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Planning and taking care of your pregnancy

Pregnant women with diabetes are classified into two categories: those who had diabetes before pregnancy and those whose diabetes develops during the pregnancy, which is called gestational diabetes. Gestational diabetes goes away after the baby is born.

Because of possible harm to the baby, women with diabtes who plan to become pregnant must work with their doctor and diabetes team to keep their diabetes under careful control. With insulin for those who need it and the tools for good blood glucose control, we can lower the risks to both mother and baby. Careful control before and during pregnancy is crucial.

For Preeexisting Diabetes
Both type 1 and type 2 diabetes can affect the baby's development in the womb. In African American women over age 30, type 2 diabetes complicates pregnancy more often then type 1 diabetes. In general, the better the diabetes control of the mother, the fewer complications in the baby. Poor diabetes control appears to cause birth defects in the developing baby in the first few weeks after conception. Later in the pregnancy, high blood glucose levels result in other complications: large babies, babies whose lungs do not work properly after birth, and babies with hypoglycemia after delivery. These problems can result in a difficult birth, longer hospital stays for the baby, or, in worst cases, death of the baby.


What can go wrong

Miscarriages occur more often in women with preexisting diabetes. Another major concern is birth defects, which occur as the baby develops in the womb. The way to handle these scary stadistics is to get your diabetes under excellent control before you become pregnant. Careful blood glucose control before pregnancy can dramatically decrease the risk of birth defects. The risk of these problems occurring in a woman with excellent blood glucose control is less than 5 percent, close to the risk in a woman who does not have diabetes. This means that, with careful diabetes care, the risk to your baby will be little more than the risk of any pregnant woman.

Your baby's major organs heart, brain, kidneys are already formed 6 weeks into your pregnancy (the 8th week after your last menstrual period). Poorly controlled diabetes in the early weeks of pregnancy, often before a woman even knows that she is pregnant, greatly increases the risk of either a miscarriage or a baby with a major malformation. There is a connection between glycated hemoglobin level and the risk of miscarriage and birth defects: the higher mother's glycated hemoglobin, the higher the risk to the baby's health.


Counseling should begin early

Because of the possible risks for both mother and child, some doctors begin prepregnancy counseling around the time of a young woman's first menstrual period, when she is 11 or 12 years old. Women in their child-bearing years, and teenagers in particular, should regularly discuss contraceptive nedds and any concerns about future pregnancy with their health care team.


Medications you can't take

There are medications you cannot use during pregnancy. These include all the oral medications for diabetes, including sulfonylureas, metformin (Glucophage), and acarbose (Precose). You will need to stop using these drugs before you get pregnant. You must consult with your doctor about this. Your doctor may switch you to insulin for the time that you are pregnant. Antidepressants or other medications may also need to be discontinued during the pregnancy, so you should tell your doctor about every medication you're taking, including over-the-counter drugs.


Measuring the risks

To determine the risks to both you and the developing baby, you will need some tests. You'll be examined by an ophthalmologist or optometrist (because retinopathy may worsen during pregnancy), have microalbuminuria and kidney function checked, and have an electrocardiogram (ECG). Your glycated hemoglobin should be tested regularly, and you will need to learn SMBG for testing at home. Some pregnant women may test as often as 8 times a day to maintain good control.


Reviewing the treatment plan

Blood glucose control is crucial for a healthy pregnancy for mother and child. If you have type 1 diabetes and care considering pregnancy, you need to understand all of the pinciples of intensive diabetes management nutrition counseling, frequent SMBG, regular exercise, and how to adjust insulin doses as needed. You will need to see a dietitian and also get advice about your exercise program before you become pregnant.


Stress

Pregnancy may cause tremendous emotional stress for some women. Your relationship with your partner can relieve the stress or make it worse, and the doctor may ask questions about this. In some situations, you may see a mental health professional, especially if you have a history of depression and your antidepressants are discontinued during the pregnancy. Financial stresses must also be considered, Pregnancy for a woman with type 1 diabets can be quite expensive, and it's best to deal with questions about insurance coverage before you get pregnant.


