A woman with Type I diabetes presented at 6+0/40 with a history of severe retinopathy, hypertension and nephropathy. A previous combined renal and pancreatic transplant had failed necessitating haemodialysis five times a week. She miscarried a DCDA twin pregnancy at 21 weeks the previous year. At 25+6/40 fetal ultrasound indicated growth restriction, with absent umbilical artery diastolic flow. Dexamethasone was administered. Fetal wellbeing was monitored with biophysical profiling until 27+1/40 when reversed flow in the Ductus Venosus A wave prompted delivery by LSCS under GA.
Post-partum, the primary concern was fluid and electrolyte balance. Intra-operative haemorrhage was replaced with IV crystalloid and a return to restricted oral fluid intake was encouraged. Blood glucose was controlled with a reduced basal-bolus regime.
On the first post-operative day serum potassium was 6.0 mmol/L and was corrected by haemodialysis. Daily haemodialysis continued for a week post-partum to clear excess fluid and manage worsening hypertension. Initially all antihypertensive medication was stopped but had to be re-titrated to control the blood pressure.
Recovery was complicated by vomiting and ketosis secondary to basal atelectasis and pneumonia on the fourth post-operative day. This was managed with cautious fluid resuscitation and an insulin infusion.
Conclusion The challenges in this pregnancy were numerous but the peripartum fluid balance, blood sugar and thrombo-prophylaxis, are of particular interest and will be discussed. A proactive and multi-disciplinary approach to her care resulted in a live birth without significant compromise to maternal health.
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