Diabetes is a global health problem affecting children and adults, including women of childbearing age. Pregnant women with Diabetes can be broadly classified as those with pre-existing Diabetes (either Type 1 or Type 2 Diabetes) and those who have become pregnant and then developed Diabetes for the first-time during pregnancy, usually in 2nd or 3rc1 trimester. Known as Gestational Diabetes Mellitus (GDM), this type of Diabetes disappears after delivery in 90 per cent of cases.Diabetes and pregnancyHigh blood glucose in girls can delay puberty which in turn delays menarche (the first occurrence of menstruation). This may cause problems with ovulation and can cause irregular cycles. Diabetes associated obesity and insulin resistance just adds to the problem.Usually, during pregnancy, high blood glucose levels occur due to the hyperglycaemic effect of placental hormones. In pregnant women without any history of Diabetes, the pancreas can produce enough insulin to maintain normal blood glucose levels. However, in women with Diabetes, treatment is adjusted to maintain the recommended blood sugar targets with insulin.Women with Diabetes may face associated complications due to obesity, diabetic nephropathy (kidney damage), diabetic retinopathy (eye damage), Diabetic Neuropathy (nerve damage), hypertension (high blood pressure) and cardiovascular (heart) problems. This can cause difficulty in conception and successfully carrying the pregnancy to term. Every woman of child bearing age with Diabetes should ideally undergo counselling prior to conceiving as having Diabetes may affect not just a women's ability to conceive but can also precipitate problems with the pregnancy and the intrauterine growth of the baby.Precautions prior to planned pregnancyToday men and women choose to marry later in life but the age of onset of Type 2 Diabetes is lowering. People in their 20's and 30's are being diagnosed to have Diabetes (which is usually Type 2 Diabetes). This means that there is an increase in women with Type 2 Diabetes who aspire to be pregnant. It is important that HbA 1c should be lower than 6 per cent or up to 6.5 per cent and if there is a risk of hypoglycaemia specially in Type 1 Diabetes then it should be managed to be below 7 per cent.For women with Type 2 Diabetes, insulin is considered to be a safest drug for use prior to pregnancy. Most women if on metformin may not be able to achieve these goals only on metformin and they will need insulin therapy. Insulin remains the drug of the choice for all women with Diabetes during pregnancy.Cause for concernGlucose from the mother crosses the placenta to reach the baby's blood for energy. Hence, if the mother's blood glucose levels are high, it leads to high blood glucose in the baby as well. High blood glucose levels in the early stages of pregnancy increases the risk of miscarriage and birth defects. As all the organs of the foetus are primarily formed in the first 6-8 weeks of pregnancy (organogenesis), good glucose control will prevent developmental problems such as microcephaly (small head), congenital heart and spine problems and preterm delivery. Research studies have shown that high HbA 1c levels at the time of conception (the average of blood sugar levels in the previous three months) increases the risk of diabetic embryopathy (abnormalities in the developing embryo).Pre-conception counsellingBefore conception, all women with Type 1 or Type 2 Diabetes must be counselled about the effect of uncontrolled or high blood glucose levels on the maternal and foetal health in pregnancy and also the effect of pregnancy on Diabetes and its related comorbidities (like high blood pressure and obesity) and the complications like eyes (retinopathy), kidneys (nephropathy) and nerves (neuropathy).Ideally, pre-conception counselling should be part of the protocol for every woman with Diabetes of child-bearing age. The counselling team should be led by a diabetologist or endocrinologist who will not only manage the blood glucose levels prior to conception but will also ensure the fitness of pregnancy through evaluation of hypertension and other checks to ensure a successful pregnancy. The counselling team should also include an experienced dietitian, a diabetes educator, a gynaecologist, a paediatrician and family members of the woman with Diabetes.Self-monitoring of blood glucoseAs the pregnancy advances, blood glucose level increases till the 36th week of pregnancy, thus self-monitoring of blood glucose (SMBG) prior, during and post pregnancy is important. During pregnancy, women with Diabetes who manage their glucose levels with diet or oral drug therapy should ideally check their glucose levels everyday by glucometer:• Fasting• 2-hour post-breakfast• 2-hour