Women who manage their diabetes well during pregnancy can have a relatively normal pregnancy and give birth to a healthy baby.
There is an alarming incidence of diabetes in women in India. So much so that Indian women are 11 times more likely to develop gestational diabetes than Caucasians. While some women are known diabetics when they conceive, others are diagnosed as diabetic for the first time when they are pregnant. This condition, wherein pregnant women are reported to have high blood sugar levels (for the first time) during pregnancy is called gestational diabetes.
Diabetes has adverse effects on both the mother and the baby. The risk factors can be short term to long term. Miscarriages, pre-eclamsia, preterm births, sudden intra-uterine deaths, and operative and traumatic deliveries are more common in these women. Moreover, babies born to these women have a high risk of congenital abnormalities, birth trauma and neonatal complications ranging from prematurity, respiratory distress syndrome, hypoglycaemia, and jaundice along with other neonatal problems including death. The long-term maternal and foetal adverse effects include obesity and development of glucose intolerance and diabetes later in life. All pregnant women should be screened for diabetes.
High risk factors
Some women have a higher risk of developing diabetes in pregnancy than others. Some of the high risk factors include obesity, age, history of diabetes in previous pregnancy, family history of diabetes in a close relation, big baby, polyhydramnios, still birth in the current pregnancy or in a previous pregnancy.
Diabetic control achieved after conception fails to reduce the congenital malformation rate. The first week of pregnancy is the time for foetal organogenesis (organ formation). A high sugar level in the maternal blood during this time is detrimental to this process and may lead to structural defects of the central nervous system and as well as the baby’s heart. An optimal control of diabetes around this time is crucial in reducing congenital malformation and spontaneous miscarriage in pregnant diabetics.
As women mostly consult their doctors a few weeks after missing a period (i.e. six to eight weeks from the last menstrual period) (hey miss the opportunity of giving a normal glucose environment to the developing foetus in early weeks.
Thus all pregnancies in diabetic women should be planned. Conception should occur only when diabetes is well controlled and medication is changed to the one appropriate* for pregnancy, wliich is usually insulin. In the case of pregnancy with diabetes, a team approach is strongly recommended involving an obstetrician, an endocrinologist, a dietician and a midwife. Women are counselled on the effect of diabetes on pregnancy, the need for a tight control of diabetes before and throughout pregnancy by a controlled diet, regular physical activity, frequent monitoring of I heir blood sugar and insulin injections, and regular follow-ups with the doctor. Women with diabetic kidnev mid retinal disease are warned of possible deterioration of their condition.
A ‘go ahead’ for conceiving is decided by the woman and her gynaecologist after a thorough workup and counselling.
Ideal blood sugar lev-els are 00-90 mg per cent in the fasting state and 100-120 mg per cent two hours after a meal. The HbAlc should be in the normal range.
Management during pregnancy
As mentioned earlier, diabetic pregnancies are managed by a team of experts including an obstetrician, endocrinologist, dietician and a midwife. A close ante-natal surveillance of the mother and the baby allows most pregnancies to reach full-term.
The mother is supposed to take extra care of her health. She should be aware of any warning sign or symptom. Feeling sick, headache or abdominal pain, or not feeling enough movements of the baby should never be ignored. Always set your doctor’s number on your mobile’s speed dial. Go for frequent blood sugar monitoring. Another point to keep in view is that with advancing pregnancy, requirement usually increases. Sudden death of the baby in pregnancy is not only tragic but also dangerous for your life. So educate yourself well on these areas.
Miscarriages, pre-eclamsia, preterm births, sudden intra-uterine deaths, and operative and traumatic deliveries are more common in diabetic women. Moreover, babies born to these women have a high risk of congenital abnormalities, birth trauma and neonatal complications ranging from prematurity, respiratory distress syndrome, hypoglycaemia, and jaundice along ith other neonatal problems including death.
Seek early consultation with an obstetrician and an endocrinologist after missing a menstrual cycle. The aim is to keep a check on one’s sugar levels. Early pregnancy nausea and vomiting may turn an otherwise controlled diabetes into an uncontrolled one causing hypoglyeaemic (low blood sugar) episodes. A pelvic ultrasound is performed to confirm a live ongoing pregnancy, ascertain the number of foetuses and gestational age, to exclude a major abnormality like aneneephaly (absence of the baby’s skull) and for Down Syndrome (chromosomal abnormality) screening. Detemtination of the length of pregnancy in early pregnancy is especially important as later, maternal hyperglycaemia may lead to macrosomia (big baby) and any calculation based on the baby’s measurements then will be misleading.
Diabetes in pregnancy is common with its short and long-term consequences to both the mother and the baby. The key to successful management of pregnancy is a tight control of maternal blood sugar levels prior to and throughout pregnancy.
Maintaining a good control of blood sugars and the general health including nutrition and weight gain, the mother is watched tor pregnancy induced hypertension and pro-eclampsia. An ultrasound examination is performed for a detailed examination of the baby for abnormalities.
More frequent ante-natal visits and blood sugar monitoring is required. A careful watch on the general health, the onset of pregnancy induced hypertension and pre-eclampsia, and pre-terra labour is maintained along with the baby’s growth. As clinical estimation of the baby’s growth has its own limitations, an assessment by serial ultrasound is recommended. Generally, a good control of diabetes throughout pregnancy is unlikely to lead to a maerosomic (big) baby. A big baby is at a higher risk of complications. The mother is asked to report if she notices any abnormality in her baby’s movements.
Planning for delivery
If diabetes is well managed, the baby is generally of an average weight and there is no obstetric indication for a caesarean section. There is no need to interfere with pregnancy before term, and a spontaneous onset of labour followed by a vaginal delivery is planned. However, owing to the risk of sudden intra-uterine death and the obvious advantages of having delivery in the daytime when maximum support of senior medical (including a neonatologist) and paramedical si all’is available, it will be justified to plan the delivery at 38 weeks provided the gestational age is well established: by induction of labour if the cervix is favourable or by a planned caesarean section after a good discussion with the mother so that she can take an informed decision.
The labour should always be conducted in a hospital where monitoring facilities for both mother and the foetus, and neonatal ICL* are present. The regular dose of insulin is omitted and a tight, sugar control is maintained with intravenous fluids and insulin as and when required. The baby’s well being is continuously monitored by eardiotocogrphy ((‘T(J). The progress of labour is monitored by regular checkups. Pain relief is offered including epidural analgesia. An emergency caesarean section is performed if indicated.
Breastfeeding is encouraged. Usually the insulin requirement showTs a dramatic decline after delivery. The diet, physical activity and diabetic care continues as before.
It is better to have pregnancies before vascular complications of diabetes develop. Thus, completing a family within the first 10 years of diagnosis of diabetes is desirable. The contraceptive choices for a well-controlled diabetic woman without complications range from barrier methods through intrauterine devices and low dose oral contraceptive pills to sterilisation. A woman who has complicated diabetes, can still find a right contraceptive for her after discussing with her doctor.
There’s an urgent need to educate women and their families on the adverse effects of the disease on them and their offspring, and proper counselling on how to manage their disease best to minimise the adverse effects. A well-managed diabetic pregnancy can be as smooth as that of a normal pregnancy.
Women who are diagnosed of fist time during pregnancy shouldi carefully follow up as 10 per cent of these women are likely to develop diabetes later in life.
By Dr Ranjana Sharma
Dr Raujana Sharma is Sr Consultant, Obstetrics & Gynaecology, Indraprastha Apollo Hospital, New Delhi.
Source: Diabetic Living India – November 2011/January 2012
Republished by Blood Glucose