PregnancyDM S3 management

Management of Pregnancy Complicated by Diabetes

Preconception Care

AACE guidelines specify that preconception care is important for all women with preexisting type 1 diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM) or previous gestational diabetes mellitus (GDM). One of the primary goals of preconception care is to educate patients about strategies to maintain adequate nutrition and glu­cose control before conception, during pregnancy, and in the postpartum period.1

Intensive glycemic management of women with diabetes prior to conception and throughout pregnancy has been shown to confer significant health benefits to both mother and child.2 When women with diabetes establish normoglycemia before pregnancy and maintain it through the first trimester, the risk of complications (eg, congenital anomalies and spontaneous abortion) is comparable to levels for women without diabetes.3

Glycemic Targets

Glycemic targets during pregnancy are defined in the 2011 AACE guidelines, shown in the table below. For all glucose management protocols, AACE recommendations stress that patient safety must be the first priority.1,4

Table 1. AACE and ADA Glycemic Target Guidelines for Pregnant Women With GMD, T1DM, or T2DM1,5

Glucose Increment

Patients With GDM

Patients With Preexisting T1DM or T2DM

Preprandial, premeal

≤95 mg/dL (5.3 mmol/L)

Premeal, bedtime, and overnight glucose:
60-99 mg/dL
(3.4-5.5 mmol/L)

Postprandial, post-meal

1-hour post-meal: ≤140 mg/dL (7.8 mmol/L) or
2-hour post-meal: ≤120 mg/dL (6.7 mmol/L)

Peak postprandial glucose 100-129 mg/dL
(5.5-7.1 mmol/L)

A1C

≤6.0%

 ≤6.0%

Table 2. Expert Recommendations for Glycemic Target Guidelines for Pregnant Women With GMD, T1DM, or T2DM*1,5,6

Some experts recommend more stringent goals, in particular, for patients on insulin therapy, to prevent maternal and fetal complications

Glucose Increment

Patients With GDM

Patients With Preexisting T1DM or T2DM

Preprandial, premeal

≤90 mg/dL (5.0 mmol/L)

≤90 mg/dL (5.0 mmol/L)

Postprandial, post-meal

1-hour post-meal:
≤120 mg/dL (6.7 mmol/L)

1-hour post-meal:
≤120 mg/dL (6.7 mmol/L)

A1C

≤5.0%*

 ≤6.0%

* Expert input (L. Jovanovic)

Glucose Monitoring

Self-monitoring of blood glucose (SMBG): SMBG is considered to be the cornerstone of diabetes management in patients with GDM.7

Some experts recommend that pregnant patients perform SMBG measurements 6 to 8 times daily. This includes a fasting measurement in the morning, premeal measurements 3 times daily, 1-hour postprandial measurements following breakfast, lunch, and dinner, as well as 1 final measurement at bedtime.8

During a healthy pregnancy, mean fasting blood glucose levels decline progressively to a remarkably low value of 75 ±12 mg/dL with peak postprandial blood glucose levels rarely greater than 126 mg/dL. The disadvantages of SMBG include the potential for human error or inconsistencies in performing the procedure and/or self-reporting its results. Due to the high frequency of SMBG required during pregnancy, use of alternative-site monitoring is appealing; however, this should be discouraged because changes in blood glucose concentrations after eating become apparent at finger sites before forearm or thigh sites. In addition, the intermittent readings obtained with SMBG produce only a partial glucose profile, with the possibility that hyper- or hypoglycemic episodes may go undetected.9

A1C: A1C testing provides valuable supplementary information to assess glycemic control in pregnant women. Both prior to and throughout pregnancy, A1C measurements should be combined with frequent SMBG to safely achieve target glucose levels.7,8

