PREGNANCY IN WOMEN WITH DIABETES

 

Diabetes currently is one of the very serious problems in the world. About 1 in 11 people suffer from diabetes. There are 3 types of diabetes, type1, type 2 and gestational diabetes. The women who are pregnant with diabetes are type 1 or 2. Gestational diabetes is what develops for the first time in pregnancy. Women with diabetes often find it difficult to get pregnant. Uncontrolled diabetes during Pregnancy causes many problems, higher risk of miscarriages, increased foetal abnormalities, macrosomia (big baby) difficult birth, shoulder dystocia, foetal death, and a few others. In view of all this it is very important to have your diabetes under control. Make sure you are taking high doses of folic acid (400mcg daily), for one to two months prior; which helps to prevent foetal abnormalities. Once you get this sorted also make sure your BMI is ok.  This often is not easy but try to exercise regularly.  Find a diabetic specialist, who specialises in pregnancy with diabetes, a dietitian and may be a Physiotherapist. Have a long term glucose test called HbA1c tested it should be 7% if you have type 1 diabetes and 6% if you have type2. In addition you should have all your systems checked that are effected by diabetes, blood pressure, eyes, nerves, and kidneys. It is important to have a pregnancy ultrasound to have precise dates and make sure the pregnancy is normal. An ultra sound is done at 12 weeks, like in any pregnancy, for any genetic abnormalities. An 18 to 20 week ultrasound needs to be done for foetal anatomy and any foetal abnormalities. Maternal blood pressure is watched in women with blood pressure, for mother’s health and adequate foetal growth. In women who have been on Metformin it is discontinued, and replaced with Insulin if required. Women with type 1 diabetes require slightly less insulin in the first trimester. The routine blood tests, full blood examination, blood group, Hepatitis B and C, Syphilis, HIV, latest cervical screening, cervical culture and any other specific tests to the situation are all done.

Regarding the management life style changes are emphasized, regular exercise, stop smoking, no alcohol. Oral antidiabetics are not generally used as they cross the placenta. Women are supposed to maintain and manage their own blood sugars fasting 5.3mmol/L (95mg/dL), one hour 7.8/mmol/L (140mg/dL), two hours 6.7 mmol/L, (120mg/dL). AIC level to be maintained at 6to 6.5 %in type 2 and 7% in type 1 diabetes. This is done every month during pregnancy. It is more important to control blood sugars than A1c. In those women who use the pump, it is also required to test the pre-prandial blood sugar before using the bolus dose of insulin. It is best to leave the insulin management to a diabetic specialist. If the women are getting too many hypoglycaemic episodes, A1c can be relaxed to 7%. A well maintained diabetes prevents preeclampsia.

The most important decision to make in diabetic women is when and how to deliver these women. It is complex in all situations, depending on how well the diabetes is controlled, what facilities are available, what personal are there such as anaesthesiologist, neonatologist and a women’s personal situation. If it is a well controlled diabetes, there are no complications, no foetal compromise, not a big baby, favourable cervix, then it is good to induce at 39 weeks. It is good to have a neonatologist standing by, as babies often require help. Depending on the other factors, induce between 37 to 39 weeks. Never let them be overdue. If there is a situation which require a caesarean section, go ahead and do it.

In the postpartum period the need for insulin decreases so be watchful. Lactation is the best way to feed the babies, they need support as well. They can often get neonatal jaundice. It is important to watch the baby for obesity and diabetes as they grow. In fact this can be transgenerational. Advise all women about contraception.