Life expectancy and complications

One of the most common questions women with diabetes ask is how pregnancy affects their life expectancy. The answer for women with type 1 diabetes is there appears to be no affect, except for those with known coronary artery disease. Pregnancy is not usually life threatening. However, women with diabetes do have a greater risk for the following complications:

Ketoacidosis a life threatening emergency. The body burns fats when it can't get enough glucose (you're not eating enough or not taking enough insulin). Ketones, a waste product of the breakdown of fats, are acids than can be extremely dangerous in large quantities.

Preeclampsia high blood glucose pressure caused by pregnancy, which can pose risks to both mother and developing baby.

Cesarean sections-partly because diabetic women tend to have large babies.


Eye problems

Stable proliferative retinopathy that has been treated with laser therapy and nonproliferative retinophaty do not usually get worse during pregnancy. If you don't have diabetic retinopathy, you probably will not develop it during pregnancy. On the other hand, active proliferative retinophathy that has not been treated with laser therapy may get much worse during pregnancy. That's why it's best to wait until the retinophathy has been treated and is stable before trying to get pregnant.


Kidney disease (nephropathy)

The effect pregnancy has on nephropathy depends on how damaged the kidneys are. Women with protein in their urine, but normal kidney function, may find that their kidneys get worse during pregnancy-they will return to normal after the baby is born. More advanced kidney disease can be harmful to the mother and baby, causing complications such as early delivery and a smaller-than-normal baby. Signs that these complications might occur are:

•  more than 3 grams of protein in the urine per day in the first trimester or more than 10 grams per day in the third trimester
a serum creatinine (measure of kidney function) level greater than 1,5 mg/dl at the start of pregnancy
high blood pressure
severe anemiaanemia severa


Home testing is essential

Blood glucose goals. Your blood glucose goals during pregnancy should be as close to a nondiabetic woman's glucose levels as possible. This is often difficult because insulin requirements commonly go down by 10-20 percent. But, after 18-24 weeks of pregnancy, insulin requirements usually increase. In addition, blood glucose control is difficult with morning sickness. You may take your insulin, but if the food doesn't stay in your stomach, and this creates a risk for hypoglycemia. Vomiting can also cause ketosis-the accumulation of the acids known as ketones-wich can be dangerous and must be avoided during pregnancy. That is why pregnant women with preexisting diabetes often need to monitor their blood glucose levels 8 times a day to reach their targets (see Table 6-1). You want your glycated hemoglobin to be in the upper range of normal. For example, if the normal range for glycated hemoglobin is 4.0-6.0 percent, the goal for a diabetic pregnancy would be 6.0 percent. The glycated hemoglobin level should be measured every 4-6 weeks to check on your diabetes control.

Ketones in the urine. The other important test that needs to be done at home is testing for urine ketones. If you don't eat enough.


Table 6-1
Blood Glucose Goals in Diabetic Pregnancy

Fasting 60-90 mg/dl
Premeal 60-105 mg/dl
1 hour postmeal 110-130 mg/dl
2 hours postmeal 90-120 mg/dl
2-6 AM 60-120 mg/dl


Calories for your and the growing baby's needs, you may find ketones in your urine, which is a sign of starvation. Ketones in the urine are also in the blood and may be dangerous to the developing nervous system of the baby. Yoy may need to make changes in diet or insulin or both. Ketones are most likely to be present when you first wake up, because this is the longest period you go without food. This is an important time to test. Your doctor will tell you what levels to watch for. Urine ketone testing is also important if you miss a meal or eat later than usual, with any illness, or with any blood glucose test above 200 mg/dl. Ketones in the urine (called ketonuria) may be the first sign of an infection preceding ketoacidosis. Ketoacidosis usually develops gradually, so be on the lookout for symptoms of it. Mothers with ketoacidosis have a 50-90 percent chance of losing the baby.

ADA published guidelines in 1996 for how often women with preexixting diabetes should have certain tests during pregnancy (Table 6-2). Routine thyroid function testing is also recommended for women with type 1 diabetes because it is so common for them.


