Diabetes and Pregnancy
Women who know they are diabetic should get themselves into the best shape possible, even before trying to get pregnant. They should be under the care of someone who understands the needs of diabetics during their child-bearing years. A “preconception checkup” is essential. There is a lot of research showing that poorly-controlled diabetes before pregnancy is associated with a higher risk of congenital abnormalities, as well as the death of the baby soon after birth. If diabetes is controlled before and during your pregnancy, the risks will go down significantly, but are still higher than in women without diabetes.
In addition to finding out how well-controlled a woman’s diabetes is, the preconception checkup, which includes laboratory tests, let the doctor know whether or not she has other diseases associated with diabetes, such as heart disease. Some conditions, such as high blood pressure, may need to be treated before pregnancy, and will continue to be treated during pregnancy. Other conditions will be monitored closely, including any damage to the kidneys or the back of the eyes.
Ideally, pregnant diabetic women should be followed by a team specializing in their care. This would include an obstetrician experienced in managing high-risk pregnancies. Other team members might include a doctor specializing in the care of diabetics, a dietitian, and a nurse.
Both type 1 and type 2 diabetics must have their sugars controlled. Type 1, or insulin-dependent diabetes, is due to a lack of insulin and is treated with insulin. Type 2 diabetes is caused by insensitivity to insulin, as well as a relative lack of insulin. It is usually managed by diet and oral medications, but is often treated with insulin during pregnancy.
There is another group of women who only have diabetes during pregnancy, called gestational diabetes. This is discovered by doing an oral glucose tolerance test during the middle of the pregnancy. Whether or not, and when, to do this test depends on the woman’s weight and her personal and family history, which might point to a risk of diabetes. Some doctors screen all their pregnant patients for gestational diabetes. Those who have it may be able to control their blood sugars with diet and exercise. Those who still have elevated blood sugars may need insulin or an oral agent.
If you are pregnant and have diabetes, your insulin dosage must be carefully adjusted and your blood sugars monitored. Elevated blood sugars are risky for both the mother and the baby. If blood sugars are near normal when pregnancy begins, and this continues throughout the first three months, the risks to mother and baby are the lowest possible. Very high blood sugar early in pregnancy significantly increases the risk of a miscarriage, as well as congenital abnormalities.
Low blood sugar is also very dangerous. For this reason, blood sugar control should be good, but the ideal sugars should not be quite as low as in women who are not pregnant. Insulin will be given by multiple daily injections in order to adjust to the dose as needed. An insulin pump may also be used.
Patients with type 2 diabetes may be told to stop their oral medicine and start insulin before getting pregnant, or if they are already-pregnant and on oral medicine, they are often switched to insulin. (One oral medication that can be continued is metformin.) Some of the other oral medications used to treat type 2 diabetes may cause damage to the fetus. There are studies going on to discover if any of them are safe. It is harder to adjust dosages of oral medication than insulin, which is another reason insulin may be used.
To best control blood sugar, as well as manage weight gain, pregnant women need the help of a dietician. Eating the right amount and types of food and getting appropriate exercise are very important.
The size of the growing fetus will be watched carefully. Because babies born to diabetic mothers can be abnormally large, delivery is usually suggested at 38 weeks of pregnancy. This may be by induced labor or C-section. Blood sugars must be monitored and insulin used as necessary during labor, delivery, and afterward.
The most important thing for women with diabetes to remember is that getting their blood sugars under control before they try to conceive will greatly affect the outcome of their pregnancy.