Great Expectations

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Not even 20 years ago, it was uncommon fora woman with diabetes to choose to havechildren of her own. Many doctors discouragedattempting pregnancy based on the highincidence of complications that both a mother and aninfant could suffer due to poor blood glucose control.

Complications of pregnancy can now be avoided withminimal risk to mother or baby as long as appropriatesteps are taken prior to and during the pregnancy. Infantsurvival rates for pregnant women with diabetes are nownearly identical to those for nondiabetic women.

While it is much more likely today that a womanwith diabetes will have a healthy pregnancy, risks arestill an issue. Poorly controlled diabetes prior to andduring pregnancy increases the risk of birth defects andmiscarriages. Uncontrolled blood glucose can lead to thebaby being too large (macrosomia) because extra glucosecrosses the placenta. This makes delivery hard on bothmother and child.

The baby may have problems with low blood glucoseat birth as its pancreas has been making extra insulinto compensate for all the extra available glucose if themother has been experiencing high blood glucose levels.Mothers with poorly controlled blood glucose are at riskfor high blood pressure, kidney infections, preterm laborand delivery and Cesarean deliveries.

The complications associated with diabetes andpregnancy can in large part be avoided if mothers arewilling to make an extra effort. Lois Jovanovic, MD, aninternationally recognized endocrinologist specializingin diabetes and pregnancy, recommends taking controlof your diabetes at least a three to six months before youbecome pregnant, so that when you conceive you willknow that you have already laid a good foundation for ahealthy delivery.

Pre-Pregnancy

See your endocrinologist for an assessment and check somelab values. Your A1C should be 6.5% or less prior to gettingpregnant, according to many experts. A 24-hour urinetest will assess kidney function. Make sure that it is safe tocontinue your medications during pregnancy. ACE inhibitorsand ARBs, blood pressure medications used to improvekidney function, are contraindicated during pregnancy.Oral diabetes medications are not currently approved bythe FDA for use during pregnancy or lactation. In mostcases, women with type 2 diabetes have to switch to insulintherapy during pregnancy and breastfeeding.

If blood glucose levels aren’t in the goal range, talk with your diabetes educator. Perhaps an insulin pump would improve your control, or you may need to increase insulindoses, or possibly improve your carbohydrate countingskills. Plan to meet with a dietitian to design an appropriateeating plan during pregnancy.

See an ophthalmologist to evaluate your eyes for retinopathyprior to pregnancy. You may need to continue seeing aspecialist for eye care during the pregnancy. And be sure tochoose an obstetrician who has experience dealingwith diabetes.

Pregnancy

Once you are pregnant, plan to keep seeing yourendocrinologist and diabetes educator regularly. Bloodglucose levels are variable during pregnancy and candrop significantly in the first trimester. Be aware thathypoglycemia will almost certainly be an issue. Keep anemergency glucagon kit on hand at all times along withglucose tablets or glucose gel, and carry snacks in the car,in your purse and anywhere else you might suddenly needone. Plan to check blood glucose before meals and onehour after meals, at bedtime and possibly in the middle ofthe night.

Lois Jovanovic, MD, recommends fasting blood glucoselevels of less than 90 mg/dl and less than 120 mg/dl onehour after meals. The American Diabetes Associationrecommends blood glucose levels less than 140 mg/dlone hour after meals during pregnancy. Ultimately, themore tightly controlled your blood glucose, the better yourchance of a healthy outcome.

With weight gain and increased placental hormones, youwill become more resistant to insulin, and your insulinneeds will gradually rise until they are almost double bythe time you are 36 weeks along. Your endocrinologist and diabetes educator can help you adjust insulin doses to keep up with your increasing needs.

Exercise is appropriate during pregnancyand will help to keep your blood glucoseunder control. The more consistent theexercise, the better for blood glucosecontrol. However, do not try to addintense exercise once you are pregnant.Simply walking for 15 to 20 minutes aday will improve blood glucose. Again,be aware of possible hypoglycemia andcarry a snack when you exercise. Checkwith your doctor to see what types andamounts of exercise are safest for youduring pregnancy.

