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Pregnancy
From a study carried out in Finland and published in Diabetic Medicine 2002, Vol 19 looking at pregnancy from 22 weeks to one year after birth.
· The rate of congenital abnormalities in babies born to women with diabetes has not changed in recent years.
· The perinatal mortality remains 3-5 times higher in women with diabetes than in non-diabetic women.
· The proportion of perinatal deaths caused by congenital abnormalities has reduced but the post-natal mortality has significantly increased.
· Diabetic mothers of malformed babies were significantly younger than mother of babies that were not malformed.
· Nearly two thirds of the malformed babies were boys.
The study points out that the reduction in prenatal deaths and increase in post-natal deaths could be due to better care during pregnancy. But it is also worth noting that the mortality rate in the general population has also reduced markedly. In England in 1960 it was 32.5 per 1000 total births compared with 7.6 per 1000 births in 1992.
Note: A perinatal death is usually defined as death of the foetus after 28 weeks of pregnancy and the first week of the baby’s life.
Pre-conception
It has been known for some years that good diabetic control at the time of conception improves the chances of having a healthy baby. Entering the pregnancy with good control increases the chances of a healthy baby because important organs of the foetus develop during the early part of pregnancy - the brain, the spine, the heart, the kidneys and the gastrointestinal system. Malformations associated with diabetes are spina bifida, where the spine does not completely close and heart defects. As these malformations are formed during early pregnancy, getting into better control later in the pregnancy does not change what has already developed. However, it is important to remember that just because a woman is not in good control does not mean that she is bound to have a baby that is affected.
For these reasons, a planned pregnancy with good blood glucose control at the time of conception is the ideal situation although it is estimated that as many as two thirds of pregnancies are unplanned. A planned pregnancy also means that folic acid supplements, which reduce the risk of spina bifida and other defects, can also be taken prior to conception. Many diabetes clinics now offer ‘pre-conception counselling’ for couples intending to have a baby to try to ensure that the mother's blood glucose control is good at conception and from the outset of the pregnancy.
Checking the safety of
insulin and other drugs
It is worth checking at this stage the
safety of the insulin you are using and any other drugs. None of the
analogues have been tested in pregnant women or those planning pregnancy
so any risks to the foetus and/or mother are unknown. Commonly
prescribed for people with diabetes are ACE-inhibitors for the treatment
of blood pressure and/or to slow down the progression of kidney disease
and also statins to reduce cholesterol levels. Both these classes of
drugs are potentially toxic for the foetus.
But do women
attend pre-conception counselling?
Researchers in Hull [ref1]
who carried out a study looking into the use of Humalog during pregnancy
were struck by the large number of women in this study who did not have
pre-conception counselling despite the fact that this was freely
available to them – only 40% took it up.
So they carried out a questionnaire study in 69 women between the ages of 16 and 45 to survey their attitudes and knowledge of maternal diabetes and pregnancy. 18 of the women already had children and the rest didn’t. The results were surprising but according to the researchers are similar to other studies:
· In both women with and without children, a high proportion of women [85%] knew that their diabetes could affect the health of the baby and that good control was important at the time of the conception.
· Of the 18 with children only 44%, less than half, had attended pre-conception counselling before their last pregnancy.
· Only 52% of those without children and 28% of those with children reported the intention to do so before a future pregnancy.
So although the knowledge about the need for pre-conception counselling was there, this knowledge is not acted upon. What is more, the women that had already had one pregnancy were even less likely to seek counselling before a future pregnancy! The researchers point out that teaching and knowledge do not necessarily change behaviour and they suggest that a novel approach is needed if pregnancy outcomes are to be improved and that this should continue throughout the reproductive years.
Just a comment……..
It is a
shame that the questionnaire did not ask why women don't attend
pre-conception counselling. It is well recognised that pregnant women
with diabetes go to great lengths to maintain very tight blood sugars to
safeguard the health of the baby and indeed, their own health, so it is
surprising that so few women attend. Perhaps the term ‘Pre-conception
counselling’ is not one that appeals to people contemplating having
a baby, especially young people! The word counselling alone can be
off-putting for some people. Straight forward ‘Family Planning’ may be
more appealing but a little imagination would produce a better name.
