Below is a **stylish, concise-but-complete medical reference** on **Diabetes in Pregnancy** and **Shoulder Dystocia**, written in an exam-ready, high-yield format with clean headings and clinical depth.

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# 🎀 **Diabetes in Pregnancy — Complete Stylish Note**




## 🌸 **Definition**

Diabetes diagnosed **before pregnancy** (Type 1 / Type 2) or **first detected during pregnancy** (Gestational Diabetes Mellitus – GDM).

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## 🌸 **Pathophysiology**

* Pregnancy → ↑ **Placental hormones** (hPL, progesterone, estrogen, cortisol, TNF-α).
* Causes **progressive insulin resistance**, peaking at **24–28 weeks**.
* Mother: ↑ post-prandial glucose.
* Fetus: Maternal glucose crosses placenta → **fetal hyperinsulinemia** → macrosomia.

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## 🌸 **Risk Factors**

* Obesity
* PCOS
* Previous GDM
* Family history
* Age > 25
* Prior macrosomic baby (>4 kg)
* Unexplained stillbirth
* Acanthosis nigricans

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## 🌸 **Clinical Features**

Often asymptomatic.
May show:

* Polyuria
* Polydipsia
* Recurrent infections
* Excessive fetal growth on USG

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## 🌸 **Diagnosis**

### ✔ **Screening (24–28 weeks)**

1️⃣ **DIPSI / WHO one-step test**

* 75 g oral glucose, **2 hr ≥ 140 mg/dL = GDM**

2️⃣ **OGTT (75 g) ADA criteria**

* Fasting ≥ 92 mg/dL
* 1 hr ≥ 180 mg/dL
* 2 hr ≥ 153 mg/dL
→ Any **one** abnormal = GDM.

### ✔ Early pregnancy testing

* Fasting ≥126 mg/dL
* HbA1c ≥6.5%
* RBS ≥200 mg/dL + symptoms
→ **Overt diabetes in pregnancy**.

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## 🌸 **Maternal Complications**

* Polyhydramnios
* Preeclampsia
* Preterm labour
* Infections
* DKA (especially Type 1)
* Obstructed labour (macrosomia)
* Increased C-section rates

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## 🌸 **Fetal & Neonatal Complications**

* **Macrosomia** (key)
* Shoulder dystocia
* Congenital anomalies (pre-gestational DM)

* Caudal regression syndrome
* Cardiac defects
* IUGR (if vasculopathy)
* IUFD
* Neonatal hypoglycemia
* Hypocalcemia, hypomagnesemia
* RDS
* Polycythemia, hyperbilirubinemia

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## 🌸 **Management**

### **1. Medical Nutrition Therapy**

* 3 major + 3 snack meals
* Low GI diet
* Total calories:

* Normal weight: 30 kcal/kg/day
* Obese: 25 kcal/kg/day
* Underweight: 35–40 kcal/kg/day

### **2. Exercise**

* 30 minutes walking after major meals
* Avoid supine position

### **3. Glucose Monitoring**

* Fasting target: <95 mg/dL
* 1 hr PP: <140 mg/dL
* 2 hr PP: <120 mg/dL

### **4. Pharmacotherapy**

#### **Insulin (preferred)**

* Short-acting analogs preferred
* Basal–bolus regimen
* Safe in pregnancy

#### **Metformin**

* Used if diet fails
* Crosses placenta but considered safe
* Not preferred in early organogenesis for overt diabetes

### **5. Fetal Monitoring**

* Growth scans every 4 weeks
* NST/BPP from 32–34 weeks
* Doppler if vasculopathy

### **6. Delivery Timing**

* GDM well controlled: **39 weeks**
* Poorly controlled / insulin-requiring: **37–38 weeks**
* Estimated fetal weight >4.5 kg → consider **elective C-section**

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## 🌸 **Postpartum**

* Insulin needs drop sharply
* Reassess glucose at **6–12 weeks postpartum** using 75 g OGTT
* Risk of future Type 2 DM → counselling essential

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# 🌟 **Shoulder Dystocia — Stylish Complete Note**







## 🌸 **Definition**

An obstetric emergency where after the fetal head delivers, the **anterior shoulder is impacted behind the maternal pubic symphysis**, preventing delivery.

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## 🌸 **Risk Factors**

* Macrosomia (>4 kg)
* Maternal obesity
* Diabetes in pregnancy
* Post-term pregnancy
* Instrumental delivery (vacuum/forceps)
* Prolonged second stage of labour
* Prior shoulder dystocia

*(Note: Most cases are **unpredictable**.)*

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## 🌸 **Signs**

* **Turtle sign**: Retraction of the fetal head after delivery
* Failure of restitution
* Difficulty delivering the face/chin
* “No progress” after the head is out

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## 🌸 **Complications**

### **Maternal**

* PPH
* 3rd/4th degree perineal tears
* Uterine rupture

### **Fetal**

* **Brachial plexus injury (Erb palsy)**
* Clavicle/humerus fracture
* Hypoxia → brain damage
* Neonatal death (rare but feared)

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## 🌸 **Management — Mnemonic: HELPERR**

### **H – Help**

Call senior obstetrician, pediatrician, anesthetist.

### **E – Episiotomy**

Not mandatory, but may give space for internal maneuvers.

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### 🌷 **L – McRoberts Maneuver (First-line)**

* Hyperflex maternal thighs onto abdomen
* Straightens sacral angle
* Resolves **90%** cases.

### 🌷 **P – Suprapubic Pressure**

* Apply downward & lateral pressure
* Dislodges fetal anterior shoulder.

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### 🌷 **E – Enter Maneuvers (Internal Rotations)**

* **Rubin II**: Pressure on posterior aspect of anterior shoulder
* **Woods Screw**: Rotate shoulder like a screw
* **Reverse Woods Screw**

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### 🌷 **R – Remove Posterior Arm**

* Deliver posterior arm → reduces shoulder diameter.

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### 🌷 **R – Roll to All-Fours (Gaskin Maneuver)**

* Maternal position changes pelvic dimensions.

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### **Last-Resort Maneuvers (Rare & Heroic)**

* **Zavanelli maneuver** (cephalic replacement + emergency C-section)
* **Clavicle fracture**
* **Symphysiotomy**

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## 🌸 **Prevention**

* Good glycemic control in pregnancy
* Consider elective C-section if:

* Diabetic mother with EFW > 4.5 kg
* Non-diabetic EFW > 5 kg

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