Tests ordered by your physician will helpto ensure a healthy birth. Ultrasoundwill allow your perinatologist to assessthe fetus’s health and development.Non-stress tests use two monitors on themother’s abdomen; one records fetal heartrate and the other detects contractions.The heart rate should increase withactivity and stimulation. Amniocentesis may beperformed to assess lung maturity if induction oflabor or elective Cesarean section is planned priorto 39 weeks.

Labor and Delivery

You have worked hard for nine months inpreparation for this remarkable moment, andit is finally here. In the hospital, typically an IVis started which will provide glucose as wellas insulin. Insulin pump therapy has been usedsuccessfully during labor and delivery, but you andyour doctor should determine the best way to keepyour blood glucose under control during delivery.The real key to a safe delivery is frequent bloodglucose testing, which will indicate whether insulinor glucose is necessary throughout labor.

Once the Baby Arrives

Once the baby is born and the placenta isdelivered, hormone levels change and your insulinneed will be cut in half. You may not even need any insulinfor the first 24 to 48 hours following delivery. Again, yourendocrinologist and diabetes educator will help you adjustyour insulin as needed.

Hypoglycemia is again a risk as your insulin needs changeand as your first instinct is to take care of the baby ratherthan yourself. If you do get low, care for yourself first andthen the baby. In the long run, your baby will be better offwith a healthy mother.

Many of the medications that are not recommended whileyou are pregnant continue to be off limits if you choose tobreast feed. However, breastfeeding is strongly encouragedas it provides health benefits for both the baby and themother.

It is certainly an added challenge to have diabetes duringpregnancy, but a few extra visits to the doctor and someextra blood glucose testing are a small price to pay when youfinally see the baby you have been carrying for nine months.Suddenly, you have a wonderful reward, and all your hardwork and effort were worthwhile.


Gestational Diabetes

When Diabetes First Appears During Pregnancy

In about four percent of pregnancies, gestationaldiabetes occurs. Women at high risk for developinggestational diabetes are overweight, have a history ofglucose intolerance, a family history of diabetes, are25 years or older or have had diabetes during a previouspregnancy.

• Blood glucose control is the key to a healthypregnancy for women with diabetes, and itshould be tested before meals, one hour aftermeals and at bedtime.

• Target blood glucose goals are the same forany woman with diabetes during pregnancy,regardless of type of diabetes.

• It is critical to have a healthy meal plan withconsistent carbohydrate intake and to consult regularly with a dietitian.

• Adding moderate exercise to your routine,even just a daily 20-minute walk, will significantly improve blood glucose levels.

• Insulin therapy may become necessary atsome point during your pregnancy, becauseblood glucose levels continue to rise withdecreased insulin sensitivity and increasedplacental hormones as your pregnancy progresses.

• Once your baby arrives, it is wise to checkyour blood glucose levels several times. Youmay be one of the 2 percent of women whohad undiagnosed type 2 diabetes prior togetting pregnant. Ask your healthcare teamwhen your follow-up glucose tolerance testwill be scheduled.

• Breastfeeding benefits both the baby andthe mother, and it is strongly encouraged byhealthcare professionals.


Top 10 Ways to Improve Your Odds for a Healthy Pregnancy

10. Choose an obstetrician who has experience workingwith women with diabetes.

9. See an ophthalmologist to screen for retinopathybefore conception.

8. Review all of your medications to determine theirsafety during pregnancy.

7. Keep your blood pressure under control.

6. Continue to do safe exercise on a daily basis.

5. See a registered dietitian to review your eatinghabits.

4. Follow up with your diabetes educator.

3. See your endocrinologist regularly.

2. Keep your A1C at 6.5% or less.

1. Do your best to keep your blood glucose in line withyour goal for pregnancy.


Maternal Nutrition During Pregnancy
By Lois Jovanovic, MD

The old adage “You are whatyou eat” can also be applied to adeveloping fetus; you might say,“Your baby becomes what youeat.”