Table 6-2
Frequency of Testing During Pregnancy for Women With Preexisting Diabetes

Test Frecuency
Glycated hemoglobin Every 4-6 weeks
Glucose Fingerstick at home, 4-8 times daily
Fasting ketone Daily
Kidney function: 24-hour urine for total protein and creatinine clearance Each trimester
Eye status 1 st trimester and then as necesary
Thyroid function Baseline; repart as needed

Gestational Diabetes
Diabetes that develops during pregnancy is called gestational diabetes. Two to 3 percent of pregnant women are diagnosed with gestational diabetes.


When to test ?

ADA recommends that all pregnant women be screened for gestational diabetes at 24-28 weeks after conception. This does not need to be a fasting test. If your blood glucose 1 hour after drinking the 50-gram glucose drink is above 140 mg/dl, you will be asked to take a 100-gram-3-hour oral glucose tolerance test (Table 6-3). The 3-hour-test is done after an overnight fast of 8-14 hours and after 3 days of carbohydrate loading. The test is designed for these conditions and, if it is not done this way, it will give inaccurate results. During these tests, your blood glucose must be measured by a lab, not by a fingerstick glucose measurement with a meter. The lab cheks plasma glucose, while the fingerstick test you do at home checks blood in the small blood vessels called capillaries.


What can go wrong?

Fortunalety, if gestational diabetes is diagnosed and managed, nothing much goes wrong. However without proper care during pregnancy, women with gestational diabetes may have some problems. The two most common complications are large babies and hypoglycemia in the baby immediately after birth. The baby will need to be given glucose in a vein. These complications occur because from the mother the glucose freely crosses the placenta and causes the developing baby to secrete extra insulin. With extra glucose and insulin, the baby gains more weight than usual. The baby's extra insulin causes hypoglycemia after birth because the glucose from the mother has been turned off.


Table 6-3
Criteria for Diagnosis of Gestational Diabetes

Time of Testing Basal 1 hour 2 hours 3 hours
Plasma Glucose 105 mg/dl 190 mg/dl 165 mg/dl 145 mg/dl

Gestational diabetes is diagnosed if 2 or more of these plasma glucose levels are met or exceded.


Goal 1: normal blood glucose

If you have gestational diabetes, your first goal is to achieve normal blood glucose levels. These may be defined as:

•  fasting plasma glucose below 105 mg/dl
1 hour aftermeal plasma glucose bellow 140 mg/dl (this test is done in the table)
2 hours aftermeal blood glucose bellow 120 mg/dl

Goal 2: eating well

The second goal is to eat enough good foods. Your food choices should include all for the essential nutrients the baby needs plus all you need to maintain good health. You want the weight you gain to be healthy weight, and you want to avoid ketonuria.

Your doctor may consider putting you on insulin if your meal plan does not bring your fasting blood glucose bellow 90 mg/dl or 1 hour aftermeal blood glucose bellow 120 mg/dl most of the time. If you are starting insulin for the first time, a qualified diabetes educator should teach you how. You'll need to know the basic timing and action of insulin, how to give yourself injections, adjustments to make to your meal plan, and how to recognize and treat hypoglycemia.


Will it reoccur?

If you have had gestational diabetes once, you have a 65 percent chance of developing it in future pregnancies. Also, your chance of developing type 2 diabetes in the next 5-15 years ranges from 40 to 60 percent. It is recommended that every woman who has had gestational diabetes have weaned the baby, you will want to lose the weight you gained with the pregnancy. Returning to a healthy weight and getting regular exercise will help you prevent getting type 2 diabetes in the future.

