How diabetes can affect your pregnancy What you can do to control it What care you will need before, during, and after pregnancy

Most women who have diabetes can have healthy babies.

Causes

Diabetes occurs when there is a problem with the way the body makes or uses insulin. Insulin is a hormone that converts glucose in food into energy. When the body does not make enough insulin, or when the body is not using insulin properly, the level of glucose in the blood becomes too high. This is called hyperglycemia (high sugar levels in the blood).

During pregnancy, the hormones produced by the placenta can limit the actions of insulin. As a result, gestational diabetes may occur.

Gestational diabetes can occur even when no risk factors or symptoms are present. For this reason, pregnant women often are tested for diabetes (see box). Gestational diabetes usually goes away after the baby is born. However, women who have had gestational diabetes are at a greater risk of developing diabetes many years later. You should tell your doctor if you have had gestational diabetes.

The risk of diabetes increases with age. It also is more likely in women who:

• Are overweight
• Are not physically active
• Have high blood pressure
• Have high cholesterol
• Have family history of diabetes
• Have polycystic ovary syndrome
• Have a history of cardiovascular disease
• Are Native American, Asian, Hispanic, African American, or Pacific Islander

The risk of problems during pregnancy is greatest when blood sugar levels are high. Some of these problems may increase the chance of a cesarean birth. This is why you need good blood sugar control during pregnancy. Good control of glucose levels, before and during pregnancy, can lower the risks.

If you have diabetes or if you are at risk of developing gestational diabetes, you should be aware of the problems that may arise:

• Macrosomia (very large baby) occurs when the mother's blood sugar level is high throughout pregnancy. This allows too much sugar to go to the baby. It can cause the baby to grow too large. If the baby is too large, delivery can be difficult. For instance, there may be problems delivering the baby's shoulders because they may be too big for the birth canal.
• Preeclampsia is high blood pressure and protein in the urine during pregnancy. This can pose problems for the mother and the baby. It may require the baby to be delivered early. Severe preeclampsia can lead to seizures or kidney or liver problems.
• Hydramnios occurs when there is too much amniotic fluid in the sac that surrounds the baby. This can cause some women discomfort. It may result in preterm labor (labor before 37 weeks of pregnancy) and preterm delivery.
• Urinary tract infections can occur without symptoms. If the infection is not treated, it may spread from the bladder to the kidneys.
• Respiratory distress syndrome can make it harder for the baby to breathe after birth. The risk of this condition is greater in babies of mothers with diabetes.
• Stillbirth—delivery of a baby that has died before birth—occurs more often in babies of women whose diabetes was not well controlled before and during pregnancy.

Diabetes Control

Testing for Diabetes Women with high risk factors should have blood glucose screening at their first prenatal visit. Others may be tested between 24 and 28 weeks of pregnancy. The test for diabetes is safe and simple. Samples of your blood are taken after you drink a sugar solution. The glucose level then is measured. A high level suggests that there may be a problem with glucose control. If you have a high level of glucose on the screening test result, further testing will be done to find out if you have diabetes.

There are a number of ways that you can measure your glucose level. You may have to go to a lab to have your blood tested, or you may be able to check your blood sugar level yourself using a glucose meter. With a glucose meter, a simple device is used to obtain a small drop of blood, most often from the tip of your finger. The drop of blood is placed on a strip of special paper. The glucose level then is read with the meter. There are several types of glucose meters. All are safe and simple to use on a daily basis. You may need to check your glucose often each day to keep it at a normal level. To be most effective, the results should be kept accurately and reported to your doctor. Your doctor will tell you when and how often to check. Urine tests are not a good way to monitor glucose levels.

Glucose can be controlled with diet and exercise and, in some cases, by taking pills or insulin. You and your doctor will decide together on the best method or mixture of methods for you.

Diet

A balanced diet is key in pregnancy. Your baby depends on the food you eat for its growth and nourishment. This is even more important if you have diabetes. Not eating properly can cause glucose levels to go too high or too low.

The number of calories in your diet will depend on your weight, stage of pregnancy, age, and level of activity. Your doctor may adjust your diet from time to time to improve glucose control or to meet the needs of the growing baby. In most cases, the diet consists of small meals and snacks spread throughout the day and before bedtime.

Exercise

Moderate exercise is always good. For women with diabetes it is even more important. Regular exercise helps keep blood glucose levels low. The amount of exercise that is right for each woman varies. You and your doctor will decide how much and what type of exercise you need.

Medications

Some women with diabetes need to use insulin shots to keep their glucose at normal levels. Insulin shots can be safely used during pregnancy to control diabetes.

