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Thread: Pregnancy with Preexisting Diabetes Mellitus

  1. #1

    Default Pregnancy with Preexisting Diabetes Mellitus

    Health care providers now know that the key to a healthy pregnancy for a woman with diabetes is keeping blood glucose (sugar) in the target range—both before she is pregnant and during her pregnancy.

    Contents

    • Before Pregnancy
    • Prenatal Care
    • Delivery
    Last edited by admin; Tue 26th January '16 at 4:01pm.
    Clinical Pharmacy Specialist - Hematology

  2. #2

    Default Before Pregnancy

    Despite advances, babies born to women with diabetes, especially women with poor diabetes control, are still at greater risk for birth defects.

    High blood glucose levels and ketones (substances that in large amounts are poisonous to the body) pass through the placenta to the baby. These increase the chance of birth defects.

    High blood glucose levels during the first trimester — the time when the baby's organs are forming — increase the risk of birth defects and also miscarriage. Since the baby's organs are completely formed by 7 weeks after your last period, when you may have just realized you are pregnant, it's important to get blood glucose levels under control before getting pregnant.

    Because these early weeks are so important to your baby, you need to plan your pregnancy. If your blood glucose levels are not in your target range, work to bring your diabetes under control before getting pregnant. It is a good idea to be in good blood glucose control three to six months before you plan to get pregnant. You'll want to keep excellent blood glucose control during pregnancy, and after as well.

    Some of the possible risks to the mother and baby if blood glucose levels are too high during pregnancy are:

    • Risks for the baby
    • Premature delivery
    • Miscarriage
    • Birth defects (not usually a risk for women with gestational diabetes)
    • Macrosomia (having a large baby)
    • Low blood glucose at birth (hypoglycemia)
    • Prolonged jaundice (yellowing of the skin)
    • Respiratory distress syndrome (difficulty breathing)



    Risks for the mother

    • Worsening of diabetic eye problems
    • Worsening of diabetic kidney problems
    • Infections of the urinary bladder and vaginal area
    • Preeclampsia (high blood pressure usually with protein in the urine)
    • Difficult delivery or cesarean section
    • Target blood glucose goals before getting pregnant



    Premeal (before eating): 60-119 mg/dl (textbook's range 60-90 mg/dL)
    1 hour after meals: 100-149 mg/dl (textbook's range 100-120 mg/dL)
    Your health care provider may have you use goals such as these, but check with your own team about your specific goals.

    Along with getting your blood glucose levels in your target range, it's also important to establish a set of healthy lifestyle habits that will reduce the risk for complications and improve the health of your baby. For women with diabetes, this means an A1C as normal as possible (less than 7%), achieving or maintaining a healthy body weight, improving diet and exercise, and having a pre-pregnancy exam.

    A pre-pregnancy exam by your doctor typically includes: measuring your A1C level to make sure blood glucose levels are under control. It also will include an assessment of any complications, such as high blood pressure, heart disease, and kidney, nerve, and eye damage. If you have type 1 diabetes, your doctor will likely check the function of your thyroid.

    You should also review all you medications and supplements with your doctor to make sure they are safe to continue using with pregnancy. Drugs commonly used to treat diabetes and its complications may not be recommended in pregnancy, especially statins, ACE inhibitors, ARBs, and most noninsulin therapies.

    While you are getting your blood glucose levels under control and your healthy lifestyle habits where you want them to be, its important to have a family planning method in place. Women with diabetes have the same birth control options as women without diabetes. The pill, the intrauterine device (IUD), implants, barrier methods such as a diaphragm or condoms, and spermicides are all ways to reduce the risk of unplanned pregnancy. Which method you choose will depend on your own health history and you and your partner's preferences.

    If you have any concerns, be sure to bring them up with your health care team.

    Last Reviewed: August 1, 2013
    Last Edited: November 5, 2013

    - See more at: Before Pregnancy: Women and Diabetes
    Last edited by CheneyHsiung; Fri 22nd January '16 at 9:58pm.
    Clinical Pharmacy Specialist - Hematology

  3. #3

    Default Prenatal Care

    Pregnancy is often a time of great highs and lows. It can be awesome and thrilling—when you hear the baby's heartbeat or feel the first tiny kick. It can also be frustrating and even scary.
    Because we know more about diabetes than ever before, there has never been a better time for you to plan a pregnancy. For the best prenatal care, assemble a team that includes the following:


    • A doctor, trained to care for people with diabetes, who has cared for pregnant women with diabetes
    • An obstetrician who handles high-risk pregnancies and has cared for other pregnant women with diabetes
    • A pediatrician (children's doctor) or neonatologist (doctor for newborn babies) who knows and can treat special problems that can happen in babies of women with diabetes
    • A registered dietitian who can change your meal plan as your needs change during and after pregnancy
    • A diabetes educator who can help you manage your diabetes during pregnancy

    It’s important to remember that YOU are the leader of your health care team. Keep track of any questions you have and make sure to ask your health care team.

