25. CONTROLLING DIABETES DURING / BEFORE PREGNANCY

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1 Health Administrator Vol: XXII Number 1& : CONTROLLING DIABETES DURING / BEFORE PREGNANCY Phyllis Ring Many doctors once discouraged women with diabetes from having children at all, but advances in insulin use and diet management have significantly improved prospects for a healthy pregnancy and delivery. Experts say it's all in the planning, and in a regimen that safeguards mother and baby. Both pre-existing and gestational diabetes require bloodsugar control throughout pregnancy. The difference is that gestational diabetes occurs after a woman is pregnant, when her unborn child is already welldeveloped. (This type of diabetes generally disappears after birth, though it can recur in the future.) However, women with pre-existing diabetes must, for the baby's well-being master tight control of blood sugar before conception, maintain it during early pregnancy as infant organ systems develop, and in later trimesters, so the baby won't grow too large. Avoid the Risks "Plan on achieving excellent blood-sugar control by six months before conception," recommends Robert Meloni, M.D., Fellow of the American College of Endocrinology. "It takes time to get everything together - diet, exercise, insulin - in the proper proportion for continuous, excellent control." Most diabetic-related fetal birth defects occur before women even know they're pregnant and are due to fetal exposure to the diabetic mother's high blood sugars in the first two weeks of development, he says. "If severe defects occur, they cannot be 'fixed' by good sugar-control later." "Diabetes doesn't usually interfere with fertility unless the disease is out of control or in very poor control," Meloni says. He cited birth defects that result from poor preconception blood-sugar control as macrosomia (baby over 9.5 pounds); immature lung development; cardiovascular or centralnervous-system malformations; and cleft palate. Mothers with either pre-existing or gestational diabetes can tend to have larger babies when their high blood -sugar levels constantly feed their child glucose through the placenta. Babies respond with increased growth, much of it stored as fat, and eventually develop high insulin levels of their own. This can lead to another potential infant risk-severe postpartum hypoglycemia- when a baby's insulin levels remain high following birth and the mother's glucose can no longer counteract them. For the mother, poorly controlled diabetes also increases the risk for miscarriage in the early weeks, with the rate about twice as high for women with uncontrolled diabetes. Other possible complications of diabetes itself, such as neuropathy and retinopathy and retinopathy, can worsen in pregnancy if there is poor sugar control. "During my first pregnancy, I was sent to an eye specialist during and after, just to make sure that there was no damage to the blood vessels," says Christine Bleackley of Aylmer, Quebec, mother of 1-15 monthold son and a child due in early April. Take Control To achieve blood-sugar control prior to conception, Meloni recommends that women: Reach their near-ideal body weight. 118

2 Follow a diet that provides good sugar control. Avoid hyper - and hypoglycemia "This requires multiple injections of regular or lispro insulin per day before meals," he says. "At bedtime and /or in the morning, intermediate - acting insulin is used to smooth out the 'bumps' in blood sugar. Adding snacks to the diet and reducing meal size necessary" is often "Plan on testing blood sugar at least 5 to 6 times a day, "says Dawn Prindall of Orr's Island, Maine, mother of sons ages 11 and 6. " And get regular Heboglobin A1C tests before you get pregnant to give you an indication of how you're doing with control.". Two recent developments that have improved blood - sugar control for all diabetics, pregnant women in particular, are carbohydrate counting and Humalog, a rapidly absorbed mealtime insulin that mimics the body's own insulin activity after meals. "Carb counting takes the guess work out of blood-sugar management, Prindall says. "There is a formula for determining insulin doses based on what you actually eat. You adjust the dose to meet your personal insulin requirements," all with adequate medical supervision, she adds. "Carb counting lets me eat more how I want to," says Bleackley. "If I'm not feeling particularly well one day i.e. morning sickness), I can reduce my insulin a little and eat less. In addition, carb counting makes it a little easier to adjust to increased insulin requirements as pregnancy goes on." Amanda Clark, whose pre-existing diabetes wasn't diagnosed until 12 weeks into her first pregnancy, is now on an insulin pump for her second. The device releases insulin on-demand as her body needs it, and allows her to maintain her usual eating habits and keep her blood sugar at consistent levels, even with morning sickness. Managing diabetes before and during pregnancy is more of a lifestyle than a chore, Bleackley says, "I get the meals on time, keep some healthy food in the fridge, try to eat normally, but a little lower in fat than most. I walk that mile to the store and groceries (I push them along with the stroller) instead of driving. Use the stairs instead of the elevator. Go to the pool when you have time take a walk in the park." A Team Approach to Healthy Pregnancy The American Diabetes Association recommends that diabetic women, when possible, assemble a support team prior to conception. That team should include: An endocrinologist or physician specializing in diabetes and skilled in treating pregnant women. A diabetes nurse educator. A registered dietitian. An ophthalmologist. An obstertrician who handles high - risk pregnancies and has cared for other pregnant women with diabetes. "It is important to remember that the mother is more than 50 percent of the 'team' in getting all this to work," says Meloni. "I see the OB/GYNs every two weeks, the endocrinologist every four to six weeks, and maternal fetal health specialist for level II ultrasounds every four weeks," says Clark, whose second child is due in late December. Diet demands and insulin requirements will slowly change after the third month as the 119

