The Practical Aspects

Diabetic "Conception"

Introduction

Until fairly recently, pregnancy was risky affair for women with diabetes Discovery and introduction of insulin did improve the outcome of diabetic pregnancy, but the latest medical care and rigorous treatment regime has done a world of good. The mortality rate at the period around birth decreased from 500 to less than 50 per 1000 live births.

No matter, what the type of diabetes or the level of complexity is, there are certain guidelines that apply to all women. Following them can substantially reduce the adverse outcomes of diabetic pregnancy.

Background

As is widely known, diabetic pregnancy comes with nearly 4-fold increased risk in complications for mother as well as the baby. Even though this is the state of affairs, with adequate pre-pregnancy blood sugar control, the risk of premature delivery and excess perinatal mortality can be significantly reduced. One must accept the grim reality that a long way has to be gone before outcome of all women with diabetes will match with the background population.

Foetal Development: The Different Stages

Foetal development could be separated into three distinct phases namely the embryonic phase, the foetal growth phase, and the maturation phase. It must be mentioned that the development of the second stage is best possible within the uterine environment, where as the third stage can be sustained and developed outside also.

It is during the embryonic phase (up to 10 weeks of gestation) that malformations develop. It has been found that the incidence of such malformations in the diabetic populations is about three-fold higher than in the normal population. Better blood sugar control in the first three months in diabetic pregnancy can lead to a significant reduction in malformations.

Counseling for diabetic women is an effective method of increasing the awareness about the disease as well as the preventive measures. If there are no major contraindications in the pregnancy, the counseling for diabetes women should include:

Balanced diet should include fish, vegetables, fruit, and more fibre and less saturated fat. Three regular meals and snacks in between the meals should be advised.

Special Care

For women with diabetic pregnancy, it is always better to start the preventive care at the earliest available opportunity. This would help in adjusting the diet, insulin timing and doses so that any adverse impact on the unborn child can be avoided. Ideally, a diabetologist, obstetrician, specialist diabetes nurse, midwife, dietitian, and pediatrician should form the part of the staff, which attends the patient. Frequency of visits to the clinic should be determined by the stage of pregnancy. Usually once in two weeks would be necessary unless otherwise specified by the attending doctor.

Insulin dosage

The insulin dose increases as the stage of pregnancy advances. Insulin requirement in the first three months depends on different factors. Woman, who has a well-controlled blood sugar, with no first trimester nausea may not require any change. If food intake were decreased as a result of the nausea, then the insulin dose would also fall. Once a reasonable control over blood sugar is achieved and the first trimester nausea has resolved, the insulin dose do not change much until 22 to 24 weeks. From 24 weeks onwards, there is roughly a 10% rise every 4 weeks with a steeper rise between 28 to 32 weeks.

Monitoring Foetal Growth

Over time, ultrasound measurements have become an invaluable tool in managing the pregnancy related medical needs. It is used to detect anomalies, and to monitor foetal growth. Special scans of the foetal heart can identify anomalies so that necessary measures can be taken in advance.

Premature delivery is one of the risks associated with diabetic pregnancy. In such cases, there is not only anxiety about the survival of the newborn but also the life of the mother is also put at risk. Regular monitoring and tight glucose control can avoid such unwelcome situation as well as mental agony.

Women with diabetes of childbearing age should be informed about:

1. The importance of carefully planning a pregnancy with advice from their diabetes care team
2. How pregnancy and labour can affect and be affected by their diabetes
3. The need for effective contraception
4. The need for optimising blood glucose control prior to and during pregnancy with any improvement in HbA1c being encouraged
5. Hypoglycaemia and the treatment options of hypoglycaemia
6. The need to check that medications are suitable for use in pregnancy
7. Their baseline retinal (eye) and nephropathy (kidney) results
8. The advantages of healthy eating and taking folic acid supplements in an appropriate dose (see Care recommendation document: Folic acid supplementation in pregnancy)
9. Stop smoking advice
10. Cut down or cut out alcohol
11. The need to be a healthy weight for your height.

Diabetes and contraception

Information on pregnancy and contraception should be given to all women with diabetes of childbearing age. There are no contraceptive methods that are specifically contraindicated in women with diabetes. Methods with proven high degrees of effectiveness are to be preferred.

Diabetic complications should be assessed and treated if indicated.

A baseline retinal examination and assessment of albuminuria (protein in urine) should be performed pre conception. Diabetic retinopathy, if present, can accelerate during pregnancy. All women with diabetes should be made aware of the requirement to have regular retinal examinations during pregnancy. Untreated cardiovascular disease is associated with a high mortality, and should be excluded.

The woman should have access to members of the multidisciplinary team appropriate to her needs: diabetologist, obstetrician, psychologist, specialist diabetes dietitians, specialist diabetes nurses and special diabetes midwives. The woman with diabetes (and partner) should be included as members of the team, be involved in decisions about their care and be offered the opportunity to make choices by provision of appropriate and sufficient information.

