Future Moms Should Focus on Glycemic Control

Diabetes complicates 3–5% of pregnancies and is a major contributor to increased levels of morbidity and mortality in both the mother and the fetus.¹ Of these, 90% of the mothers are diagnosed with gestational diabetes, and 3% are women with pregestational type 2 diabetes. It's also been established that excellent control of blood glucose levels before conception and in early pregnancy reduces the incidence to near normal.

“Whenever we see a woman of childbearing age with diabetes, it should be considered a prepregnancy visit,” says Steven Gabbe, MD, dean of Vanderbilt School of Medicine and professor of obstetrics and gynecology in Nashville, Tenn. “We should always ask her if she's thinking about having a baby and remind her of the importance of stabilizing her diabetes before conception.”

Essentially, clinicians will see two types of patients in a given practice. Some will plan ahead and work with their primary caregiver and other support personnel to make sure that their blood glucose is well controlled, a preliminary history and physical have been completed, and any concerns about complications of diabetes have been addressed. They will also have begun a weight control and exercise program.

Unfortunately, these patients are in the minority. A study by Emily Holing found that fewer than half (41%) of the population-based sample of women diagnosed with diabetes prior to becoming pregnant said their pregnancies were planned.²

FIRST, GAIN GLYCEMIC CONTROL

“The first encounter with the woman who is already pregnant without previous planning focuses on getting good glycemic control,” says John Kitzmiller, MD, a diabetologist and consultant to the Maternal/Fetal Medicine Program at Santa Clara Medical Center in San Jose, Calif. “The [glycated] hemoglobin [A1C] results should be obtained immediately to guide both current and future risk analysis. Guidelines suggest an A1C level as close to normal as possible without causing debilitating increases in hypoglycemia.”

A complete medical and obstetrical history is imperative. In addition to background on the patient's diabetes, the history would include any previous pregnancies and their outcomes, family or personal history of congenital or inherited diseases, and other medical conditions for which the mother-to-be may have been treated or for which she is currently receiving care. Clinicians should also screen all medications the woman may be prescribed or supplements she is taking for appropriate use during pregnancy.

“The safety of oral antidiabetics has not yet been established postconception, so they are generally discontinued when a person is pregnant,” adds Kitzmiller. “If the primary care physician is not comfortable starting [pregnant patients] on insulin during that first encounter, keep them on their oral medications until the change can be completed. Several studies show that high glucose is much more detrimental to the fetus than a few days of the oral drugs.”

As with any pregnancy, a physical examination is imperative. In addition, the physician should undertake a complete workup for diabetic complications such as retinopathies, nephropathies, neuropathies, and coronary artery disease. Autonomic neuropathy such as gastroparesis may be worsened by the nausea and vomiting seen in pregnancy. Presence of these complications can have an adverse impact on either the mother or fetus.

During this process, the physician should be sure to obtain an ultrasound to establish fetal age and estimated delivery date.

“Early treatment decisions are impacted by the patient's history with me,” says Sagi Mathew, MD, assistant professor of clinical family medicine at Indiana University School of Medicine in Indianapolis. “If I have been seeing the patient for awhile and know she has had numerous glycated hemoglobin [A1C] tests in the proper range, I will approach her differently than I might someone I know has control problems or have never seen before.”

The first visit should include assessment of the patient's diabetes self-management skills; any concerns she brings up should be addressed directly by the care provider. Education should be completed, or at least begun, on self-monitoring of glucose. Make sure the patient is able to properly use a blood glucose meter and understands what her response should be to both high and low readings. Refer the patient to dieticians and diabetes educators who have an understanding of the specialized needs of the mother-to-be with diabetes.

The American College of Obstetrics and Gynecology recommends women with pregestational diabetes maintain fasting plasma glucose levels 60–90 mg/dl and 2-hour postprandial levels <120 mg/dl during the pregnancy.³

The American Diabetes Association (ADA) has no published guidelines for acceptable levels during pregnancy, but an ADA statement suggests patients meet the following goals before starting pregnancy:

1. Capillary plasma glucose <80–110 mg/dl before meals

2. Capillary plasma glucose <155 mg/dl at 2 hours postprandial.⁴

LACK OF PLANNING CAUSES TREATMENT SCRAMBLE

“If there is no preconception planning, you have to scramble to establish a relationship, educate her about the importance of optimal blood glucose control, and start treatment with insulin,” says Virgilio Licona, MD, associate medical director of Plan de Salud del Valle, Inc., in Fort Lupton, Colo., and a member of the board of directors of the American Academy of Family Practice. “You have to make sure they know about keeping a log of blood sugar test results, the differences between fasting, 1- and 2-hour blood glucose, diet needs, and insulin adjustment. You take everything you would have done at leisure in a planned pregnancy and truncate it into a few visits.”

The response during early pregnancy will be driven mostly by the results of the A1C tests. If the woman has attained good control, the primary care physician may decide to wait a month between visits. If her control is unsatisfactory, it may be prudent for the doctor to contact the patient on a daily basis.

“In nondiabetic pregnancies, visits are usually monthly to 28 weeks gestation, every 2 weeks to 36 weeks, and then weekly,” says Licona. “All of these standards go out the door with these patients, and you have to tailor her care based on her control of the diabetes.”

WATCH MOM AND BABY CLOSELY DURING LATE PREGNANCY

Because of the higher risk for congenital malformation, physicians should ensure ultrasound assessment for anatomical concerns at 18–20 weeks gestation. Any follow-up should be based on clinical concerns and findings. Physicians also should closely track fundal height to see if the baby is becoming too big for gestational age. Non-stress testing and fetal movement counting are other important studies to consider during the last trimester.

