Diabetes in pregnancy is on the increase. This can be put down to a variety of reasons, not least being increasing weight - 18% of the Irish population is now obese in comparison with 6% in 1980.
This has been influenced by the fact that Irish people are not exercising enough and are not eating enough wholegrains and fibre.
Exercise promotes an increased feeling of well-being and more efficient glucose uptake in the body, leading to better blood glucose levels.
With more and more refined foods now available, many people are not eating a healthy, balanced diet. Fibre rich foods are absorbed more slowly and tend not to cause sudden rises in blood glucose levels.
When diabetes is first discovered in a woman during pregnancy, it is known as gestational diabetes. It is usually diagnosed in the final three months of pregnancy, but may occur at any stage.
In some ways this type of diabetes behaves like type 2 diabetes in that the woman's body becomes resistant to insulin. Every cell in the body needs glucose for energy and insulin is needed to allow glucose into the cells. This means that insulin resistance causes glucose to stay in the blood circulation for longer than normal.
Hormones produced during pregnancy increases insulin resistance.
The baby tends to put on its main body weight towards the end of pregnancy and high blood glucose levels in the mother will make the baby gain extra weight. This may lead to difficulty at delivery time, such as increased risk of forceps delivery or Caesarean section.
The good news is that the mother's blood glucose levels will usually return to normal after the baby is born.
In my experience before being diagnosed with diabetes, pregnant women complain of extreme tiredness - more than could be explained by their stage of pregnancy. While increased thirst and increased urination are symptoms, very few tend to complain of these, as the need to pass urine frequently is common in later pregnancy.
Testing for diabetes in pregnancy differs from hospital to hospital. In general, a screening test will be carried out first. Known as a Glucose Challenge Test (GCT), the woman is given a sweet drink (50g carbohydrate) followed by a blood sugar test after one hour.
If the result is normal, no further action is taken. If it is abnormal, a more detailed diagnostic test will be carried out. Called a Glucose Tolerance Test (GTT), this is done by fasting for 12 hours, having a blood sugar test, a sweet drink (100g carbohydrate) and a blood test one hour, two hours and three hours later. An abnormal GTT indicates diabetes.
On diagnosis, the woman will be reassured to hear that when her blood glucose levels are back to normal she should have a sense of having more energy and feeling much better overall.
To achieve this an appointment will be made for the next special Diabetes Clinic - usually within a week. In some hospitals, this clinic is combined with the antenatal clinic, which is more convenient for pregnant women.
Ideally the team that the woman will meet includes a consultant diabetes specialist, a diabetes midwife or nurse specialist, a dietitian and an obstetrician (although provision of services varies greatly throughout the country).
The first visit to the clinic involves assessment by the diabetes midwife specialist who will explain all about diabetes in pregnancy and its effects. The clinic routine will also be outlined and any questions or fears will be addressed. This may be a time of great anxiety for women who may sometimes experience a sense of misplaced guilt. They will need emotional support.
The specialist diabetes doctor (diabetologist) will see and assess the woman's test results and will decide on follow up care. The importance of the recommended lifestyle changes will be reinforced and the woman will usually be reviewed within one week.
High blood glucose levels are not healthy for the baby. The recommended blood glucose levels are <5mmol/l before a meal and <7mmol/l one hour after a meal.
With this in mind, the first change in lifestyle that will be suggested is to eat healthily.
The dietitian will take a detailed history of eating habits and preferences, and will work out an individual eating plan with the woman to aim for a well balanced diet. Normal healthy eating is advised, with the recommendation that a mid-morning, mid-afternoon and bed-time snack are included as part of the overall meal plan. The dietitian may use food samples to demonstrate recommended portion sizes. The inclusion of some carbohydrate, eg. bread, pasta, rice, potatoes or breakfast cereals, at each main meal is advised as part of a balanced diet.
Exercise helps to lower glucose levels so walking or swimming regularly are very beneficial, taking into account the stage of pregnancy. A little exercise every day is better than a lot once or twice a week. In the later stages of pregnancy, care needs to be taken to exercise within limitations and to take medical advice if there are any other health problems.
