Pregnancy and Diabetes
At first, it would be better to understand the diabetes which is a glucose metabolism disorder.
In the course of the normal metabolic rate, the blood sugar in the blood is kept constant at 100 ml per 100 ml. When we eat, our blood sugar rises, and the hormone insulin is secreted from the pancreas and it inserts the blood sugar into the cell, allowing the cells to use the blood sugar and normalizing the blood sugar. When we are hungry, glucagon hormone is secreted and glucose is released from the liver from our glycogen stores and is given to the blood, and our blood sugar reaches a normal level.
Abnormal metabolism can proceed in three different ways:
In type 1 diabetes, enough insulin hormones cannot be secreted from the pancreas for various reasons, and since the metabolic rate cannot reach normal, hunger and satiety values remain high.
In type 2 diabetes, insulin hormone cannot bring blood sugar into the cells and the metabolic rate is impaired by this deficiency.
In secondary diabetes, the metabolic rate is impaired due to another disease, medication, or condition. These include diseases such as Cushing’s syndrome, acromegaly endocrine, and health problems such as autoimmune diseases that require the use of external cortisone, which often returns to normal after treatment or discontinuation of cortisone.
When we consider all these conditions, pregnancy is a new challenge for every condition, because the metabolic rate will change again and our approach to the new metabolic state will also be rearranged.
Diabetes in Pregnancy
This arrangement and preparation should ideally start before pregnancy and the woman should be prepared for pregnancy. When diabetes is high in diabetes for many years, the veins are damaged, and basic organ damage such as eyes, kidneys and heart may occur.
In addition, we are talking about increased abnormal rates for the baby in a woman who becomes pregnant with high blood sugar. In fact, there is an increased risk for both mother’s and baby’s life. In infants of uncontrolled diabetic mothers who became pregnant with high sugar rates, heart anomalies, central nervous system anomalies (neural tube defects), skeletal system anomalies and digestive system, urinary tract and genital system abnormality rates have also seen as increased.
In diabetic pregnancies, the fetus is more prone to danger with the course of pregnancy and birth drops, which we call fetal distress during labour. Preeclampsia (pregnancy toxaemia) is seen in diabetic pregnant women and the rate of development retardation increases in the womb. In addition, large babies and polyhydramnios (excessively increased amniotic fluid) can also be seen.
In these pregnancies, while the rate of loss in the womb remains high, birth trauma rates also increase. As non-progressive labour can take place, the frequency of shoulder stuck has increased significantly. With the deterioration of fetal well-being, the risk of emergency cesarean can always be high.
After birth, the babies of diabetic mothers may require lung ripening and, accordingly, respiratory help. While trying to reach the new metabolic balance of the baby after birth, hypoglycaemia (low blood sugar), hypocalcaemia (low blood calcium level) and hyperbilirubinemia (jaundice) may occur most frequently.
Taking all this into account, the expectant mother should cooperate with her physician to correct the metabolic rate months before pregnancy, and be conscious about oral anti-diabetic or, if necessary, insulin, as well as exercise and diet applications. It should be remembered that folic acid intake in methyl form should be started before pregnancy in order to reduce the frequency of central nervous system anomalies.
Looking for Hba1c or fructosamine in the blood indicates that the blood sugar is higher than months and if pregnancy is detected after this period, this can never be a reason for termination of pregnancy. However, due to the increased anomaly and risk of loss, the tests that we will talk about in a short time should be followed carefully.
