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Diabetes is present in 2-6% of pregnant women in the United States.
88% of the women have gestational diabetes (GDM). This is a form of diabetes which appears during pregnancy, typically during the second or third trimester.
The prevalence of GDM has increased due to the increased incidence of obesity in the US. It is now seen in 5-7% of all pregnancies.
It is diagnosed by a 75 gram oral glucose tolerance test between 24-32 weeks of pregnancy.
Risk factors for GDM include prior history of GDM, a family history of DM, obesity and increased age.
The remaining 12% of pregnant women with diabetes have pre-existing type 1 or type 2 diabetes.
In all women who become pregnant, increased production of hormones by the placenta, such as human placental lactogen, causes resistance to insulin's action.
Normal women are able to overcome this by increased production of insulin. Their sugars are thus maintained in the normal range.
Women with GDM, as well as pre-existing type 1 DM and type 2 DM, are unable to compensate for pregnancy associated insulin resistance.
In type 1 DM, this is due to absence of insulin production.
In GDM and type 2 DM this is due to pre-pregancy insulin resistance. Many of these women may also have defects in insulin production.
Their inability to compensate for pregnancy related insulin resistance results in blood sugar elevation.
If sugars are increased in women with pre-existing diabetes during the first weeks of pregnancy, there is an increased risk of spontaneous abortions and birth defects.
These risks may be increased 3-6 fold in women with average blood sugar values greater than 200 mg/dl.
If sugars remain elevated throughout their pregnancy, there is an increased risk of large babies and delivery associated injuries. There may also be an increased lifetime risk for obesity and/or diabetes in the child.
Elevated sugars are also associated with an increased risk of high blood pressure and preeclampsia.
High sugar levels in women with GDM are associated with similar risks.
Given the known association of high blood sugar with complications in the newborn and mother, good sugar control is important.
Among women with pre-existing diabetes, every effort should be made to normalize blood sugar before conception.
HA1c levels (a blood test which gives the 2-3 month average blood sugar) should be as close to normal as possible.
Fasting sugars should be in the 70-100 mg/dl range. 1 hour after meal sugars should be <140 mg/dl.
Consultation with a dietitian, endocrinologist, and high risk obstetrician is often recommended.
Once pregnant, typical goals are morning fasting sugars of 70-90 mg/dl and 1 hour after meal sugars <120 mg/dl.
Middle of the night (3-4 AM) and bedtime testing may also be recommended.
70-80% of women with GDM will be able to achieve these goals with changes in their diet and light exercise.
Consultation with a dietician is important.
Typical dietary recommendations include 3 meals per day with a high fiber, low saturated fat, low sweet intake. Snacks are included as needed. Carbohydrate intake should be monitored and reviewed with a dietician as needed.
Light exercise may help reduce insulin resistance, but should only be started after consultation with your medical team. Weight lifting should be avoided.
If sugar goals are not achieved with lifestyle changes, medical therapy is initiated.
In women with pre-existing diabetes, insulin is the most common therapy.
Among women with GDM, treatment with oral diabetes agents such as Glyburide is another option.
Many endocrinologists (myself included) prefer insulin therapy due to lack of long-term safety data, as well as less dosing flexibility, with the oral agents.
Since the degree of resistance to insulin increases as the pregnancy progresses, increasing doses of medications are typically required through the third trimester.
Blood sugars typically return to pre-pregnancy values after delivery.
Sugar control may be erratic in women with type 1 diabetes after delivery.
If nursing is planned, medication regimens should be reviewed with an obstetrician.
Nursing may be recommended given its known health benefits, as well as several reports which suggested a lower incidence of type 1 diabetes in children who were breast fed.
Women with GDM are at a significantly increased risk (up to 50% in some studies) for developing diabetes in the future.
A glucose tolerance test is typically performed 6 weeks after delivery in women with GDM.
Even if the test is normal, efforts should be made to maintain a healthy lifestyle and weight.
If sugar levels are managed carefully in pregnant women with diabetes, the chances for a healthy pregnancy and healthy child are similar to those reported in non-diabetic women.
Future advances in management, as well as earlier diagnosis, should continue to improve the outlook for women with pregnancy and diabetes.
Dr. Michael Dempsey is an endocrinologist with over 20 years of experience caring for people with diabetes. His goal is to improve diabetes control within the parameters of your life. You can learn more about Dr. Dempsey's practice at https://sites.google.com/site/thediabetesdoc/. You can also follow him on his Facebook page for daily updates on diabetes and nutrition at http://www.facebook.com/profile.php?id=100002052992954&ref=tn_tnmn
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