“As pregnancy continues, prevention of excess fetal insulin production should be encouraged,” says Kitzmiller. “Some wonder what is wrong with a big baby. The major problem is that these big and fat babies are still big and fat later in life with higher risks for diabetes. I stress to the moms that this is a chance to improve the baby's lifelong health.”

While the early weeks are vitally important, loss of control during the second half of the pregnancy can lead to major problems. Fetal death risk increases, premature labor becomes more common, and preeclampsia is seen more often in those women with poor blood glucose control later into the pregnancy.

Physicians should inform the patient about hormonal and other changes of pregnancy that will impact her body's glucose control. Studies have shown an increased incidence of moderate hypoglycemia requiring assistance and severe hypoglycemia with loss of consciousness.⁵ “Accelerated starvation,” related to placental and fetal glucose consumption overnight while the mother is fasting, may also be a source of nocturnal hypoglycemia.

Any pregnancy complicated by diabetes is considered a high-risk pregnancy. As such, the clinician will be charged with coordinating a rather large complement of health care team members, including diabetologists, high-risk obstetricians, diabetes educators, and dietitians.

“When making a referral to a specialist, always make sure they are experienced with, and knowledgeable about, the care of diabetes and pregnancy,” says Kitzmiller. “This is a very intensified treatment program that is different from [that for] nonpregnant women with diabetes or a nondiabetic pregnancy.”

“Referral decisions are mainly a matter of the experience and comfort level of the individual clinician,” notes Gabbe. “It has got to be a team effort because these are very complex cases that require input from a lot of knowledgeable folks.” ▪

Facts About Gestational Diabetes

PATIENT RISK

Discuss with patients their risk of developing gestational diabetes if they fall into one of these categories:

1. Has a parent, brother, or sister with diabetes

2. Is African American, Native American, Asian American, Hispanic/Latino, or Pacific Islander

3. Is ≥ 25 years

4. Is overweight

5. Had gestational diabetes previously, or gave birth to at least one baby with weight >9 lbs

6. Has been diagnosed with pre-diabetes.

Patients are at high risk if they are very overweight, had gestational diabetes previously, have a strong family history of diabetes, or have glucose in their urine. Patients are at average risk if they fall into one or more risk categories. Patients are at low risk if they do not fall into any risk categories.

SYMPTOMS

Teach patients to alert clinicians to any of the following symptoms during their pregnancy:

1. Increased thirst

2. Increased urination

3. Weight loss in spite of increased appetite

4. Fatigue

5. Nausea and vomiting

6. Frequent infections including those of the bladder, vagina, and skin

7. Blurred vision

COMPLICATIONS

Inform patients of potential problems:

1. Low blood glucose or illness in the newborn

2. Increased incidence of newborn deaths

3. Development of diabetes later in the child's life

Source: National Diabetes Information Clearinghouse: What I Need to Know About Gestational Diabetes, pub. no. 06-5129. Available online at http://diabetes.niddk.nih.gov/dm/pubs/gestational/. Accessed April 3, 2007.

Pesticides Pose Risk

Add one more risk factor for women when it comes to gestational diabetes: pesticide exposure. Risk appears to be greatest during the first trimester and in women who mix or apply pesticide for use in agricultural spreading equipment in agricultural settings. Women with exposure to household pesticides showed no increased gestational diabetes risk, according to researchers at the National Institute of Environmental Health Sciences (NIEHS).

The findings suggest that more studies are needed to understand the environmental exposure and subsequent risks for pregnant women, concludes Tina Saldana, MD, lead researcher at NIEHS.¹

Out of a total sampling of 11,273 women, 506 reported having gestational diabetes. Data were taken from the Agricultural Health Study from a 25-year period.

Prior studies have linked diabetes risk and pesticide exposure, but none has focused specifically on gestational diabetes. Four herbicides and three insecticides were associated with the increased risk of developing gestational diabetes.

Patient and Family Action Steps

FOR MOM

1. Confirm a diagnosis of gestational diabetes with clinician and notify future health care providers of gestational diabetes history.

2. Get tested for diabetes 6–12 weeks after baby is born, then every 1–2 years after.

3. Breastfeed your baby. It may lower the child's risk of developing type 2 diabetes.

4. Tell your clinician if you plan to get pregnant again in the future.

5. Try to return to prepregnancy weight 6–12 months after baby is born. If goal is not achieved, work to lose 5–7% of body weight slowly over time, and keep it off.

6. Make healthy food choices, including fruits and vegetables, fish, lean meats, dry beans and peas, whole grains, low-fat or skim milk and cheese. Choose water to drink.

7. Eat smaller portions of healthy foods to help reach and maintain a healthy weight.

8. Be active ≥30 minutes, 5 days/week to help burn calories and lose weight.

FOR THE FAMILY

1. Ask the clinician for an eating plan to help children grow properly and stay at a healthy weight. Inform your children's clinician that you had gestational diabetes. Tell your child about his or her risk for diabetes.

2. Help children make healthy food choices and help them to be active ≥60 minutes/day.

3. Follow a healthy lifestyle as a family. Help family members stay at a recommended weight by making healthy food choices and being active.

4. Limit TV, video, and computer game time to 1–2 hours/day.

Source: National Diabetes Education Program, January 2007. NIH Pub. No. 07-6019.