Diabetes In Pregnancy

What Is Diabetes in Pregnancy?

Diabetes mellitus, commonly known as diabetes, is a disorder in the way the body gets energy from food. It occurs:

• When there isn’t enough insulin, a hormone made by the pancreas that is essential for using food properly, or
• When the insulin the body makes doesn’t work normally

Glucose is a sugar that results from the digestion of food. When food is digested, glucose enters the bloodstream and is carried to all the cells in your body. Your cells use glucose as fuel-it is the energy that keeps you alive.

Insulin is the key that lets glucose into your cells. Without insulin, glucose can’t be used for energy. Instead, it builds up in the blood. High levels of glucose in the blood can, over many years, damage blood vessels, nerves and vital organs. Some people with diabetes need daily insulin injections to prevent these complications.

There are three main types of diabetes: type 1, type 2 and gestational. Type 1 is also known as juvenile diabetes, and type 2 is known as adult onset diabetes. In relation to a woman’s pregnancy, these would be described as “pre-existing” diabetes.

Gestational diabetes develops during pregnancy, typically between weeks 24 and 28, and generally disappears following the birth. All types have similar symptoms and result when there is too much sugar, or glucose, in the blood.

During pregnancy, diabetes can cause complications that affect both you and your baby. These problems are largely preventable. You can control diabetes, reduce your health risks and protect your baby by following these steps:

• Maintain a special diet
• Monitor your blood glucose
• Follow a regular exercise program
• Use insulin when necessary

What Causes Diabetes During Pregnancy?

Glucose, a sugar that results from the digestion of food, is the body’s main nourishment. During pregnancy, your body also supplies your baby with glucose, which is delivered through the placenta and is your baby’s only source of nourishment.

The placenta also makes certain hormones to help the baby develop. But these hormones make it harder for your body to use insulin. About halfway through pregnancy, the placenta increases its production of these anti-insulin hormones.

If your body makes too many anti-insulin hormones, they can block the movement of glucose from your bloodstream into your cells. This is called insulin resistance. At the same time, your pancreas may not be able to produce enough insulin. When too much glucose builds up in your bloodstream, diabetes can result.

Who Is At Risk?

Several factors increase your chances of developing diabetes during pregnancy. These include:

• A family history of diabetes
• Previously giving birth to a stillborn baby or to a baby weighing more than nine pounds
• Obesity
• Being over age 25
• Being African-American, Native-American or Hispanic

How Do I Know If I Have Diabetes?

Gestational diabetes has no obvious symptoms. The American Diabetes Association recommends that all women be screened for gestational diabetes between the 24th and 28th week of pregnancy, or sooner if you have a history of gestational diabetes or other risk factors.

Screenings include:

• Blood glucose test – A sweet, specially prepared glucose mixture is swallowed. One hour later, a blood sample is taken and tested to determine how much glucose is still present. If your blood glucose level is above 140 mg/dl (milligrams per deciliter), your doctor will recommend a glucose tolerance test.
• Glucose tolerance test – You follow a special diet for three days, then fast for eight hours. Before you are permitted to eat or drink anything, a blood sample is taken and tested. A glucose drink is consumed, and a blood sample is taken every hour for three hours. If your blood glucose is in the abnormal range, gestational diabetes is diagnosed.

What If I Already Have Diabetes?

Women with pre-existing diabetes used to be warned against pregnancy because they were more likely to have a baby with birth defects. Today, with careful planning and preconception care, diabetic women have as much chance as non-diabetic women of having a problem-free pregnancy and a healthy baby.

Pregnancy can, however, worsen some long-term diabetes complications. Before stopping birth control, it’s a good idea to have the following evaluations:

• An eye exam
• Kidney function test, which involves providing a blood and/or urine sample
• Blood pressure reading
• Pelvic exam
• Assessment for heart disease
• Hemoglobin A1c test (a blood test that shows whether your blood sugar has been normal over the past three to four months). If the hemoglobin A1c value is very high when you get pregnant, your baby has an increased chance of a birth defect when born.

How Does Diabetes Affect Pregnancy?

In women with gestational diabetes and type 2 diabetes, the sugar (glucose) in your blood directly affects the size of your baby. If your blood sugar level is high, the baby gets too much nourishment and overgrows. This can lead to a condition called macrosomia or “fat” baby. Macrosomia causes problems for both you and your baby.