post-lunch• 2-hour post-dinnerWomen who are on multiple-dose of insulin therapy (four pricks per day) or have Type 1 Diabetes should ideally check their following blood sugar levels on a daily basis:• Fasting• Post-breakfast• Pre-lunch• Post-lunch• Pre-dinner• Post-dinner• At 3 a.m.The more you monitor, the better your blood glucose control is going to be. Irrespective of the therapy, strict control of blood glucose levels is the first step to managing them successfully.Continuous Glucose MonitoringIn addition to SMBG, Continuous Glucose Monitoring (CGM) is an additional way to check blood glucose during pregnancy, especially for women with Type 1 Diabetes. CGM is a useful tool to determine the dosage of insulin required in order to achieve the best glycaemic control and avoid blood glucose fluctuation.Studies have shown that fetus of women with Type 1 Diabetes benefit if blood glucose levels are in a range known as lime In Range (TIR). During pregnancy, blood sugar levels must be managed to stay within 63 to 140 mg/dL. Ideally, TIR is to be kept more than 70 per cent for women with Type 1 Diabetes and more than 80 per cent of the time for women with Type 2 Diabetes and GDM.ComplicationsMishandling of blood glucoseChildren of women with Diabetes or GDM are more likely to develop Diabetes, obesity and cardiovascular disease in their adult life. Good blood glucose control during pregnancy can prevent this risk. Thus, early detection and adequate treatment can save future generations.Persistent high blood glucose levels during pregnancy causes excessive foetal insulin secretion in the womb before birth. These babies are prone to severe low blood glucose levels at the time of birth due to the continued high insulin secretion in their body.In the latter half of pregnancy, high blood glucose levels in the mother causes hyperinsulinemia in the foetus. This may result in larger size and weight of the baby, resulting in complications during and after the delivery. Large babies may require a caesarean section for delivery as vaginal birth may be difficult. High blood glucose levels in the last phase of pregnancy increase the risk of developing pregnancy-induced hypertension called preeclampsia in mothers. It is characterised by high blood pressure, fluid retention or swelling of the face and the sudden expulsion of placenta may lead to vitreous haemorrhage.Thus, pregnancy is contraindicated amongst women with pre-existing Proliferative Diabetic Retinopathy (PDR)Diet during pregnancyAvoiding sweets, sugar, honey, jaggery, fruit juices and soft drinks is necessary. A high protein diet should be started in the second trimester. Intake of moderate amount of carbohydrates and low amounts of fats is advised. It is best to consult a dietician for personalised diets suitable for pregnant women with Diabetes.Safe deliveryAt the time of the delivery, blood glucose level should be between 70 to 120 mg/dl. If your blood glucose levels, at the delivery time is high then it may certainly enter into baby1s blood causing the baby to have hands and spilling of protein in the urine hyperglycaemia. When fetal insulin is being (called proteinuria). Hence, blood sugar control is very important, especially in pregnancy to avoid complications for both mother and the baby.Effects of Diabetes on retinaWomen with pre-existing Diabetes should be counselled about the development or progression of retinopathy. Diabetic retinopathy is one of the early complications of Diabetes caused by the damage to the blood vessels of the light sensitive tissue in the back of the eye called the retina. Initially, the person may be asymptomatic or have only mild vision problems. This risk is high in women with high HbAlc or whose HbAlc falls very rapidly. Pre-existing retinopathy may deteriorate during pregnancy. At delivery, secreted, it could lead the baby to have a hyper-insulinemia. At the moment when the placenta is cut and the mother is separated completely from the baby, the baby's blood sugar level is going to rapidly drop and the baby may develop hypoglycaemia (very low blood glucose levels). Therefore, maternal blood sugar control prior to delivery is very important.Women with Diabetes who have good blood glucose control and no Diabetes associated complication can undergo a normal delivery (based on their obstetrician's advice)Healthy pregnancyWomen with Type I DiabetesThe important step of having a healthy pregnancy is blood glucose control. The basal-bolus insulin therapy works best to achieve this goal. It is important to check blood glucose levels as mentioned previously. As women with Type 1 Diabetes are already treated with insulin, pregnancy safe insulin NPH or insulin detemir is used as the basal insulin to control fasting blood