine fetal demise. Poor control of blood glucose levels is associated with an increased risk of stillbirth and hence earlier delivery should be considered. If fetal macrosomia of estimated fetal weight above 4.5kg is present, inform the patient of the increased risk of birth injury, shoulder dystocia and obstetric anal sphincter injury. Counsel the patient regarding the mode of delivery with induction of labour for vaginal birth or elective caesarean section. Earlier delivery may be needed if evidence of fetal compromise such as fetal growth restriction, which may require caesarean section if Dopplers are abnormal. Obstetric indications requiring caesarean section such as placenta previa will necessitate a caesarean section. If the patient declines delivery at 38 weeks gestation, offer weekly tests of fetal well-being.

A.

History should be taken to evaluate end organ damage due to long standing diabetes which can lead to retinopathy, nephropathy, and neuropathy and macrovascular disease. History of visual disturbance or previous eye surgery,   diagnosis of hypertension, is asked. Present symptoms of hypoglycemia as dizziness, sweating fainting attack should be asked as vomiting of first trimester and decrease awareness of hypoglycemia may exacerbate hypoglycemia. Is she monitoring the blood sugar level, what value is she able to achieve and informed about a target value of pre-prandial 3.5- 5.9 mmol/l and postprandial sugar of less than 7.8 mmol/l after 1 hour.

When was her last   retinal checkup and assessment of renal function done?.When did she visit the respective specialties?

Drug review for hypertension treatment is done if not in prepregnancy period. She is advised to stop angiotensin converting enzyme inhibitor and angiotensin receptor blocker and change to safer alternative as labetalol or methyl dopa . Is she taking folic acid 5 mg ? And if not advised to take till 12 completed weeks.

 Her body mass index is calculated by checking her weight and height, and her blood pressure measured.

Her glycemic control is assessed by checking glycosylated hemoglobin( HbA1c).If retinal assessment is not done in prior 12 months, digital  assessment of retina following mydriasis is offered , if it normal, it is repeated at 28 weeks of gestation if abnormal repeated at 16-18 weeks. Serum creatinine is checked and urinary protein quantification is done. Estimated glomerular function test used outside pregnancy for renal assessment is not advised in pregnancy.

 Along with anomaly scan four chamber view of heart and outflow tract visualization done at 18 -20 wk. of gestation. In the presence of end organ damage where the fetus is at risk of intrauterine growth restriction serial growth scan with umbilical artery Doppler is offered from 28 weeks onwards

B

She is advised that her management will be by multidisciplinary team involving diabetic specialist, diabetic nurse, obstetrician and need more frequent visit every 1 -2 weeks. In first trimester due to vomiting she is at risk to develop hypoglycemia, she should carry sugar tablets or wear a wrist band mentioning that she is diabetic. Her family member involvement in her care is of paramount importance. She is also prone for diabetic ketoacidosis so should check for urine ketone in case of not feeling well.. In first trimester HbA1c is indicator of good glycemic control, as values above 6.1 are associated with high chance of congenital anomalies. Aggressive control of sugar may exacerbate retinopathy but it do not deteriorate nephropathy she should maintain her fasting blood sugar  between 3.5-5.9 mmol/l and postprandial after 1 hour less than 7.9mmol/l . Same applies for second and third trimester. There is no role of monitoring HbA1c in second and third trimester. As she on insulin she should check her blood sugar before going to bed. Poor control of sugar is associated with maternal complication as polyhydramnios and associated risk of preterm delivery ,sudden intrauterine fetal death, increase in intervention and operative delivery and  fetal complication as macrosomia, shoulder dystocia, birth injuries, neonatal complications as hypoglycemia, respiratory distress, need for neonatal care admission. She is assured about safety of insulin.

C

Maternal blood glucose control, presence of end organ damage leading to complication such as intrauterine growth retardation, presence of macrosomia determine the timing and mode of delivery

In absence of complication, well controlled diabetes and normal size fetus should be advised induction of labor after 38 completed weeks.

Patient with ultrasound evidence macrosomia as weight more than 4.5 kg should be offered caesarean section. They should be explained about the risk associated with vaginal delivery , induction of labour and caesarean section.

Diabetes is not a contraindication for vaginal birh after caesrean

Hello Paul i know there was no marking system for question on complex social factors but can you post the ideal answer please?

A)Woman should be assessed in a joint clinic with a diabetologist.Detailed history to be taken concerning,symptoms ofchronic diabetic complications-peripherel neuropathy,,visual loss,autonomic neuropathy.Recent history of diabetic complications like,hypoglycemia and keto acidosis..Drug history of insulin dose and any other drugs..Review recent glycemic controll.To take detailed obstetric history and review any old notes..Social history, availability of support and smoking..Clinical exam P,Bp,BMI.fundoscope,leg ulcer.,peripherel neuropathy.Additional investigation..Ensure routine booking investigation .Renal function test,hba1c,24 hrs urine protein excretion..Request retinal assessment.request dating scan.

B)Test FBS,and bld. gluc. 1 hr after every  meal.Aim to keep FBS at  3.5-5.9 mmol/Land ppbs <7.8 mmol/l.Check blood glucose before going to bed at night.Provide ketone testing strips and advise to test for ketonuria or ketonemia, if she becomes hyperglycemic or unwell.Explain risk of hypoglycemia and hypoglycemia unawarness in pregnancy.Provide conc. glucose solution and glucogon,in case of hypoglycemia.Woman and her partner,and other family members to instructed in their use.

