This article discusses in detail how to act if a woman’s diabetes mellitus is diagnosed before pregnancy. If elevated blood glucose levels are already detected during pregnancy, then this is called gestational diabetes. Diabetes type 1 or 2, as a rule, is not a contraindication for motherhood, but significantly increases the risks for both the woman and the fetus.
The best way to prevent complications of diabetes during pregnancy - intensive control of blood sugar levels
Diabetes pregnant requires close attention from doctors. A pregnant woman with diabetes is under the supervision of an obstetrician-gynecologist. If necessary, they also turn to narrow specialists: an oculist (eyes), a nephrologist (kidneys), a cardiologist (heart), and others. Nevertheless, the main measures are to support blood sugar levels close to normal, which the patient herself is conducting.
It is good to compensate for diabetes, that is, to ensure that blood glucose is almost like healthy people - this is the main thing that needs to be done in order to give birth to a normal baby and preserve the health of a woman. The closer to the optimal values of sugar in the blood, the lower the probability of problems at all stages of pregnancy, from conception to childbirth.
Learn from it:
- How does blood sugar and insulin requirements change in the first, second and third trimesters of pregnancy.
- Preparing for childbirth so that there is no hypoglycemia and everything went well.
- The effect of breastfeeding on blood sugar in a woman.
Risk assessment and contraindications for pregnancy in diabetes
A woman with type 1 or type 2 diabetes needs to be examined by an obstetrician-gynecologist, an endocrinologist and a therapist at the planning stage of pregnancy. It assesses the patient’s condition, the likelihood of a favorable outcome of pregnancy, and the risk that gestation will accelerate the development of diabetes complications.
What tests do a woman with diabetes need to undergo at the stage of assessing the likelihood of a successful outcome of pregnancy:
- Take a blood test for glycated hemoglobin.
- Independently measure blood sugar with a glucometer 5-7 times a day.
- Measure blood pressure at home with a tonometer, as well as determine whether there is postural hypotension. This is a significant drop in blood pressure, which is manifested by dizziness when rising abruptly from a sitting or lying position.
- Take tests to check your kidneys. Collect daily urine to determine creatinine clearance and protein content. Take blood plasma creatinine and urea nitrogen.
- If there is protein in the urine, check for urinary tract infections.
- Check with an ophthalmologist to assess the condition of the retinal vessels. It is desirable that the textual description of the fundus was accompanied by color photographs. They will help to visually compare and evaluate the changes with further re-examinations.
- If a woman with diabetes has reached the age of 35, suffers from arterial hypertension, nephropathy, obesity, elevated levels of cholesterol in the blood, has problems with peripheral vessels, then you need to undergo an ECG.
- If the electrocardiogram showed pathology or there are symptoms of coronary heart disease, then it is desirable to undergo research with a load.
- Examined for signs of peripheral neuropathy. Check the tactile, pain, temperature and vibration sensitivity of nerve endings, especially on the legs and feet
- Check whether autonomic neuropathy has developed: cardiovascular, gastrointestinal, urogenital and its other forms.
- Assess your tendency to hypoglycemia. Do hypoglycemia occur frequently? How heavy is it? What are typical symptoms?
- Examined for diabetic peripheral vascular lesions
- To pass blood tests for thyroid hormones: thyroid-stimulating hormone (TSH) and thyroxin free (T4 free).
To assess the risk of fetal malformations since 1965, the classification developed by the American obstetrician-gynecologist R. White has been used. The risk depends on:
- the duration of diabetes in a woman;
- at what age the disease began;
- what complications of diabetes are already there.
The degree of risk in diabetes in a pregnant woman according to R. White
|Class||Age of first manifestation of diabetes mellitus, years||Duration of diabetes, years||Complications||Insulin therapy|
|A||Any||Started during pregnancy||Not||Not|
|H||Any||Any||F + CHD||+|
- DR - diabetic retinopathy; DN - diabetic nephropathy; Coronary artery disease - ischemic heart disease; CKD - chronic renal failure.
- Class A - the lowest risk of complications, class RF - the most unfavorable prognosis of pregnancy outcome.
