Pregnancy and Diabetes: Risk Factors and Avoiding Complications
Birth Weight
Birth Defects
Death in-Utero and Death Following Birth
Health of the Diabetic Mother
Preventive Measures
Testing
Pre-Conception Counseling
Medical and Advisory Team
Pregnancy requires more insulin in the body than normal because of the increased production of hormones that can lead to insulin resistance.
For a woman suffering from type 1 diabetes this is especially problematic because she already has difficulty producing or responding to insulin. Not only is the mother’s health at risk, but the baby’s health may suffer as well. As insufficient insulin causes blood sugar to rise in the mother, the sugar travels across the placenta to the baby. When the baby’s blood sugar is high, the baby makes extra insulin to keep its own blood sugar normal. Problems of the developing baby may include larger or smaller size, increased risk for malformations or birth defects, or death in-utero. Fortunately, there are several precautions that a woman can take to dramatically decrease the risk of complications.
Large and small birth-weight babies are a significant problem in the deliveries of diabetic mothers. Smaller than usual size typically occurs when the mother has had diabetes for several years and has changes in her blood vessels. On the other hand, the combination of high sugar and high insulin make cause the baby to grow larger than normal. Large birth weight, macrosomia, occurs two to three times more often in diabetic pregnancies as in the general population. Risks of fetal macrosomia include:
Injury to the nerves to the arm called brachial plexus palsy
The collar bone may break, called fractured clavicle
The baby may need more help breathing at birth because it took longer for the head and shoulders to come out.
The doctors may need to use forceps or a suction cup to help with delivery
Due to the increased risk of fetal macrosomia, women with diabetes are three to four times more likely to have a cesarean section.
If a diabetic woman does not receive preconception care to regulate blood sugar levels, the rate of major congenital malformations in women with preexisting diabetes is ten percent vs. zero to five percent for women who receive preconception care. Other birth defects frequently associated with diabetes include eye defects, respiratory tract defects, cleft palate, anal atresia/stenosis, hypospadias, urinary tract defects, and positional defects of the foot. The most common birth defects include damage to the heart and central nervous system.
Babies of a diabetic mother face an uphill battle for survival. The physician must closely monitor a diabetic woman during pregnancy for death in-utero. If the child makes it through delivery, three to five percent of pregnancies among women with diabetes result in death of the infant within twenty-eight days. In contrast, one and a half percent of women who do not have diabetes lose their newborn during this same time frame.
After birth, infants of diabetic mothers commonly have low blood sugar, breathing problems such as Respiratory Distress Syndrome and Transient Tachypnea, Polycythemia, and Meconium Plug.
The health of the diabetic woman is also at risk as a result of her pregnancy. These women are up to five times as likely to develop toxemia, a disorder of unknown cause whose symptoms include hypertension, protein in the urine, edema, headache, and visual disturbance. Diabetic women are also five times as likely to develop a condition called hydramnios which involves excessive amounts of amniotic fluid as women without diabetes.
The good news is that perinatal and neonatal centers that provide preconception counseling and early prenatal care report that the risks for diabetic mothers and their newborns do not exceed those for women without diabetes. But, a diabetic woman must carefully plan her pregnancy and must take adequate birth control measures to avoid pregnancy until she is medically ready to carry a child. It is recommended that a woman obtain good blood sugar control three to six months before getting pregnant. The main problem is that many women do not know they are pregnant until the baby has been growing for two to four weeks. For the diabetic woman this in unacceptable because blood sugar levels during these early weeks affect the baby’s organs and can lead to birth defects. A blood test called the glycosylated hemoglobin test (HbA1c) evaluates how well diabetes has been controlled. This test is used along with home glucose monitoring to make treatment adjustments. Other tests such as a urinalysis to screen for diabetic kidney complications, cholesterol and triglyceride blood tests, and an eye exam to screen for glaucoma, cataracts and retinopathy may also help prevent the development of diabetic complications during pregnancy.
Pre-conception counseling is also another necessary step to prepare for pregnancy. A preconception appointment typically includes:
An evaluation of weight with the goal of reaching an ideal body weight before becoming pregnant.
A discussion of lifestyle such as smoking and drinking habits.