C)If normal preg. with normal growth aim for vadinal delivery at 38-39 weeks.Complicated pregnancies need earlier delivery such as iugr,hypertension,renal deterioration,retinal worsening.(caesarean to be done).If macrosomia (EFW 4.5 ) for elective caesarean as soon as detected.All other cases  caesarean for obstetric indications

a) I will ask her about her control of diabetes, and whether she is compliant with follow up. Control is important as uncontrolled diabetes is associated with increased fetal abnormalities. I would ask her what medications she is on, for example ace-inhibitors, angiotensin receptor blockers or statins, as these need to be stopped. I would ask her about any end organ damage, namely vascular, cardiac, retinal and renal. I would ask her when her last retinal screen for proliferative retinopathy was, and if it is more than 6 months ago, I would arrange a retinal screen. Ask about any associated autoimmune conditions such as thyroid disorders. Ask if she is on folic acid 5mg/day, as she is at high risk of neural tube defects. Ask if she has started on aspirin, as she is at high risk of pre-eclampsia. Do examination for BMI, BP and pulse. She is at high risk of pre-eclampsia so booking BP is important. Auscultate the heart and lungs for any signs of cardiac disease. Do an abdominal examination for any scars or abnormalities. Offer retinal screen if not done in the past 6 months. Do baseline BP, proteinuria tests such as 24hour urine total protein or spot urinary protein:creatinine ratio and renal panel to assess for underlying nephropathy. Do a HbA1c to assess glucose control for past 3 months. Do a dating scan. Offer a first trimester screening for aneuploidies and nuchal translucency test as she is at high risk of cardiac anomalies. Offer screening scan at 20 weeks for fetal anomalies and fetal echocardiogram at 22 weeks as she is at high risk of cardiac anomalies. Offer serum aFP as she is at high risk of neural tube defects. Serial growth scans for fetal growth restriction or macrosomia.                                                     b) Explain that keeping blood glucose in the optimal range is very important as hyperglycaemia will increase the risk of fetal abnormalities, stillbirth and macrosomia, with associated birth trauma. The optimum range is pre-meal 3.5 to 5.9, and 1 hour post prandial less than 7.8. She should monitor hypocount at home once or twice a week, 7 times a day. HbA1c will also be done once per trimester at least to monitor control. Also, explain risk of hypoglycaemia with insulin. Explain the signs and symptoms of hypoglycaemia, and how it is important to have regular meals to prevent it. Also, have a concentrated glucose drink and glucagon injection at all times, and educate her family on their use. The glucose monitoring will be multi-disciplinary with a diabetic nurse and her diabetitian.                c) If her fetus is normally grown, offer induction of labour at 38 weeks. This is to prevent shoulder dystocia and to reduce stillbirth. If the baby's estimated weight is more than 4.5kg, offer elective caesarean to reduce incidence of shoulder dystocia. The mode of delivery should be vaginal in the absence of obstetric contraindications.  

Hello Paul i know there was no marking system for question on complex social factors but can you post the ideal answer please?

A 28 year old woman with a 10 year history of insulin-dependent diabetes mellitus is referred to the antenatal clinic at 10 weeks gestation. (a) Describe the clinical assessment and the additional investigations you would undertake. [10 marks]. (b) Describe the advice that you would give her regarding the monitoring of blood glucose concentrations [6 marks]. (c) Discuss the factors that will influence your decision on the timing and mode of delivery [4 marks].

I would assess this woman in a joint obstetric diabetic clinic .history of recent glycemic control and episodes of acute complications like hypoglycemia and ketoacidosis should be enquired about. I would also enquire regarding chronic complications like neuropathy, nephropathy & diabetic retinopathy and recent screening undertaken for it. The type of insulin and dosage should be noted as long acting insulin analogues are not safe in pregnancy. Medications for chronic complications such as ACE  inhibitors , acetyl choline receptor blockers & statins should  be enquired as they have potential teratogenicity. Previous obstetric history including complications & perinatal outcome should be noted. I would check her blood pressure, BMI & presence of leg ulcers and discoloration which may suggest long standing poor glycemic control. I would arrange for assessment of retinopathy if not done in the last 12months. I would request for fasting And 1 hr postprandial sugar along with HbA1c which will help in identifying the glycemic control  during the periconceptional period  and thereby help in counseling the women regarding risk of  fetal anomalies. Renal function is assessed by s.urea , creatinine And quantification of proteinuria,  if present ., by serum protein  creatinine ratio.Mid stream culture should be offered to rule out asymptomatic bacteriuria.

I will advice the woman to do fasting ,1 hr postprandial and night time  sugars daily . I would provide  her with standardized glucometer and educate her regarding its use. The woman and  her family should be counseled regarding risk of hypoglycemia and should be provided with concentrated glucose solutions and  glycogen for use during hypoglycemia. Ketone strips should be provided and testing for ketonuria will be advised if the women feels unwell. Review in diabetic clinic is advised every 2 weeks.

 I would offer induction of labour at 38 weeks after counseling the women regarding risks and benefits and considering factors such as previous obstetric history, bishop score  & presence of macrosomia. The women's wishes will  be taken into consideration .  In the presence of complication like preeclampsia and fetal growth restriction delivery maybe considered earlier. Caesarean section is reserved for obstetric indications. Delivery in an consultant led unit with neonatal resuscitation facilities will improve perinatal outcome