glucose levels. For managing the post-meal elevation in blood glucose levels, short acting bolus insulin such as regular Human insulin, or aspart or lispro insulin is prescribed three times a day with every meal. The requirement of insulin progressively increases with advancementof pregnancy and is reduced to 50 per cent following delivery of the baby. Mer delivery, the mother should be monitored closely for low blood glucose levels and insulin dose should be adjusted accordingly.Women with Type 2 DiabetesWomen with Type 2 Diabetes are usually treated with oral anti-diabetic medications. However, these medications are not safe in pregnancy and expecting mothers should be shifted to insulin. Similar to Type 1 Diabetes, basal- bolus insulin therapy in preferred while managing Diabetes in pregnancy.Note: If you are on drugs such as statins, ARBs, ACE-inhibitors then contact your diabetologist immediately before planning a pregnancy as they are contraindicated during pregnancy.During lactationAfter delivery, the requirement of insulin decreases considerably. Insulin remains the drug of choice till baby is being breastfed. But few medications, like metformin or glipizide can be started if insulin is unacceptable to the mother. Breast feeding increases the risk of hypoglycaemia in mothers so monitoring their blood glucose is important. Breast feeding helps prevent onset of Diabetes and obesity in the mother. Longer the duration of breast feeding, lesser is the risk of developing Diabetes.To concludeDiabetes care in pregnancy should consist of pre-conception care including proper counselling, education assessment of micro and macro vascular complications and screening for other conditions like hypertension, thyroid disease etc. These should be continued with good blood glucose control all through the pregnancy, labour, delivery and post-partum (post delivery) period for the best outcome of the pregnancy and the best future for the children of women with Diabetes - Dr Sunil Gupta is well known Diabetologist, CEO & MD at Sunil's Diabetes Care n' Research Centre Pvt. Ltd., Nagpur: Dr. Sunil Gupta has MD, FACE (USA), FRCP (London, Glasgow & Edinburgh). He is the Associate Editor of International Journal of Diabetes in Developing Countries & Journal of Clinical Diabetology. He is also the National President of DIPS/ (Diabetes In Pregnancy Study group India).
Diabetes is a global health problem affecting children and adults, including women of childbearing age. Pregnant women with Diabetes can be broadly classified as those with pre-existing Diabetes (either Type 1 or Type 2 Diabetes) and those who have become pregnant and then developed Diabetes for the first-time during pregnancy, usually in 2nd or 3rc1 trimester. Known as Gestational Diabetes Mellitus (GDM), this type of Diabetes disappears after delivery in 90 per cent of cases.Diabetes and pregnancyHigh blood glucose in girls can delay puberty which in turn delays menarche (the first occurrence of menstruation). This may cause problems with ovulation and can cause irregular cycles. Diabetes associated obesity and insulin resistance just adds to the problem.Usually, during pregnancy, high blood glucose levels occur due to the hyperglycaemic effect of placental hormones. In pregnant women without any history of Diabetes, the pancreas can produce enough insulin to maintain normal blood glucose levels. However, in women with Diabetes, treatment is adjusted to maintain the recommended blood sugar targets with insulin.Women with Diabetes may face associated complications due to obesity, diabetic nephropathy (kidney damage), diabetic retinopathy (eye damage), Diabetic Neuropathy (nerve damage), hypertension (high blood pressure) and cardiovascular (heart) problems. This can cause difficulty in conception and successfully carrying the pregnancy to term. Every woman of child bearing age with Diabetes should ideally undergo counselling prior to conceiving as having Diabetes may affect not just a women's ability to conceive but can also precipitate problems with the pregnancy and the intrauterine growth of the baby.Precautions prior to planned pregnancyToday men and women choose to marry later in life but the age of onset of Type 2 Diabetes is lowering. People in their 20's and 30's are being diagnosed to have Diabetes (which is usually Type 2 Diabetes). This means that there is an increase in women with Type 2 Diabetes who aspire to be pregnant. It is important that HbA 1c should be lower than 6 per cent or up to 6.5 per cent and if there is a risk of hypoglycaemia specially in Type 1 Diabetes then it should be managed to be below 7 per cent.For women with Type 2 Diabetes, insulin is considered to be a safest drug for use prior to pregnancy. Most women if on