Ref 1 Diab Med 2002, Vol 19:605
Pregnancy
Blood glucose
control throughout pregnancy
Blood sugar control is important throughout pregnancy but for different
reasons. In the early stages of pregnancy it is important for the
healthy development of the fetus and in the later stages, it is
important to avoid hyperglycaemia because of the impact on the baby's
metabolism.
Excess glucose in the mother's circulation easily passes through the placenta to the baby and it is as if it is eating sweets all the time. This stimulates insulin production in the baby, insulin is a potent growth hormone and so fat is deposited which can result in a large baby which can lead to complications at delivery because the baby will not easily fit through the birth canal. After delivery the baby still produces large amounts of insulin which can result in the new born baby being hypoglycaemic. The hypoglycaemia can be dealt with by the paediatrician.
The first
trimester – the first 3 months
Low blood sugars are more common during the first 3 months of pregnancy
because the baby begins to feed off the mother’s glucose stores. In
addition to this, the hormones are working hard to create the placenta
and this can make it hard to control blood sugars. So it is important to
blood test frequently and be prepared for unexpected hypos. Sometimes
during this period the symptoms of hypos may change and you may not
always recognise them, so it is advisable to warn friends and work
colleagues about the signs of hypos. If you don’t already have glucagon
for emergencies, then it may be a good idea to discuss this with your
doctor. Glucagon is an emergency drug/hormone that is injected if you
have a severe hypo and are unconscious and so cannot eat or drink. It
works by making the liver release its own stores of glucose.
Morning sickness is common in 70% of pregnant women. It is worse on an empty stomach and some women find that eating a cracker or something similar may help. It may also help to make sure that you have a bedtime snack with protein and carbohydrate. Sometimes eating smaller and more frequent meals helps. If morning sickness is a real problem, you should discuss this with your dietitian. If it is so severe that you are vomiting up to 10 times a day, then you should call your doctor because there is a risk of ketoacidosis [very high blood sugars that are out of control].
The doses of insulin you need may change frequently because of the body’s hormone activity during this time. It may also be necessary to change your insulin regime – your meal times and injection times.
The second and third trimesters [4 to 9 months]
During this time insulin requirements usually increase and could be as
high as two or three times your normal daily amount. This is because the
placenta produces a hormone that makes it more difficult for the insulin
to work. So frequent testing and dose adjustments when necessary, are
essential. Once the baby is born, insulin requirements quickly drop back
to normal.
During this time the doctors will continue to monitor your blood glucose levels, blood pressure and kidney function. Some women with and without diabetes develop high blood pressure and oedema [fluid retention causing swelling] during the latter part of their pregnancy. If this is left untreated it can lead to pre-eclampsia which puts both mother and baby at risk.
Labour
Many women with diabetes go
into labour on their own and delivery is normal but this depends largely
on the baby’s size and position. Women with diabetes tend to have bigger
babies and so if the baby is large it may have problems moving safely
through the birth canal. This is one of the reasons the healthcare team
monitor the health and size of the baby very closely. If the baby is
large then labour may be induced.
The decision to induce labour is usually taken after 36 weeks and this will depend on the baby’s size, the maturity of its lungs, the health of the placenta and the mother’s health.
If the baby is too large or the health of mother and baby is at risk then a Caesarian section will be carried out. This is much more common in women with diabetes than in women without diabetes.
Caesarean Section
Women with diabetes are more likely to give birth by Caesarean section, the main reasons being are that their babies tend to be larger, labour tends not to progress as smoothly and/or if the mother’s safety is at risk. If the mother to be has diabetes complications this can make vaginal delivery of the baby more dangerous for both mother and baby. However giving birth by Caesarean section has disadvantages:
· Diabetes increases the chances of infection and can slow down wound healing so making surgery such as a caesarian section more risky.
· Caesarean section means a longer stay in hospital, greater chance of transfusions and a slower recovery.
If a woman has
had one Caesarean section does it mean that this will happen with the
birth of subsequent children?
A study published in The Journal of Reproductive Medicine [Dec 2000]
looking at 127 women most of whom had already given birth by Caesarean
showed that only 43.7% of diabetic women that attempted vaginal birth
after a Caesarean, succeeded but in women without diabetes 60 – 80% of
them had successful vaginal births after a Caesarean. The authors of the
study called for more research because they felt unable to conclude that
vaginal birth after a Caesarean was safe for women with diabetes.