Evidence from a recent study suggests that frequent (weekly) A1C measurements during pregnancy may be instrumental in improving the accuracy of glucose monitoring in women with GDM. Specifically, when A1C results are combined with SMBG data, the patient has more complete information regarding her level of glucose control, since certain high glucose values may be missed using SMBG alone. As such, weekly A1C testing can be a tool to enable healthcare providers to further optimize treatment decisions.7

However, findings from the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study suggest that A1C is less useful than OGTT as a predictor of adverse pregnancy outcomes in women with diabetes.10

Continuous glucose monitoring (CGM): CGM enables the assessment of a patient’s glucose levels over a 24-hour period, at 5-minute intervals, taking ~288 separate measurements over a single day.11

CGM consists of a sensor tip implanted subcutaneously in the abdominal wall to measure the glucose concentration of the interstitial fluid.9,11 Professional CGM devices are owned by a healthcare professional and are typically implanted for 3 to 5 days. Personal CGM devices are owned by the patient and may be implanted for longer periods (eg, several weeks).12 Data from professional CGM devices are downloaded and analyzed by a healthcare professional, whereas personal CGM devices provide continuous feedback on glucose values, which may be read by the patient in real time.12 CGM can supply close to real-time data that reflect a patient’s glycemic response to changes in diet, physical activity, or treatment regimens.9

CGM may be recommended when patients are unable to achieve target glucose levels with SMBG alone.8 For example, CGM can be useful for identifying glycemic excursions that may go undetected with SMBG, such as episodes of postprandial hyperglycemia or overnight hypoglycemia.11 As such, CGM may be valuable as an educational tool to improve treatment adherence.12

Use of CGM in pregnant women with diabetes has been associated with improved glycemic control during the third trimester of pregnancy, reduced infant birth weight, and a decreased risk of infant macrosomia.8,9,11

Importance of Near-Normal Glycemic Control in Pregnancy Complicated by Diabetes

The risk of adverse health outcomes for both mothers with diabetes and their infants is correlated with maternal glucose levels during the first trimester of pregnancy.4 A large randomized controlled trial has shown improvements in both the rate of serious perinatal complications and maternal health-related quality of life with intensive diabetes management versus standard care in patients with GDM.13

Some of the most important concerns for maternal and fetal/infant health in pregnancy complicated by diabetes are outlined below.

Complications of Diabetes in Pregnancy

Pregnancy is a risk factor for the development and/or progression of chronic complications of diabetes, such as retinopathy, nephropathy, neuropathy, and cardiovascular disease, particularly in patients with uncontrolled glycemia. Patients should be carefully evaluated at each visit to detect any development and/or worsening of these conditions.14

Since improved glycemic control can slow the progression of retinopathy, regular ophthalmologic exams are recommended starting in the first trimester and extending through the first year postpartum in women with diabetes. Individuals with active lesions should be examined more frequently.1,4

Gestational hypertension and preeclampsia are common complications of pregnancy complicated by diabetes.2,15,16

  • During pregnancy, recommended blood pressure targets for patients with chronic hypertension are 110-129 mmHg systolic and 65-79 mmHg diastolic.
  • Hypertension should be managed with a combination of lifestyle changes, behavior therapy, and medications that are safe for use in pregnancy.
  • ACE inhibitors and angiotensin receptor blockers are contraindicated in pregnancy.17

Other diabetes-related maternal complications during pregnancy include hypoglycemia, infection (eg, pyelonephritis), ketoacidosis, polyhydramnios, preterm labor, and seizures.3,17 The 3 main goals of antepartum fetal surveillance are avoidance of fetal death, early detection of fetal compromise, and prevention of unnecessary premature delivery and caesarean delivery.15,16,18 Higher maternal blood glucose levels are associated with increased production of insulin from the fetal pancreas. Overproduction of fetal insulin is associated with adverse outcomes, as mentioned previously.