Medical nutritional managementis the primary intervention thatcan result in improved outcomesin pregnancy. Examples includefolate supplementation to preventneural tube (birth) defects,protein supplementation in thecase of malnutrition and ironsupplementation for anemia.

Pregnant Women WithDiabetes Need to Count Carbs

Diabetic women have specialneeds, and the mainstay oftreatment during pregnanciescomplicated by diabetes—type1, type 2 and gestational—isattention to the carbohydratecontent of the meal plan.

Meticulous awareness of the typesand quantities of carbohydratesis important because fetal growthis directly dependent on themetabolism of carbohydrates, bothsimple and complex, that thenappear in the blood stream andcompose more than 90 percent ofthe peak after-meal blood glucose.

Some fetuses are more sensitiveto minor elevations in bloodglucose than others. When thecarbohydrate content of a mealplan has more than 40 percent ofthe total calories, then the peakafter-meal levels may be markedlyelevated.

Examples of foods to avoid andfoods that may be eaten becausethey do not affect the after-mealglucose levels are listed in Table 1.

What Is Overnutrition?

Overnutrition of the fetus occurs when the mother’s blood glucose is elevated above the normal range for a pregnant woman.

Normal pregnant women have a blood glucose levelthat is 20 percent below that of nonpregnant women.Thus the normal pregnant fasting blood glucose is60 to 90 mg/dl, and no blood glucose is ever higherthan 120 mg/dl, even one hour after eating. Whenthe blood glucose levels are elevated, the fetus isforce-fed too many calories.

The after-meal glucose levels are more potent thanthe fasting or the average blood glucose levels. Thus,attention to meal planning is even more importantduring pregnancy than even the treatment of diabetesin general, for the sake of the healthy growth patternof the unborn child.

When the mother’s blood glucose levels areelevated, there is an increased risk of complicationsfor the infant (see Table 2).


Table 1 Impact of Foods on After-Meal Glucose Levels

Foods to avoid or restrict portion size
Simple Sugars Complex Carbohydrates Fruits
Cake Bread Oranges
Candy Pancakes Cherries
Cookies Rice (brown and white) Melons
Sodas with sugar Tortillas Bananas
Ice cream Potatoes Pineapples
Pies Cereal Grapes
Syrups Pasta, noodles Plums
Ketchup    
 
Foods with minimal impact on after-meal glucose levels
Vegetables Protein Fruits
Peas Eggs Lemons
Broccoli Cheese Limes
Green beans Cream Tomatoes
Asparagus Poultry  
Lettuce Beef  
Brussels sprouts Pork  
Cabbage Fish  
Raw carrots Tofu, bean curd  
Celery Whole milk  
Beans    


Table 2 Consequences of Fetal Overnutrition Mediated by Elevated Maternal Glucose

Note: Goal maternal blood glucose levels are less than 90 mg/dl for before-meal glucose levels and less than 120 mg/dl for peak after-meal glucose levels at one hour after the first bite of food.

Fetal and Neonatal Complications of Maternal Hyperglycemia

  • Birth defects
  • Spontaneous abortion
  • Fetal obesity
  • Onset of insulin resistance syndrome before birth and sustained after birth (metabolic problems and concentration of fat in the abdominal cavity that is associated with an increased risk of blood pressure elevation, heart disease and liver problems)
  • Hypoglycemia (low blood glucose)
  • Hyperinsulinemia (high insulin levels)
  • Hypocalcemia (low blood calcium)
  • Hyperbilirubinemia (yellow jaundice)
  • Erythrocytosis (high red blood cell count)
  • Birth trauma (shoulder and clavicle damage)
  • Respiratory distress (difficulty breathing)
  • Cerebral anoxia (lack of oxygen to the brain and risk of cerebral palsy and mental retardation)
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