DMpregnancy

Diabetes In Pregnancy

Dr.Joe's Data Base

What Is Diabetes?

Today most pregnant women with diabetes can look forward to having a healthy
baby. Recent advances in the management of pregnancies complicated with
diabetes have greatly reduced the risks associated with this disorder. The
pregnant woman with diabetes can do a great deal to improve her chances of
having a healthy baby.

Diabetes is a disorder in which the body does not produce enough insulin or
does not utilize insulin properly. Insulin is a hormone that allows sugar to
enter cells, where it can be turned into energy. Without treatment, high
levels of sugar can accumulate in the blood, and damage can occur to many
organs, including blood vessels, eyes, and kidneys. Some individuals with
diabetes need daily insulin injections to help prevent these complications.

About 1 in 1,000 pregnant women has had diabetes requiring insulin treatment
before becoming pregnant. Another 3 to 12 percent develop diabetes for the
first time during pregnancy: this is called gestational diabetes. In both
forms of diabetes, it is crucial to control blood sugar levels to reduce
risks to the pregnant woman and her fetus.

Women with inadequately controlled diabetes and high blood sugar are several
times more likely than non-diabetic women to have a baby with a serious birth
defect, such as heart defects or spina bifida (open spine). They also are at
increased risk of miscarriage and stillbirth.

Gestational diabetes has been implicated only in heart defects, and only when
severe enough to require insulin treatment in the last three months of
pregnancy. Diabetes also can result in a baby who is extremely large and,
therefore, especially susceptible to birth injuries.

Babies of all diabetic women are at increased risk of health problems arising
during the newborn period, including respiratory distress, low blood and
sugar and calcium levels, and jaundice. Fortunately, early and regular
prenatal care -- beginning prior to pregnancy when a woman has preexisting
diabetes -- can greatly reduce all of these risks.

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>Preconception Care

Women with diabetes should consult their doctors before they become pregnant
to ensure that their blood sugar levels are well controlled. It is important
to do this before conception because the most serious birth defects
associated with diabetes originate in the earliest weeks of pregnancy, often
before a woman realizes she is pregnant.

A March of Dimes-funded study by John L. Kitzmiller, M.D., and other
researchers at the University of California, San Francisco, provides strong
evidence that blood sugar control begun prior to pregnancy reduces the risk
of birth defects in infants of women with insulin-dependent (type I)
diabetes. Other studies also show that careful blood sugar control beginning
before or early in pregnancy reduces the risk of miscarriage, stillbirth and
complications in the newborn period.

Women with preexisting diabetes who do not use insulin (type II diabetes) may
be taking oral medications to control their blood sugar levels. These
medications should be discontinued prior to pregnancy as they have not been
proven safe in pregnancy. Some women with this form of diabetes may have to
take insulin to control their blood sugar levels while they attempt to
conceive and during their pregnancy.

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Screening for Gestational Diabetes

According to the American College of Obstetricians and Gynecologists,
gestational diabetes occurs in 3 to 12 percent of pregnancies and is one of
the most common complications of pregnancy. It usually develops during the
second half of pregnancy, when pregnancy hormones interfere with the body's
ability to use its own insulin.

Some women are at increased risk of gestational diabetes. These include women
who are over age 30, obese, have a family history of diabetes, or have had a
baby who was especially large (over 9 1/2 pounds) or stillborn. Most pregnant
women with gestational diabetes have no symptoms, though some may experience
extreme thirst, hunger or fatigue.

The American Diabetes Association recommends that all pregnant women be
screened for gestational diabetes. The screening test, which is usually done
between the 24th and 28th week of pregnancy, involves taking a blood sample
one hour after consuming a drink containing 50 grams of glucose (sugar).
Women with a high level of glucose in their blood will be asked to take a
similar, though longer, test called the glucose tolerance test, which
involves drawing blood samples one, two and three hours after drinking 100
grams of glucose.

Once gestational diabetes is diagosed, most pregnant women can control their
blood sugar levels with diet, although about 10 percent may require insulin
injections. After delivery, blood sugar levels should return to normal.
However, women with gestational diabetes are at increased risk of developing
diabetes in the future and of developing gestational diabetes in any later
pregnancy.