This classification is good for doctors and women with type 1 or type 2 diabetes who are planning a pregnancy.
What is the risk of diabetes pregnant women for mother and fetus
|Risk to mother with diabetes||Risk to the fetus / baby|
The risk of developing type 1 diabetes during a child’s life is:
- about 1-1.5% - in type 1 diabetes in the mother ;;
- about 5-6% - in type 1 diabetes in the father;
- more than 30% - if type 1 diabetes in both parents.
Women and doctors who advise her at the planning stage of pregnancy should be given evaluation answers to the questions:
- How will diabetes affect your baby’s pregnancy and health? What are the chances of making a pregnancy and having a healthy baby?
- How will pregnancy affect diabetes? Does it stimulate the accelerated development of its dangerous complications?
Contraindications for pregnancy in women with diabetes:
- severe nephropathy (serum creatinine> 120 µmol / l, glomerular filtration rate 2 g / day);
- hypertension, which cannot be controlled, i.e. blood pressure above 130-80 mm Hg. Art., despite the fact that the woman takes medication for hypertension;
- proliferative retinopathy and maculopathy, prior to laser coagulation of the retina;
- ischemic heart disease, unstable angina;
- acute or chronic infectious and inflammatory diseases (tuberculosis, pyelonephritis, etc.);
- diabetic coma - in the first trimester of pregnancy is an indication for its artificial interruption.
Preparing for pregnancy for women with diabetes
So, you have read the previous section, and yet, you are determined to get pregnant and have a baby. If so, then for a woman with diabetes comes the stage of preparation for pregnancy. It requires considerable effort and can be very long, but it is absolutely necessary to pass it so that the offspring will turn out healthy.
The main rule: you can start conceiving only when your glycated hemoglobin HbA1C index decreases to 6.0% or lower. And most of the blood sugar measurement with a glucometer that you do should also be normal. The diary of self-monitoring of blood glucose should be kept and analyzed together with a doctor every 1-2 weeks.
Also, blood pressure should keep below 130/80, even when you are not taking medication. Keep in mind that “chemical” pressure pills have a negative effect on the development of the fetus. Therefore, during pregnancy they will have to cancel. If you, even without being pregnant, cannot keep hypertension under control without medication, it is better to give up motherhood. Because the risk of a negative outcome of pregnancy is extremely high.
In order to achieve a good compensation for diabetes, during the preparation for pregnancy, a woman needs to do the following:
- measure blood sugar daily with a glucometer painlessly on an empty stomach and 1 hour after meals;
- sometimes it is desirable to measure your sugar also at 2 or 3 o'clock in the morning - make sure that there is no night hypoglycemia;
- master and apply the basic-bolus scheme of insulin therapy;
- if you take sugar pills for type 2 diabetes, discard them and go for insulin;
- Exercise in diabetes - without over-exertion, with pleasure, regularly;
- follow a diet with a restriction of carbohydrates that are quickly absorbed, eat 5-6 times a day in small portions
Additional activities to prepare for pregnancy in diabetes:
- regular blood pressure measurement;
- if there is hypertension, then it needs to be brought under control, and “with a reserve”, because during pregnancy the drugs for hypertension will have to be canceled;
- be examined in advance by an ophthalmologist and treat retinopathy;
- take folic acid at 500 mcg / day and potassium iodide at 150 mcg / day if there are no contraindications;
- quit smoking.
Pregnancy with diabetes: how to give birth to a healthy baby
During pregnancy, in diabetes, a woman should make considerable efforts to keep her blood sugar close to normal values. And focus on the indicators of glucose in the blood after 1 and 2 hours after eating. Because it is they who can rise, and fasting blood sugar is likely to remain normal or even go down.
In the morning it is necessary to check ketonuria with the help of test strips, i.e. if ketones have appeared in the urine. Because pregnant women with diabetes have an increased likelihood of nighttime episodes of hypoglycemia. These episodes are manifested by the appearance of ketones in the morning urine. According to research, ketonuria is associated with a decrease in the intellectual coefficient of future offspring.
