Diabetes During Pregnancy

 

Rachel Pessah-Pollack, M.D.
 
Each year, diabetes is becoming more common in the United States, with over 1.5 million new cases diagnosed annually.  As a result, more women are faced with the challenge of dealing with diabetes during pregnancy. Here are some things you need to know if you have diabetes and are planning to become pregnant soon. You will also find important suggestions that you can use to optimize your health for both you and your baby.
 
How Can Diabetes Affect Your Pregnancy
Having diabetes during pregnancy can cause birth defects, miscarriages, birth injury (due to delivering an unusually large baby,) and preeclampsia (a condition of pregnancy marked by high blood pressure and excess protein in your urine which can be associated with an increased mortality). By optimizing your sugars prior to pregnancy, you can reduce the risk of these complications for you and your baby.
 The first trimester is a critical time when your baby's organs are forming. Because of this, it is extremely important to make sure your first trimester sugars are within a normal range.  To achieve this goal, diabetics may find it necessary to hold off becoming pregnant until their sugars are well controlled.  One way to assess your level of control is though a Hemoglobin A1c (HbA1c). The HbA1c provides a measurement of what your average blood glucose levels have been over the previous 2 to 3 months. It can help guide you in determining when it is the right time to become pregnant.  The target HbA1c level differs by various organizations so you should ask your physician to help determine what your goals should be.
During pregnancy, home blood glucose monitoring is very important. You will be asked to check your sugars when you wake up in the morning and one to two hours after your meals.  This differs from not being pregnant because then you are asked to check your sugars before eating. Your doctor will help decide what your glucose levels should be during pregnancy.  The pregnancy goals for glucose levels are stricter than in the non-pregnant state.
 
Check Your Medications
Certain medications that can be extremely useful before pregnancy are often not safe when you become pregnant. Before you become pregnant, have your doctor review if any of your medications need to be changed.
 
Diabetes Medications: Discuss with your physician whether your diabetes can be controlled with careful monitoring of your diet during pregnancy or if other medications will be needed.  Many pills for diabetes are not safe during pregnancy; therefore, insulin may be needed to keep your sugars in a normal range.
 
Blood Pressure Medications: A specific class of blood pressure medications called "ACE inhibitors" are extremely beneficial for women with diabetes who are not pregnant but are contraindicated during pregnancy as they risk harm to your infant's kidneys.  Check with your doctor if you need to be on blood pressure lowering medications or if you need to be switched to an alternative medication that is safe during pregnancy.
 
Cholesterol Medications: "Statins" are common, helpful medications for women with diabetes who are not pregnant. Some examples include "Lipitor" and "Zocor."  These medications are contraindicated during pregnancy and must be stopped before pregnancy due to the risk of fetal birth defects.
 
Prenatal Multivitamins: All women who are planning a pregnancy should be taking a daily prenatal multivitamin containing at least 400 micrograms of folic acid.  Studies have shown that at least 400 micrograms of folic acid daily can help prevent neural tube (spinal cord) defects in babies.
 
Work Closely with Your Doctors
Compliance with your medications is extremely crucial prior to becoming pregnant and while pregnant. If you tend to miss doses of insulin or do not always take your medications regularly, make a commitment now to take all of your prescribed medications.

You are not alone in the managing your diabetes during pregnancy.  There are many physicians who specialize in helping women with diabetes have successful pregnancies.  Some of the specialists you should become familiar with are listed below:
 
Endocrinologist: This is a physician who specializes in diabetes and other problems involving your hormones.  He/she will help coordinate your care, manage your diabetes regimen, and make sure your sugars are in a good range during pregnancy.

High Risk Obstetrician: Depending on the severity of your diabetes, you may need to see an obstetrician who specializes in high-risk pregnancies.  Your doctor will help you decide whether or not this is necessary for you based on your current control of diabetes and if you have had any prior complications.
 
 
Ophthalmologist: It is very important to have an ophthalmologist (eye doctor) check your eyes before you become pregnant to assess if you have diabetic eye disease (also known as retinopathy).  If your disease is mild, you will be watched closely during pregnancy with frequent eye exams, however if you have a more severe case, your doctor may choose to treat your eye disease with laser surgery before you become pregnant.  In certain situations, eye disease can worsen during pregnancy, and routine care by an eye doctor can prevent and manage complications.
 
Podiatrist: Diabetic nerve disease, also known as peripheral neuropathy, can develop if your sugars have not been well-controlled or if you have had diabetes for a long time.  Your doctor may suggest you see a foot specialist (podiatrist) to evaluate you if you have problems with your feet from diabetes.  Remember to look at your feet every day, especially during pregnancy, and avoid walking around with bare feet.
  
Focus on a Healthy Lifestyle
With the start of the New Year, right now is the best time to begin (and hopefully continue) good eating habits using a low-carbohydrate, portion-controlled diet.  Choosing a balanced diet1, which includes fruits, vegetables, and fiber, will help you maintain normal sugar levels during your pregnancy.   Your doctor may suggest you meet with a registered nutritionist prior to pregnancy to help make the right dietary choices. In addition to opting for healthy foods, now is the time to maintain a healthy lifestyle.  If you are using tobacco and/or alcohol, now is the time to stop.  These toxins can affect your baby and should be discontinued before attempting to conceive.
We now know that there are a number of problems that you and your baby may develop during pregnancy if you are overweight or obese prior to becoming pregnant. Theses include a higher incidence of cesarean section, birth defects, and premature infants.  If your doctor says you have no contra-indications to physical activity, initiating an exercise regimen2 is a great way to lose weight and reduce your risk for problems during pregnancy. Losing even a few pounds can make all the difference in making your diabetes easier to control during pregnancy.
By working closely with your health care team, you can succeed in controlling your diabetes during pregnancy.  The planning process may seem overwhelming, but the preparations will all be worth it and your end result will be a healthy baby during this New Year.

Dr. Rachel Pessah-Pollack has recently joined the endocrine department of ProHealth. She completed her endocrine fellowship at Mount Sinai Medical Center in New York City, where she also received her internal medicine training.  She has a special interest in pregnancy-related endocrine disorders and written numerous articles on the subject.  She is currently editing a book on endocrine disorders during pregnancy and is co-authoring the American Association of Clinical Endocrinology's "Diabetes during Pregnancy" Clinical Practice Guidelines.