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Gestational Diabetes During Pregnancy Increases Risk of Shoulder Dystocia & Erb’s Palsy

MANY WOMEN, WHO HAVE NO HISTORY OF DIABETES PRIOR TO CONCEIVING, DEVELOP GESTATIONAL DIABETES DURING PREGNANCY. THIS OFTEN OCCURS AROUND THE 24TH WEEK OF GESTATION. OVER THE COURSE OF THE PREGNANCY, HORMONAL CHANGES LEAD TO PROGRESSIVE IMPAIRED GLUCOSE INTOLERANCE (HIGHER BLOOD SUGAR LEVELS), AND IN SOME WOMEN THIS CAN CAUSE GESTATIONAL DIABETES.

Excessive weight gain during pregnancy is a significant risk factor for gestational diabetes. It is a well-known aspect of prenatal care for obstetricians to advise their patients regarding weight gain, blood glucose (blood sugar) levels, diet, exercise and medical treatment for this condition. However, a recent study found that despite guidelines issued in 2009, few women report being counseled correctly about weight gain during pregnancy1.

Gestational diabetes starts when the mother’s body is not able to make and use all the insulin it needs during the pregnancy. Without enough insulin, glucose cannot leave the mother’s blood and be changed to energy, and thus glucose builds up in her blood to high levels. This is called hyperglycemia. The extra blood glucose goes through the placenta, giving the baby high blood glucose levels. This causes the baby’s pancreas to make extra insulin to process the extra blood glucose. Since the baby is getting more energy (glucose) than it needs to grow and develop, the extra energy is stored as fat.

This extra fat can lead to a condition called macrosomia. Fetal macrosomia has been defined in several different ways, including birth weight of 4000-4500 g (8 lb 13 oz to 9 lb 15 oz) or greater than 90% for gestational age.

Babies with macrosomia face a risk of injury to their shoulders during birth if the delivery is not properly managed. This birth injury is caused by improper management of a condition called shoulder dystocia. Shoulder dystocia occurs when a baby’s shoulder becomes lodged behind a mother’s pubic bone during delivery.

Shoulder dystocia is an obstetrical emergency and must be quickly and appropriately treated by the obstetrician to enable the delivery of the baby’s shoulders and body without injuring the brachial plexus nerves.

The brachial plexus is a group of nerves near the shoulder that control movement to the arm and hand. When these nerves are damaged, weakness, numbness or full paralysis can ensue.

Erb’s palsy (also called brachial plexus palsy) is a birth injury that is caused by damage to these nerves. It typically affects the upper portion of the arm, and results from too much pressure and pulling on a baby’s head during delivery.

The rate of shoulder dystocia has increased over the past two decades2. Proper training in the management of this obstetrical emergency is critical to preventing birth injury.

A recent study found that the incidence of Erb’s palsy were significantly decreased when a hospital put in place a shoulder dystocia training program3. The program involved in the study included training regarding the risk factors (including gestational diabetes), early recognition, and proper management of shoulder dystocia. It also included mandatory, individual hands-on simulated shoulder dystocia training, including repeat training sessions for physicians whose performance in the training was unsatisfactory. This study shows that Erb’s palsy can be avoided by proper training of health care providers, including the assessment and treatment of risk factors such as gestational diabetes and proper management during delivery.

Other risks faced by a macrosomic baby include brain damage due to hypoxia (decreased oxygen supply) during a difficult or prolonged labor and delivery. Proper assessment, counseling and treatment of gestational diabetes can significantly reduce these risks of injury.

Therefore, throughout pregnancy obstetricians have a continuing role in the prevention and treatment of gestational diabetes and its associated risks to the baby. First, gestational diabetes must be timely diagnosed with periodic prenatal testing. Once a diagnosis of gestational diabetes is made, the condition must be treated in such a way as to keep the blood glucose under control to prevent macrosomia from developing. Should the baby become macrosomic, proper planning for the delivery must be undertaken, including an assessment of whether the mother’s pelvis can accommodate delivery of the baby. In some cases a primary caesarian section may be indicated. If a vaginal delivery is attempted, the baby must be closely monitored for signs of shoulder dystocia, fetal distress and hypoxia. If signs of these conditions arise, they must be properly and promptly addressed to avoid damage to the brachial plexus nerves or injury to the baby’s brain.

ATTENTION: If you had gestational diabetes during pregnancy that was not kept under control, and your baby has been diagnosed with brachial plexus injury, Erb’s palsy, or brain damage, you may have legal recourse to compensate your child for those injuries. For a free consultation with the medical malpractice lawyers at Levy Konigsberg LLP please call our 24/7 toll-free hotline at (800) 315-3806 or submit an email inquiry.

1 McDonald SD, et al. American Journal of Obstetrics & Gynecology, 205:333.e1-6 (October 2011);
2 Dandolu V., Lawrence L., Gaughan J.P., et al. Journal of Maternal-Fetal and Neonatal Medicine, 18.305-310. 2005;
3 Inglis SR, Feier N, et al. American Journal of Obstetrics & Gynecology, 204:322.e1-6 (2011).

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