New techniques for
Caesarean sections
Research
carried out in Austria, published in the Journal Obstetrics and
Gynaecology [January 2003], describes a new technique for Caesarean
sections which is less painful and far quicker than current methods,
taking about 20 minutes in all. The new method reduces blood loss in the
mother by half so cutting the length of the procedure and allowing the
mother to recover more quickly.
The new method means that doctors use a sharp knife to cut the skin but then blunt instruments to gently pull the uterine wall apart and deliver the baby. This compares with sharp dissection used by some doctors. The women need fewer stitches because only three layers need to be stitched compared to between four and seven in other methods.
Professor James Walker of the Royal College of Obstetricians and Gynaecologists reported to the BBC that many aspects of this technique are already in use in Britain as this is ‘good practice’. Perhaps this is a question that mothers-to-be should raise during pregnancy.
Note: One in five births in Britain is now by Caesarean section and the World Health Organisation state that just one in ten births is by Caesarean section.
In April 2004 the National Institute for Clinical Excellence [NICE] introduced guidelines on Caesarian Section and there is a section that provides information for pregnant women, their partners and the public. This can be obtained as a booklet and can be ordered from the NHS Response Line: tel 0870 1555 455 quoting reference number N0479 or it can be viewed by visiting the NICE website: http://www.nice.org.uk/CG013NICEguideline.
Report - Diabetes in Pregnancy: Caring for baby after birth [2007]
Do babies of diabetic mothers need to be placed in special care units?
This is an issue that has been raised with IDDT as pregnant women with diabetes have been advised that their newborn babies will be babies removed from them and placed in the special baby care unit with some being told that this is a necessary and normal procedure – even in hospitals with a ‘good reputation’. While this could be necessary on health grounds, many diabetic mothers are being separated from their babies for no other reason than hospital convenience or ‘hospital policy’.
The findings of a national inquiry, the Confidential Enquiry into Maternal and Child Health [CEMACH] produced in a report, Diabetes in Pregnancy: Caring for baby after birth [2007], stated that in over half of mothers with Type 1 and Type 2 diabetes their newborn babies are automatically moved to a special care baby unit when there was no specific medical indication for admission and in other cases because babies were not being kept warm enough. This leads to unnecessary separation of babies from their parents. The report goes on to confirm that there are many benefits of early interaction between mother and baby and hospitals should have policies to enable this to happen.
The author of the report stated: “Babies of mothers with diabetes have more complications and do need careful monitoring, nevertheless in the absence of specific risks or complications, every effort should be made to ensure that these babies can be kept with their mothers safely in order for bonding, temperature control and breast feeding to take place.”
The report also shows that there were a number of barriers to breastfeeding and these were:
· A quarter of babies did not have early feeding on the labour ward.
· Instant formula was given as first feed to two thirds of babies.
· Maternal choice nit to breastfeed was the main reason for instant formula feeding on the postnatal ward.
· The first blood glucose test was often performed too early to be informative, with inaccurate methods of testing used and insufficient documentation of management.
The report recommends that:
· Mothers with diabetes to receive advice about the benefits of breastfeeding for their child during the antenatal period.
· Babies to be with their mothers immediately after birth, provided there are no postnatal complications. Early mother-baby contact helps to establish breastfeeding and to regulate the temperature in babies.
· Encouragement of breastfeeding within an hour of birth, but all mothers should be supported in the feeding method of their choice.
· Better guidelines and training for healthcare professionals in the management of babies of mothers with diabetes.
IDDT advice to pregnant women with diabetes: make sure that you know the hospital system before you are due to have your baby and make it clear that you don’t want to be separated from your newborn baby unless there are medical grounds for doing so.
A great deal is published about pregnancy and women with diabetes but what about after the birth? It is difficult to find research that deals with the effects of breast finding on diabetic mums and the control of their diabetes. There seems to be even less information on how to deal with weaning and advice is usually given on the basis of common sense.
A great deal is published about pregnancy and women with diabetes but what about after the birth? It is difficult to find research that deals with the effects of breast finding on diabetic mums and the control of their diabetes.
Breast Feeding
A great deal is published about pregnancy and women with diabetes
but what about after the birth? It is difficult to find research that
deals with the effects of breast feeding on diabetic mums and the
control of their diabetes.