• What are the risks to the baby?
• What are the risks to the mother?
• How can I avoid complications?
• Will my baby be healthy?

What Are The Risks To The Baby?

Babies who get too much sugar (glucose) from their mother’s blood accumulate fat around the shoulders and trunk. That can make them too difficult to delivery vaginally. Your doctor may recommend delivering the baby early.

Other risks associated with gestational diabetes and type 2 diabetes include:

• Damage to the baby’s shoulders during delivery
• Low blood sugar in the baby at birth
• Higher risk for obesity and type 2 diabetes later in life for the baby
• Jaundice (a yellowish discoloration of the skin) two to three days after birth

Risks associated with type 1 diabetes include:

• Low blood sugar at birth
• Breathing problems at birth
• Jaundice two to three days after birth
• Increased chance of major birth defects

What Are The Risks To The Mother?

Risks associated with gestational and type 2 diabetes include:

• Possible need for cesarean delivery
• Pregnancy-related high blood pressure and swelling of the hands and feet
• Urinary tract infections
• An increased chance of developing diabetes later in life or in a subsequent pregnancy

Risks associated with type 1 diabetes include:

• Premature labor and delivery
• Possible need for cesarean delivery
• Pregnancy-related high blood pressure and swelling of the hands and feet
• Urinary tract infections
• Buildup of ketones (harmful acids) in the blood
• Possible worsening of eye disease
• Possible (reversible) progression of kidney disease

How Can I Avoid Complications?

Problems associated with diabetes in pregnancy are manageable and preventable. The key to prevention is careful control of your blood sugar as soon as gestational diabetes is diagnosed.

• Women with pre-existing diabetes should get their blood sugar under control three to six months before conception, to lessen the risk of birth defects.
• Gestational diabetes, which starts later in pregnancy, does not cause birth defects.

Will My Baby Be Healthy?

During pregnancy, several tests will be done to make sure your baby is developing properly and to help predict the time of delivery.

• Ultrasound – This test involves passing a special wand over the skin of the abdomen. Sound waves are transmitted into the body and bounce back, creating an image that shows the growth and development of the baby.
• Alpha-fetoprotein test – This is a blood test that detects a particular protein produced by the baby’s liver. Abnormal levels of alpha-fetoprotein (AFP) indicate a high risk for certain types of birth defects.
• Amniocentesis – In this test, a long thin needle is inserted into the abdomen and a sample of amniotic fluid (the fluid that surrounds the baby within the uterus) is taken. Cells in the fluid help doctors determine if the baby’s lungs are mature enough to withstand early delivery.
• Non-stress test – A fetal monitor, strapped to the mother’s abdomen, records the baby’s heart rate for a short period of time. This reading helps doctors assess the health of the baby in the last weeks of pregnancy.
• Fetal monitoring – During labor and delivery, a fetal monitor keeps constant track of the baby’s heart rate in order to detect the first indications of distress.

Managing Diabetes During Pregnancy

The goal in treating diabetes is to keep blood sugar levels as normal as possible. That usually involves:

• Daily blood glucose monitoring
• Taking insulin
• Following a special diet
• Following an exercise program

It’s normal to feel stressed during pregnancy. Diabetes creates additional stresses. You have to see your doctor more often than women without diabetes, follow a special diet, and monitor your blood sugar several times per day. Here are some strategies for coping.

• Listen to your body.
• Learn to ask for help.
• Enlist the support of family, friends, or other women facing the same concerns.
• Make time for regular exercise.
• Keep your sense of humor.
• Take good care of yourself.
• Learn a relaxation or meditation technique.
• Be positive.

During your pregnancy, contact your doctor if you have:

• Vaginal bleeding
• Sharp back pain
• Burning or painful urination
• An infection
• Dizziness or fainting
• Rapid weight gain
• Swelling in the hands, face or feet
• Severe nausea with high blood sugar
• A decrease in your baby’s movement

Monitoring Blood Sugar

The level of sugar in your blood is affected by:

• Your diet
• Your activity level
• The insulin in your body
• Stress

Checking your blood sugar is very motivating. It gives you immediate feedback and lets you fine-tune your routine accordingly. It also lets your doctor adjust your treatment, if necessary.