The list of activities for diabetes during pregnancy:
- The diet of a pregnant woman should not be too strict, with enough "slow" carbohydrates to prevent starvation ketosis. Low-carb diets are not suitable for pregnant women with diabetes.
- Measuring blood sugar with a glucometer is at least 7 times a day. On an empty stomach, before and after each meal, at night, and sometimes at night. Insulin dosage should be adjusted for blood sugar levels, not after an empty stomach, but after a meal.
- Pregnancy Diabetes Insulin Therapy - detailed below in this article.
- Control the appearance of ketones (acetone) in the urine, especially during early gestosis and after 28-30 weeks of pregnancy. At this time, the need for insulin rises.
- A blood test for glycated hemoglobin needs to be taken at least once a trimester.
- Take folic acid at 500 mcg / day before the 12th week of pregnancy. Potassium iodide 250 µg / day - in the absence of contraindications.
- Examination of the ophthalmologist with fundus check - 1 time per trimester. If proliferative diabetic retinopathy develops or preproliferative retinopathy rapidly deteriorates, an immediate laser coagulation of the retina is performed, otherwise complete blindness is threatened.
- Regular visits to an obstetrician-gynecologist, endocrinologist or diabetologist. Up to 34 weeks of pregnancy - every 2 weeks, after 34 weeks - every day. At the same time measurement of body weight, arterial pressure is carried out, the general analysis of urine is given.
- In the case of a urinary tract infection in case of diabetes, pregnant women will have to take antibiotics on prescription (!). These will be in the first trimester - penicillins, in the second or third trimesters - penicillins or cephalosporins.
- Doctors and the pregnant woman herself observe the growth and condition of the fetus. Ultrasound examination is carried out by appointment of an obstetrician-gynecologist
What pills for pressure prescribed by doctors during pregnancy:
- Discuss with your doctor so that you are prescribed magnesium-B6 and taurine on the method of treating hypertension without medication.
- Of the "chemical" drugs, the drug of choice is methyldopa.
- If methyldopa does not help enough, then calcium channel blockers or β1-selective blockers can be prescribed.
- Diuretic drugs - only for very serious indications (fluid retention, pulmonary edema, heart failure).
During pregnancy, all pills belonging to the following classes are contraindicated:
- drugs that lower blood sugar;
- for hypertension - ACE inhibitors and angiotensin-II receptor blockers;
- antibiotics (aminoglycosides, tetracyclines, macrolides, etc.);
- statins to improve the results of blood tests for cholesterol.
Diet for pregnant women with diabetes
On this website, we convince all patients to effectively treat type 2 diabetes and even type 1 to go on a low-carbohydrate diet. This diet does not fit only:
- during pregnancy;
- with severe renal failure.
A low-carbohydrate diet for pregnant women with diabetes is prohibited because it can cause harm to the development of the fetus.
The restriction of carbohydrates in the diet often leads to the fact that the body switches to eating its own fat reserves. With this, ketosis begins. Ketone bodies are formed, including acetone, which can be found in urine and in the smell of exhaled air. With type 2 diabetes, it may be helpful for the patient, but not during pregnancy.
As you read in the article “Insulin and carbohydrates: the truth you need to know,” the less carbohydrates you eat, the easier it is to maintain normal blood sugar. But during pregnancy - to prevent the development of ketosis is even more important. Elevated blood glucose levels can lead to pregnancy and childbirth complications. But ketonuria is even more dangerous. What to do?
Carbohydrates that are absorbed immediately, consume diabetes is not worth it at all. But during pregnancy, you can afford to eat sweet vegetables (carrots, beets) and fruits, which in everyday life, it is desirable to exclude from the diet. And carefully monitor the appearance of ketones in the urine with the help of test strips.
Official medicine used to recommend a diet for diabetes in pregnant women, which was 60% carbohydrate. In recent years, they recognized the benefits of reducing the percentage of carbohydrates and now recommend a diet in which 40-45% of carbohydrates, 35-40% of fats and 20-25% of protein.