There is no reason why women with diabetes should not breast feed like any other mum. Breast milk production uses a lot of glucose/carbohydrate from the mother’s supply so it is important to avoid hypoglycaemia by lowering insulin doses as necessary. According to the Nutritional Subcommittee of Diabetes UK, [Diab Med 20.786-807] the high energy needs of lactation mean that a mother is likely to require 40-50g carbohydrate per day compared with pre-pregnancy amounts. Extra carbohydrate may be required before going to bed while the baby is still having night feeds. However once breastfeeding stops, insulin doses and carbohydrate intake will need to be changed.
Although only small, a recently published study [Pract Diab Int October 2003, Vol.20 No.8] showed:
• in both breastfeeding and non-breastfeeding
mothers with Type 1 diabetes glucose levels were lower during the first
week after delivery.
• Insulin requirements remained lower than before pregnancy throughout
the 2 months after the baby is born, whether the mothers were
breastfeeding or not.
• Hypoglycaemia does not occur more frequently during or immediately
after breastfeeding.
Weaning
There seems to be even less information on how to deal with weaning and
advice is usually given on the basis of common sense.
If you have been doing a lot of regular exercise and then you stop your
blood sugars would go up unless you either ate less or increased insulin
doses. The same applies when milk production ceases when the child is
weaned.
Although there is little research on this, the
general advice for diabetic mums is that weaning should be done
gradually so that adjustments in diet and insulin can be slow and
smooth. Natural weaning where the child outgrows his/her need for
breastfeeding, is the easiest to allow the mother’s body to adjust. But
if there is an active decision to wean the baby, then reducing
breastfeeds by no more than one feed per week seems to be the general
advice. This enables blood glucose control to be more easily managed.
For copies of IDDT's new leaflet on Pregnancy and Diabetes, contact
IDDT, PO Box 294, Northampton. Tel 01604 622837 or e-mail
leaflets@iddtinternational.org
Insulin Analogues and pregnancy
Naturally pregnant women or those considering pregnancy are always concerned about any medications they take at this time. Clearly women with diabetes have to take insulin but still need to know about any safety issues for both themselves and the unborn baby. For the newer insulin analogues it is important to know that the information about their safety is limited as trials have not been carried out in sufficient numbers of pregnant women. Here is some information that may be helpful.
Lantus
Some experimental studies have shown that insulin analogues have growth-promoting effects and concerns have therefore been raised that use of Lantus insulin
during pregnancy could cause excessive foetal growth and other problems. Reuters reported that a review actually recommended Lantus was not used during pregnancy, but called for further studies to investigate its safety.
A small study carried out in Oxford [ref 1] involving 20 pregnant women with Type 1 diabetes and 44 with gestational diabetes [diabetes during pregnancy] investigated the safety of Lantus [glargine]. Half the women used Lantus and the other half 'standard' insulin.
There were no significant differences in birth weight between infants born to Lantus users and those born to standard insulin users. [The rate of excessively large babies was actually slightly lower in the Lantus group: 38 versus 41%.] The groups were also comparable in terms of infant complications, admission to special care infant units, and congenital abnormalities.
The authors recommend that large trials should be carried out to confirm the efficacy and safety of Lantus for the treatment of pregnant women with Type I diabetes and those with gestational diabetes.
Ref 1 British Journal of Obstetric and Gynecology, April 2007
NovoRapid
The information from the manufacturers of NovoRapid [NovoLog in the US] states: "There are no adequate well-controlled clinical studies of the use of NovoRapid in pregnant women. NovoRapid should be used during pregnancy only if the potential benefit justifies the potential risk to the foetus."
A recently published study [ref 1] concluded that NovoRapid is as safe and effective as GM 'human' insulin in pregnant women with Type 1 diabetes as the mother and pregnancy outcomes were the same. In this study the long-acting insulin used was NPH insulin, a 'human' intermediate insulin and NOT an analogue insulin.
Ref 1 Diabetes Care, April 2007
For the use of other analogues in pregnancy, the Specific Product Characteristics documents say:
Humalog: Data on a large number of exposed pregnancies do not indicate any adverse effect on pregnancy or on the health of the foetus/newborn.
