Diabetes mellitus and pregnancy: clinical outcomes and management

Diabetes Mellitus & Pregnancy

The increasing incidence of diabetes mellitus is described by some as epidemic in proportion. The concern regarding the disease is often linked to the increased incidence of refined foods, and especially sugars, as well as increased reports of sedentary living, that are both associated with the modern world. Increases in such behavioral concerns, as the above compounded by the fact that there is a positive link between overweight and obesity (also caused by poor nutrition and sedentary lifestyle) increases the incidence of one of the several types of diabetes mellitus. With these demographic and epidemiological changes in society there is an increased risk of diabetes occurring, simultaneously with pregnancy, a risk factor that is multi-causal and can put mother and child at increased risk for severe and even fatal complications.

Introduction:

The increasing incidence of diabetes mellitus is described by some as epidemic in proportion. The concern regarding the disease is often linked to the increased incidence of refined foods, and especially sugars, as well as increased reports of sedentary living, that are both associated with the modern world. Increases in such behavioral concerns, as the above compounded by the fact that there is a positive link between overweight and obesity (also caused by poor nutrition and sedentary lifestyle) increases the incidence of one of the several types of diabetes mellitus. One of the gravest concerns, with regard to diabetes is the number of people living with the disease who are unaware that they have it and as the age of onset continues to decline these people are much more likely to be within child bearing ages. (Lewis, 2001, p. 26) ("Childhood Obesity and Early Onset of Adult Diseases," 2005, p. 4)

Women with diabetes are at a much greater risk of complications in pregnancy and the fact that many may not be aware of the condition these concerns may become seriously compromising to the individual and the unborn child. (Mansfield, 1986, p. 95)

This work will cover the pathophysiology of diabetes mellitus, in its various forms, the increased incidence of diabetes mellitus in the younger population, i.e. women of childbearing age. The topic was chosen as a result of the fact that diabetes mellitus occurring simultaneously with pregnancy is a serious concern in my community. This is in part due to diversity in the community, as some genetic groups are at higher risk for diabetes mellitus, this includes Latinos, Asians, African-Americans and Pacific Islanders, though the genetic predisposition is a narrowing concern as the proportions of the disease are more likely to follow the predisposition for overweight and obesity, a situation that leaves no genetic group unburdened in this culture of high fat, high sugar and low levels of physical activity. (Clark, 2004, p. 4)

Pathophysiology:

Diabetes mellitus can come in one of several forms, all requiring slightly different forms of treatment and causal factors but all resulting in increased overall glucose levels in the blood and much more frequent highs and lows, than are found within the healthy population.

Diabetes mellitus is a chronic disease in which the pancreas produces too little or no insulin, impairing the body's ability to turn sugar into usable energy....The number of people diagnosed with diabetes has increased more than six-fold from 1.6 million in 1958 to 10 million in 1997, according to the... (CDC)... Today, some 16 million people have the disease -- making it a leading cause of death in the United States -- yet 5 million don't know they have it. And nearly 800,000 new cases of diabetes are diagnosed each year. There is no cure for the disease, and the resulting health complications from poorly controlled diabetes are what make it so frightening. Consistently high blood sugar levels can, over time, lead to blindness, kidney failure, heart disease, limb amputations, and nerve damage. In fact, diabetes is the leading cause of new cases of blindness in adults between the ages of 20 and 74, and it accounts for 40% of people who have kidney failure. Cardiovascular disease is 2 to 4 times more common among people with diabetes, and is the leading cause of diabetes-related deaths. The risk of stroke is also 2 to 4 times higher in people with diabetes, and 60% to 65% have high blood pressure. (Lewis, 2001, p. 26)

These general complications, associated with diabetes are significant areas of concern for pregnancy, as all or even one of them can adversely effect the body, when compounded by changes of diabetes and put the unborn child at significant risk for complications. Diabetes Mellitus, can come in several forms, type 2 diabetes, type 1 diabetes and gestational diabetes. All three forms, though they may have different causes can create equally troubling complications when complicated by pregnancy. In general type 1 diabetes mellitus is associated with a complete lack of insulin production, while type 2 occurs when less insulin is produced by the pancreas and/or the insulin which is produced is resisted by receptor cells. The result is frequent uncontrolled high glucose levels in the blood, causing a myriad of complications and concerns, not the least of which is death. (Leung, Kamla, Lee & Mak, 2007, p. 38)

The disease requires foundational levels of monitoring and control, through activity and nutrition. Gestational diabetes is a relatively common occurrence in pregnancy, with 3-5% of pregnant women experiencing it.

