Pregnancy and diabetes pose unique challenges. Educating pregnant women with diabetes is an extraordinary opportunity to impact two lives at one time. As a diabetes educator, you will have the chance to meet and take care of all kinds of inspirational women, in all stages of pregnancy and all degrees of “paranoia.” You will need to empathize with these women, especially those going through a pregnancy for the first time.

There will be different approaches for each type of diabetes in pregnancy. There are three major subtypes: Type 1, Type 2 , and Gestational diabetes. For all, blood sugar control is more important than ever. It should be emphasized that good blood sugar control during pregnancy can:

Reduce the risk of miscarriage and preterm birth – Good blood sugar control reduces the risk of miscarriage and preterm birth – primary concerns for pregnancy and diabetes.

Reduce the risk of birth defects – Good blood sugar control during early pregnancy greatly decreases the baby’s risk of birth defects, particularly those affecting the brain, spine and heart.

Reduce the risk of excess growth – Uncontrolled diabetes causes extra glucose to cross the placenta. This triggers the baby’s pancreas to make extra insulin, which can cause the baby to grow too large (macrosomia). A large baby makes vaginal delivery difficult and puts the baby at risk of injury during birth. Prevent complications for mom – Good blood sugar control decreases the risk of high blood pressure and other potentially serious pregnancy complications.

Prevent complications for baby – Sometimes babies of mothers who have diabetes develop low blood sugar (hypoglycemia) shortly after birth because their own insulin production is high. Good blood sugar control can help promote a healthy blood sugar level for the baby. Good blood sugar control also helps prevent a yellowish discoloration of the baby’s skin and eyes (jaundice) after birth, low levels of calcium and magnesium in the blood, as well as other problems.

It is part of complete diabetes management to have a multidisciplary team taking care of the special needs of a pregnant woman with diabetes. So, make sure your patient has access to a physician (endocrinologist or diabetes specialist), nurse, and dietitian, in addition to an obstetrician and pediatrician. An ophthalmologist can monitor diabetes-related damage to the small blood vessels in the eyes, which can progress during pregnancy.

After emphasizing the important facts, the next role of the diabetes educator is to calm down the nerves of a pregnant woman. Many patients come with their husbands, some come with their parents, some alone, all nervous about being diagnosed with gestational diabetes, or being pregnant in the setting of pre-existing diabetes. Most are concerned about the inconvenience of frequent sugar monitoring, insulin injections, effects of diabetes on the baby, and lifelong implications.

Make sure you have a lot of time to answer all these questions appropriately. It is important to make your patient feel that there is an ally in you; and that, the two of you will be in this together, at least for the next nine months or so.

MANAGEMENT OF PRE-GESTATIONAL DIABETES (PRE-EXISTING TYPE 1 OR TYPE 2 DIABETES)

PRE-PREGNANCY COUNSELLING
– For all fertile women of child¬bearing age with diabetes, identify possibility of pregnancy by direct questioning on every relevant occasion.
– Offer pre-pregnancy advice to all women so identified, especially with respect to diabetes complications, folic acid supplementation, and thyroid status.
– Provide education on the management of pregnancy with diabetes, explaining risks and how they can be minimized.
– Advise optimization of glycemic control, actively discouraging women with HbAl c values above 8% from becoming pregnant until their control is improved.
– Stop ACE Inhibitors and ARBs and use appropriate substitutes.
– Stop statins, fibrates, niacin.

FIRST PRENATAL VISIT
– Review understanding of management of diabetes in pregnancy, drug therapy, blood glucose control, diabetes complications, and presence of other medical conditions.

FREQUENCY OF SUBSEQUENT VISITS
– Visits should be as frequently as required, depending on achievement of glycemic targets and management of other diabetes
– associated and obstetric problems.

ONGOING MANAGEMENT OF DIABETES DURING PREGNANCY

LIFESTYLE
– Offer nutritional management and education. Advice should be individualized, delivered by a healthcare professional, ideally someone with specific expertise in medical nutrition therapy (MNT).
– If not contraindicated, encourage physical activity, tailoring advice to the previous exercise habits of the individual. Explain that exercise can counter the decline in insulin sensitivity that occurs during pregnancy.

GLUCOSE CONTROL
– Use HbA1c as an ancillary aid to self-monitoring. Aim for an HbA1c <6, or lower if safe and acceptable.
– Self-monitoring of blood glucose should be done frequently.
– Adjust the dose of oral glucose-lowering agents or insulin on the basis of self-monitoring results, HbAl c, and experience of hypoglycemia, and be prepared to change from oral glucose-lowering agents to insulin if necessary. Use insulin that is safe for pregnancy.

OTHER DIABETES-RELATED PROBLEMS
– Have eyes examined at first prenatal visit and each trimester.
– Monitor blood pressure and treat accordingly.

MANAGEMENT OF GESTATIONAL DIABETES
– Advice on risks of adverse pregnancy outcome and how these may be reduced.
– Instruct in self-monitoring of blood glucose (to be used four times daily, fasting and 1 hour after each meal), and advise on lifestyle modification.
– Individualize nutrition management and education. Daily calorie requirements may be calculated based on the pre-pregnancy Body Mass Index (Table 2). Most women do well when about 40-45% of daily calories come from carbohydrates, 20-25% should come from protein, and 30-40% of daily calories should come from fat.

– There are different re-commendations for target blood glucose. According to the American Diabetes Association, fasting blood glucose should register 90 mg/dl or less, and one hour after a meal blood glucose should measure 120 mg/ dl or less.

– If agreed glucose control targets are not met within 1-2 weeks of initiation of lifestyle management, offer medication. Insulin has been, and is likely to remain, the treatment of choice. But there is now adequate evidence to consider the use of metformin and glibenclamide as treatment options for women who have been informed of the possible risks.

AFTER DELIVERY
– Anticipate changed insulin requirements (immediate reduction), and thus the need for more frequent glucose monitoring, if continuing insulin postpartum and during breastfeeding.
– For women with Gestational Diabetes, stop glucose-lowering therapy. At discharge, reinforce lifestyle management advice.

BREASTFEEDING
– Encourage breastfeeding.
– Review medications, taking into consideration the potential risks associated with any transfer into the milk.

FOLLOW-UP WITHIN 6 WEEKS.
– Around 6 weeks after delivery, check for real diabetes for the women who had Gestational Diabetes. If normal, advise on high risk of future diabetes and on preventive lifestyle measures.
– Advise check for diabetes every 1-3 years. If further pregnancies are planned, advise on the risk of developing Gestational Diabetes again.

EVALUATION
– Delivery weight of the infant and achieved maternal HbA1c each trimester may be useful surrogate outcomes for quality assurance.

IN SUMMARY
It cannot be overemphasized that the goal of diabetes management in pregnancy is tight sugar control, if at all possible, without any side effects. The diabetes team should be accessible, and visited as frequently as needed by the pregnant woman with diabetes. Delays in visits should be avoided because time is limited. Resources such as glucometers with acceptable accuracy should likewise be made easily available and affordable. It is indeed a multi-disciplinary and very demanding condition, that requires regular coordination among the members of the health team. Every pregnancy is extremely special, and every healthy child born is unparalleled success every time.

Pregnancy Category B is given to medicines that have not been adequately studied in pregnant humans, but do not appear to cause harm to the fetus in animal studies. Pregnancy Category C is given to medicines that have not been studied in pregnant humans, but do appear to cause harm to the fetus in animal studies. Also, medicines that have not been studied in any pregnant women or animals are automatically given a “default” pregnancy Category C rating.

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