At the end of the first visit the woman will be given an appointment for the next week. She will be asked to fast from midnight and to attend the Diabetes Clinic at 9am - for her first visit to the 'Breakfast Club'!
A fasting blood sugar test will be taken, followed by breakfast and a further blood test an hour later.
Providing these levels are normal, women are reviewed fortnightly in this way and also have an antenatal check up (depending on the stage of pregnancy). As long as the baby's weight gain is normal and the mother's blood glucose levels remain satisfactory, the pregnancy will be expected to proceed normally.
Even with careful eating and exercise, sometimes blood glucose levels remain higher than desired. For these women it may become necessary to have insulin injections for the rest of the pregnancy.
This usually involves a few days in hospital to learn all that is involved in adjusting to the lifestyle changes needed. Some hospitals have a diabetes midwife specialist, who provides continuity between the clinic, the person with diabetes and the hospital ward, which is reassuring for the woman at this stressful time.
As soon as the baby is born, the mother will no longer require insulin injections and her glucose levels usually return to normal within the first 48 hours. Babies may need to have blood glucose levels checked for the first two days until they are feeding well. This is usually done at ward level so that mother and baby are kept together.
Research shows that breastfed babies are less likely to develop diabetes in the future and it also helps to keep the mother's glucose levels under control.
Six weeks after the birth, a Glucose Tolerance Test is carried out on the mother to ensure that all is well.
Women who develop diabetes in pregnancy will have a 60% risk of developing type 2 diabetes within the following five years. Therefore they should be advised to maintain a healthy lifestyle and to plan future pregnancies ensuring that glucose levels are normal before conception. High blood glucose levels in the first few weeks of pregnancy increases the risk of both heart defects and spina bifida.
It can be very stressful when a woman is told she has a condition that may affect her baby's well-being, however, diabetes developed during pregnancy responds well to lifestyle changes and careful monitoring.
It is a tribute to each mother and a testament to the power of the human spirit that they cope so well with the necessary adjustments to everyday life.
Mary Coffey is a clinical midwife specialist in diabetes at the National Maternity Hospital, Holles Street, Dublin
Pregnancy over the age of 40
A history of diabetes in the immediate family
A previous unexplained stillbirth
Previous baby weighed 4.5kg or more at term
Weight 100kg or more at first antenatal visit
Glucose in a urine sample
Excess fluid around the baby in current pregnancy (polyhydramnios)
Excess weight gain of baby in current pregnancy (macrosomia)
Long term steroid use
Many thoughts will cross your mind when you learn that you have diabetes. Perhaps one of them is: 'Now I can't have a baby!' Yes you can, if that is what you want. With tight control of diabetes and modern obstetrical care, the chances are excellent that you will have as safe a pregnancy and as healthy a baby as any other woman.
Women with diabetes should plan their pregnancies in consultation with the doctor. It is important that blood sugar levels are well controlled before conception occurs.
If you are considering a pregnancy, you and your partner should see your doctor and other members of your diabetes care team. Together, you will review your general health and discuss any concerns. You will also discuss how to control your blood sugar.
Planning a safe pregnancy
The key to a safe pregnancy is planning. You must begin planning before you become pregnant. Your blood sugar should be consistently well controlled several months before you become pregnant. Effective birth control is recommended until your blood sugar has been normal or near normal for at least two months. Be prepared to maintain excellent blood sugar control throughout your pregnancy.
Blood sugar control
Excellent control of your blood sugar during the course of pregnancy will help minimise the risk of birth defects and decrease the risk of miscarriage. It helps your baby stay healthy and grow properly, and prevents your baby from growing too large. Large babies are a potential problem for women with poorly controlled diabetes, and they can make delivery more difficult.
Need to adjust insulin
The body undergoes major physical changes during pregnancy. Your hormone levels will change dramatically. Changing hormone levels and your growing baby will affect your need for insulin throughout the course of your pregnancy.
You can do it!
The success of your pregnancy depends a lot on you. It will take time and effort on your part. Yet, you are not alone. Your diabetes care team, and those people who are close to you, will do everything they can to make your pregnancy a safe and special time. Once you have that happy, healthy baby in your arms, you'll know that the effort to control your diabetes during pregnancy was well worth it.
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