How Is Self (Or Home) Blood Glucose Monitoring Done?

Self-monitoring your glucose levels involves obtaining a drop of your blood, then testing the sample to determine how much sugar is in it. Some items you will need include:

• Lancets to prick your skin, or a spring-loaded finger-sticking device
• Chemically treated test strips and color chart to compare the color on the test
• Glucose meter to read the test strip and give a numerical result (One system on the market requires a smaller blood sample than most, which permits testing from multiple sites. This may be less painful than testing at the fingertip.)
• A log book

The more often you monitor, the more precisely you can control your blood sugar.

If you don’t take insulin, test your blood sugar:

• When you wake up
• One to two hours after meals

If you take insulin, test your blood sugar:

• One hour before and one hour after meals
• Before bed
• About 3 a.m.

What Should Blood Sugar Levels Be During Pregnancy?

Talk to your doctor about the target ranges that meet your needs. Goals may be a little higher in the first trimester.

Contact your doctor if you have two consecutive glucose readings greater than 200 mg/dl

What Other Tests Are Needed?

Besides blood testing, you may be asked to check your urine for ketones. They result when your body burns fat for energy. That can happen if your pancreas has not produced (or you have not injected) enough insulin, or if you haven’t eaten in a long time or haven’t eaten enough.

Ketones cross the placenta, and large amounts can harm the baby. To avoid a buildup of ketones:

• Don’t skip meals or snacks.
• Have a bedtime snack that contains carbohydrates and protein, such as cheese and crackers.
• Don’t go more than five hours without eating.

Taking Insulin During Pregnancy

Women with type 1 diabetes will already be taking insulin. In women with type 2 or gestational diabetes, sometimes diet, exercise and regular monitoring fail to keep blood glucose levels in the target range.

Generally, your doctor will recommend you start taking insulin injections if:

• Your blood sugar first thing in the morning (or “fasting” blood sugar) is over 105 mg/dl.
• Your blood sugar two hours after a meal is over 120 mg/dl two separate times in a week

If you need insulin:

• Your nurse will show you how to draw up and inject insulin.
• Your dietitian will review your food plan and adjust it to match your insulin dose.
• You will be given a daily schedule with times for insulin injections, meals and snacks.

How Much Insulin? And How Often?

There are two kinds of insulin: short acting and intermediate acting. The two types are often combined to treat gestational diabetes.

• Short-acting insulin is effective quickly and for a short period of time.
• Intermediate-acting insulin is effective over a longer period.

If your fasting glucose measurements are above normal, a single injection of intermediate-acting insulin before bed may be all that’s needed. If your blood sugar after meals is too high as well, you may need two or more injections a day.

If both fasting and after-meal glucose levels are above normal, you may need to inject a dose of:

• Intermediate-acting as well as short-acting insulin before breakfast
• Short-acting insulin before dinner
• Intermediate-acting insulin at bedtime

Your doctor will calculate how much insulin is needed to keep your blood sugar levels in the normal range. Women with type 1 or type 2 diabetes who were taking insulin before pregnancy will need two or more injections a day during pregnancy.

Insulin Reaction

Sometimes blood sugar goes too low. This is called hypoglycemia or “insulin reaction.” Hypoglycemia is caused by:

• Not consuming enough food
• Exercising too much without eating enough extra food
• Injecting too much insulin

Hypoglycemia isn’t dangerous to the baby, but it can be harmful to the mother-to-be. Warning signs include:

• Sweating
• Shakiness
• Dizziness
• Fast heartbeat
• Hunger
• Nausea

Nutrition Know How for Diabetes During Pregnancy

In any pregnancy, it’s important to eat the right foods to provide for you and your baby. Women with diabetes have added goals:

• Emphasizing foods that help keep blood glucose normal
• Preventing the buildup of ketones
• Getting enough calories to support healthy weight gain

Meal planning during pregnancy can be challenging. A registered dietitian can teach you how to match your insulin doses with your food intake and activity level, so that your blood sugar remains stable. He or she can also help you meet your needs for vitamins and other key nutrients.

Pay special attention to:

• Iron found in meat and poultry
• Calcium in milk and dairy products
• Folic acid in leafy green vegetables and yellow fruits

How Does Food Affect Blood Sugar?

