Diabetes in Pregnancy

What is it ?

Diabetes is present in about 1 in 50 (2%) of pregnancies. Some women, like you, have diabetes before they become pregnant. Pregnancy can also cause some women to develop diabetes. This is called gestational diabetes. Diabetes can affect both you and your baby. Pregnancy will raise your sugar level. This happens because of all the hormone changes. It will mean a change of treatment: bigger doses of insulin, or a change from diet or tablets to insulin (which is safer for the baby). As you know, eyes and kidneys might be affected by diabetes: these problems may need extra supervision and treatment. Diabetes also affects the pregnancy itself: Affecting mother : high blood pressure in pregnancy, often with protein in your urine is more likely to occur. This is called pre-eclampsia. Infections, such as thrush and urine infections, are also more common, particularly if the sugar levels are not ideally controlled. Affecting baby : there is a higher risk of miscarriage and birth defects (especially of the baby's heart, spinal cord, brain and kidneys). The higher the levels of sugar in your blood, the more gets through the afterbirth (placenta) into your baby. This can lead to your baby growing larger than usual. In turn, this can mean a long labour, possible injury to the baby during labour and a greater likelihood of needing Caesarean section. Sometimes the diabetes results in a reduced blood supply getting through to your baby: this may cause your baby not to grow properly inside your womb. This can lead to stillbirth, the baby not coping with labour, or premature labour. The baby's lungs may also be temporarily affected.

How does it occur ?

The cause of diabetes remains unclear. However, we do know that it is not just a disorder which affects the blood sugar level. Other chemical changes occur in the blood and particularly in the blood-vessels. Diabetes can therefore affect the blood circulation to the womb and to the afterbirth in particular. To some extent, the longer the diabetes has been present and the older you are, the more likely it is that problems will arise.

What does treatment involve ?

Pre-pregnancy : it is important to have your diabetes under the best possible control well before you even become pregnant. This will greatly reduce the risk of birth defects, almost to that of the non-diabetic person. You should visit your diabetic specialist several months before you plan to start a family so that diet and the amount of insulin that you need can be carefully checked. Your own glucose levels and a special blood test (haemoglobin A1c or blood fructosamine level) are very important: they should be as near to normal as possible. It is important that you ask your doctor to advise you when he thinks it is safe for you to become pregnant. Antenatal care : this will take place almost entirely at the hospital clinic. You will be cared for by a team of doctors, midwives and nurses. Some specialize in pregnancies, others in diabetes. You will be seen at the clinic about every 2 weeks until 28 weeks, and then each week until the birth of your baby. At each visit the control of your diabetes and weight will be checked. You may be changed to a four times daily injection routine. Your baby will also be checked. An ultrasound scan (like a radar picture) done at 18 to 20 weeks will look for any birth defects: later in the pregnancy, it will show how well your baby is growing. Delivery : this will usually be vaginal unless there are other complications. Delivery will be planned close to the date that your baby is due. It may be necessary to deliver the baby earlier, if the baby is large or there are other complications. You will be given glucose and insulin through a needle in an arm vein. Your blood glucose levels will be checked, and the amounts of glucose or insulin adjusted accordingly. An epidural anaesthetic is a safe method of pain relief. It involves an injection into your lower back. Your baby will be delivered in a hospital which has a special care baby unit, in case it needs extra care. This may be done in order to deal with any of the possible problems mentioned earlier. After your baby is born, the amount of insulin that you need falls quickly. You should be able to stop insulin if you didn't have it before you were pregnant, and will be able to breast-feed quite normally.

During treatment …

If you are not already doing it, you will be taught how to check your own blood sugar levels (using a finger-prick sample of blood) several times a day before and after meals. Using these results, the amounts of food and insulin can be altered to achieve blood glucose levels ideally 4 to 7 mmol/l (70 to 120 mg/dl) before meals and no more than 10 mmmol/l (180 mg/dl) after meals. Another test called HbA1c or fructosamine will be done to check your diabetes control. Really good control of your diabetes makes it less likely that the baby will grow too large, and also reduces risks of other complications.

After delivery …

Your baby's lungs may not mature normally. At birth he or she may have breathing problems and may need to be in an incubator and be treated with special drugs to help the lungs to mature. If you have very high levels of blood sugar, this leads your baby to make lots of insulin. When your baby is separated from the afterbirth and no longer supplied with the sugar in your blood, this large amount of insulin may give your baby sugar levels that are too low. This will be carefully watched for and promptly treated. Your baby has only a 4% chance of having diabetes at some stage of his or her life, but about 10% if your partner also has diabetes. It is not considered worthwhile checking your child for diabetes; if it does occur, the symptoms are usually fairly clear-cut.

What if you were not treated ?

If diabetes is not controlled at the time of conception, your baby is more likely to have a birth defect. Without control of your diabetes and supervision of the pregnancy, the risks of miscarriage, extra fluid in the womb (hydramnios), stillbirth, pre-eclampsia, premature labour, and a large baby with lung problems are higher.

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