Risk of Future Maternal T2DM

Uncontrolled glycemia in pregnant women is associated with an increased risk of future T2DM development.18 Between 5% and 10% of women with GDM develop T2DM immediately post-pregnancy.19 Furthermore, women with a history of GDM have a 35% to 60% chance of developing T2DM over the subsequent 10 to 20 years.19

A 2-hour 75-g OGTT is recommended at 6 to 8 weeks postpartum and at 1 year. If within normal limits, measurement of A1C yearly and OGTT every 3 years is recommended.20 Additionally, one-third of women with GDM have dyslipidemia and should have lipid testing assessed at 1 year postpartum and annually after.

Effects on the Fetus/Child

Fetal and neonatal risks in pregnancy complicated by uncontrolled diabetes include birth injuries, childhood obesity, hyperbilirubinemia, hypoglycemia, increased cord-blood serum C-peptide levels, macrosomia, respiratory distress syndrome, and shoulder dystocia.15,16,18

Maternal glucose levels have a direct association with newborn birth weight. An infant with an abnormal birth weight (low or high) has an increased likelihood of developing T2DM and/or GDM later in life.12 Thus, monitoring fetal size using measurements such as abdominal circumference (AC) is important throughout pregnancy.17

Increased maternal A1C levels during the first trimester of pregnancy have been linked to a higher risk of spontaneous abortion and congenital malformations. For example, the risk of spontaneous abortion in diabetic pregnancies has been reported to be between 30% and 60%, twice that of the general population.17 Congenital malformations occur at a rate of 6% to 12% in the offspring of women with diabetes, compared with 2% to 3% in the general population.14

Studies have shown that the risk of congenital malformations is lower when women receive preconception care, including training on diabetes self-management using SMBG, diet, and insulin therapy.4,7

To minimize health risks and optimize outcomes for pregnant women and their babies, the following strategies are key:1,8

  • Early and accurate diabetes diagnosis
  • Prepregnancy education of women with T1DM or T2DM or a history of GDM
  • Meticulous glycemic control prior to and throughout pregnancy
  • Optimized patient compliance through regular (weekly) assessments

Approaches to Managing Pregnancy Complicated by Diabetes

To optimize diabetes management throughout pregnancy, early referral to a clinic that specializes in diabetes care is recommended.8 Diabetes management during pregnancy should involve a collaborative effort between the obstetrician/midwife, endocrinologist, ophthalmologist, registered dietitian, and nurse educator. Ideally, all team members should be engaged in patient education/care prior to and throughout pregnancy.2 Treatment plans must be individualized for each patient and may involve a combination of medical nutrition therapy (MNT), pharmacotherapy, exercise, and weight management strategies.

MNT in GDM

Patients requiring MNT should ideally be referred for nutritional counseling with a registered dietitian who is familiar with the specialized needs of pregnant women.8,21 MNT for patients with GDM is based on standard nutritional recommendations during pregnancy,22 with customization based on an individual’s height, weight, nutritional assessment, and level of glycemic control.17,22,23

The goals of MNT in GDM are to provide a nutritionally adequate diet for pregnancy and to achieve normoglycemia. Normoglycemia in GDM is defined based on the target glucose levels shown in the table below.17

Table 3. Target Glucose Levels in GDM


Target Glucose Levels in GDM4

Preprandial glucose ≤95 mg/dL (5.3 mmol/L)

1-hour postprandial glucose ≤140 mg/dL (7.8 mmol/L)
or
2-hour postprandial glucose ≤120 mg/dL (6.7 mmol/L)

In many cases, GDM patients’ glucose levels can be controlled with dietary restrictions alone. Studies have shown that 80% to 90% of mild GDM cases can be managed with MNT and other lifestyle changes alone.4,9 However, since glucose intolerance typically worsens throughout pregnancy, patients with GDM may ultimately require insulin therapy to maintain normoglycemia.9,23

MNT Recommendations for Patients With GDM

The focus should be on avoiding large meals and foods with a high percentage of simple carbohydrates.