Levermir: There is no clinical experience with Levemir [insulin detemir] during pregnancy. ….Caution should be exercised when prescribing to pregnant women.
Apidra: There are no adequate data on the use of Apidra [insulin glulisine] in pregnant women. Caution should be exercised when prescribing to pregnant women.
Interpretation of expressions used by drug companies in the above statements
· 'Limited clinical experience in pregnancy' - means that no or few clinical trials have taken place.
· 'No clinical data on exposed pregnancies are available' - no clinical trials have taken place.
· 'No clinical experience during pregnancy' - no clinical trials have taken place.
· 'Information on large numbers of exposed pregnancies do not indicate any adverse effect on pregnancy' - this does not state that there have been trials carried out and implies that the information is from observation.
GESTATIONAL DIABETES
Gestational diabetes is the type of diabetes that occurs during pregnancy. Like other forms od diabetes, gestational diabetes affects the way the body uses the glucose [sugar] in the blood and as a result the blood sugars rise too high. The glucose in the blood is the body’s main source of energy.
If gestational diabetes is untreated or uncontrolled, it can result in a variety of health problems for both that mother and baby. So it is important that a treatment plan is worked out to keep blood sugars within the normal range. The good news is that controlling blood sugars can help to ensure a healthy pregnancy and a healthy baby.
SIGNS AND SYMPTOMS
Most women do not have any signs or symptoms of gestational diabetes but your healthcare professional will check for gestational diabetes as part of your prenatal care.
When signs and symptoms do occur they include:
· Excessive thirst
· Increased urination.
About 3 to 5% of all pregnant women develop gestational diabetes.
THE CAUSES OF GESTATIONAL DIABETES
Normal metabolism
Normally during digestions the body breaks down the carbohydrates you eat into simple sugars [glucose] and this glucose is absorbed into the blood and transported around the body by the blood vessel system to provide the energy needed for all our activities. However this process cannot take place without insulin.
Insulin is produced in the pancreas, a gland behind the stomach, and helps the glucose to pass into the cells to provide energy and at the same time maintains normal levels of glucose in the blood.
The liver also plays a part in maintaining normal blood glucose levels. When there is more glucose in the cells than you body needs for energy, your body removes it from the blood and stores it in the liver as glycogen. It can then be used when necessary such as at times when you run low on glucose eg if you have missed a meal. In this situation the liver releases glucose into the bloodstream.
The amount of glucose in the blood varies according to several factors – the food eaten, exercise, stress and infections. The relationship between insulin, glucose and the liver makes sure that the blood glucose levels stay within normal limits. This should be 4 to 7mmols/l.
During pregnancy, the placenta [supplies your baby with nutrients] produces hormones that prevent the insulin from working properly. These hormones include oestrogen, cortisol and human placental lactogen and they are vital for a healthy pregnancy but they also make the cells in your body more resistant to insulin.
As the placenta grows larger in the second and third trimesters, it produces even more of these hormones so further increasing insulin resistance. Normally the pancreas will respond by producing enough extra insulin to overcome this resistance. But sometimes three times as much insulin as normal may be necessary and the pancreas can’t produce enough. When this happens the blood the glucose in the blood cannot be transported into the cells and too much remains in the blood so raising the blood glucose levels above normal and this is gestational diabetes.
WHO IS AT RISK OF DEVELOPING GESTATIONAL DIABETES?
Many women who develop gestational diabetes have no known risk factors and any woman can develop it although some are at greater risks than others. The risks increase with:
· Age – women older than 25 are more likely to develop it
· Family history – if a close family member, such as a parent or sibling, has Type 2 diabetes.
· Personal history – if you’ve had it with a previous pregnancy or if you have had an unexplained still birth or a baby weighing more that 9 pounds, you may be screened more closely for gestational diabetes with the next pregnancy
· Weight – being overweight before the pregnancy makes gestational diabetes more likely but gaining weight during the pregnancy does noit cause it
· Race – women from certain races are more prone to gestational diabetes eg black women.
DIAGNOSIS AND SCREENING
Until recently there was no evidence from research that screening for gestational diabetes resulted in fewer childbirth complications and healthier babies but a study in 2005 showed that screening women and treating gestational diabetes aggressively resulted in fewer complications and healthier babies. So screening is usually a routine part of prenatal care for most mothers. There is some debate amongst doctors about whether women under 25 with no risk factors for gestational diabetes undergo the test because their risk is low.