Pregnant women with diabetes are advised to eat small meals 6 times a day. These are 3 main meals and 3 additional snacks, including overnight to prevent nighttime hypoglycemia. Most researchers believe that the calorie diet for pregnant women should be normal, even if the woman is obese.
During pregnancy, a woman’s body under the action of placenta hormones decreases the sensitivity of tissues to the action of insulin, that is, insulin resistance develops. To compensate for this, the pancreas begins to produce more insulin. Fasting blood sugar remains normal or decreases, and after eating it increases significantly.
All this is very similar to the development of type 2 diabetes. But these are normal natural metabolic changes to ensure the development of the fetus. If earlier the pancreas was already working at the limit of its capabilities, then during pregnancy a woman may experience gestational diabetes, because now she is unable to cope with increased stress.
Insulin is actively prescribed to pregnant women not only for type 1 diabetes, but also for type 2 diabetes and gestational diabetes, if it is not possible to maintain normal blood sugar by diet and exercise.
High blood sugar can lead to pregnancy complications that are dangerous for the fetus and the woman. Diabetic fetopathy - manifested in fetal edema of subcutaneous fat, dysfunction of many organs. May cause significant problems in the early postpartum period.
Macrosomia - excessive weight gain by the fetus, under the influence of an increased level of glucose in the mother's blood. Causes difficulty in passing through the birth canal, premature birth, leads to injury to the child or woman during childbirth.
Therefore, do not hesitate with the beginning of insulin injections in diabetes of pregnant women, if there is a need. The scheme of insulin therapy prescribed by a doctor. A woman should consider using an insulin pump instead of traditional injections with syringes or syringe pens.
Please note that in the second half of pregnancy, the need for insulin can increase dramatically. Dosages for insulin injections may need to be increased by a factor of 2-3 compared to how many were injected before pregnancy. It depends on the indicators of blood sugar after a meal, which a woman measures every time painlessly with a glucometer.
Pregnancy diabetes and nephropathy (kidney problems)
Diabetic nephropathy is a complex name for various lesions of the kidneys and their blood vessels that occur in diabetes. This is the most dangerous complication that affects 30-40% of diabetics and often leads to renal failure.
As indicated at the very beginning of this article, severe nephropathy is a contraindication for pregnancy. But many women with diabetes mellitus of “mild” or “moderate” severity tend to become pregnant and become mothers.
In most cases, diabetic nephropathy can be expected to give birth to a viable child. But, most likely, the course of pregnancy will be complicated, it will require observation of specialists and intensive treatment. The worst odds are in women with pronounced renal dysfunction, with reduced creatinine clearance and elevated plasma creatinine concentration (take tests - check!).
Diabetic nephropathy increases the risk of adverse pregnancy outcomes for the following reasons:
- Pregnancy is complicated by preeclampsia several times more often. Especially in those women with diabetic nephropathy who had high blood pressure before conception. But even if a woman initially had normal blood pressure, preeclampsia is still very likely.
- Premature birth in diabetic nephropathy occurs very often. Because the condition of the woman can worsen, or there will be a threat to the child. In 25-30% of cases, childbirth occurs before the 34th week of pregnancy, in 50% of cases - before the 37th week.
- During pregnancy with nephropathy in 20% of cases there is a depletion or underdevelopment of the fetus.
Preeclampsia is a serious complication of pregnancy, which leads to a deterioration of the blood supply to the placenta, nutritional deficiencies and oxygen to the fetus. His symptoms are:
- high blood pressure;
- an increase in the amount of protein in the urine;
- a woman quickly gains weight due to fluid retention.
Whether pregnancy will accelerate the development of diabetic kidney damage is difficult to predict in advance. There are at least 4 factors that can affect this:
- In normal pregnancy, the level of glomerular filtration increases by 40-60%. Diabetic nephropathy is known to occur due to increased glomerular filtration. Thus, pregnancy can worsen the course of this complication of diabetes.
- High blood pressure is an important cause of kidney damage. Therefore, hypertension and preeclampsia, which often occur in pregnant women with diabetes, can have a negative effect on kidney function.
