Diabetes and pregnancy

Definition

Diabetes is a condition in which glucose (a blood sugar that supplies the body with energy) cannot work properly because of a problem with insulin production or use in the body. Insulin is a hormone produced by the pancreas to regulate blood glucose levels. It works like a key that opens the cells in our bodies to accept glucose, thus providing us with energy.

There are two types of diabetes: type 1 and type 2. With type 1, the pancreas produces either little or no insulin to meet the body's needs. With type 2, the body cannot properly use the insulin it produces or produces too little insulin. With both types, the sugar stays in the bloodstream rather than passing into the cells, causing hyperglycemia (high blood sugar), which can damage a variety of body systems.

Pregnancy and diabetes

If you have diabetes and become pregnant, you face a greater risk of developing serious complications during pregnancy. Prepregnancy planning and prenatal care are essential in reducing this risk.

During pregnancy, your body may not produce enough insulin to meet its needs as well as the additional needs of your growing baby. As the baby develops, it needs more energy. As a result, your body needs more insulin to transform sugar into energy. If your blood sugar is higher than normal when the baby is born, the excess sugar is passed on to your infant and may cause medical complications.

During pregnancy, a mother who has diabetes has an increased risk of:

• miscarriage
• pregnancy-induced high blood pressure
• urinary tract, kidney and vaginal yeast infections
• stillbirth, sometimes without an identifiable cause
• preterm birth
• cesarean delivery

The baby has an increased risk of:

• serious birth defects, such as heart, brain, spinal cord, kidney or intestinal malformations
• hydramnios (excessive amniotic fluid)
• macrosomia (excessive weight at birth that can increase the risk of birth injuries)
• insufficient weight at birth
• if born prematurely, breathing difficulty
• low blood sugar after birth
• newborn jaundice (yellowing of the skin or whites of the eyes)
• obesity in childhood and possibly during adult life
• diabetes later in life

Two major factors influence the development of these risk factors, including:

• your ability to control your blood sugar during the three to six months before pregnancy and during the pregnancy itself
• the severity of any blood vessel damage that may have been caused by your diabetes

To reduce the risk of complications, careful prepregnancy planning and prenatal care are essential when you have diabetes. It's important to keep your blood sugar levels normal for several months before pregnancy -- and to maintain this control until your child is born. With proper care, you have nearly the same chances of having a healthy baby as a woman without diabetes.

Signs/symptoms

If your blood sugar level is too high (hyperglycemia), you may experience:

• increased thirst
• frequent urination
• weight loss despite an increase in appetite
• extreme fatigue and lack of energy
• nausea and vomiting
• blurred vision

If your blood sugar level is too low (hypoglycemia), you may experience the following mild symptoms, often with little warning:

• shakiness
• dizziness
• sweating
• irritability
• hunger
• heart palpitations or rapid heartbeat

Moderate to severe symptoms may include:

• headache
• difficulty concentrating or confusion
• poor coordination
• unusual behavior patterns such as stubbornness or uncooperativeness (may resemble a state of intoxication)
• eventually, stupor or unconsciousness

Diagnosis

To help ensure a safe, healthy pregnancy, your doctor may do a number of diagnostic tests before and during your pregnancy. Before conception, you'll have an eye exam and urine studies. If your pregnancy is unplanned, these tests will be done as early in the pregnancy as possible. A blood test called hemoglobin A1C (HgbA1C) can help the doctor determine how well controlled your blood sugar was in the three to four months before conception. The goal for this test is a result less than 7 percent, with 4 to 6 percent considered optimal.

During pregnancy, other tests may include:

• home testing of blood sugar levels four or more times a day
• a maternal serum alpha fetoprotein test (a blood test) at 16 to 20 weeks after conception to indicate the risk of certain birth defects
• an ultrasound (using sound waves to create images of internal body parts) at 16 to 20 weeks to check for birth defects, as well as accurately date the pregnancy
• nonstress tests to monitor your baby's heart rate at least weekly during the third trimester
• HbA1C test at least monthly
• measuring urine ketones (the end product of fat metabolism) each morning
• other tests, depending on the needs of you and your baby

Treatment

Your diabetes may be managed by a team of health care specialists during your pregnancy, possibly including an obstetrician specializing in high-risk pregnancy, an endocrinologist (a doctor who specializes in treating disorders of the hormone-producing endocrine glands), a dietitian, a diabetic educator and a pediatrician specializing in high-risk newborns. Your health care team will design a treatment plan to fit your specific needs, including a combination of proper diet, regular exercise and insulin. The goal of treatment is to keep your blood sugar as close to normal as possible.

Diet

Dietary counseling is an important part of your treatment plan. There are no universal dietary standards for pregnant women who have diabetes. Your doctor will help you plan a diet that takes both your pregnancy and diabetes into account. The required number of calories may need to be adjusted depending on your needs at particular points during the pregnancy. For example, you may need fewer calories during the first 12 weeks of pregnancy.

