Miriam's casebook - The diabetic mother
Jill developed insulin-dependent diabetes at 25 while she was pregnant with her second child, and has had the disease for a couple of years. She has two healthy sons. Her third pregnancy should be fine, but she's well aware of the importance of frequent antenatal checks. She knows that uncontrolled diabetes would create complications for her and lead to far more serious complications for her baby.
Pregnancy and diabetes
There's no need for women who have or develop diabetes during pregnancy to worry that they'll have a difficult pregnancy or problems giving birth to a normal, healthy baby. As long as diabetes is carefully managed, with an obstetrician and diabetic advisor in close cooperation, the outcome should be good.
As well as being 50 per cent more likely than men to become diabetics, women have a tendency to develop the disease during pregnancy. Certain women are recognized as potential diabetics. They've usually had at least one heavy baby or have a family history of diabetes in parents or siblings. Other women can develop diabetes during pregnancy. Some may remain diabetic after pregnancy but others go back to normal.
Pregnancy can complicate established diabetes, causing the kidneys to function less effectively and changes to occur in eyes and vision. While most sufferers will have been treated with insulin, some women with diabetes may have been treated with diet alone or with diet and blood-sugar lowering (hypoglycaemic) tablets. The extra demands of pregnancy are likely to lead to insulin having to be prescribed so any diabetic who plans to get pregnant should change to insulin before conceiving. Having been an insulin-dependent diabetic for two years, Jill was meticulous about her pre-pregnancy preparations. She planned this present baby and made sure her diabetes was fully assessed well before she became pregnant. In particular, she was concerned about controlling her blood-sugar levels, the functioning of her kidneys, and the health of her eyes. In the months before conceiving she kept up careful control of her diabetes. She also took folic acid supplements in the period before conceiving.
Controlling diabetes in mothers
Jill knows that diabetes can mean a greater risk of her baby having cardiac and skeletal problems but that good control of her diabetes during the first trimester should greatly reduce this risk (see Possible health considerations). She came to ask my advice very early in the pregnancy.
I explained to Jill that now she's pregnant, she may need less insulin for the first three months. Then her body will start to produce hormones with an anti-insulin effect, so she'll need more insulin than before. Jill will need to test her blood sugar and adjust her dosage of insulin accordingly.
Pregnant women with diabetes usually go to an antenatal clinic where there is an obstetrician and a specialist in diabetes. Diabetic women usually have extra scans at 28, 32, and 36 weeks to check their baby's growth. As an established diabetic, Jill may have a number of disorders while she's pregnant because of fluctuations in her blood-sugar levels. She may suffer from urinary tract infections, thrush, high blood pressure, pre-eclampsia, and polyhydramnios (an excess of amniotic fluid). She could go into premature labour.
How diabetes affects her baby
If a mother's blood-sugar levels get high, sugar crosses the placenta and is converted into fat, muscle, and enlarged organs. The baby then becomes overweight. The baby produces large quantities of insulin to cope with the high sugar levels. At birth, when he's suddenly cut off from the source of sugar, the baby experiences a sudden, severe drop in blood sugar, while his insulin production remains high. If left untreated, this causes profound hypoglycaemia (shortage of blood sugar), which can ultimately result in coma and death but this is prevented with good antenatal care.
A preterm baby of a diabetic mother can be prone to respiratory distress syndrome, as the diabetes prevents the baby's lungs from producing the surfactant they need to aid breathing. The good news for Jill is that her careful control of her diabetes will make a big difference. Unless there are complications, such as high blood pressure or pelvic disproportion, and as long as her diabetes remains under control, Jill can hope for a normal vaginal delivery. She'll probably be advised to have an induction at 38 weeks if her baby isn't born by then, so he doesn't grow too big. I advised her to have a glucose and insulin intravenous drip to control the diabetes during labour, and continuous fetal heart monitoring and fetal blood sampling to detect any fetal distress. After the birth her baby will be checked in a neonatal special care unit in case he needs any immediate treatment, he'll be given to Jill so he can be breastfed.
Jill's doctor will be aware that her baby may be very large so he may have to be delivered with forceps or by Caesarean section. It is also possible that he may suffer from mild hypoxia (low oxygen supply to the tissues) shortly before birth, and this can lead to neonatal jaundice - a condition that can be treated after birth.
Jill's baby will be carefully checked after birth for any complications. In some hospitals, all babies of diabetic mothers are taken to special care so their blood-sugar levels can be closely checked, and Jill will be advised to breastfeed as soon as possible in order to counteract any trace of hypoglycaemia (shortage of blood sugar) her baby may have after birth.
Some diabetic mothers tend to have bigger and bigger babies, and they can be very heavy at birth: 4-5kg (9-11lb) for instance. While such a large baby may of course be delivered without a hitch, some obstetricians prefer to induce before term (at around 36 weeks, say) or opt for a planned Caesarean section before the baby has reached its full size or outgrown its food supply.
Miriam's top tips
As long as diabetes is closely managed during pregnancy, with help from your obstetrician and diabetic advisor, the outlook for mother and baby is good. Keep in mind the following:
- have a full assessment of your diabetes before becoming pregnant and start taking 400mcg folic acid daily.
- consult your doctor about changing to insulin before conceiving because the extra demands of pregnancy are likely to lead to insulin having to be prescribed.
- watch your diet very carefully during your pregnancy.
- Food in pregnancy
- Miriam's casebook - The vegetarian mother
- Food-related risks in pregnancy
- Average weight gain during pregnancy
- The best food to eat during pregnancy
- Eating well in pregnancy
- The foods you need in pregnancy
- Eating for two at Christmas
- Vitamins for a healthy pregnancy
- A vegetarian pregnancy?
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