    Checking Your Blood Glucose


    Your body is changing as the baby grows. Because you have diabetes, these changes will affect your blood glucose level. Pregnancy can also make symptoms of low blood glucose hard to detect.
    During pregnancy, your diabetes control will require more work. The blood glucose checks you do at home are a key part of taking good care of yourself and your baby before, during and after pregnancy.
    Blood glucose targets are designed to help you minimize the risk of birth defects, miscarriage and help prevent your baby from getting too large. If you have trouble staying in your target range or have frequent low blood glucose levels, talk to your health care team about revising your treatment plan. Target blood glucose values may differ slightly in different care systems and with different diabetic teams. Work with your health care team on determining your specific goals before and during pregnancy.
    The American Diabetes Association suggests the following targets for women with preexisting diabetes who become pregnant. More or less stringent glycemic goals may be appropriate for each individual.

    • Before a meal (preprandial) and Bedtime/Overnight: 60-99 mg/dl
    • After a meal (postprandial): 100-129 mg/dl
    • A1C: less than 6%

    *Postprandial glucose measurements should be made 1-2 hours after the beginning of the meal, which is generally when levels peak in people with diabetes.
    Check your blood glucose levels at the times your diabetes team advises; this may be up to eight tests daily and will probably include after-meal checks.

    • Write down your results.
    • Keep notes on your meal plan and exercise.
    • Make changes in your meal plan and insulin only with the advice of your diabetes team.


    Insulin and Diabetes Pills


    Insulin is the traditional first-choice drug for blood glucose control during pregnancy, because it is the most effective for fine-tuning blood glucose and it doesn’t cross the placenta. Therefore, it is safe for the baby. Insulin can be injected with a syringe, an insulin pen, or through an insulin pump. All three methods are safe for pregnant women.

    If you have type 1 diabetes, pregnancy will affect your insulin treatment plan. During the months of pregnancy, your body's need for insulin will go up. This is especially true during the last three months of pregnancy. The need for more insulin is caused by hormones the placenta makes. The placenta makes hormones that help the baby grow. At the same time, these hormones block the action of the mother's insulin. As a result, your insulin needs will increase.

    If you have type 2 diabetes, you too need to plan ahead. If you are taking diabetes pills to control your blood glucose, you may not be able to take them when you are pregnant. Because the safety of using diabetes pills during pregnancy has not been established, your doctor will probably have you switch to insulin right away. Also, the insulin resistance that occurs during pregnancy often decreases the effectiveness of oral diabetes medication at keeping your blood glucose levels in their target range.

    For women with gestational diabetes, meal planning and exercise often work to keep blood glucose levels in control; however, if blood glucose levels are still high, your doctor will probably start you on insulin.

    Only a small number of studies have been published analyzing the safety and effectiveness of oral medications during pregnancy. Unlike insulin, oral medications cross the placenta to the unborn baby in varying degrees. For these reasons, the American Diabetes Association does not recommend their use in pregnancy. However, oral medications are now used more frequently than in the past by some health care providers to manage blood glucose levels that are not controlled by diet and exercise alone during pregnancy.

    Food


    During pregnancy you and your dietitian or doctor may need to change your meal plan to avoid problems with low and high blood glucose levels. This is the most important reason for keeping track of your blood glucose results. For most women, the focus of a good meal plan during pregnancy is improving the quality of foods you eat rather than merely increasing the amount of food eaten. A good meal plan is designed to help you avoid high and low blood glucose levels while providing the nutrients your baby need to grow.

    Including a variety of different foods and watching portion sizes is key to a healthy diet. Healthy eating is important before, during, and after pregnancy, as well as throughout your life. Healthy eating includes eating a wide variety of foods, including:

    • vegetables
    • whole grains
    • nonfat dairy products
    • fruits
    • beans
    • lean meats
    • poultry
    • fish

    Many people think eating for two means eating a lot more than you did before. This isn’t true. You only need to increase your calorie intake by about 300 more calories each day. If you start pregnancy weighing too much, you should not try to lose weight. Instead work with your dietitian or doctor to curb how much weight you gain during pregnancy.