- During pregnancy, a woman's diet should contain a significant percentage of protein, because the fetus needs a lot of it. But a large amount of protein in the diet leads to an increase in glomerular filtration. This can accelerate the natural course of diabetic nephropathy.
- In diabetic nephropathy patients are often prescribed drugs - ACE inhibitors - which slow down the development of kidney damage. But these drugs adversely affect the development of the fetus, so during pregnancy they are canceled.
On the other hand, during pregnancy, women with diabetes are advised to carefully monitor their blood sugar levels. And this can have a significant beneficial effect on kidney function.
Symptoms of kidney problems usually appear already in the late stage of diabetic nephropathy. Prior to this, the disease is detected according to urine protein analysis. First, albumin appears in the urine, and this is called microalbuminuria. Later other proteins are added, larger ones.
Proteinuria is the excretion of protein in the urine. During pregnancy in women with diabetic nephropathy, proteinuria often increases significantly. But after giving birth, it is likely to decrease to the previous level. At the same time, the negative impact that pregnancy had on the work of the kidneys may appear later.
Childbirth in the presence of diabetes in a pregnant woman
With diabetes pregnant women for each woman, the question at what time it is time to give birth, is solved individually. In this case, doctors consider the following factors:
- fetal condition;
- the degree of maturity of his lungs;
- the presence of pregnancy complications;
- nature of diabetes mellitus.
If a woman gets gestational diabetes during pregnancy and has a normal fasting blood sugar, then most likely she brings the child to the natural term of labor.
Cesarean section or physiological delivery is also a crucial choice. Independent labor in a woman with diabetes is possible if the following conditions are met:
- diabetes is well controlled;
- no obstetric complications;
- the weight of the fetus is less than 4 kg and it has a normal state;
- Doctors have the capacity to monitor the condition of the fetus and monitor the level of glucose in the blood of the mother during childbirth.
Cesarean section will be exactly done if:
- a pregnant woman has a narrow pelvis or scar on the uterus;
- A woman suffers from diabetic nephropathy.
Now in the world, the percentage of cesarean section is 15.2% among healthy women and 20% in patients with diabetes, including gestational diabetes. Among women who have diagnosed diabetes before pregnancy, the rate of cesarean section increases to 36%.
During childbirth, doctors monitor the level of glucose in capillary blood 1 time per hour. Sugar in the blood of the mother is very important to maintain at a normal level by intravenous administration of glucose and low doses of insulin. Also good results are obtained using insulin pump.
If the patient, together with the doctors, chose a caesarean section, then it is planned for a very early morning. Because in these hours the dose of “average” or prolonged insulin, which was administered at night, will continue. So it will be possible not to introduce glucose or insulin in the process of fetal extraction.
Here we consider the situation when a woman developed insulin-dependent diabetes before pregnancy. If diabetes was first discovered during pregnancy, read the article “Gestational diabetes” recommendations for a woman for the postpartum period.
After birth, the placenta stops its hormones to affect the metabolism in the woman's body. Accordingly, the sensitivity of tissues to insulin increases. Therefore, insulin dosages for injections should be significantly reduced to avoid severe hypoglycemia.
Approximately, the insulin dose can be reduced by 50% after delivery through the natural ways and by 33% in the case of cesarean section. But with insulin therapy, you can focus only on the individual testimony of the patient, and not on other people's “average” data. Finding the right dosage of insulin is only possible with frequent measurement of blood glucose.
A few years ago, breastfeeding a child for women with diabetes was problematic. This was hampered by:
- a high percentage of preterm labor;
- complications during childbirth;
- severe metabolic disorders in women.
Currently this situation has changed. If diabetes is well compensated and the delivery was carried out on time, then breastfeeding is possible and even recommended. In this case, keep in mind that episodes of hypoglycemia reduce blood flow to the mammary gland and the production of mother's milk. Therefore, we must try not to allow them.
If the patient controls her diabetes, the composition of her milk will be the same as that of healthy women. Is that the glucose content may be elevated. Still, it is believed that the benefits of breastfeeding outweigh the problem.