An evaluation of diet and a discussion of appropriate prenatal vitamins.
Managing diabetes medicines during pregnancy (Generally, more insulin is required during pregnancy, especially during the last three months).
Meal planning to help avoid problems with low and high blood sugar levels.
Exercise planning to help control blood glucose and stay fit.
Monitor planning to ensure that the mother regularly checks blood glucose and urine ketones and acts upon when needed.
Because a diabetic has special needs, her medical and advisory team will need to be well versed in diabetic-specific issues related to pregnancy. The doctor will need to have training to care of pregnant women with diabetes; the obstetrician will need to know how to handle high-risk pregnancies including diabetic women, a pediatrician or neonatology who knows and can treat special problems that can happen in babies of women with diabetes, a registered dietitian who can modify meal plans as needs change during and after pregnancy; and a diabetes educator who can help the diabetic women manage diabetes during their pregnancy.
The key to a healthy pregnancy for a woman with diabetes is keeping blood sugar in the target range, both before she is pregnant and during her pregnancy. With blood sugar in the target range and good medical care, chances of a trouble-free pregnancy are almost as good as they are for a woman without diabetes. However, for women with poor diabetes control, the risks of problem pregnancies, birth defects and ill health are tremendous and have devastating consequences.
Bibliography
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WebMD, 11 Oct. 2003. http://my.webmd.com/content/article/15/2971_110.htm?lastselectedguid={5FE84E90-BC77-4056-A91C-9531713CA348}
Correa, Adolfo, Botto, Lorenzo, Liu, Yecai, Mulinare, Josephh, and Erickson, J. David.,
Do Multivitamin Supplements Reduce the Risk for Diabetes-Associated Birth Defects?,” Pediatrics 111 (May 2003): 1146-51.
Diabetes and Pregnancy.” American Diabetes Association. 11 Oct. 2003. http://www.diabetes.org/type1/living/sex_pregnancy/diab_pregnancy.jsp
Diabetes and Pregnancy.” American Medial Network, 11 Oct. 2003. http://www.dental.am/eng/diabetes/6.html
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Infant of a Diabetic Mother (IDM).” University of Wisconsin Medical School Department of Pediatrics, 11 Oct. 2003. http://www.pediatrics.wisc.edu/childrenshosp/parents_of_preemies/IDM.html
Diabetes Facts.” U.S. Food and Drug Administration, 11 Oct. 2003. http://www.fda.gov/womens/taketimetocare/diabetes/fswomen.html
Correa, Adolfo, Botto, Lorenzo, Liu, Yecai, Mulinare, Josephh, and Erickson, J. David., “Do Multivitamin Supplements Reduce the Risk for Diabetes-Associated Birth Defects?,” Pediatrics 111 (May 2003): 1146-51.
Diabetes Facts.” U.S. Food and Drug Administration, 11 Oct. 2003. http://www.fda.gov/womens/taketimetocare/diabetes/fswomen.html
Infant of a Diabetic Mother (IDM).” University of Wisconsin Medical School Department of Pediatrics, 11 Oct. 2003. http://www.pediatrics.wisc.edu/childrenshosp/parents_of_preemies/IDM.html
Diabetes Facts.” U.S. Food and Drug Administration, 11 Oct. 2003. http://www.fda.gov/womens/taketimetocare/diabetes/fswomen.html
Diabetes Mellitus.” Merck. 11 Oct. 2003. http://www.merck.com/pubs/mmanual/section18/chapter251/251g.htm
Diabetes and Pregnancy.” American Diabetes Association. 11 Oct. 2003. http://www.diabetes.org/type1/living/sex_pregnancy/diab_pregnancy.jsp
Diabetes and Pregnancy.” American Medial Network, 11 Oct. 2003. http://www.dental.am/eng/diabetes/6.html
Caring for Diabetes During Pregnancy.”
WebMD, 11 Oct. 2003. http://my.webmd.com/content/article/15/2971_110.htm?lastselectedguid={5FE84E90-BC77-4056-A91C-9531713CA348}
Diabetes and Pregnancy.” American Diabetes Association. 11 Oct. 2003. http://www.diabetes.org/type1/living/sex_pregnancy/diab_pregnancy.jsp
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