  • Patients should be counseled on healthy low-carbohydrate, high-fiber sources of nutrition, as well as the importance of avoiding sugars, simple carbohydrates, and highly processed foods.8,17
  • According to ADA guidelines, dietary carbohydrate content should be individualized for each patient.17
    • Restriction of carbohydrates to 35% to 40% of total caloric intake has been found to decrease maternal glucose levels and improve outcomes for both mother and child.23
    • Fresh vegetables are the preferred carbohydrate sources for pregnant women with diabetes.8
    • Patients should be trained to perform carbohydrate counting and should adjust their carbohydrate intake throughout the day based on fasting, premeal, and postprandial SMBG measurements.2,8
  • Consumption of dairy products should be limited; juices and most fruits should be avoided altogether.8,17
  • Consumption of frequent small meals is the best strategy to reduce the risk of postprandial hyperglycemia and preprandial starvation ketosis.17
    • At breakfast, the goal should be to consume no more than 10% of the total daily carbohydrate intake, corresponding to 10-20 grams of carbohydrate.2,17

MNT in Pregnant Women With Established Diabetes

Guidelines for MNT in pregnant women with preexisting diabetes are comparable to the recommendations summarized above for patients with GDM.21,24

Pharmacologic Therapy

For pregnant women with GDM or T2DM who are not able to maintain normoglycemia with MNT alone, the treatment plan should be revised to include pharmacotherapy. The American Diabetes Association (ADA) recommends insulin for glycemic control in women with type 1 or type 2 diabetes and for women with GDM who are unable to maintain normoglycemia with medical nutritional therapy alone because the safety of oral hypoglycemic agents is less clear during early pregnancy.1 Insulin therapy is required for the treatment of T1DM during pregnancy.8 Due to concerns about the efficacy and safety of oral antihyperglycemic agents during pregnancy, the ADA does not recommend the use of these agents as first-line treatment of GDM or preexisting T2DM, although they may be appropriate for some patients.21,23

The two most commonly prescribed oral antihyperglycemics during pregnancy are metformin and glyburide.1,8 Their administration to pregnant women had previously been restricted due to concerns of teratogenic effects in early pregnancy and lack of strict glycemic control. Metformin and glyburide may also be insufficient to maintain normoglycemia at all times, particularly during postprandial periods.8 However, several studies have found no harmful effects from glyburide in either early or late pregnancyand have reported effective glycemic control with favorable neonatal outcomes including reduced rates of macropsomia, neonatal intensive care unit admissions, and neonatal hypoglycemia. Glyburide exhibits minimal transfer across the placenta; some formulations of this drug have been classified as category B for pregnancy, while others have been classified as category C.1,17,25,26 Insulin is preferred over glyburide in women diagnosed with GDM prior to 20 weeks gestation and/or fasting blood glucose >110. Glyburide may be a suitable alternative to insulin therapy for women whose blood glucose remains uncontrolled despite a 2-week trial of medical nutrition therapy and exercise. Women should be made aware that the US Food and Drug Administration (FDA) has not approved glyburide for use during pregnancy.

Metformin crosses the placenta and is classified as a category B drug for pregnancy.1 Metformin is not recommended as first-line treatment for GDM and should be used only when a woman refuses or is unable to use insulin or glyburide to achieve glycemic control.

Insulin Use During Pregnancy

ADA guidelines indicate that insulin is the preferred pharmacologic option for the treatment of GDM when MNT has failed.23 The ADA recommends initiating insulin therapy when MNT alone is insufficient to maintain the following glucose levels:23

Table 4. ADA Recommendations for Initiating Insulin Therapy in GDM When MNT Fails

Glucose Levels for Initiation of Insulin in GDM When MNT Fails23

Fasting plasma glucose ≥105 mg/dL (5.8 mmol/L)

1-hour postprandial plasma glucose ≥155 mg/dL (8.6 mmol/L)

2-hour postprandial plasma glucose ≥130 mg/dL (7.2 mmol/L)