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<Diet

All pregnant women with diabetes should follow a special diet, such as the
one recommended by the American Diabetes Association. Most women with
gestational diabetes are referred to dieticians to help plan their diet. A
woman with preexisting diabetes should already be following such a diet, but
also will benefit from nutritional counseling in pregnancy.

The American Diabetes Association recommends a diet that consists of 50
percent carbohydrates, 20 percent protein, and 30 percent fats. The woman
with gestational diabetes may be encouraged to eat a high fiber diet that
consists of 40 percent carbohydrates, 20 percent protein and 40 percent fats.
All women with diabetes should avoid sweets. This balance helps utilize
insulin in the body and minimizes periods of both high and low blood sugar
levels. While the number of calories required depends on a woman's weight and
stage of pregnancy, most pregnant women of average weight should consume
about 2200 calories a day, divided among three meals and about three snacks.

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Exercise

Exercise can help control diabetes by prompting the body to use insulin more
efficiently. However, pregnant women with diabetes should always consult with
their physicians about continuing or starting an exercise program. Pregnant
women with poorly controlled diabetes or certain complications, such as blood
vessel damage caused by preexisting diabetes, probably should exercise only
upon the advice of their health care provider.

Because exercise can cause drops in blood sugar levels, a pregnant woman
should carry along a carbohydrate snack during exercise. It is also best to
exercise following a meal, preferably at the same time each day, and avoid
injecting insulin into an actively exercising body area.

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<Picture>Insulin

Many women who had diabetes before pregnancy require insulin injections to
keep their blood sugar levels under control. Good blood sugar control
beginning prior to pregnancy greatly improves the outlook for the pregnancy.
Insulin requirements will change as the pregnancy progresses, generally
increasing after 20 to 24 weeks of pregnancy and stabilizing by about 36
weeks.

Most pregnant women with gestational diabetes do not require insulin.
However, if blood sugar levels do not stabilize after about two weeks on a
new diet, one or more insulin injections may be needed daily for the
remainder of the pregnancy.

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<Picture>Home Glucose and Urine Monitoring

Pregnant women who need insulin should monitor their blood sugar levels
several times a day, as recommended by their doctor. Blood glucose meters or
colored strips used with finger-stick devices have made it far easier for
those with diabetes to monitor their blood sugar levels and fine-tune their
insulin dosage between doctor's visits.

The doctor also may recommend a home urine test to measure the level of
ketones, weak acids that are produced when diabetes is poorly controlled and
the body is forced to burn fat instead of sugar for energy. Moderate to large
amounts of ketones in the urine can be a sign of ketoacidosis, a serious
complication of pregnancy that, unless promptly treated, can lead to death of
the fetus.

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<Picture>Pregnancy Complications

Women with diabetes, especially poorly controlled preexisting diabetes, are
at increased risk of certain pregnancy complications. These include
pregnancy-induced hypertension (preeclampsia), a condition characterized by
high blood pressure and protein in the urine, that can slow fetal growth and
result in premature delivery and polyhydramnios, an excess of amniotic fluid,
that also can result in premature birth.

The doctor will carefully monitor women with diabetes for signs of these and
other complications. He or she may recommend tests such as ultrasound to
assure that the fetus is growing at a normal rate. Late in pregnancy, the
doctor also may recommend a "nonstress test" (which may be repeated weekly),
a simple painless procedure in which the fetal heart rate is electronically
monitored before and during fetal movement. In most cases, these tests will
show that the pregnancy is progressing normally. Though women with diabetes
are at increased risk of cesarean delivery, most can have a normal vaginal
delivery.

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<Picture>Psychosocial Support

While the risks from diabetes in pregnancy have been greatly reduced,
pregnant women with this disorder face some additional concerns. They must
see their doctor more often than most non- diabetic women, follow a carefully
prescribed diet and, in some cases, monitor their blood-sugar level several
times a day. Although these steps will improve the outlook for a healthy
baby, they also may lead to additional stress. Many pregnant women with
diabetes can benefit from contact with a support group of other couples who
are facing the same concerns, or from meeting other women with diabetes who
now have healthy babies. A doctor, dietician, and local chapter of the
American Diabetes Association might provide such referrals.

January 7, 1993

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March of Dimes
Birth Defects Foundation
P.O. Box 1657
Wilkes-Barre, PA 18703
1-800-367-6630
Fax: (717) 825-1987