metformin may not be able to achieve these goals only on metformin and they will need insulin therapy. Insulin remains the drug of the choice for all women with Diabetes during pregnancy.Cause for concernGlucose from the mother crosses the placenta to reach the baby's blood for energy. Hence, if the mother's blood glucose levels are high, it leads to high blood glucose in the baby as well. High blood glucose levels in the early stages of pregnancy increases the risk of miscarriage and birth defects. As all the organs of the foetus are primarily formed in the first 6-8 weeks of pregnancy (organogenesis), good glucose control will prevent developmental problems such as microcephaly (small head), congenital heart and spine problems and preterm delivery. Research studies have shown that high HbA 1c levels at the time of conception (the average of blood sugar levels in the previous three months) increases the risk of diabetic embryopathy (abnormalities in the developing embryo).Pre-conception counsellingBefore conception, all women with Type 1 or Type 2 Diabetes must be counselled about the effect of uncontrolled or high blood glucose levels on the maternal and foetal health in pregnancy and also the effect of pregnancy on Diabetes and its related comorbidities (like high blood pressure and obesity) and the complications like eyes (retinopathy), kidneys (nephropathy) and nerves (neuropathy).Ideally, pre-conception counselling should be part of the protocol for every woman with Diabetes of child-bearing age. The counselling team should be led by a diabetologist or endocrinologist who will not only manage the blood glucose levels prior to conception but will also ensure the fitness of pregnancy through evaluation of hypertension and other checks to ensure a successful pregnancy. The counselling team should also include an experienced dietitian, a diabetes educator, a gynaecologist, a paediatrician and family members of the woman with Diabetes.Self-monitoring of blood glucoseAs the pregnancy advances, blood glucose level increases till the 36th week of pregnancy, thus self-monitoring of blood glucose (SMBG) prior, during and post pregnancy is important. During pregnancy, women with Diabetes who manage their glucose levels with diet or oral drug therapy should ideally check their glucose levels everyday by glucometer:• Fasting• 2-hour post-breakfast• 2-hour post-lunch• 2-hour post-dinnerWomen who are on multiple-dose of insulin therapy (four pricks per day) or have Type 1 Diabetes should ideally check their following blood sugar levels on a daily basis:• Fasting• Post-breakfast• Pre-lunch• Post-lunch• Pre-dinner• Post-dinner• At 3 a.m.The more you monitor, the better your blood glucose control is going to be. Irrespective of the therapy, strict control of blood glucose levels is the first step to managing them successfully.Continuous Glucose MonitoringIn addition to SMBG, Continuous Glucose Monitoring (CGM) is an additional way to check blood glucose during pregnancy, especially for women with Type 1 Diabetes. CGM is a useful tool to determine the dosage of insulin required in order to achieve the best glycaemic control and avoid blood glucose fluctuation.Studies have shown that fetus of women with Type 1 Diabetes benefit if blood glucose levels are in a range known as lime In Range (TIR). During pregnancy, blood sugar levels must be managed to stay within 63 to 140 mg/dL. Ideally, TIR is to be kept more than 70 per cent for women with Type 1 Diabetes and more than 80 per cent of the time for women with Type 2 Diabetes and GDM.ComplicationsMishandling of blood glucoseChildren of women with Diabetes or GDM are more likely to develop Diabetes, obesity and cardiovascular disease in their adult life. Good blood glucose control during pregnancy can prevent this risk. Thus, early detection and adequate treatment can save future generations.Persistent high blood glucose levels during pregnancy causes excessive foetal insulin secretion in the womb before birth. These babies are prone to severe low blood glucose levels at the time of birth due to the continued high insulin secretion in their body.In the latter half of pregnancy, high blood glucose levels in the mother causes hyperinsulinemia in the foetus. This may result in larger size and weight of the baby, resulting in complications during and after the delivery. Large babies may require a caesarean section for delivery as vaginal birth may be difficult. High blood glucose levels in the last phase of pregnancy increase the risk of developing pregnancy-induced hypertension called preeclampsia in mothers. It is characterised by high blood pressure, fluid retention or swelling of the face and the sudden expulsion of placenta may lead to vitreous