Healthy eating for a Healthy Infant
Meal planing is the most important part of gestational diabetes therapy. You should develop your own meal plan with a dietitian, but these are recommendations for everyone:
•  Avoid sweets. This includes candy, pastries, soft drinks, cookies, and ice-cream. They give you few nutrients but a lot of calories.
Avoid convenience foods, such as hamburgers, fries, and pizza, because they tend to be high in fat.
Eat 5 or 6 small meals instead of 3 big ones-this keeps aftermeal blood glucose levels down and may help with nausea and heartburn, common complaints during pregnancy.
Protein foods are absorbed more slowly than carbohydrates like bread, potatoes, starchy vegetables, beans, pasta, and fruit. Good choices include low-fat meats such as turkey, chicken, or lean beef; tofu; low-fat yogurt or cottage cheese; fish; and legumes (dried beans and peas).
Choose high-fiber foods such as whole-grain breads, oatmeal, beans, and raw fruits and vegetables. They cause blood glucose to rise more slowly after a meal.
Limit fatty foods such as pastries, sausage, bacon, butter, salad dressing, and nuts. Per gram, they have twice as many calories as protein or carbohydrate. They make you and the baby gain weight and can cause higher blood glucose levels.

Avoiding Unplanned Pregnancies
Because an unplanned pregnancy could be so devasting to a woman with any type of diabetes, contraception is crucial. There is no best method for all women with diabetes. Each has advantages and drawbacks.


The pill

Oral contraceptives (birth control pills) contain either estrogen plus progestin or progestin only. The combination pill can increase your insulin requirement and raise your blood pressure. Today, oral contraceptives have lower doses of hormones than in the past. However, the estrogen in some pills may increase the risk of a blood clot in a vein, a stroke, or a heart attack, particulary in older women and those who smoke. If you smoke or are older than 35, you should avoid contraceptives that combine estrogen and progestin. High blood pressure is also considered a reason not to use control pill that contains estrogen.

If a combined contraceptive is used, ask about one with a low dose of estrogen (less than or equal to 35 micrograms) and a low dose of progestin. The progestin-only pills do not have a great risk associated with a progestin called norgestimate and low levels of a synthetic estrogen seems to work best for women with diabetes.


Norplant

The Norplant system is another option. Six small capsules inserted under the skin of the upper arm release progestin slowly ans steadily. The capsules may be effective for 5 years. The major disadvantage is irregular menstrual periods in one in four women. It will change your insulin requirements, and you will need to check with your health care team often to make insulin adjustments.


Depo-Provera

Depo-Provera, a progestin, is injected every 3 months and is highly effective. Irregular bleeding may be troublesone at first, but after 1 year of use, most women cease having menstrual periods. Your insulin requirements will change, and you will need to make insulin adjustments with your health care team.


Diaphragm

The diaphragm, when used correctly with spermicide jelly, carries no medical risks. It is a barrier method of birth control. This method could be 98 percent effective if women use it correctly. This method is frequently chosen by women with diabetes who want to delay childbearing or the time between babies and are not ready for permanent sterilization methods.


Condoms

The condom, used with spermicidal foam, is another barrier method and is about as effective as the diaphragm. Latex condoms also offer protection against a number of sexually transmitted diseases.


Other options

Table 6-4 gives information about birth control options. Intrauterine devices (IUDs) are effective, but one study indicated a higher failure rate in women with diabetes than in women who did not have diabetes. There is also a risk of pain, irregular bleeding, perforation of the uterus, and infection. Because of the risk of infection, IUDs are not usually recommended for women with diabetes. The rhythm method has an effectiveness rate of 75-80 percent-not reliable enough to recommended for women with diabetes.


Table 6-4
Contraceptive Methods for Diabetic Women

Class Type Effectiveness
Oral contraceptive Combined estrogen and progestin 98 %
Progestin only 94 %
Norplant System 99 %
Depo-Provera 99 %
Barrier methods Diaphragm + spermicide 98 %
Condom + foam 88 %
Intrauterine devices Progesterone containing 97 %
Copper containing 97 %
Rhythm 80 %
Sterilization +99 %


Permanent methods

If you are sure you will not want any more children, you may choose to have your tubes tied, or your partner may opt for a vasectomy. In particular, women with advanced complications of diabetes, such as kidney or eye disease or nerve damage, may choose one of these options. With advanced complications, pregnancy is often more difficult. With advanced kidney disease, it is extremely difficult.
By Irl B. Hirsch MD
Associate Profesor of Medicine Medical Director of the Diabetes Care Center
University of Washington School of Medicine in Seattle.
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