Facing a serene gestation for pregnant women with diabetes is possible thanks to adequate preparation and dedicated pathways

An all-round care of the pregnant woman and an appropriate treatment pathway before, during and after pregnancy can help women with type 1 or type 2 diabetes to live the period of pregnancy with awareness and serenity.

Pregnancy and diabetes: the importance of turning to specialised centres

Women with type 1 or type 2 diabetes may be apprehensive about the idea of embarking on a pregnancy, due to possible complications related to diabetes, or, on the contrary, have little awareness of the risks resulting from limited or no preparation for pregnancy and inadequate care for their underlying condition during pregnancy.

It is important to emphasise that, with the support of a specialised centre and adequate preparation, women with diabetes can embark on a pregnancy with serenity.

In Italy, there are ‘Diabetes and Pregnancy’ centres in almost all large hospitals in the major metropolitan areas.

Access to one of these centres is essential:

• before pregnancy to prepare for it in the best possible way
• during gestation and near childbirth in case hospitalisation becomes necessary.

What are the risks of diabetes in pregnancy

The recommendations of the specialists must be followed with the awareness that the woman with diabetes can do a great deal to mitigate the risks that diabetes, if not kept under control, can pose during pregnancy.

Diabetes in fact

• increases the frequency of miscarriages and congenital malformations if glycaemic control is not optimal during the period of conception;
• increases the risk of hypertension and pre-eclampsia, a condition that can cause serious organ damage in the second part of pregnancy and may be associated with placental malfunction;
• it increases the risk of pre-term deliveries and caesarean sections if blood glucose during pregnancy is not well controlled;
• it increases the risk of hypoglycaemia in the newborn if blood glucose control in the last weeks of pregnancy is not optimal.

What is involved in the pregnancy course for women with diabetes

The course of pregnancy in women with diabetes is challenging and involves

• continuous blood glucose monitoring possibly with the use of continuous blood glucose sensors and alarms for hypoglycaemia;
• insulin therapy with a pump or multiple injections continuously adjusted to changes in insulin resistance at different stages of pregnancy to keep blood glucose levels as close to the normal range as possible;
• frequent obstetric outpatient check-ups in specialised centres.

The pre-conception pathway for women with type 1 or type 2 diabetes

The pre-conception pathway for a woman with type 1 or type 2 diabetes, elaborated and carefully monitored by a special multidisciplinary team, is the starting point and aims at optimising blood sugar levels, which, before conception, should be as close as possible to normal, limiting hypoglycaemic episodes as much as possible.

For this, it is also checked that patients have available and know how to use correctly all those aids that help to manage extreme glycaemic events, such as, for example

• glucagon;
• the strips;
• the ketonemia measuring device.

If the woman is not yet using a sensor, consideration should be given to prescribing one by educating her in its use.

Re-evaluation of eating habits and the ability to adjust insulin therapy at mealtimes is also important.

Specialists, at this stage, are also concerned with assessing possible pre-existing complications of diabetes (hypertension, retinopathy or nephropathy) and the drugs taken in addition to insulin (e.g. anti-hypertensives, statins, etc.), verifying that they are also indicated during pregnancy.

The majority of women with type 2 diabetes take oral antidiabetic drugs: with a view to pregnancy, they must necessarily be replaced with insulin therapy before pregnancy begins, to avoid exposing the embryo to drugs whose effects are unknown during pregnancy.

These women must therefore learn to carry out daily blood glucose checks and insulin injections independently.

Mothers-to-be with type 2 diabetes tend to arrive unprepared for conception: this makes their care in a specialised centre and the development of a pre-conception pathway even more important.

Before conception: folic acid supplementation

Folic acid supplementation, in the diet of women of childbearing age, through food and/or by supplementation, i.e. supplementing the diet with supplements, under the advice of one’s gynaecologist, is very important for the prevention of spina bifida and cardiac malformations in the foetus.

It is important to remember that the risk of developing cardiac malformations or spina bifida is three times higher for babies of mothers with pre-pregnancy diabetes: 6-9% compared with 2-3% in physiological pregnancies.

It is therefore very important to take a daily preventive intake of at least 4-5 mg of folic acid, a higher dose than is normally found in pregnancy supplements, in the 2 months prior to conception and for at least the first trimester of pregnancy.

Regular check-ups during pregnancy

During pregnancy, in specialised centres, women are visited every 15 days by a team of specialists, including the diabetologist and gynaecologist.

Routine examinations and periodic check-ups are varied:

• blood and urine tests
• weight and blood pressure checks;
• glycosylated haemoglobin checks: glycaemic control index for the last 2 months;
• thyroid function;
• presence of protein in the urine to detect the onset of possible pre-eclampsia at an early stage;
• ultrasound scans to assess the possible presence of malformations and the progressive growth of the baby;
• fetal heart monitoring, i.e. cardiotocographic monitoring, over the last 2 months, from which the well-being of the fetus can be deduced.

The woman must make daily efforts to

• perform frequent blood glucose checks herself, at least 6-8 times a day;
• use a sensor for continuous interstitial blood glucose monitoring and download the data onto specific platforms so that they can be evaluated remotely if necessary.

Insulin therapy is calibrated, modified and controlled over the 9 months with the support of the diabetologist who, at each visit, assesses measured blood glucose levels, changes in insulin therapy and the frequency of hypoglycaemia.

Childbirth: before and after

Childbirth is generally planned with an induction of labour at 38/39 weeks: in women with diabetes the percentage of caesarean sections is 65-75%.

The newborn, particularly if heavy, may experience hypoglycaemia, which often resolves with early breastfeeding, but sometimes requires intravenous glucose infusion.

After the birth of the baby, it is necessary for the mother to regain a good glycaemic balance and lose the excess weight acquired during pregnancy.

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Source:

GSD