Other authors recommend insulin initiation if dietary management fails to maintain normoglycemia (fasting <90 mg/dL and/or 1-hour postprandial glucose concentrations <120 mg/dL) within 1 week of the recommended carbohydrate restriction. When insulin therapy is started, patients will require proper training and education regarding insulin administration (eg, timing, injection techniques), recommended dietary modifications in response to SMBG measurements, and hypoglycemia awareness and management.17

Basal insulin needs during pregnancy can be achieved with intermediate- or long-acting insulin administered by injection or with rapid-acting insulin administered by insulin pump.1,8 Rapid-acting insulin analogues are recommended for the treatment of postprandial hyperglycemia during pregnancy.1 Regular insulin must be administered 60 to 90 minutes prior to meals and is considered less effective and may increase the risk of hypoglycemia.8 The prescribed insulin regimen, including dosage level and timing of administration, should be determined based on SMBG results.23

Insulin Options During Pregnancy

  • Insulin neutral protamine Hagedorn (NPH) and insulin detemir are safe intermediate- and long-acting alternatives, respectively, for use during pregnancy; both are category B drugs.1,8
  • The rapid-acting insulin analogues lispro and aspart are 2 available options for pregnant women with diabetes. Both are classified as category B drugs for pregnancy.1,8
  • Although insulin glargine is frequently prescribed in patients who are pregnant, the safety of glargine in this population has not been definitively established and it remains a category C medication.1,8

The insulin formulations that have been shown to be safe for use during pregnancy are summarized in the table below.8 Following a positive pregnancy test, patients who are receiving other types of insulin before pregnancy for the treatment of T1DM or T2DM should be transitioned to one of these options.21

The only randomized, controlled trial comparing the efficacy and safety of insulin detemir versus NPH in pregnant women with T1DM was recently published and found a lower fasting plasma glucose level with detemir use and a noninferior A1C at 36 gestational weeks compared with NPH insulin, with similar rates of hypoglycemia. Detemir provides 12-hour coverage for the basal insulin requirements and allows women to forgo the midnight dose of NPH, which previously required staying awake until midnight. Skipping the bedtime dose can cause a rise in the fasting blood glucose, which requires additional insulin injections to make up the difference and may result in hypoglycemia.

Table 5. Insulin Options Shown to Be Safe During Pregnancy Complicated by Diabetes8,21

Name

Type

Onset

Peak Effect

Duration

Recommended Dosing Interval

Insulin aspart

Rapid-acting (bolus)

15 minutes

60 minutes

2 hours

Start of each meal

Insulin lispro

Rapid-acting (bolus)

15 minutes

60 minutes

2 hours

Start of each meal

Regular insulin

Intermediate-acting

60 minutes

2-4 hours

6 hours

60-90 minutes prior to meal

Insulin NPH

Intermediate-acting (basal)

2 hours

4-6 hours

8 hours

Every 8 hours

Insulin detemir

Long-acting (basal)

2 hours

-

12 hours

Every 12 hours

Insulin Dosing During Pregnancy

Initial insulin dosage may be calculated based on gestational age. Insulin dosing guidelines during pregnancy are shown in the table below and are valid for women with GDM or preexisting diabetes.3,8

Table 6. Initial Insulin-Dosing Guidelines During Pregnancy and the Postpartum Period8

Weeks Gestation

Total Daily Dose (TDD) of Insulin†

1-13 weeks

(0.7 x weight in kg) or
(0.30 x weight in lbs)

14-26 weeks

(0.8 x weight in kg) or
(0.35 x weight in lbs)

27-37 weeks

(0.9 x weight in kg) or
(0.40 x weight in lbs)

38 weeks to delivery

(1.0 x weight in kg) or
(0.45 x weight in lbs)

Postpartum (and lactation)

(0.55 x weight in kg) or
(0.25 x weight in lbs)

† The total daily dose (TDD) of insulin should be split, so that 50% is used for basal insulin and 50% is used for premeal, rapid-acting insulin boluses.
‡ Nighttime basal insulin should be decreased by 50% in lactating women to prevent severe hypoglycemia.