Screening usually takes place between 24 and 28 weeks of the pregnancy because the condition can’t be detected until then although if your doctor thinks that you are at patrticular risk, it may be done earlier.
What is the test?
You will be asked to drink a glucose solution that tastes very sweet and then you are asked to wait for an hour after which a blood sample is taken from a veitnin your arm. This will measure the level of sugar [glucose] in your blood and will tell how efficiently your body deals with sugar.
A blood sugar levels of below 7.5mmols/l is usually considered normal in this test but having a blood sugar levels above this does not necessarily mean that you have gestational diabetes but it does mean that you will need a further test. For the next test you will be asked to fast overnight, then you will be given another sweet drink that has a higher concentration of glucose. This time your blood sugar levels will be monitored every hour for 3 hours and if at least two of these are abnormally high, this confirms the diagnosis of gestational diabetes.
During pregnancy routine urine tests are carried out but these are not sufficiently reliable to diagnose gestational diabetes because the amount of sugar in the urine can vary throughout the day as a result of the food eaten.
TREATMENT
Controlling your blood sugar is essential to having a healthy baby and avoiding complications during the delivery. Most women are able to do this with lifestyle changes – with diet and exercise, but some made need medication as well. In both cases measuring blood sugar levels is essential because it tells you whether your blood sugars are within the normal range.
Monitoring your blood sugar levels
This might sound difficult at first but once you have learnt how to do it, it is will become routine. You draw a drop pof blood from your finger with a special device and place it on a test strip which is then put into a blood glucose monitor and this will give you your blood sugar level.
Blood sugar levels fluctuate throughout the day according to what you have eaten and how much exercise you have taken, so your doctor may suggest that you carry out blood sugar tests several times a day to ensure that they stay within healthy limits.
Note: your doctor will measure your blood sugars during labour – if they rise too high, your baby’s will also rise and this will cause the baby to produce insulin which may lead to low blood sugars [hypoglycaemia] after the birth.
Diet
A healthy diet is important for all pregnant women but for those with gestational diabetes, diet is part of the treatment – eating the right kind of food in the correct amounts is one of the best ways to control blood sugar levels.
Generally you should eat more fruit, vegetables and whole grains that are high in nutrition but low in fats and calories with fewer animal products and sweets. However, no one diet is suitable for everyone and you should discuss the diet that is suitable for you with a dietitian.
Exercise
Physical exercise generally lowers blood sugar levels for two reasons:
· it causes sugar [glucose] to be transported to the cells where it is needed for energy and so the blood sugar levels drop
· it also reduces blood sugar levels by increasing body’s sensitivity to insulin - so your body needs less insulin to transport glucose to your cells.
Exercise is important for all pregnant women as it:
· helps to prevent some of the discomforts during pregnancy – back pain, muscloe cramps, constipation and sleep difficulties
· it prepares you for labour by increasing muscle strength and the endurance developed by regular exercise reduces the stress on your ligaments and joiunts during delivery.
Type of exercise suitable for women with gestational diabetes:
This should be discussed with your doctor or healthcare professional and then you can decide which activities you enjoy. Safe aerobic activities are a good way to lower blood sugars eg walking, cycling and swimming but ordinary activities such as gardening and housework can also have a similar effect. If you haven’t been active for some time, then you should build up your exercise levels gradually until you are carrying out moderate aerobic exercise on most days.
Stretching and strength training exercises combined with aerobic exercise at the same time everyday is the best combination. Varying your exercise routine and
working out with other pregnant women can help you stay motivated.
Medications
Sometimes exercise and diet do not lower your blood sugar levels sufficiently and so medication may be necessary. Until recently insulin was the only option for women with gestational diabetes because it does not cross over to the baby through the placenta but more recently the oral drug metformin [glyburide] is used inn Europe. [Its use for the treatment of gestational diabetes is still being studied in the US.]
MONITORING YOUR BABY
Ultrasound
When you have gestational diabetes your baby’s growth will be closely monitored by ultrasound. Ultrasound uses high-frequency sound waves and computer processing to give pictures of your baby inside the uterus. Ultrasound is less accurate as your baby gets bigger.