The amount of insulin needed to control glucose levels throughout the day varies from woman to woman and depends on many factors. Your doctor will tell you how to use insulin and how many daily shots you will need. The number of shots and amount of insulin you need may change during pregnancy. When insulin is needed to control diabetes during pregnancy, the diet and the insulin dose must be balanced at all times to prevent harmful levels of glucose.

Some women take diabetes pills instead of insulin shots. In some cases, pills alone will not control the diabetes and you may be switched to insulin shots. Talk with your doctor to see which treatment is best for you.

Prenatal Care

You play a key role in controlling your diabetes. Prenatal care helps monitor your condition as well as that of the baby. You may need to see your doctor often for regular checkups and tests.

A woman with diabetes often needs to be monitored closely during pregnancy. She may need to have certain tests done more often. These tests can help the doctor be aware of any problems and take steps to correct them. Your doctor can answer questions and tell you more about these tests:

• Ultrasound uses sound waves to create pictures of the baby. This allows the doctor to check its growth and development.
• Electronic fetal monitoring helps your doctor detect signs of problems the fetus may be having late in pregnancy. Monitors are placed on the woman's abdomen. The heartbeat and activity of the baby, as well as contractions of the woman's uterus, are then measured and recorded.
• A biophysical profile uses electronic fetal monitoring and ultrasound results to assess the well-being of your baby.
• A kick count is a record of how often you feel your baby move. A healthy baby tends to move the same amount each day. You may be asked to keep track of this movement in the latter part of pregnancy and to contact your doctor if the baby is not active. It could mean the need for more tests and sometimes even early delivery of your baby.

Delivery

In most cases, women with diabetes go into labor normally when the time comes and have a normal vaginal delivery. They may require special monitoring of their glucose levels and the baby during labor. If there are problems during pregnancy, labor may need to be induced (brought on) early.

Postpartum Care

Problems in the Newborn

After birth, most babies do well. Some babies may need to spend time in a special care nursery. Problems that may occur include:

• Low glucose levels
• Low blood calcium and magnesium levels
• An excess of red blood cells
• Neonatal jaundice (yellow discoloration of the skin)
• Breathing problems

Contraception

Women with diabetes or those who develop gestational diabetes need to plan future pregnancies with care. Because you can become pregnant soon after childbirth, you should begin using a form of birth control right away. In general, women with diabetes can use most of the available methods. You and your doctor can decide which method is best for you.

Glucose Control

Your blood sugar levels may be monitored after you give birth. If they remain high, you may need to take medication to control your blood sugar.

If you had gestational diabetes but your blood sugar levels are normal after delivery, remember you are more likely to develop diabetes later in life. This is an important part of your medical history. Be sure to tell any other doctors you see that you had gestational diabetes. You also should be tested for diabetes from time to time.

Weight Control

Weight loss during pregnancy is not a good idea—even if you are overweight. You and your doctor should set up a program of diet and exercise for you to follow after delivery. For women with gestational diabetes, diet and exercise may lower the risk of developing diabetes again.

Finally...

Most women with diabetes can have healthy babies. You and your doctor can work together to plan your pregnancy and control your glucose level. These measures will help you have a successful pregnancy and a healthy baby.

Glossary

Amniotic Fluid: Water in the sac surrounding the fetus in the woman's uterus.

Biophysical Profile: An assessment by ultrasound of fetal breathing, fetal body movement, fetal muscle tone, and the amount of amniotic fluid. May include fetal heart rate.

Cardiovascular Disease: Disease of the heart and blood vessels.

Cesarean Birth: Delivery of a baby through an incision made in the mother's abdomen and uterus.

Hormone: A substance produced by the body to control the functions of various organs.

Placenta: Tissue that provides nourishment to and takes away waste from the fetus.

Polycystic Ovary Syndrome: A condition in which increased androgen causes multiple small cysts to persist on the ovaries.

Respiratory Distress Syndrome: A condition of some babies in which the lungs are not completely mature.

Urinary Tract Infections: Infections of the bladder and urethra.

This Patient Education Pamphlet was developed under the direction of the Committee on Patient Education of the American College of Obstetricians and Gynecologists. Designed as an aid to patients, it sets forth current information and opinions on subjects related to women's health. The average readability level of the series, based on the Fry formula, is grade 6–8. The Suitability Assessment of Materials (SAM) instrument rates the pamphlets as "superior." To ensure the information is current and accurate, the pamphlets are reviewed every 18 months. The information in this pamphlet does not dictate an exclusive course of treatment or procedure to be followed and should not be construed as excluding other acceptable methods of practice. Variations taking into account the needs of the individual patient, resources, and limitations unique to the institution or type of practice may be appropriate.

Copyright © August 2005 by the American College of Obstetricians and Gynecologists. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher.

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