Diabetes - The Medical Perspective
Diabetes and Pregnancy
Diabetes is the most prevalent complication in pregnancy. The goal of all pregnancies is a healthy outcome for mom and baby. Diabetes adds a unique set of challenges to pregnancy.
Pregnancy complicated with diabetes incudes two groups. The first is women with pre-existing diabetes. This group includes both type 1 diabetes and type 2 diabetes. The second group is women with gestational diabetes. Gestational diabetes is diabetes diagnosed during the second or third trimester of pregnancy, and not clearly type 1 or type 2 diabetes.
Greater attention to diabetes self-management and intensive insulin therapy in both groups of women have resulted in improved maternal blood glucose control. This means better outcomes for both mother and child. In the United States, it is estimated that some form of diabetes complicates 6% - 7% of all pregnancies. Gestational diabetes makes up 90% of these cases and rates are increasing. These increasing rates are likely due to the prevalence of overweight or obesity in women of childbearing age.
Pre-conception counseling is a very important part of diabetes care for women of childbearing age with existing diabetes. This counseling helps identify and manage risk that can affect the pregnancy outcome. Complications decrease when a pregnant woman enters pregnancy with optimal glucose levels. Women of childbearing age with diabetes should maintain an effective method of contraception until a hemoglobin A1C level less than 6.5% is achieved. This assures the least risk of fetal abnormalities.
Glucose control is the key to a healthy outcome for both mom and baby. Some women with gestational diabetes may be able achieve adequate glucose control by following a healthy meal plan, maintaining appropriate gestational weight gain, and being physically active, within the recommendations of their health care provider. Insulin is the preferred medication to control glucose levels in pregnancy because it does not cross the placenta to any measurable degree. Metformin and glyburide may also be used, but do cross the placenta and lack long-term safety data.
There is a lack of agreement for exact timing of glucose monitoring and target ranges during pregnancy. You will likely be asked to check your fasting blood glucose each morning, one or two hours after each meal and at bedtime. Depending on your needs and treatment plan, you may also need to check your blood glucose before meals. There is no disagreement however, that maintaining normal glucose levels is the critical goal of diabetes and pregnancy.
Work with your health-care team to set target blood glucose ranges and a monitoring schedule appropriate for you to achieve optimal glucose management. A multi-disciplinary health-care team can support you and may consist of the following disciplines, depending on your needs:
- Obstetrician-will monitor you and your baby’s health throughout the pregnancy
- Endocrinologist-a medical doctor that specializes in treating diabetes
- Ophthalmologist-an eye specialist that can monitor any diabetes- related changes to the small blood vessels of your eyes that can progress with pregnancy
- Registered dietitian-will assist you in diabetes meal planning to assure adequate blood glucose control and proper nutrition
- Certified diabetes educator-will provide education regarding blood glucose monitoring and insulin administration
Diabetes and Food
A healthy diet is important for all pregnancies. This starts with an individualized diabetes food plan with the following goals:
- Maintain appropriate gestational weight gain
- Provide adequate nutrients for mom and baby
- Maintain adequate glucose control and minimize fluctuations in blood glucose
- Avoid ketosis
Adequate calories are necessary for normal fetal growth and are determined by the mother’s age, height, weight and physical activity. Each woman’s meal plan should be individualized and based on her personal food preferences, blood glucose levels, and physical activity. A meal plan of three meals and three snacks works well for many women with diabetes. The Dietary Reference Intake for carbohydrate in pregnancy for women 19-50 years of age is a minimum of 175 grams of carbohydrate. This minimum amount of carbohydrate is necessary to provide adequate glucose for fetal growth and for the maternal brain.
Mealtime insulin must be adequate to match carbohydrate intake. An insulin-to-carbohydrate ratio is used by many women to adequately dose insulin at meals, and snacks. Insulin requirements increase as the pregnancy progresses. The insulin-to-carbohydrate ratio will likely change often during the second and third trimester.