Non-stress test or biophysical profile
If you are taking medications for your gestational diabetes your doctor may suggest a non-stress test [NST] or biophysical profile to make sure that your baby is getting enough oxygen and nourishmenmt, esoecially nearer to the due date. This is a non-unvasive test and causes your baby no stress. It takes about 30 minutes and does not require hospitalisation and is a simple test that checks how often your baby moves and how much the baby’s heart rate increases with this movement.
Length of pregnancy
In most cases doctors try to prevent your pregnancy from going longer than 40 weeks because this may increase the risk of complications. Most women with gestational diabetes deliver healthy babies, labour is not routine and delivery by Caesarian section is necessary in some cases. Gestational diabetes does not affect your ability to breast feed or look after your new baby.
COMPLICATIONS
If you have gestational diabetes, it is understandable that you may
worry about the health of your baby and the possibility that it may
cause birth defects. However this is not usually the case because in
general birth defects develop during the first 3 months of pregnancy and
gestational diabetes does not develop until the second or third
trimester so blood sugar levels are normal during the early, critical
months. So most women go on to deliver healthy babies. But untreated or
uncontrolled blood sugar levels can cause problems for you and your
baby.
Complications that may affect your baby
Consistently keeping your blood sugar levels within the normal range can reduce these possible complications.
· Macrosomia is when the baby grows too large because extra glucose crosses the placenta into the baby’s blood. The baby’s pancreas then makes extra insulin to cope with this and the baby grows too large [macrosomia]. Very large babies may have difficulty during delivery and are more likely to sustain birth injuries or be born by Caesarian section.
· Hypoglycaemia [low blood sugar levels] occurs in some babies immediately after birth. This is because the babies are accustomed to receiving large amounts of blood sugar from their mothers and their own insulin production is high. Babies with hypoglycaemia have their blood sugar levels checked regularly after birth through an intravenous drip to prevent the blood sugars dropping too low.
· Respiratory distress syndrome is a condition that makes breathing difficult. It is more likely to occur in premature babies. It is caused by a lack of certain substances in the lungs that help prevent the lungs from collapsing when the baby takes a breath. Some babies may need help with their breathing until their lungs become stronger.
· Jaundice is a yellowish colouring of the skin and the whites of the eyes. It occurs because the baby’s liver is not sufficiently mature. New born jaundice may begin within 2 or 3 days after birth but sometimes it does not appear for a week. New born jaundice is not a disease in itself and is not serious but will be monitored by the doctor.
· Shoulder dystocia can occur if the baby is very large and the shoulders are too big to move through the birth canal. In most cases doctors can free the baby but injuries may occur. This is a rare but serious complication of gestational diabetes.
· Stillbirth or death is a rare occurrence and if it occurs it is usually because gestational diabetes is undetected and therefore untreated.
Complications that may affect you
If you have gestational diabetes, then you may be at risk of the following complications:
· Pre-eclampsia is characterised by significant increase in blood pressure and left untreated, it can lead to serious complications for mother and baby, even death. Having gestational diabetes increases the risk of pre-eclampsia.
· Caesarian section may be recommended if your baby is large [macrosomia] but gestational diabetes itself does not mean that a Caesarian section has to be planned.
· Type 2 diabetes is more likely to develop in later life in women that gestational diabetes although many cases can be prevented with a healthy lifestyle of a health diet and regular exercise. Up to 40% of women develop Type 2 diabetes within 5 to 10 years after deliveryn and the risk may be increased in obese women.
LIVING WITH GESTATIONAL DIABETES
It is not easy living with a condition that can affect the health of your unborn baby and you may find it stressful, especially as you have to carry our regular blood sugar monitoring, follow a healthy diet and take regular exercise.
Prolonged stress itself can raise blood sugar levels and so it is important to learn as much as you can about your condition – books from the library, talking to other women with the same condition and of course, talking to your doctor, a dietitian, your midwife and a diabetes specialist nurse. They can answer your questions and help you to learn how to manage your blood sugar levels during pregnancy.
AFTER YOUR BABY IS BORN
You can breast feed and look after your baby. After the birth your blood sugar levels will be checked frequently and then again in 6 weeks. Gestational diabetes usually clears up after the baby is born because when the placenta is removed, the hormones it was producing which caused your insulin resistance are also removed.
