Diabetes During Pregnancy

By Emeritus Professor Datuk Dr Mustaffa Embong Consultant Diabetologist, National Diabetes Institute (NADI)

KUALA LUMPUR (Bernama) --  Rahmah, 30, went for a check-up after missing her period. She was confirmed pregnant. However, blood tests also showed that she had diabetes.

This is Rahmah’s third pregnancy. Her first resulted in a miscarriage at six weeks while her second led to her delivering her baby by caesarean at 36 weeks. The baby weighed 4.3 kilogrammes at birth and developed breathing difficulty soon after delivery and had to be placed in an incubator for two weeks.

Rahmah has been overweight since young. Her present body mass index (BMI) is 32.4 kg/m2 and there are velvety dark patches around her neck and abdomen. Her mother and sister have diabetes.

GESTATIONAL DIABETES

Gestational diabetes refers to diabetes that is detected during pregnancy. The pregnant person may have type 2 diabetes (T2DM) which is only diagnosed during the pregnancy or she may have developed type 1 diabetes, possibly precipitated by the stress of pregnancy.

But, most likely, the person is already at risk of having diabetes (“prediabetes”) before she becomes pregnant and the pregnancy has caused her to develop full-blown diabetes – a condition referred to as (true) gestational diabetes.

RISK FACTORS

Rahmah has many features to suggest that she may develop gestational diabetes: she is obese and has dark patches around her neck and abdomen (“acanthosis nigricans”) known to be associated with insulin resistance and T2DM.

She has a family history of diabetes. Her pregnancy history is also suggestive of a person prone to developing diabetes: her first pregnancy ended in a miscarriage and her only child was delivered before term but weighed much heavier than normal births.

Other features associated with increased risk of developing gestational diabetes include age greater than 30 years, having high blood pressure or abnormal blood lipid levels and lack of physical activity (see Table 1).

Table 1: You are more likely to develop gestational diabetes if you:

 

are overweight or obese have a close relative (for example, parents, sister) with diabetes have given birth to a large baby (weighing 4.0 kg or higher) have had gestational diabetes in a previous pregnancy have high blood pressure or high blood cholesterol levels are not active physically or seldom exercise are 30 years or older have polycystic ovary syndrome have prediabetes

RISK OF COMPLICATIONS TO MOTHER AND BABY

Due to the hormonal changes occurring during pregnancy, blood glucose levels of people with diabetes during pregnancy are likely to rise and may be difficult to control. The uncontrolled high blood glucose levels increase the risk of complications, both for the mother and baby.

Persons with diabetes may have difficulty in conceiving and once they conceive, they are more prone to miscarriage (abortion) and premature delivery.

They may also develop high blood pressure or have too little or too much water in the womb. These women are more likely to develop fits (seizures) due to eclampsia which may be life-threatening.

And because the baby may be larger than normal, a woman with (poorly-controlled) diabetes would have difficulty during delivery and is more likely to end up with a caesarean section. 

Babies of mothers with (uncontrolled) diabetes before or in early pregnancy are at higher risk of having congenital abnormalities such as heart defects, cleft palate or more serious, neural tube defects.

They are also likely to suffer from a condition referred to as intrauterine growth retardation (IGR) resulting in stunted growth in the womb.

 High blood glucose levels in the mother may also cause excessive weight increase in the baby (“macrosomia”), which can lead to injuries during delivery. Babies of mothers with diabetes require close observation after delivery as they are more prone to developing complications such as low blood glucose levels (hypoglycaemia), breathing difficulty or severe jaundice.

 Researchers have also established that babies of mothers who had diabetes during pregnancy are more likely to develop diabetes (and obesity and heart disease) as adults, compared to children of non-diabetic mothers (see Box).

Poorly controlled diabetes increases risk of complications for mother and baby

Mother  Abortion (miscarriage)  Premature delivery  Too much or too little water in womb  High blood pressure  Fits (seizures)   Difficult delivery  Caesarean delivery

Baby Congenital deformities Stunted growth in womb Large size at delivery Injuries during delivery Severe jaundice Breathing problems Low blood glucose after delivery Prone to developing diabetes, obesity, heart disease as adults

SAFE PREGNANCY

Studies have shown that with proper care during (and just as important, before) pregnancy, a person with diabetes can reduce the risks and have a safe pregnancy. 

Complications of diabetes, such as those affecting the nerves, eyes, kidneys and heart, tend to occur in those with long-standing diabetes, especially when the disease is not properly managed. A woman with diabetes must make sure that she does not have complication(s) that would compromise her pregnancy.

As a rule, women with serious complications such as advanced diabetic retinopathy (eye disease), kidney or heart disease are not recommended to get pregnant.

Once you are cleared for pregnancy, you will now need to take positive steps to ensure a safe pregnancy, free of complications so that you will have a healthy baby.

Your priority is to make sure that your diabetes and other associated conditions (such as high blood pressure and overweight/obesity) are well controlled not only during your pregnancy but also before you conceive.

OPTIMISING DIABETES CONTROL 

High blood glucose levels early in pregnancy put your baby at high risk of birth defects. The baby’s organs develop within the first seven to eight weeks of pregnancy -- when you may not even realise that you are pregnant.

That is why you need to ensure that your blood sugar (glucose) control is optimised at least three months before attempting to conceive. Aim to have your HbA1c level (a measure of blood glucose levels over the last three months) closest to normal.

Discuss with your doctor the most appropriate HbA1c level for you. To achieve this, you may need to check your blood glucose level more frequently (ideally, six to seven times each day while pregnant) at home.