In diabetic pregnancies, Hba1c or fructosamine, which we mentioned before, is definitely added to the first general control tests performed in each pregnant woman. During the follow-up, diet and exercise are applied meticulously and if necessary, insulin doses can be adjusted very well and insulin can be used. In addition, 11-14 weeks screening test, 16-18 weeks of AFP and quad screening by age, and 18-21 weeks of detailed ultrasonography and fetal echocardiography are performed. Thus, neural tube defects and heart anomalies, which are increased risk in the diabetic pregnants as well as the natural Down syndrome risks determined by age, should be searched meticulously and it should be remembered that heart abnormalities do not have a 100% diagnosis in the womb. During follow-up, preeclampsia criteria should be sought and growth retardation, large baby or polyhydramnios development should be monitored. NST (non-stress test) and biophysical profile are examined every week in pregnancy after 36 weeks at the latest. If preeclampsia has developed, weekly follow-up begins at 28 weeks. Depending on the condition of pregnancy, follow-up can go up to 2 or 3 times a week. It would be beneficial to monitor the diabetic patients using diabetes after 36 weeks in the hospital.
Delivery method is decided at the end of pregnancy. If vaginal delivery is planned, fetal monitoring should be performed during the action, and emergency cesarean conditions should be prepared and a hospital with a baby intensive care center should be preferred.
I think the most important subject that we should emphasize here is that the diabetic woman is likely to have a natural pregnancy before and during pregnancy with a good quality and active endocrinology cooperation. It should not be forgotten that the risk factors can be explained and such mixed medical information and complication rates can be idealized to a significant extent. I believe that our fears and concerns will be reduced by a team spirit that patients and physicians will act together to ensure the pleasure of pregnancy, and to support the woman until the end, and to bring the family into this trend will ensure the common peace of all of us.
Gestational diabetes should be evaluated in a completely different context.
Risk Factors in Gestational Diabetes
family history of diabetes
giving birth to a big baby
advanced maternal age
2nd Trimester and later losses with unknown cause
may have some risk factors such as large baby or polyhydramnos (increased amniotic fluid increase) during current pregnancy or may not be any risk factor
Mechanism of Development of Gestational Diabetes
During pregnancy, the human placental lactogen (HPL) hormone is normally secreted from the placenta and this hormone creates a natural and mild hyperglycaemia by reducing the blood sugar regulating effect of insulin to ensure that the baby reaches enough glucose. When this process is exaggerated, it comes out of the natural course and pregnancy-related diabetes (gestational diabetes) develops. This process usually occurs after the 24th week in the 2nd trimester.
Diagnosis of Gestational Diabetes
In the group of women with risk factors for diagnosis, it is more appropriate to load 100 g glucose as the first test. In the group without risk factor, glucose load is applied on fasting blood glucose 105 and satiety blood glucose above 140 and 10 gr glucose loading in 50 g glucose load. If two values are above normal limits at 100 g loading, gestational diabetes is accepted. If only one value is high, even if the name is not gestational diabetes, necessary precautions should be taken considering the high risk. In this group of women or women considered to be at high risk, 100 gr screening test can be repeated around 32 weeks.
In gestational diabetes, as the pre-pregnancy blood sugar is normal, fetal anomaly rates are equivalent to the rates in normal pregnancy and follow anomaly like normal pregnancies.
Follow-up in Gestational Diabetes
The first thing to do in follow-up is to arrange the diet individually and exercise (the best is walking). In gestational diabetes, blood sugar monitoring is done regularly. Because as the weeks increase and the fetus grows, the metabolic rate will change and it may be necessary to adjust the diet or exercise, and even rest and stress management. Our suggestion is that working women should always start the prenatal leave process in 32 weeks and check their fatigue and stress. In gestational diabetes, NST and biophysical profile follow-up is started at the latest in 36 weeks and can be increased as the gestational week increases according to the condition of pregnancy.
Contrary to the pre-existing diabetes, sugar coma is much less common in the gestational diabetes, but the preeclampsia rates are observed at the same rate. Other risks, from the risk of loss in the womb we mentioned earlier during the pregnancy or delivery, are common risks. These risks can be minimized by the ideal follow-up.
Birth decision should be determined according to the condition of pregnancy at the end of pregnancy. This decision should be made by evaluating the common situation of the mother and baby. If insulin is started to regulate the blood sugar of the woman and normal delivery is planned, it should be followed up at the hospital after 38 weeks.