Diabetes and pregnancy

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For pregnant women with diabetes, some particular challenges exist for both mother and fetus. If the pregnant woman has diabetes as a pre-existing disorder, it can cause early labor, birth defects, and larger than average infants. Therefore, experts advise diabetics to maintain blood sugar level close to normal range about 3 months before planning for pregnancy. [1]

Contents

When type 1 diabetes mellitus or type 2 diabetes mellitus is pre-existing, planning in advance is emphasized if one wants to become pregnant, and stringent blood glucose control is needed before getting pregnant. [1]

Physiology

Pre-gestational diabetes can be classified as Type 1 or Type 2 depending on the physiological mechanism. Type 1 diabetes mellitus is an autoimmune disorder leading to destruction of insulin-producing cell in the pancreas; type 2 diabetes mellitus is associated with obesity and results from a combination of insulin resistance and insufficient insulin production. Upon becoming pregnant, the placenta produces human placental lactogen (HPL), a hormone with counter-regulatory actions leading to increased blood glucose levels. [2] In combination with pre-existing diabetes, these maternal physiological changes can lead to dangerously high blood glucose levels. This is significant because the consequences of poor glycemic control are more severe during pregnancy compared to non-pregnant states.

Risks for the fetus

The negative effects of pregestational diabetes are due to high blood sugar and insulin levels primarily during the first trimester of pregnancy (in contrast to gestational diabetes, which can lead to fetal complications during the second and third trimester). Since this period is when many of the major internal structures and organs of the fetus is decided, pre-existing diabetes can lead to congenital abnormalities. These include abnormal development of the heart and the central nervous system (brain and spinal cord). Strong correlations have been reported between diabetes and sacral agenesis, holoprosencephaly, and longitudinal limb deficiency. [3] With regards to the heart, increased likelihood of truncus arteriosus, atrioventricular septal defect, and single ventricle complex has been found. [4] It is important to note that these complications are generally rare and can be averted with tight blood sugar control. Mild neurological and cognitive deficits in offspring — including increased symptoms of ADHD, impaired fine and gross motor skills, and impaired explicit memory performance — have been linked to pregestational type 1 diabetes and gestational diabetes. [5] [6] [7]

Pre-existing diabetes can also lead to complications in the neonate after birth, including neonatal jaundice, hypoglycemia, and macrosomia. Pregestational diabetes does not, however, increase the likelihood of diseases due to chromosomal alterations (e.g., Down Syndrome). Furthermore, miscarriages are also increased due to abnormal development in the early stages of pregnancy. [8]

Furthermore, when blood glucose is not controlled, shortly after birth, the infant's lungs may be under developed and can cause respiratory problems. [9] Hypoglycemia can occur after birth if the mother's blood sugar was high close to the time of delivery, which causes the baby to produces extra insulin of its own. A hyperglycemic maternal environment has also been associated with neonates that are at greater risk for development of negative health outcomes such as future obesity, insulin resistance, type 2 diabetes mellitus, and metabolic syndrome. [10]

Diabetes pregnancy management

Blood glucose levels in pregnant women should be regulated as strictly as possible. During the first weeks of pregnancy less insulin treatment is required due to tight blood sugar control as well as the extra glucose needed for the growing fetus. [11] At this time basal and bolus insulin may need to be reduced to prevent hypoglycemia. Frequent testing of blood sugar levels is recommended to maintain control. As the fetus grows and weight is gained throughout the pregnancy, the body produces more hormones which may cause insulin resistance and the need for more insulin. [11] At this time it is important for blood sugar levels to remain in range as the baby will produce more of its own insulin to cover its mother's higher blood sugar level which can cause fetal macrosomia. [12] During delivery, which is equivalent to exercise, insulin needs to be reduced again or hyperglycemia can occur. After the baby is delivered and the days following, there are no more hormones from the placenta which demanded more insulin, therefore insulin demand is decreased and gradually returns to normal requirements. [9]

Diabetes mellitus may be effectively managed by appropriate meal planning, increased physical activity and properly-instituted insulin treatment. Some tips for controlling diabetes in pregnancy include:

The National Institute of Health and Care Excellence now recommends closed-loop insulin systems as an option for all women with type 1 diabetes who are pregnant or planning pregnancy. [14] [15] [16]