haemorrhage.Thus, pregnancy is contraindicated amongst women with pre-existing Proliferative Diabetic Retinopathy (PDR)Diet during pregnancyAvoiding sweets, sugar, honey, jaggery, fruit juices and soft drinks is necessary. A high protein diet should be started in the second trimester. Intake of moderate amount of carbohydrates and low amounts of fats is advised. It is best to consult a dietician for personalised diets suitable for pregnant women with Diabetes.Safe deliveryAt the time of the delivery, blood glucose level should be between 70 to 120 mg/dl. If your blood glucose levels, at the delivery time is high then it may certainly enter into baby1s blood causing the baby to have hands and spilling of protein in the urine hyperglycaemia. When fetal insulin is being (called proteinuria). Hence, blood sugar control is very important, especially in pregnancy to avoid complications for both mother and the baby.Effects of Diabetes on retinaWomen with pre-existing Diabetes should be counselled about the development or progression of retinopathy. Diabetic retinopathy is one of the early complications of Diabetes caused by the damage to the blood vessels of the light sensitive tissue in the back of the eye called the retina. Initially, the person may be asymptomatic or have only mild vision problems. This risk is high in women with high HbAlc or whose HbAlc falls very rapidly. Pre-existing retinopathy may deteriorate during pregnancy. At delivery, secreted, it could lead the baby to have a hyper-insulinemia. At the moment when the placenta is cut and the mother is separated completely from the baby, the baby's blood sugar level is going to rapidly drop and the baby may develop hypoglycaemia (very low blood glucose levels). Therefore, maternal blood sugar control prior to delivery is very important.Women with Diabetes who have good blood glucose control and no Diabetes associated complication can undergo a normal delivery (based on their obstetrician's advice)Healthy pregnancyWomen with Type I DiabetesThe important step of having a healthy pregnancy is blood glucose control. The basal-bolus insulin therapy works best to achieve this goal. It is important to check blood glucose levels as mentioned previously. As women with Type 1 Diabetes are already treated with insulin, pregnancy safe insulin NPH or insulin detemir is used as the basal insulin to control fasting blood glucose levels. For managing the post-meal elevation in blood glucose levels, short acting bolus insulin such as regular Human insulin, or aspart or lispro insulin is prescribed three times a day with every meal. The requirement of insulin progressively increases with advancementof pregnancy and is reduced to 50 per cent following delivery of the baby. Mer delivery, the mother should be monitored closely for low blood glucose levels and insulin dose should be adjusted accordingly.Women with Type 2 DiabetesWomen with Type 2 Diabetes are usually treated with oral anti-diabetic medications. However, these medications are not safe in pregnancy and expecting mothers should be shifted to insulin. Similar to Type 1 Diabetes, basal- bolus insulin therapy in preferred while managing Diabetes in pregnancy.Note: If you are on drugs such as statins, ARBs, ACE-inhibitors then contact your diabetologist immediately before planning a pregnancy as they are contraindicated during pregnancy.During lactationAfter delivery, the requirement of insulin decreases considerably. Insulin remains the drug of choice till baby is being breastfed. But few medications, like metformin or glipizide can be started if insulin is unacceptable to the mother. Breast feeding increases the risk of hypoglycaemia in mothers so monitoring their blood glucose is important. Breast feeding helps prevent onset of Diabetes and obesity in the mother. Longer the duration of breast feeding, lesser is the risk of developing Diabetes.To concludeDiabetes care in pregnancy should consist of pre-conception care including proper counselling, education assessment of micro and macro vascular complications and screening for other conditions like hypertension, thyroid disease etc. These should be continued with good blood glucose control all through the pregnancy, labour, delivery and post-partum (post delivery) period for the best outcome of the pregnancy and the best future for the children of women with Diabetes - Dr Sunil Gupta is well known Diabetologist, CEO & MD at Sunil's Diabetes Care n' Research Centre Pvt. Ltd., Nagpur: Dr. Sunil Gupta has MD, FACE (USA), FRCP (London, Glasgow & Edinburgh). He is the Associate Editor of International Journal of Diabetes in Developing Countries & Journal of Clinical Diabetology. He is also the National President of DIPS/ (Diabetes In Pregnancy Study group India).
