Pregnancy and delivery in a woman with type 1 diabetes, gastroparesis, and a gastric neurostimulator.

Pregnancy in women with type 1 diabetes may cause worsening of diabetes complications, thereby posing a risk to both themother and fetus. In particular, diabetic gastroparesis has traditionally been considered a contraindication to pregnancy (1,2). A 28-year-old nullipara with type 1 diabetes for 13 years was diagnosed as being pregnant. She had a prepregnancy BMIof 26.1kg/m, no evidenceof diabetic nephropathy, and modest background retinopathy. Five years earlier, shewas diagnosed with diabetic gastroparesis. At that time, she was severely disabled due to chronic upper abdominal pain, nausea, vomiting, and constipation. A gastric neurostimulatorwas implanted andall gastrointestinal symptoms receded. One year prior to pregnancy, continuous subcutaneous insulin infusion therapy was initiated and blood glucose levels were maintained at near-normal levels. Insulin requirements before pregnancy were approximately 34 IU/day (A1C 6.0% [42mmol/mol]), increasingtoapproximately 87 IU/day (A1C 6.1% [43 mmol/mol]) in week 371. Repeated ultrasound scans confirmed normal fetal growth. Gastric symptoms were sparse during the first two trimesters. In the third trimester, the patient reported upper abdominal pain attacks, modest nausea, and constipation necessitating periodical bed rest. Rare episodes of vomiting occurred after the first trimesterdfive or six times in total. Analgesics were avoided. The patient only had a mild sensation of gastric pacemaker activity, with no discomfort. Total gestational weight gain constituted approximately 10 kg and in gestational week 3810, spontaneous labor and uncomplicated vaginal delivery occurred (healthy boy, 51 cm, 3,090 g ,20.4 z-score). Diabetic gastroparesis is generally viewed as being a contraindication to pregnancy (1,2), based on evidence derived from a few and sporadic case reports (2–4). Here, we report on a pregnancy in a patient who had been severely affected by diabetic gastroparesis andwhowas successfully treatedwith a gastric neurostimulator before pregnancy. Insulin pump therapymayhave contributed to the favorable outcome by allowing optimized glycemic control (5). During the first and second trimesters, the patient only experienced mild abdominal discomfort as often found in a normal pregnancy. However in the third trimester, gastrointestinal symptoms became more prevalent, forcing the patient to an earlymaternity leave. Nevertheless, symptoms were mild and tolerable in general. Gestational weight gain was normal and A1C levels during pregnancy were at the upper normal range, indicating that nutritionwassufficientandglycemic control was good. To our knowledge, pregnancy in a patient diagnosed with diabetic gastroparesis treated with a gastric neurostimulator has not been reported before. It appears possible that the gastric neurostimulator contributed to the successful course of pregnancy. We observed that the pacemaker activity of the gastric neurostimulator did not have harmful effects to any clinically recognizable extent during pregnancy and that the modest deterioration of the abdominal symptoms occurring in the third trimester did not preclude normal intrauterine fetal growth and delivery. Hence in selected cases, gastroparesis is not a contraindication to pregnancy, provided that the clinical course is carefully monitored.