Breastfeeding

In general, breast feeding is good for the child even with a mother with diabetes mellitus. In fact, the child's risk for developing type 2 diabetes mellitus later in life may be lower if the baby was breast-fed. Breast feeding also helps the child maintain a healthy body weight during infancy. However, the breastmilk of mothers with diabetes has been demonstrated to have a different composition than that of non-diabetic mothers, containing elevated levels of glucose and insulin and decreased polyunsaturated fatty acids. [17] Although benefits of breast-feeding for the children of mothers with diabetes have been documented, ingestion of diabetic breast milk has also been linked to delayed language development on a dose-dependent basis. [17]

In some cases, pregnant women with diabetes may be encouraged to express and store their colostrum during pregnancy, in case their blood sugar is too low for feeding the baby breast milk after birth. [18] There is no evidence on the safety or potential benefits when pregnant women with diabetes express and store breast milk prior to the baby's birth. [18]

Classification

The White classification, named after Priscilla White [19] who pioneered research on the effect of diabetes types on perinatal outcome, is widely used to assess maternal and fetal risk. It distinguishes between gestational diabetes (type A) and diabetes that existed before pregnancy (pregestational diabetes). These two groups are further subdivided according to their associated risks and management. [20]

There are 2 classes of gestational diabetes (diabetes which began during pregnancy):

The second group of diabetes which existed before pregnancy can be split up into these classes:

An early age of onset or long-standing disease comes with greater risks, hence the first three subtypes.

