Diabetes, Pregnancy And Advancement In Assisted Reproductive Technology
With the advancement in Assisted Reproductive Technology (ART), women with type 1 diabetes who were typically advised against becoming pregnant in the middle of the 20th century can safely plan to have their babies.
Diabetes that is not well controlled causes the baby’s blood sugar to be high. The baby is “over‑ fed” and grows extra-large. Besides causing discomfort to the woman during the last few months of pregnancy, an extra-large baby can lead to problems during delivery for both the mother and the baby.
You should see your doctor if you develop symptoms of high blood sugar, such as increased thirst, needing to urinate more often than usual, and a dry mouth. Do not wait until your next test. You should have the tests even if you feel well, as many people with diabetes do not have any symptoms.
Preconception
Every woman of childbearing age with diabetes should be counseled about the importance of tight glycemic control before conception. Studies show an increased risk of diabetic embryopathy, especially anencephaly, microcephaly, congenital heart disease, and caudal regression, directly proportional to elevations in A1C during the first 10 weeks of pregnancy.
Hemoglobin A1C is a blood test that represents the average blood glucose level over the previous two to three months. This test may be done once per trimester during pregnancy or more frequently as recommended by the health care provider.
There are opportunities to educate all women and adolescents of reproductive age with diabetes about the risks of unplanned pregnancies and the opportunities for improved maternal and fetal outcomes with pregnancy planning. Effective preconception counseling could avert substantial health and associated cost burden in offspring. Family planning should be discussed, and effective contraception should be prescribed and used until a woman is prepared and ready to become pregnant.
To minimise the occurrence of complications, beginning at the onset of puberty or at diagnosis, all women with diabetes of childbearing potential should receive education about first, the risks of malformations associated with unplanned pregnancies and poor metabolic control.
The second is the use of effective contraception at all times when preventing pregnancy. Pre‑ conception counseling using developmentally appropriate educational tools enables adolescent girls to make well-informed decisions. Preconception counseling resources tailored for adolescents should be available at no cost during antenatal care sessions.
Preconception testing
Preconception counseling visits should include rubella, syphilis, hepatitis B virus, and HIV testing, as well as Pap smear, cervical cultures, blood typing, prescription of prenatal vitamins (with at least 400 μg of folic acid), and smoking cessation counseling if indicated.
Diabetes-specific testing should include A1C, thyroid-stimulating hormone, creatinine, and urinary albumin-to-creatinine ratio; review of the medication list for potentially teratogenic drugs, that is, ACE inhibitors, angiotensin receptor blockers, and statins; and referral for a comprehensive eye exam. Angiotensin-converting enzyme (ACE) inhibitors are medications that help relax the veins and arteries to lower blood pressure. ACE inhibitors are used to treat high blood pressure and diabetes, both of which are more common in people with obesity. High blood pressure, diabetes, and obesity increase a woman’s chance of having a miscarriage.
Glycemic targets in pregnancy
Pregnancy in women with normal glucose metabolism is characterised by fasting levels of blood glucose that are lower than in the nonpregnant state due to insulin-independent glucose up‑ take by the fetus and placenta and by postprandial hyperglycemia and carbohydrate intolerance as a result of diabetogenic placental hormones.
Insulin physiology
Early pregnancy is a time of insulin sensitivity, lower glucose levels, and lower insulin requirements in women with type 1 diabetes. The situation rapidly reverses as insulin resistance increases exponentially during the second and early third trimesters and levels off toward the end of the third trimester. In women with normal pancreatic function, insulin production is sufficient to meet the challenge of this physiological insulin resistance and to maintain normal glucose levels. However, in women with GDM and preexisting diabetes, hyperglycemia occurs if treatment is not adjusted appropriately.
Glucose Monitoring
Reflecting this physiology, fasting and postprandial monitoring of blood glucose is recommend‑ ed to achieve metabolic control in pregnant women with diabetes. Preprandial testing is also recommended for women with preexisting diabetes using insulin pumps or basal-bolus therapy so that premeal rapid-acting insulin dosage can be adjusted. Post‑ prandial monitoring is associated with better glycemic control and a lower risk of preeclampsia. There are no adequately powered randomised trials comparing different fasting and post-meal glycemic targets in diabetes in pregnancy.
Dr Taiwo Orebamjo is an experienced Consultant Obstetrician and a medical administration expert from the Kingston Academy of Learning and Career College Canada. He is a post-graduate of the Royal College of Obstetricians and Gynaecologists, London. The Research Fellow in assisted conception at the St. George’s Teaching Hospital in Tooting London, is also the Consultant Obstetrician &Gynaecologist, Medical Director, at Parklande Specialist Hospital & Lifeshore Fertility and IVF Clinic.