Once you have had gestational diabetes it is sensible to have your blood sugars tested at least once a year and also to maintain a healthy lifestyle to lessen your chances of developing Type 2 diabetes later in life.
RESEARCH
Physical activity before pregnancy may reduce the risk of gestational diabetes
In this study a questionnaire about physical activity and sedentary behaviour was used and information analysed from 21,765 women who reported at least one 1 pregnancy between 1990 and 1998.
There were 1428 cases of gestational diabetes and after taking into account body mass index, dietary factors etc, the results showed that the risk of gestational diabetes was significantly less in women who took vigorous activity before pregnancy. Equally brisk walking pace was associated with significantly lower risk compared with an easy pace.
Women who spent 20 hours per week or more watching television but did not perform vigorous activity had a significantly higher risk of gestational diabetes than women who spent less than 2 hours per week watching television and were physically active.
The scientists concluded that the study provides strong evidence that regular physical activity before pregnancy is associated with lower risk of gestational diabetes.
Diabetes Care May 2006
The longer a woman breastfeeds, the less likely her child will become overweight later
Breastfeeding longer than three months can cut by more than 40% a child's risk of later becoming overweight or obese by the age of 8 if the child was born to an overweight mother diagnosed with gestational diabetes during her pregnancy.
The study carried out in Germany included 324 children born between 1995-2000 to women with gestational diabetes. More that 37% of children who were never breastfed had become overweight by the age of 8. Of those who were breastfed for up to three months, 32.5% became overweight children but of those who were breastfed longer than three months, only 22% became overweight.
The study also found, however, that obese women, whose children were therefore at greater risk for obesity, were less motivated to breastfeed than non-obese women and twice as likely to forego breastfeeding their children as women of healthier weights.
The researchers recommend anyone diagnosed with gestational diabetes to breast feed for as many months as possible to reduce the risk of their children gaining excessive weight as they grow up and is a means of getting children started on a path to good health.
Diabetes Care May 2006
Research
Pesticides may increase the risk of gestational diabetes
Research has shown that exposure to agricultural pesticides during the first trimester increases the risk of a woman developing gestational diabetes [diabetes during pregnancy]. The study was carried amongst farmers wives.
Of 11,273 women who became pregnant 506 reported having gestational diabetes within 25 years after entering the study. 57% of the women had mixed or applied pesticides at some time in their life and the proportion was similar in those with and without gestational diabetes. However, women who mixed, applied or repaired pesticide equipment during the first trimester had a more than twofold increased risk of developing gestational diabetes. By contrast, women with residential exposure to pesticides or indirect exposure during the first trimester had no increased risk and nor did women who had mixed or applied pesticides before the study when they were not pregnant.
This study may have significant public health benefits and farmers' wives may be advised to avoid handling pesticides during pregnancy.
Diabetes Care, March 2007
Very tight versus
tight control for diabetes in pregnancy
Pregnancies complicated by
pre-existing insulin dependent diabetes are high risk for a number of
poor pregnancy and neonatal outcomes. The objective of this review was
to assess the effects of very tight glycaemic control compared
with tight control in women with Type 1 diabetes.
Main results: Two trials involving 182 women were involved. The two trials were difficult to compare. Maternal hypoglycaemia was more common among women whose diabetic control was very tight compared to tight control based on one trial. There was no difference detected in perinatal outcome between the groups.
Reviewers' conclusions: There appears to be no clear evidence of benefit from very tight glycaemic control for pregnant diabetic women. Since very strict control may have a substantial impact on lifestyle, this suggests caution in advising such a tight degree of control.
Diabetes Care in Pregnancy
3.12.02 reported in the British Medical Journal
Researchers in Norwich studied 158 pregnancies in women with Type 1 diabetes between 1991 and 2000 They divided them into two groups – one that had fair control and the other that had poor control of their blood glucose levels. The researchers defined adverse pregnancy outcome as spontaneous abortion, congenital malformation, still birth or infant death. They found that adverse outcome was fourfold higher in the poor control group compared to the fair control group. The poor control group had a ninefold increase in congenital malformation that was potentially life threatening or linked to long-term disability.
The authors of
the study recommend that diabetic women and their carers need to be
advised of the risks and encouraged to optimise glycaemic control before
and during pregnancy.