See also

Footnotes

  1. 1 2 "Pregnancy if You Have Diabetes | NIDDK". National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved 2020-10-29.
  2. ↑ Barbour, Linda A.; McCurdy, Carrie E.; Hernandez, Teri L.; Kirwan, John P.; Catalano, Patrick M.; Friedman, Jacob E. (2007-07-01). "Cellular Mechanisms for Insulin Resistance in Normal Pregnancy and Gestational Diabetes". Diabetes Care. 30 (Supplement 2): S112–S119. doi: 10.2337/dc07-s202 . ISSN   0149-5992. PMID   17596458.
  3. ↑ "Home - Eastern Virginia Medical School (EVMS), Norfolk, Hampton Roads". www.evms.edu. Retrieved 2021-09-10.
  4. ↑ Tinker, Sarah C.; Gilboa, Suzanne M.; Moore, Cynthia A.; Waller, D. Kim; Simeone, Regina M.; Kim, Shin Y.; Jamieson, Denise J.; Botto, Lorenzo D.; Reefhuis, Jennita (February 2020). "Specific birth defects in pregnancies of women with diabetes: National Birth Defects Prevention Study, 1997–2011". American Journal of Obstetrics and Gynecology. 222 (2): 176.e1–176.e11. doi:10.1016/j.ajog.2019.08.028. PMC   7186569 . PMID   31454511.
  5. ↑ Nomura Y, Marks DJ, Grossman B, Yoon M, Loudon H, Stone J, Halperin JM (January 2012). "Exposure to Gestational Diabetes Mellitus and Low Socioeconomic Status: Effects on Neurocognitive Development and Risk of Attention-Deficit/Hyperactivity Disorder in Offspring". Archives of Pediatrics & Adolescent Medicine. 166 (4): 337–43. doi:10.1001/archpediatrics.2011.784. PMC   5959273 . PMID   22213602.
  6. ↑ Ornoy A, Ratzon N, Greenbaum C, Wolf A, Dulitzky M (2001). "School-age children born to diabetic mothers and to mothers with gestational diabetes exhibit a high rate of inattention and fine and gross motor impairment". Journal of Pediatric Endocrinology & Metabolism. 14 Suppl 1: 681–9. doi:10.1515/jpem.2001.14.s1.681. PMID   11393563. S2CID   11884127.
  7. ↑ DeBoer T, Wewerka S, Bauer PJ, Georgieff MK, Nelson CA (August 2005). "Explicit memory performance in infants of diabetic mothers at 1 year of age". Developmental Medicine and Child Neurology. 47 (8): 525–31. doi:10.1017/s0012162205001039. PMC   2829746 . PMID   16108452.
  8. ↑ "First Trimester complications in pregnancy with diabetes". September 2016. Archived from the original on 2018-11-25. Retrieved 2018-11-06.
  9. 1 2 Walsh, John (2006). Pumping Insulin. San Diego, California: Torrey Pines Press. p. 288. ISBN   978-1-884804-86-1.
  10. ↑ Calkins, Kara; Sherin Devaskar (2011). "Fetal Origins of Adult Disease". Curr Probl Pediatr Adolesc Health Care. 41 (6): 158–176. doi:10.1016/j.cppeds.2011.01.001. PMC   4608552 . PMID   21684471.
  11. 1 2 Scheiner, Gary (2004). Think like a Pancreas . Da Capo Press. pp.  173. ISBN   978-156924-436-4.
  12. ↑ "Infant of Diabetic Mother". Children's Hospital of Philadelphia. 2014-08-24.
  13. ↑ "Prenatal Care | ADA". www.diabetes.org. Retrieved 2020-10-29.
  14. ↑ "Overview | Diabetes in pregnancy: management from preconception to the postnatal period | Guidance | NICE". www.nice.org.uk. 2015-02-25. Retrieved 2024-01-31.
  15. ↑ Lee, Tara T.M.; Collett, Corinne; Bergford, Simon; Hartnell, Sara; Scott, Eleanor M.; Lindsay, Robert S.; Hunt, Katharine F.; McCance, David R.; Barnard-Kelly, Katharine; Rankin, David; Lawton, Julia; Reynolds, Rebecca M.; Flanagan, Emma; Hammond, Matthew; Shepstone, Lee (2023-10-26). "Automated Insulin Delivery in Women with Pregnancy Complicated by Type 1 Diabetes". New England Journal of Medicine. 389 (17): 1566–1578. doi:10.1056/NEJMoa2303911. ISSN   0028-4793. Archived from the original on 19 October 2023.
  16. ↑ "Closed-loop insulin systems are effective for pregnant women with type 1 diabetes". NIHR Evidence. 16 January 2024.
  17. 1 2 Rodekamp E, Harder T, Kohlhoff R, Dudenhausen JW, Plagemann A (2006). "Impact of breast-feeding on psychomotor and neuropsychological development in children of diabetic mothers: role of the late neonatal period". Journal of Perinatal Medicine. 34 (6): 490–6. doi:10.1515/JPM.2006.095. PMID   17140300. S2CID   26423226.
  18. 1 2 East, Christine E.; Dolan, Willie J.; Forster, Della A. (2014-07-30). "Antenatal breast milk expression by women with diabetes for improving infant outcomes" (PDF). The Cochrane Database of Systematic Reviews. 2014 (7): CD010408. doi:10.1002/14651858.CD010408.pub2. ISSN   1469-493X. PMC   9939873 . PMID   25074749.
  19. ↑ White P (November 1949). "Pregnancy complicating diabetes". Am. J. Med. 7 (5): 609–16. doi:10.1016/0002-9343(49)90382-4. PMID   15396063.
  20. ↑ Gabbe S.G., Niebyl J.R., Simpson J.L. OBSTETRICS: Normal and Problem Pregnancies. Fourth edition. Churchill Livingstone, New York, 2002. ISBN   0-443-06572-1

Related Research Articles

The following is a glossary of diabetes which explains terms connected with diabetes.

Fetal distress, also known as non-reassuring fetal status, is a condition during pregnancy or labor in which the fetus shows signs of inadequate oxygenation. Due to its imprecision, the term "fetal distress" has fallen out of use in American obstetrics. The term "non-reassuring fetal status" has largely replaced it. It is characterized by changes in fetal movement, growth, heart rate, and presence of meconium stained fluid.

<span class="mw-page-title-main">Gestational diabetes</span> Medical condition

Gestational diabetes is a condition in which a person without diabetes develops high blood sugar levels during pregnancy. Gestational diabetes generally results in few symptoms; however, it increases the risk of pre-eclampsia, depression, and of needing a Caesarean section. Babies born to individuals with poorly treated gestational diabetes are at increased risk of macrosomia, of having hypoglycemia after birth, and of jaundice. If untreated, diabetes can also result in stillbirth. Long term, children are at higher risk of being overweight and of developing type 2 diabetes.