3 pregnancy progresses, Meloni says. Both Type 1 and Type 2 diabetics will have to monitor their weight, snacks and diet composition. Insulindependent Type 1 diabetics may need to increase their dosage, while Type 2 diabetics controlled by diet and/or oral medication, and even those with gestational diabetes, may have to add insulin in the final trimester. With all the attention a diabetic woman must pay to planning for pregnancy and following guidelines within it, a spouse can be an important member of the team, too. "He helped me test my blood sugar when I was tired, helped me through blood-sugar lows, encouraged me, and went to nearly every doctor's appointment to help us understand the best paths to take," says Prindall of her husband. "I cou\dn't have done it without him." Diabetes Only During Pregnancy WHAT ABOUT YOU? Have you ever had diabetes when you were pregnant before? [ ] Yes [ ] No If yes, when? Have you had large babies before (more than 9 to.;? [ ] Yes[ ] No If yes, how large? Does anyone in your family have diabetes? [ ] Yes[ ] No How much weight have you gained? lb. What was your weight before you got pregnant? lb How many meals and snacks do you eat a day? meals snacks. WHY LEARN ABOUT GESTATIONAL DIABETES? Your food plan is one key to controlling diabetes during pregnancy. If your diabetes is well controlled, you and your baby can stay healthy. You need to know what can happen if your diabetes is not kept under control. You can lessen our risk of having type II diabetes later in life if you eat healthy, exercise regularly, and maintain a reasonable weight after the baby is born. WHAT IS GESTATIONAL DIABETES? Gestational diabetes is diabetes (high blood glucose) that you have only when you are pregnant. It usually goes away after your baby is born, but it means you are at risk to have diabetes later in life. Pregnant women should have a blood test to check for gestational diabetes between the 24th and 28th weeks of pregnancy (6th to 7th month). Between 2% and 4% of all pregnant women have gestational diabetes. It is found more often now because more women have babies after age 35, more women are overweight and more women are tested for diabetes. Pregnancy puts extra strain on your body. Some women cannot make enough insulin to keep up with the added need during pregnancy. Some women make plenty of insulin but their bodies can't use it properly. In either case, blood glucose goes up. High blood glucose increases some risks for you and your baby. 120

4 CONTROLLING GESTATIONAL DIABETES Food plan -Your registered dietitian will help you put together a food plan to keep your blood glucose under control. Physical activity - walking, biking or other exercise can help lower your blood glucose. Check with your doctor to make sure exercise is safe for you. Monitoring - Your educator will teach you to check your blood glucose and test your urine for ketones. Make sure you know when to test and what the numbers mean. Insulin - You may need insulin injections if your blood glucose can't be controlled with a food plan and exercise. EATING FOR A HEALTHY BABY You need the same healthy foods as other pregnant women. Gain a healthy amount of weight. The weight you gain depends on your weight before you were pregnant and the weight you have gained so far. It's OK to have foods and drinks sweetened with aspartame or acesulfame- K. Saccharin is not recommended during pregnancy or breast-feeding. Eat plenty of fruits, vegetables and grains because they are healthy and help prevent constipation. Practice moderation with caffeine - limit coffee, tea and chocolate. Use decaffeinated products when able. These are some tips for morning sickness - keep some crackers by your bedside, keep liquids separate from meals, avoid greasy and fatty foods, do not let yourself get too hungry. If you take insulin and have morning sickness make sure you know how to treat low blood glucose. Eat three small meals and two or three snacks spread out over the day. Don't skip meals or snacks. Eat a small breakfast. Blood glucose is most likely to be high first thing in the morning. Food Group Servings Serving Sizes Grains/beans/starchy vegetables 6 or more 1 slice bread, 4 to 6 crackers, inch tortilla, Vz cup starchy vegetables, cooked pasta or rice, % cup dry cereal, 1 small potato Vegetables 3 to 5 1 cup raw vegetables, Vz cup cooked vegetables Fruit 3 to 4 1 small fresh fruit, Vz cup canned fruit or fruit juice Milk 3 to 4 1 cup nonfat or low-fat milk or yogurt Meat and other 2 to 3 2 to 3 ox cooked lean meat, poultry or fish, 2 to 3 oz cheese, 1 egg, 2 tbsp peanut butter. Fats and sweets Limit Eat sweets seldom. Use fats sparingly. Alcohol avoid 121

5 WHAT AND HOW MUCH TO EAT KEEP TRACK Have foods high in iron every day - liver, kidney, shellfish, lean meat, poultry, fish, dried Date Blood glucose Ketones in urine Action beans, green leafy vegetables and whole- grain and enriched bread and cereals. Most women need a prenatal vitamin and mineral supplement to meet the nutritional needs of pregnancy. Drink at least eight cups of liquid a day (including milk).. Avoid wine, beer liquor and other alcoholic drinks. AFTER YOUR BABY IS BORN Breast - feeding is a best for all babies. Your blood glucose will be lower if you breast-feed your baby. Help your whole family learn healthy food and exercise habits to lessen your chances of having type II diabetes later on. Get your weight down and keep it at a reasonable level to prevent diabetes. HERE'S THE CHALLENGE; WHAT'S YOUR SOULTION? For the past two weeks you have been eating dinner later than usual. You haven't felt hungry at bedtime so you've been skipping your snack. Your blood glucose has been mg/dl and your ketones have been positive first thing in the morning. What will you do? Have your blood glucose checked when the baby is 6-10 weeks old and again after you stop breast-feeding. If you are pregnant again, tell your health care provider that you had gestational diabetes. Have your blood glucose checked once a year. About 40% of women who have diabetes during pregnancy get diabetes later in life. You do not like to drink milk. What can you do to get enough calcium? SET YOUR SIGHTS 1 I plan to gain a total of lb. or lb. per week. 2 I will eat meals and snacks at these times: 122