The following should all be discussed in detail:

1. Diet, including folic acid supplements (see Care recommendation document: Folic acid supplementation in pregnancy)
2. General health measures - particularly smoking and alcohol awareness, if pertinent
3. The local program of pregnancy care
4. The effect of diabetes on pregnancy and of pregnancy on diabetes.
5. Counselling should be provided about the:
6. Risk of congenital malformations
7. Risk of obstetric complications
8. Effect of pregnancy on diabetic complications.

Hypoglycaemia (Very low blood sugar resulting from poor diet)

The Diabetes Control and Complications Trial showed that attempts to achieve tight glycaemic control in people with Type 1 diabetes increases the risk of severe hypoglycaemia. Severe, frequent or unexplained episodes of hypoglycaemia are due to a number of factors, including:

• Hypoglycaemia unawareness
• Insulin dose errors
• Excessive alcohol intake.

There is no evidence that such hypoglycaemia is an independent risk to the developing human embryo. The mother, however, is clearly at risk, and the woman with diabetes contemplating pregnancy should have that explained to her. Means of prevention and treatment should be provided to her and her family. It is essential to include family members and friends of the patient in the education.

After the initial visit, the woman should have access to phone or personal contact details for adjustment of insulin doses and other aspects of treatment. Once the woman has achieved stable glycaemic control that is as good as she can achieve, she can then be counseled about the risk of malformations and spontaneous abortions. When she wishes, contraception can be discontinued. If conception does not occur within one year, the woman and her partner's fertility should be assessed.

Diabetes And Congenital Malformations

Major congenital malformations remain the leading cause of mortality and serious morbidity in infants of mothers with type 1 or type 2 diabetes. Several studies have established an association between elevated maternal glucose and glycohemoglobin levels during embryogenesis and high rates of spontaneous abortions and major malformations in newborns.

Clinical trials of preconception care to achieve stringent blood glucose control in the preconception period arid during the first trimester of pregnancy have demonstrated striking reductions in rates of malformations compared with infants of diabetic women who did not participate in preconception care.

Unfortunately, unplanned pregnancies occur in about two-thirds of women with diabetes, precluding adequate preconception care and leading to a persistent excess of malformations in their infants. To minimize the occurrence of these devastating malformations, standard care for all women with diabetes who have childbearing potential should include

1. Counseling about the risk of malformations associated with unplanned pregnancies and poor metabolic control and
2. Use of effective contraception at all times unless the patient is in good metabolic control and actively trying to conceive.

Diabetes And Contraception

There are no contraceptive methods that are specifically contra-indicated in women with diabetes. Thus, the selection of a method for an individual patient should be made by a provider who is familiar with contraceptive prescribing practices, using the same guidelines that apply to women without diabetes. Because unexpected failure of contraception can lead to such serious complications for the infant of a woman with diabetes, the focus should be on methods with proven high degrees of effectiveness.

Preconception Care Program

To prevent excess spontaneous abortions and congenital malformations in infants of diabetic mothers, diabetes care and education must begin before conception. This is best accomplished by a multidisciplinary team that includes a diabetologist, internist, or family practice physician skilled in diabetes management; an obstetrician familiar with the management of high-risk pregnancies; diabetes educators, including a nurse, dietitian, and social worker; and other specialists, as deemed necessary. Ultimately, the woman with diabetes must become the most active member of the team, calling upon the other members for specific guidance and expertise to help her achieve her goal of a healthy pregnancy and newborn.

The primary purpose of these guidelines is to define the elements of a preconception care program. This program should be sufficient to minimize congenital malformations and thereby substantially reduce health care costs. This document describes the recommended intensive outpatient treatment plan, based on risk assessment, health promotion, and intervention, and outlines effective teamwork strategies to implement the plan before and during early pregnancy.

The model of diabetes preconception and early pregnancy health care described in this document is interactive.

It includes four main elements

1. Patient education about the interaction of diabetes, pregnancy, and family planning;
2. Education in diabetes self-management skills;
3. Physician-directed medical care and laboratory testing; and
4. Counseling by a mental health professional when indicated to reduce stress and improve adherence to the diabetes treatment plan. All four elements are important for patients to achieve the level of sustained glycemic control necessary to prevent excess congenital malformations and spontaneous abortions.

Use of an appropriate meal plan

• Self-monitoring of blood glucose (SMBG)
• Self-administration of insulin and self-adjustment of insulin doses
• Treatment of hypoglycemia (patient and family members)
• Incorporation of physical activity
• Development of techniques to reduce stress and cope with denial

An initial individual educational evaluation session with a diabetes educator, a registered dietitian, and, when needed, a psychosocial expert is valuable. Members of the patient's immediate family should participate in this session. In conjunction with the primary physician, these professionals will review the patient's current management plan and develop a comprehensive treatment plan.