Maturity-onset diabetes of the young (MODY) refers to any of several hereditary forms of diabetes mellitus caused by mutations in an autosomal dominant gene disrupting insulin production. Along with neonatal diabetes, MODY is a form of the conditions known as monogenic diabetes. While the more common types of diabetes involve more complex combinations of causes involving multiple genes and environmental factors, each forms of MODY are caused by changes to a single gene (monogenic). GCK-MODY and HNF1A-MODY are the most common forms.

<span class="mw-page-title-main">Gestational hypertension</span> Medical condition

Gestational hypertension or pregnancy-induced hypertension (PIH) is the development of new hypertension in a pregnant woman after 20 weeks' gestation without the presence of protein in the urine or other signs of pre-eclampsia. Gestational hypertension is defined as having a blood pressure greater than 140/90 on two occasions at least 6 hours apart.

A complication in medicine, or medical complication, is an unfavorable result of a disease, health condition, or treatment. Complications may adversely affect the prognosis, or outcome, of a disease. Complications generally involve a worsening in the severity of the disease or the development of new signs, symptoms, or pathological changes that may become widespread throughout the body and affect other organ systems. Thus, complications may lead to the development of new diseases resulting from previously existing diseases. Complications may also arise as a result of various treatments.

<span class="mw-page-title-main">Hyperinsulinemia</span> Abnormal increase in insulin in the bloodstream relative to glucose

Hyperinsulinemia is a condition in which there are excess levels of insulin circulating in the blood relative to the level of glucose. While it is often mistaken for diabetes or hyperglycaemia, hyperinsulinemia can result from a variety of metabolic diseases and conditions, as well as non-nutritive sugars in the diet. While hyperinsulinemia is often seen in people with early stage type 2 diabetes mellitus, it is not the cause of the condition and is only one symptom of the disease. Type 1 diabetes only occurs when pancreatic beta-cell function is impaired. Hyperinsulinemia can be seen in a variety of conditions including diabetes mellitus type 2, in neonates and in drug-induced hyperinsulinemia. It can also occur in congenital hyperinsulinism, including nesidioblastosis.

<span class="mw-page-title-main">Large for gestational age</span> Medical condition

Large for gestational age (LGA) is a term used to describe infants that are born with an abnormally high weight, specifically in the 90th percentile or above, compared to other babies of the same developmental age. Macrosomia is a similar term that describes excessive birth weight, but refers to an absolute measurement, regardless of gestational age. Typically the threshold for diagnosing macrosomia is a body weight between 4,000 and 4,500 grams, or more, measured at birth, but there are difficulties reaching a universal agreement of this definition.

<span class="mw-page-title-main">Complications of pregnancy</span> Medical condition

Complications of pregnancy are health problems that are related to, or arise during pregnancy. Complications that occur primarily during childbirth are termed obstetric labor complications, and problems that occur primarily after childbirth are termed puerperal disorders. While some complications improve or are fully resolved after pregnancy, some may lead to lasting effects, morbidity, or in the most severe cases, maternal or fetal mortality.

Metabolic imprinting refers to the long-term physiological and metabolic effects that an offspring's prenatal and postnatal environments have on them. Perinatal nutrition has been identified as a significant factor in determining an offspring's likelihood of it being predisposed to developing cardiovascular disease, obesity, and type 2 diabetes amongst other conditions.

Women should speak to their doctor or healthcare professional before starting or stopping any medications while pregnant. Non-essential drugs and medications should be avoided while pregnant. Tobacco, alcohol, marijuana, and illicit drug use while pregnant may be dangerous for the unborn baby and may lead to severe health problems and/or birth defects. Even small amounts of alcohol, tobacco, and marijuana have not been proven to be safe when taken while pregnant. In some cases, for example, if the mother has epilepsy or diabetes, the risk of stopping a medication may be worse than risks associated with taking the medication while pregnant. The mother's healthcare professional will help make these decisions about the safest way to protect the health of both the mother and unborn child. In addition to medications and substances, some dietary supplements are important for a healthy pregnancy, however, others may cause harm to the unborn child.

Maternal obesity refers to obesity of a woman during pregnancy. Parental obesity refers to obesity of either parent during pregnancy.