Starches (breads, grains and starchy vegetables)
Six to 11 servings per day
One serving:

• one slice of bread
• half bagel or English muffin
• one plain rice cake
• six crackers (such as rye crisps or saltines)
• 6-inch tortilla
• 3/4 cup dry cereal
• 1/3 cup rice
• 1/2 cup pasta or cooked cereal
• 1/2 cup corn, cooked beans, lentils or peas
• one small, plain baked potato
• 1 cup winter squash
• 1/2 cup sweet potato or yam

Fruits
Two to four servings per day
One serving:

• one small fruit (apple, orange, banana or peach)
• one melon wedge
• 1/2 cup chopped, cooked, frozen or unsweetened canned fruit
• 2 tablespoons dried fruit
• 1/2 cup fruit juice

Vegetables
Three to five or more servings per day
One serving:

• 1/2 cup cooked or chopped raw vegetables
• 1 cup leafy, raw vegetables
• 1/2 cup tomato or vegetable juice

Milk and yogurt
Two to three servings per day
One serving:

• 1 cup low-fat milk
• 1 cup soy milk
• 1 cup low-fat, unsweetened yogurt

Protein (meat and meat substitutes)
Two to three servings per day
One serving:

• 2 to 3 ounces cooked lean meat or poultry or fish
• 2 ounces cheese
• 1/2 cup tofu
• one egg or equivalent egg substitute
• 2 tablespoons peanut butter

Fats and oils
Fats and oils supply mostly calories and few nutrients, so use them sparingly. Foods in this group include salad dressing, oil, cream, butter, margarine, gravy and cream cheese. One serving is 1 tablespoon of regular salad dressing, 2 tablespoons of light salad dressing, 1 tablespoon of light mayonnaise, and 1 teaspoon of regular margarine or oil.

Sugary foods
Small amounts of sugary foods can be worked into a meal plan as carbohydrates. As with fats and oils, however, sugary foods are low in nutrients and high in fat. Use them sparingly.

Exercise
Exercise can help you stay healthy during pregnancy. Moderate aerobic exercise, such as walking or swimming for 20 to 30 minutes three times a week, can help control your blood sugar. Discuss any exercises with your doctor first, however, because some may not be safe in your situation.

Insulin
It's important to tightly control your blood sugar (keep it as close to normal as possible). Because insulin does not cross the placenta (the structure that develops in the uterus during pregnancy to nourish the fetus), it's safe to take insulin injections while you're pregnant. Oral diabetes medications have not been used during pregnancy due to possible harm to the fetus.

Blood glucose levels and the amount of required insulin tend to be unstable during the first trimester (first three months). The situation often stabilizes during the second trimester, but the need for insulin during the third trimester typically rises steadily. Sometimes, the need for insulin doubles or triples during the third trimester.

Because insulin requirements vary throughout pregnancy, you'll need close monitoring and follow-up. Your doctor will recommend the right amount of insulin to help control your blood sugar. You may need to have several insulin injections each day and measure your blood sugar at home several times a day, often upon awakening, and before or after meals. For some women whose blood sugar cannot be controlled with insulin injections, an insulin pump that delivers insulin automatically according to your changing needs may be recommended.

Labor and delivery

Most pregnant women who keep their blood sugar in the normal range and do not have medical complications can deliver at or near full term. During labor and delivery and in the early postpartum period (after the baby is born), the doctor will closely monitor your blood sugar levels and provide any needed insulin. After delivery, you may not need much insulin for the first days. Your baby will also be closely monitored for low blood sugar levels, jaundice and other possible health problems.

If your doctor recommends an early delivery because of the baby's large size or other complications, the baby's lung maturity will probably be tested. Labor is sometimes induced with medication. In some cases, cesarean delivery may be necessary.

Complications

Hypoglycemia (low blood sugar) is most common during the early weeks of pregnancy, especially between 10 and 15 weeks after conception. It's important for family members and other close contacts to be aware of the signs, symptoms and treatment of hypoglycemia. As listed above, mild symptoms of hypoglycemia -- which can occur with little warning -- include:

• shakiness
• dizziness
• sweating
• irritability
• hunger
• heart palpitations or rapid heartbeat

Moderate to severe symptoms may include:

• headache
• difficulty concentrating or confusion
• poor coordination
• unusual behavior patterns such as stubbornness or uncooperativeness (may resemble a state of intoxication)
• eventually, stupor or unconsciousness

To prevent hypoglycemia, do not miss or delay meals, and keep a source of sugar with you at all times.

In contrast to hypoglycemia, ketoacidosis is an emergency condition that develops when diabetes is uncontrolled. The blood sugar gets too high and there's not enough insulin to move the sugar into cells for energy. To get energy, the body breaks down its store of fat. This process, called ketosis, produces an excessive accumulation of ketones in the blood and tissues. As the level of ketones rises, other chemicals in the body become unbalanced and lead to ketoacidosis. The condition is most common in people who have type 1 diabetes. It's often due to missed doses of insulin, infection or serious illness. Ketoacidosis is associated with a significant infant death rate, but it rarely occurs when the mother's diabetes is controlled.

Prevention

Planning is the essential step to reduce the risk of birth defects and other pregnancy complications. If you're planning to get pregnant, tightly control your blood sugar for at least three to six months before conception -- as well as throughout your pregnancy. If you're taking oral diabetes medications, your doctor will help you replace them with insulin before you conceive. Preconception planning with your doctor and close follow-up throughout your pregnancy can help safeguard you and your baby against complications. Of course, discuss any changes to your diet, exercise or insulin plan in advance with your doctor.