    Your dietitian will keep track of your weight gain. If you start pregnancy at a normal weight, expect to add between 25 to 35 pounds. Women who start pregnancy too thin need to gain more. If you are obese at the start of your pregnancy, work with your dietitian to limit your weight gain to about 15–25 pounds. You can determine your healthy weight by finding your BMI level by using our BMI calculator.

    Pregnancy Weight Goals
    If your prepregnancy weight is… Then gain…
    Underweight 28-40 pounds
    Normal 25-35 pounds
    Overweight 15-25 pounds
    Obese 11-20 pounds
    These are averages to give you an idea of how much weight you should gain. Talk to your health care provider about your specific weight goals during pregnancy. (Adapted from American Diabetes Association Complete Guide to Diabetes, 5th edition, American Diabetes Association, 2011).

    Exercise


    Exercise is a key part of diabetes treatment. Just as you need to get your blood glucose under control before getting pregnant, it's best to get fit before you get pregnant. Can you keep your current exercise program during pregnancy? Is it safe to start exercise after you are pregnant?

    Discuss your exercise plans with your diabetes team. Ask for guidelines. Pregnant women frequently question whether it is safe to exercise during pregnancy. Regular physical activity is not only safe for pregnant women, it benefits health by offsetting some of the problems of pregnancy, such as varicose veins, leg cramps, fatigue and constipation. For women with diabetes, exercise, especially after meals may help the muscles use the glucose in the bloodstream, and help keep your blood glucose levels in your target range. But if you have any of the following conditions (see the list below), then you will need to talk to your diabetes team about the risks of exercise during pregnancy.

    • High blood pressure
    • Eye, kidney, or heart problems
    • Damage of the small or large blood vessels
    • Nerve damage

    In general, it's not a good idea to start a new strenuous exercise program during pregnancy. Good exercise choices for pregnant women include walking, low-impact aerobics, swimming, or water aerobics. Activities to avoid during pregnancy are:

    • Activities that put you in danger of falling or receiving abdominal injury, such as contact sports
    • Activities that put pressure on your abdomen (exercises done while lying on your stomach)
    • Scuba diving
    • Vigorous, intense exercise, such as running too fast to carry on a conversation
    • Activities with bouncing or jolting movements (horseback riding or high-impact aerobics)


    • Last Reviewed: August 1, 2013
    • Last Edited: March 18, 2014


    - See more at: Prenatal Care for Women With Diabetes
    Last edited by CheneyHsiung; Fri 22nd January '16 at 10:06pm.
    Clinical Pharmacy Specialist - Hematology

  4. #4

    Default Delivery

    As your due date nears, your doctors will study your health and that of your growing baby. Then, you and the team will discuss the best time and method for delivery.


    To determine the safest time and method to deliver your baby, your health care team will examine a variety of factors:

    • blood glucose control
    • blood pressure
    • kidney function
    • any diabetes complications you may have.

    The team will also study your baby’s size and movements, his or her heart-rate pattern and the amount of amniotic fluid in the uterus.

    Labor

    Your labor may start on its own, or you may decide to have labor induced or have a planned cesarean section (C-section). During a cesarean birth, an incision is made through the abdomen and uterus, through which the baby is removed. Because of the surgery, your recovery time may be longer than if you delivered your baby vaginally.


    No matter how you deliver your baby, your doctors will be working during labor and delivery to keep your blood glucose level under control. At the start of active labor, your insulin needs will drop. You will most likely not need any insulin during labor and for 24 to 72 hours after delivery. Your blood glucose will be checked frequently (probably every few hours) and your insulin and glucose regimen will be tailored to your needs during that time.

    To help you prepare for labor, many hospitals and other organizations offer classes (such as lamaze) to help you have a smooth delivery. They teach you what to expect during delivery, techniques to improve delivery and to relieve pain during labor, and how to care for your baby after birth. Because of the care needed for both mom and baby during and after delivery, home births are not advised for women with diabetes.


    It’s important to have a partner or coach helping you throughout the labor and delivery process. This can be a spouse, parents, relative, or friend. Having a support system with you before and during the birth can help you be more relaxed during your time at the hospital.

    • Last Reviewed: August 1, 2013
    • Last Edited: November 5, 2013


    - See more at: Delivery: Women and Diabetes
    Clinical Pharmacy Specialist - Hematology

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