Monday, February 26, 2007

DIABETES IN PREGNANCY: HOW HARMFUL CAN THAT BE?

Rebecca B. Singson, M.D., FPOGS

WHAT IS GESTATIONAL DIABETES?

This is the most common medical complication of pregnancy affecting about 4% of pregnant women who are diagnosed with abnormal blood sugar levels occurring for the first time in pregnancy. Apparently, during pregnancy, certain rises of hormones such as the human placental lactogen, estradiol and progesterone all stimulate the synthesis and release of insulin from the mother’s pancreas. What happens is a state of high insulin levels or hyperinsulinism. If we nature were to allow this, there would be too much fluctuation in the levels of glucose So these same hormones were designed by nature to block the action of insulin to insure a steady glucose supply to the baby, inducing a state of insulin resistance. Furthermore, placental insulinase was also found in the placenta which acts to accelerate the destruction of insulin. All these make it harder for the pregnant woman to utilize insulin, creating a problem called insulin resistance. This condition makes it hard for the mother's body to use insulin. She may need up to three times as much insulin.

HOW WILL I KNOW IF YOU HAVE THIS CONDITION?

If you have a family history of diabetes, screening is done in the first 3 months of pregnancy. If you don’t have a family history, screening for gestational diabetes is routinely done for all pregnant women at 26 weeks. Screening entails a glucose challenge test (GCT) making the woman drink a sweet juice with 50g of glucose then extracting blood one hour later for sugar determination. Any level about 140 mg/dl or 7 g% is suspect and must undergo a more definitive test called the Oral Glucose Tolerance Test using 100 grams glucose and making 4 blood determinations at hourly intervals.

HOW CAN DIABETES AFFECT MY PREGNANCY?

Diabetes may harm the mother as well as the baby because of the following reasons:

1 Women with gestational diabetes have a 15% increased risk for preeclampsia (another complication in pregnancy consisting of hypertension, swelling of the feet & legs & spillage of protein in the urine); women with diabetes even before pregnancy have a 30% risk of preeclampsia

2. Some infections may be more common especially if the diabetes goes undetected or uncontrolled and these may likely become more severe in pregnant diabetic women.

3. Because so much glucose goes to the baby from the mother with high blood sugar, the fetus ends up secreting much insulin which in turn leads to stimulating much larger growth of the fetus. With a larger than usual baby, the mom becomes more prone to operative delivery either by forceps or C-section.

4. If the fetus grows so big as to weigh over 4 kilos, there is a 30% chance that if a vaginal birth is attempted, the baby can get stuck after the head is delivered since the shoulders cannot be delivered, a potentially fatal condition called shoulder dystocia can occur. It thus becomes safer to deliver by large babies by C section rather than risk fetal injury, or worse, fetal death as a result of shoulder dystocia.

5. Hydramnios (excess amniotic fluid) is more common with diabetic pregnancies and in very rare occasions, coupled with fetal macrosomia, may cause cardiorespiratory symptoms in the mother.

6. In the presence of an excessively large fetus, it becomes more difficult for the uterus to contract after delivery. Postpartum hemorrhage, therefore becomes more common.

7. In the absence of excellent diabetes and pregnancy care, death of the baby occurs considerably more compared to the general population.

8. In women who were diabetic with poor control even prior to pregnancy, there is a three-fold increase in major congenital malformations in the fetus. With the widespread use of insulin & good control, the risk of malformations have considerably decreased.

9. The infant may inherit the risk of developing diabetes as well.

HOW WILL MY DOCTOR TREAT MY DIABETES DURING PREGNANCY?

Your doctor will definitely place you on a diabetic diet and make you determine your blood glucose several times a day. If diet alone is capable of controlling the blood sugar, there will no be no need for further therapy. However, if the blood sugar remains uncontrolled, insulin treatment needs to be started to reduce the chances of delivering a macrosomic baby. Exercise appropriate for pregnancy is also encouraged both for weight control and for improvement of glucose metabolism.

DO I NEED TO BE DELIVERED BY C-SECTION?

There is no data to support a policy of Cesarean delivery purely on the basis of gestational diabetes. However, when the estimated fetal weight is greater than 4.5 k, prolonged labor or arrest in the descent of the head of the baby is an indication for C-section. If sugar control is poor and the baby or mother appears to be at risk, earlier delivery may be contemplated. However, when there is good sugar control and the weight of the fetus does not appear too large, a normal delivery may be attempted when the patient goes into labor.

Diabetes may be a dreadful complication in pregnancy when it goes unrecognized and uncontrolled. However, with good pre-natal care, one may greatly minimize the risks and have a normal pregnancy and a healthy baby.

No comments: