Diabetes and Pregnancy

Diabetes and Pregnancy

    For women with diabetes mellitus, pregnancy poses challenges for both the mother and the baby. Diabetes in pregnancy falls into two main categories: those who are known to be diabetic before conception (pre-gestational diabetes) and those in whom diabetes is discovered during pregnancy (gestational diabetes). Women with established diabetes may have menstrual problems and difficulty in conceiving. Dr Anand Gokani, consultant diabetologist, explains, "While planning a pregnancy it is important for a diabetic woman to have very good blood sugar readings for at least one month prior to conception (glycosylated Hb (HbA1c) <7.5%). In fact if the husband is diabetic and the mother is not, the blood sugar in the husband should be similarly controlled for at least a month prior to conception. Conception at the time of good control is conducive to a healthy and normal child."
Gestational Diabetes Mellitus (GDM) becomes clinically apparent only during diabetes and can happen at any stage of the pregnancy. Dr Prema Kania, consultant gynaecologist, says, "The increasing incidence of diabetes in pregnancy maybe due to increasing obesity, lower levels of physical activity and probably exposure to diabetes in utero." Dr Gokani explains, "During pregnancy there are certain factors that are operational like stress, hormones like estrogens, progesterone, human chorionic gonadotropin, thyroxin, growth hormone, all of which tend to increase the blood sugar levels."
    Dr Kania says, "During pregnancy the nutritional demands change as does the metabolism. The basal glucose production increases and insulin sensitivity decreases (due to the pregnancy hormones) raising the chances of diabetes." Modern living, family history of diabetes, increasing dependence on sugar, refined foods, aerated drinks, canned, preserved and fried foods, stressful lifestyles, lack of rest, sedentary lifestyles, alcohol and tobacco abuse are all possible triggers to developing diabetes during pregnancy.
    Dr Gokani stresses, "Every pregnancy should be screened for GDM without compromise. The blood sugar, fasting and 2 hours post meal, should be checked immediately on detecting the pregnancy, at 20 weeks, 30 weeks and 40 weeks. If the blood sugars are above the normal values, all measures to treat diabetes should be instituted."
    Dr Gokani says, "The first three months after conception are the months when the organs are forming. If at that time the maternal blood sugar levels are high, there is a serious risk of malformation in the foetus. The second and third 3 months of the pregnancy are for growth, uncontrolled diabetes in these six months will not cause organ damage but will cause the foetus to grow large (macrosomia), which can hamper normal delivery".
    "Diabetes, if not properly controlled during pregnancy, can also lead to an increased risk of pre-eclamsia, renal problems, retinopathy, skin infections and extremely low or high sugar levels which can in turn cause ketoacidosis in the mother. Risks for the baby include higher rate of first trimester abortions, foetal growth restriction in the uterus (small baby), large baby, premature delivery, greater tendency to develop hypoglycaemia, low calcium levels, high bilirubin levels and polycythemia, still birth due to sudden intrauterine death due to placental insufficiency and a high level of morbidity and mortality," cautions Dr Kania.
    Treatment: Treatment measures would include diet control, regular exercise and if blood sugars are not normal then insulin is the best and only option. Dr Gokani says, "Oral medications are absolutely contra-indicated during pregnancy and while the mother is breastfeeding. Even though some research has suggested that metformin, glibenclamide, glimepiride, glipizide maybe safe in pregnancy, it is wise to stay away from these medications as even the slightest risk of teratogenecity is avoidable. The other oral diabetic medications are unsafe in pregnancy."
    He adds, "Conventional insulin has been proven to be both efficacious and safe. It would be by far the medication of choice for the control of diabetes. The insulin analogues have so far been safe but need to be watched for a while more to prove their safety unequivocally."
    Dr Gokani explains, "The availability of pen devices have made insulin injections simple and relatively 'pain free'. In high risk pregnancies and in those who are highly motivated, the insulin pump could be used to facilitate 'near normal' blood sugar control."In pregnancy, all types of diabetes are a concern. The key to a healthy pregnancy remains good glucose control, a healthy diet, exercise, and medications, if needed.