Between 10 and 14 weeks gestation, patients with T1DM undergo a period of increased insulin sensitivity. Insulin dosing may need to be reduced accordingly during this time frame. After 14 weeks, insulin requirements typically increase steadily through 35 weeks gestation, after which they may level off or even decline.21 Obese patients may require higher insulin dosages than non-obese individuals.21

Use of Insulin Pump Therapy to Achieve Glucose Targets

Administration of rapid-acting insulin via insulin pump therapy, also known as continuous subcutaneous insulin infusion (CSII), is a safe and reliable method for satisfying basal insulin needs in pregnant patients with GDM, T2DM, or T1DM.1,3 Insulin aspart and lispro are considered the standard of care for insulin pump therapy.8 Most pregnant women require at least 4 different infusion rates in a 24-hour period, particularly the early morning hours to counteract the increased release of the anti-insulin hormones cortisol and growth hormone. For patients with T1DM, CSII may need to be combined with CGM for optimal glycemic control.1

A systematic review and meta-analysis of randomized clinical trials found no significant difference in glycemic control or pregnancy outcomes with CSII versus multiple-dose insulin (MDI) therapy used for the treatment of diabetes during pregnancy.11,27

With CSII, patients can take advantage of multiple adjustable basal rates, which can be helpful in addressing problems such as daytime or nocturnal hypoglycemia or a prominent dawn phenomenon.21 Disadvantages of CSII include its complexity and cost, as well as the potential for insulin pump failure, user error, or infusion site problems.8,21

Patients require counseling and training on insulin pump therapy initiation and maintenance. Those who are eligible for insulin pump use should either utilize CGM or be capable of performing frequent SMBG.1 Due to the increased risk of ketoacidosis during pregnancy, CSII patients should be trained to recognize and treat unexplained hyperglycemia due to insulin under-delivery.21

Physical Activity

Regular moderate-intensity physical activity (eg, walking) can help to reduce glucose levels in patients with GDM and should be included in a pregnant woman’s daily regimen, unless contraindicated for any reason.8,23 Other appropriate forms of exercise during pregnancy include cardiovascular training with weight bearing, limited to the upper body (to avoid mechanical stress on the abdominal region).17

Safety Issues

Hypoglycemia

Risk factors: Risk factors for hypoglycemic episodes in pregnant women with diabetes include:

  • A history of severe hypoglycemia before pregnancy
  • Impaired hypoglycemia awareness
  • Longer duration of diabetes
  • A1C ≤6.5% at first pregnancy visit
  • High daily insulin dosage2 

Pathophysiology: The increased risk of hypoglycemia during pregnancy in patients with diabetes may be related to fetal absorption of glucose from the maternal bloodstream via the placenta, particularly during periods of maternal fasting.2 Iatrogenic hypoglycemia may occur with the administration of too much insulin or other antihyperglycemic medication or if the patient skips a meal or exercises more than usual.17,28

Clinical consequences: The clinical signs of hypoglycemia include:

  • Anxiety
  • Confusion
  • Dizziness
  • Headache
  • Hunger
  • Nausea
  • Palpitations
  • Sweating
  • Tremors
  • Warmth
  • Weakness20

Severe hypoglycemia can lead to maternal seizures or hypoxia, both of which represent a risk of inadequate oxygen delivery to the fetus. Other risks associated with maternal hypoglycemia include coma, traffic accidents, and death.2,11

Management of hypoglycemia: Patients should be informed about the increased risk of severe hypoglycemia, particularly during the first trimester.21 Pregnant patients with diabetes should be educated to recognize and treat hypoglycemia and to institute preventive measures such as frequent SMBG, regular timing of meals and snacks, accurate medication administration, and careful management of exercise programs.21