Blood sugar sinks or soars depending on what you eat. Food is a mixture of fats, proteins, and carbohydrates. While all three are part of a healthy diet, blood glucose comes mostly from the carbohydrates in your meals.

Carbohydrates are classified as:

• Sugars – Includes table sugar as well as fruits, milk, and vegetables
• Starches – Includes cereals, breads, peas, beans, lentils, and starchy vegetables such as potatoes, squash, and corn

All carbohydrates raise your blood sugar. Some raise it faster than others, depending on:

• Whether food is raw or cooked
• How much you eat
• What other foods you eat at the same time
• How fast you eat

Blood sugar tends to be highest after breakfast. Have two carbohydrate choices, such as a slice of toast and a cup of skim milk. A brisk 20-minute walk after breakfast can help prevent a rise in blood glucose.

What And How Much Should I Eat?

The healthiest approach to good nutrition during pregnancy is to eat a variety of foods. No single food provides all the calories and nutrients necessary to both ensure healthy weight gain and support your baby’s growth. Your doctor and dietitian will help you devise a meal plan based on your weight, stage of pregnancy and food preferences.

Use the food pyramid as a guide:

What About Weight Gain?

Most women gain three to five pounds in the first three months of pregnancy and one-half to one pound each week after that. Gaining more than two pounds per week makes your body more resistant to insulin and raises your blood sugar level. Rapid weight gain in the last trimester could be an early sign of preeclampsia, or pregnancy-related high blood pressure.

Optimal weight gain depends on your weight before pregnancy.

The Importance of Exercise For Diabetes in Pregnancy

Exercise is a healthy part of any pregnancy. For women with diabetes, regular exercise:

• Reduces stress
• Improves strength and flexibility
• Helps your body use insulin better
• Controls your weight
• Leads to a quicker recovery after delivery

How Does Exercise Affect Blood Sugar?

Both exercise and insulin lower blood sugar. The combination can result in hypoglycemia (low blood sugar).

• Know the signs of low blood sugar (confusion, shakiness, extreme hunger).
• Always carry a source of sugar, such as hard candy or dried fruit, in case your blood sugar dips too low.
• Have small snacks between meals.

When The Baby Is Born

Labor is hard work. Although most women don’t need insulin injections once contractions start, you may be given fluids, calories, and, if necessary, insulin, through an intravenous tube inserted into your hand or arm.

It’s important to maintain good control of your blood sugar levels up to the time you arrive at the hospital to deliver your baby. If your blood sugar is high during labor, it can cause low blood sugar in your baby during the first few hours after birth. (The baby produces its own insulin. High levels of glucose in your blood during labor stimulate high levels of insulin production in the baby. Once the baby is born, it is no longer receiving glucose from your body. If too much insulin has been produced, hypoglycemia can result.)

Your chances of developing type 2 diabetes later in life are greater if you’ve had diabetes in pregnancy. The following lifestyle changes go a long way in detecting problems early and reducing your risk.

• Have your blood sugar checked within three months after your baby is born and rechecked every year.
• Aim to lose a pound or two a week and maintain a normal weight.
• Return to regular exercise soon after giving birth (4 weeks after a normal delivery).
• Continue monitoring your blood glucose at home while you are trying to lose weight to learn how certain foods affect your blood sugar.
• Lose excess weight before becoming pregnant again.

Diabetes In Pregnancy: Frequently Asked Questions

Here are some frequently asked questions related to diabetes in pregnancy.

Q: If I get diabetes, does that mean my baby will?

A: If you have gestational diabetes, your baby will not be born with diabetes. But both you and your baby are at risk for developing type 2 diabetes later in life. Maintaining a healthy weight and modeling good eating and exercise habits can help offset this tendency.

Q: I have diabetes and I want to get pregnant. What should I do to be healthy before, during, and after pregnancy?

A: Get your blood sugar under control before conception. The risk of birth defects is highest in the first six to eight weeks, when you barely even know you’re pregnant. Once pregnancy is underway, keep your blood sugar levels as close to normal as possible. That means between 60 and 90 mg/dl before breakfast and no higher than 120 mg/dl after meals. Continue to monitor your blood glucose levels closely after your baby is born. Keep a chart of what you eat, the times you breast feed, and your moods, and watch for low blood sugar.

Q: Why does insulin have to be injected?