During pregnancy, it is recommended that you keep your blood glucose levels at between 3.5 to 5.5 mmol/L before food, at bedtime and on waking up in the morning and less than 6.5 mmol/L two hours after the main meals (see Box). Record these results to discuss with your doctor during your scheduled visits.

Recommended blood glucose and HbA1c levels during pregnancy

 

Test	Recommended level
Fasting/before meal/at bedtime	3.5 to 5.5 mmol/L
1 hour after meal	Less than 7.8 mmol/L
2 hours after meal	Less than  6.5 mmol/L
HbA1c	Less than 6.5% (or less than 6.0%)

CHANGE TO INSULIN

Make sure to inform your doctor if your blood glucose is out of control (hypo or hyperglycaemia) or when you are not feeling well.

Some people, specifically those who develop diabetes during pregnancy (“true” gestational diabetes), can control their diabetes well during pregnancy just through (strict) dieting and regular exercise.

If this is not possible, your doctor would advise you to go on insulin for the duration of the pregnancy to ensure that your diabetes is well controlled.

Studies have shown that strict blood glucose control during (and before) pregnancy is associated with significantly reduced risk of complications for mother and baby.

Most insulin preparations are safe to use during pregnancy. Preferably, you should go on a fast-acting insulin injection before each main meal and an additional longer-acting insulin before bed, if necessary.

Many may want to negotiate with their doctor to be allowed to continue with oral diabetes medication. This is, however, not generally recommended because of possible risk to the baby, especially with the newer anti-diabetic pills.

CONTROLLING OTHER RELATED CONDITIONS 

Many other conditions are usually present in people with diabetes. These include hypertension (high blood pressure), abnormal blood lipids (dyslipidaemia) and being overweight or obese that would adversely affect you and your baby during pregnancy.

Your doctor may change your medications as some drugs for high blood pressure and high blood cholesterol, for example, are not safe during pregnancy. Weight loss medications must not be used during pregnancy (or even while attempting to conceive) as these can cause birth defects.

The doctor will also give you folic acid beginning three months before conception until at least 12 weeks of pregnancy to prevent birth defects such as spinal bifida in your child.

 

DEWI PROJECT   The DEWI (Diabetes in Women Initiative) Project is a community health project organised by National Diabetes Institute (NADI) and fully endorsed and conducted jointly with experts in the Ministry of Health and university hospitals. The project aims to empower women who have diabetes or are at risk of developing diabetes during pregnancy (gestational diabetes) so as to enable them to have a safe pregnancy.  Come join DEWI Project to ensure that you have a safe pregnancy with a healthy baby, in spite of   diabetes. Participation is FREE. For more information, please contact the National  Diabetes Institute (NADI) at Tel 03-7876 1676 / 7876 1677 Email: enquiry@nadidiabetes.com.my

CONTINUE WITH YOUR HEALTHY LIFESTYLE 

Keeping to a healthy lifestyle is important, especially when you are pregnant. This would include paying attention to your diet, being physically active and doing exercise. It is advisable that you do not smoke. You must also avoid taking alcohol and reduce caffeine intake.

Healthy diet

Make it a point to discuss with your dietitian on a good diet plan that suits not only your taste buds but also one that can help you avoid swings in your blood glucose levels while providing the necessary nutrients for your baby to grow. Maintain your healthy and balanced diet with adequate amounts of protein and fat, fibre, vitamins and minerals (especially folic acid, vitamin B12 and iron), and (smaller portions of) carbohydrates.

Be physically active

Being physically active, including performing regular exercise, can help you bring down your blood glucose levels to the target range. It would also reduce your blood pressure and cholesterol levels and relieve stress. Exercise improves muscle tone, strengthens your lungs, heart, bones and joints and improves your stamina, which would help with your delivery.

Check with your doctor what activities are most suited for you, taking into account your overall health status and stage of your pregnancy. In general, walking, swimming, yoga, stretching and low-impact aerobics are safe but avoid activities that may lead to falls or put a strain on your tummy. Aim for at least 30 minutes of (light to moderate) physical activity a day for most days of the week. Stop immediately if you feel pain or giddy or develop shortness of breath or bleeding.

Stop smoking, avoid alcohol

Smoking and consuming alcohol are not good for women who are pregnant – or planning to conceive -- especially if they have diabetes (or prediabetes). These two (unhealthy) lifestyle practices are known to cause serious complications, including miscarriage, stillbirth, premature delivery and low birth weight.

Keep to scheduled visits: Do not miss your appointments.

As a person with diabetes, you may need to be followed up more closely during your pregnancy,  especially if you have (mild) complications which may get worse.  Your doctor will check and adjust        treatment if necessary to ensure that your diabetes and other parameters (such as high blood pressure and weight gain) are well under control. He/she will also assess your baby’s growth with an ultrasound check, when appropriate.

Do take the opportunity during these clinic visits to ask questions if you are in doubt on the best way for  you to manage your diabetes, so that you can have a safe pregnancy and have a healthy baby.

CONCLUSION

It is important to note that most people with diabetes can have a safe pregnancy. But, as is obvious, there are some “sacrifices” that women with diabetes have to make to ensure an uneventful pregnancy for mother and baby. Close monitoring and strict compliance to diet, exercise and medication are essential.

While there is the possibility that gestational diabetes may go away after delivery, healthy lifestyle practices and regular check-ups (for diabetes and other conditions) will need to continue after delivery for mother (and child) to reduce the risk of future problems.

With full commitment and determination from you (and guidance from your healthcare team), you will surely have a safe pregnancy, in spite of diabetes. 

Edited by Rema Nambiar

BERNAMA