If hypoglycemia is suspected or confirmed via SMBG (blood glucose <60 mg/dL), the preferred treatment is 15 g to 20 g of glucose.17,21 Alternative treatments include other sources of fast-acting carbohydrates (eg, 8 oz nonfat milk, 4 oz juice).17 For severe hypoglycemia in patients who are unable to swallow, 1 mg glucagon should be injected subcutaneously and emergency assistance should be requested.21

Treatment should be repeated if hypoglycemia is not resolved at a 15-minute recheck of SMBG values. When normal SMBG values are confirmed, to prevent recurrence, the patient should consume a snack or meal.21

In patients with hypoglycemia unawareness, glycemic targets should be increased until the problem has been addressed.21

Weight Gain During Pregnancy

During pregnancy, objectives for total gestational weight gain are determined based on each patient’s prepregnancy BMI.8

Higher maternal BMI has been associated with an increased risk of pregnancy-related complications such as caesarean delivery, infant birth weight >90th percentile, and cord blood serum C-peptide >90th percentile; this association was shown to be independent of maternal glucose levels.15,29 For women who are categorized as obese, there is an increasing body of evidence to support a goal of minimal weight gain during pregnancy.8

During pregnancy, patients should be advised on how to achieve weight objectives by maintaining a balanced diet and exercising regularly, unless restricted from doing so by their healthcare team.8

Labor and Delivery

Women should be counseled about how to maintain normoglycemia during labor and delivery.8 Hyperglycemia during the 4 to 6 hours prior to delivery is associated with an increased risk of transient neonatal hypoglycemia.8 Labor and delivery in women with insulin-dependent T1DM should be managed by an endocrinologist or a diabetes specialist.8

Most women with GDM who are receiving insulin therapy will not require insulin once labor begins. Blood glucose levels should be monitored closely during labor to determine patients’ insulin requirements.8,17

For more information on labor and delivery in pregnancy complicated by diabetes, see Labor and Delivery at the AACE Inpatient Resource Center.

Postpartum and Lactation

Since metformin and glyburide are secreted into breast milk, these medications should not be used by women who are breastfeeding.8

Breastfeeding may lead to severe hypoglycemia in women who are receiving insulin therapy; this risk is greatest in those with T1DM. Preventive measures include a reduction in basal insulin dosage and/or carbohydrate intake prior to breastfeeding.8

Because bovine-based infant formulas have been linked to an increased risk of T1DM in the offspring of women with a genetic predisposition for this disease, some experts advise that soy-based products should be substituted, if necessary.8

Psychological Issues

Research has revealed that women with preexisting diabetes tend to postpone the initiation of medical care until after conception.30 Risk factors associated with a decreased likelihood of preconception care include less education, lower income, unmarried status, and unemployment.30

The findings from one study revealed that, among patients with diabetes, an unplanned pregnancy was more likely when women felt that their physicians had discouraged pregnancy.30 To minimize the risk of unplanned pregnancy, contraceptive counseling should be offered to all patients who have diabetes and are of childbearing potential.17

The demands of diabetes management can have a significant effect on a pregnancy. Some patients experience considerable stress and anxiety as a result of concerns about diabetes-related pregnancy complications and the risks to their own health as well as their child’s health.30

Research has shown that the mood profile of women with GDM is significantly associated with their degree of glycemic control.30 Stress can lead to worsening of glucose dysregulation and further deterioration of glycemic control.30

Healthcare teams are instrumental in providing the counseling and support necessary to help manage patients’ stress and anxiety before and during pregnancy.30 For example, to help women develop coping skills, it is important to identify and address barriers to effective diabetes management, such as fear of hypoglycemia, low diabetes self-efficacy, and an inadequate social support network. Individualized strategies for psychosocial intervention are likely to help improve both pregnancy outcomes and patient quality of life. Specialists in the psychological aspects of diabetes care should be included as part of the multidisciplinary healthcare team.

References

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