A: Insulin is a protein. The digestive system cannot distinguish it from food proteins and will digest it, thus destroying its effectiveness if it is swallowed as a pill.

Q: How can I prevent low blood sugar?

A: During pregnancy, the early warning signs can change. For example, you may find that you feel less shaky but develop drowsiness or confusion more quickly. Avoid low blood sugar by:

• Eating meals and snacks at planned times
• Checking your blood sugar as soon as you feel the symptoms of low blood sugar
• Carrying a readily available form of sugar such as hard candy, raisins, or orange juice
• Allowing 15 minutes for whatever you eat or drink to act
• Having an extra snack when you’re more active than usual

Q: Can I breast-feed?

A: Breast-feeding is strongly recommended. Breast-feeding counteracts low postpartum levels of blood sugar in your newborn and helps you lose extra pounds for four to five months after the birth.

Diabetes in Pregnancy: Putting It All Together

Here is a summary of the important facts and information related to diabetes in pregnancy.

• Eight million women have diabetes, and one in 20 pregnant women develops gestational diabetes.
• Diabetes in pregnancy is a cause for concern. But it doesn’t necessarily mean that pregnancy will be difficult, or that the chances of having a normal healthy baby are any less.
• By testing your blood glucose levels, following your food plan, and exercising regularly, you and your health care team can work together to lower your high blood sugar levels.
• Up to 50 percent of women with gestational diabetes will develop permanent type 2 diabetes within 10 to 15 years.
• Risk factors for gestational diabetes include:
  • Family history
  • Previous diagnosis of gestational diabetes
  • Previous stillbirth or live birth of a baby over nine lbs.
  • Obesity
  • Age over 25
  • African American, Hispanic, or Native American
• Women with pre-existing diabetes should be tested for various long-term complications, such as vision impairment, heart disease or reduced kidney function, before becoming pregnant. Pregnancy can make them worse.
• Risks to both mother and baby are significantly reduced when blood glucose is controlled throughout the pregnancy.
• A mother’s diabetes will not cause her baby to be diabetic, but the child is at an increased risk for developing type 2 diabetes later in life.

Diabetes in Pregnancy: Glossary

Here are definitions of medical terms related to diabetes in pregnancy.

Carbohydrate: A nutrient in food that comes mainly from sugar and starch. Carbohydrate is broken down into glucose for energy.

Diabetes mellitus: A disorder that prevents the body from converting digested food into energy.

Gestational diabetes: A form of diabetes that begins during pregnancy and usually disappears after delivery.

Glucose: The form of sugar used by the body’s cells for energy. All starches in digestible food are broken down to glucose in the intestinal tract before being absorbed into the body.

Hormone: A chemical created by the body’s glands and secreted into the blood in order to have an effect on an organ.

Hypoglycemia: A condition where the blood sugar is lower than normal. You may feel weak or shaky, feel your heart pounding, perspire, feel very hungry, or get a headache. This can be dangerous and should be avoided or treated quickly. If not, later symptoms are seeing double, not thinking clearly, and possibly passing out.

Insulin: A hormone secreted by the pancreas that lets blood glucose get into cells. Insulin lowers the level of glucose in the blood.

Insulin resistance: When insulin is blocked from doing its job. It can be caused by excess hormones made by the placenta. It’s also linked to being overweight.

Ketones: A potentially harmful waste produce created when the body breaks down fat for energy.

Macrosomia: The term used to describe a larger than normal baby. It occurs when the mother’s blood sugar levels are too high during pregnancy.

Placenta: A special tissue that joins the mother and baby. It provides hormones and supplies the growing baby with water and nutrients from the mother’s blood.

Diabetes in Pregnancy Additional Sources of Information

Here are some reliable sources that can provide more information on diabetes in pregnancy.

Disorders of Carbohydrate Metabolism: Diabetes Mellitus 
http://www.merck.com/pubs/mmanual/section2/chapter13/13a.htm

Pregnancy Complicated by Disease: Diabetes Mellitus 
http://www.merck.com/pubs/mmanual/section18/chapter251/251g.htm#A018-251-1070

Gestational Diabetes: What It Means for Me and My Baby 
http://familydoctor.org/handouts/075.html

Exercise: An Alternative Therapy for Gestational Diabetes 
http://www.physsportsmed.com/issues/mar_96/artal.htm