MODY 2 or GCK-MODY is a form of maturity-onset diabetes of the young. It is due to any of several mutations in the GCK gene on human chromosome 7 for glucokinase. Glucokinase serves as the glucose sensor for the pancreatic beta cell. Normal glucokinase triggers insulin secretion as the glucose exceeds about 90 mg/dl. These loss-of-function mutations result in a glucokinase molecule that is less sensitive or less responsive to rising levels of glucose. The beta cells in MODY 2 have a normal ability to make and secrete insulin, but do so only above an abnormally high threshold. This produces a chronic, mild increase in blood sugar, which is usually asymptomatic. It is usually detected by accidental discovery of mildly elevated blood sugar. An oral glucose tolerance test is much less abnormal than would be expected from the impaired (elevated) fasting blood sugar, since insulin secretion is usually normal once the glucose has exceeded the threshold for that specific variant of the glucokinase enzyme.

<span class="mw-page-title-main">Neonatal diabetes</span> Medical condition

Neonatal diabetes mellitus (NDM) is a disease that affects an infant and their body's ability to produce or use insulin.NDM is a kind of diabetes that is monogenic and arises in the first 6 months of life. Infants do not produce enough insulin, leading to an increase in glucose accumulation. It is a rare disease, occurring in only one in 100,000 to 500,000 live births. NDM can be mistaken for the much more common type 1 diabetes, but type 1 diabetes usually occurs later than the first 6 months of life. There are two types of NDM: permanent neonatal diabetes mellitus (PNDM), a lifelong condition, and transient neonatal diabetes mellitus (TNDM), a form of diabetes that disappears during the infant stage but may reappear later in life.

<span class="mw-page-title-main">Prenatal nutrition</span>

Prenatal nutrition addresses nutrient recommendations before and during pregnancy. Nutrition and weight management before and during pregnancy has a profound effect on the development of infants. This is a rather critical time for healthy development since infants rely heavily on maternal stores and nutrient for optimal growth and health outcome later in life.

The following outline is provided as an overview of and topical guide to diabetes mellitus :

<span class="mw-page-title-main">Diabetes</span> Group of endocrine diseases characterized by high blood sugar levels

Diabetes mellitus, often known simply as diabetes, is a group of common endocrine diseases characterized by sustained high blood sugar levels. Diabetes is due to either the pancreas not producing enough insulin, or the cells of the body becoming unresponsive to the hormone's effects. Classic symptoms include thirst, polyuria, weight loss, and blurred vision. If left untreated, the disease can lead to various health complications, including disorders of the cardiovascular system, eye, kidney, and nerves. Untreated or poorly treated diabetes accounts for approximately 1.5 million deaths every year.

Neonatal hypoglycemia, also called low blood sugar in newborn babies, occurs when an infant's blood glucose level is less than what is considered normal. There is inconsistency internationally for diagnostic thresholds. In the US, hypoglycemia is when the blood glucose level is below 30 mg/dL within the first 24 hours of life and below 45 mg/dL after, but international standards differ. Age, birth weight, metabolic needs, and wellness state of the newborn has a substantial impact on their blood glucose level. This is a treatable condition, but its treatment depends on the cause of the hypoglycemia. Though it is treatable, it can be fatal if gone undetected. Hypoglycemia is the most common metabolic problem in newborns.

Obstetric medicine, similar to maternal medicine, is a sub-specialty of general internal medicine and obstetrics that specializes in process of prevention, diagnosing, and treating medical disorders in with pregnant women. It is closely related to the specialty of maternal-fetal medicine, although obstetric medicine does not directly care for the fetus. The practice of obstetric medicine, or previously known as "obstetric intervention," primarily consisted of the extraction of the baby during instances of duress, such as obstructed labor or if the baby was positioned in breech.

<span class="mw-page-title-main">Diabetic embryopathy</span> Medical condition

Diabetic embryopathy refers to congenital maldevelopments that are linked to maternal diabetes. Prenatal exposure to hyperglycemia can result in spontaneous abortions, perinatal mortality, and malformations. Type 1 and Type 2 diabetic pregnancies both increase the risk of diabetes induced teratogenicity. The rate of congenital malformations is similar in Type 1 and 2 mothers because of increased adiposity and the age of women with type 2 diabetes. Genetic predisposition and different environmental factors both play a significant role in the development of diabetic embryopathy. Metabolic dysfunction in pregnant mothers also increases the risk of fetal malformations.

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