A elevated blood sugar due to certain hormones that occurs only during pregnancy. It is important to diagnose and treat gestational diabetes properly because it increases the risk of a baby growing larger than he or she would have been, and a large baby may have difficulty during delivery, or may be born by cesarean section. Keeping blood sugar within a normal range during the pregnancy reduces these risks. Women who experience gestational diabetes have a greater risk of developing diabetes later in life. One large study found that more than half of women who had gestational diabetes eventually developed type 2 diabetes. (Lewis, 2002, p. 26)

The traditional take on gestational diabetes, as well as other forms of diabetes occurring simultaneously with pregnancy, has been to secure as constant a level of blood sugar as possible and detect it as early in the pregnancy as possible to decrease risks to the mother and child. Furthermore with cases of, especially type 2 diabetes increasing in frequency and at younger ages, gestational diabetes could be the first real sign that a woman will or have developed type 2 diabetes and the disease will not subside, once pregnancy is over. The period during pregnancy, tends to be a period of higher levels of medical care than an individual woman may experience at any other time in her life, barring other chronic diseases that require monitoring. It is for this reason and others that type 2 diabetes may be detected during pregnancy more frequently than at other times. Though this would seem to be a good thing the concerns with decreased health insurance availability, can cause non-compliance with prenatal care, again increasing the risk that diabetes may not be detected until late in pregnancy, when the child begins to exhibit symptoms of uncontrolled maternal blood sugar levels. Though the treatment technology for diabetes has increased substantially over the last fifty years, creating a situation where diabetes mellitus is almost completely treatable, barring non-compliance.

A woman who has diabetes today has virtually as good a chance to give birth to a healthy baby as any other woman. Pregnancy is one time, however, when tight blood sugar control (preferably with the aid of home blood glucose monitoring) is essential. Despite the reassuring prospect of a normal outcome, pregnancy and childbirth raise large emotional issues when diabetes is already present in the family. These include long-range worries about heredity and childrearing as well as immediate concerns about the pregnancy itself. (Edelwich & Brodsky, 1998, p. 197)

The reality is that without the woman knowing that she has diabetes the challenges are greater, and this is compounded by the concerns associated with decreased compliance with prenatal care. Additionally, those who are aware of their preexisting diabetes mellitus, no matter the form may have to relearn how their body deals with sugar and insulin and therefore change the manner in which they treat themselves, while pregnant. The condition may also be exacerbated by the condition of pregnancy as hormonal changes, can not only cause gestational diabetes they may increase the diabetic symptomology.

Blood sugar regulation, which must be maintained more vigilantly than at other times, is thrown off by the physiological changes of pregnancy. In effect, it must be learned anew. Women with type 2 diabetes who take oral medications are sometimes advised to switch to insulin during pregnancy (itself a considerable emotional adjustment to add to the normal dislocations of pregnancy) to achieve tighter control and to avoid risks to the baby. When necessary, multiple daily injections are used to control hyperglycemia. (Edelwich & Brodsky, 1998, p. 198)

Clinical Symptoms:

woman may have many or limited symptomology of diabetes, depending on the fluctuation of blood sugar, as well as other factors. Frequent symptoms of either hypo or hyperglycemia may occur, but if symptoms are unknown to the woman may be associated with normal pregnancy announces and not followed up on. "The severity of the symptoms and the rate at which they develop may differ, depending on the type of diabetes." (Clark, 2004, p. 3) Increased urine production, glucose in the blood and urine, ketones (undigested protein) in the blood or urine, increased number of infections and decreased or limited healing of such infections, weight loss, or weight gain and occasionally (in extreme cases) numbness and/or tingling in extremities and vision disturbances are all symptoms of diabetes but as one can see from the list if such changes occur during pregnancy they could be attributed to normal pregnancy related changes, unless they become severe.

Particular attention should be paid to hypoglycemia and ketosis. Blood sugar control is essential, even in the first weeks after conception. Indeed, careful monitoring should begin as soon as pregnancy is planned, even before pregnancy is confirmed. (Edelwich & Brodsky, 1998, p. 198)

The value of early treatment is of course recognized but without clear teaching and observations the pregnant women is at increased risk for many symptoms as well as long-term complications of the disease.

Lab Findings:

Increased glucose in the blood and/or urine as well as the presence of ketones, or unprocessed protein can be the early sign of the disease's development during pregnancy and if these findings are persistent a fasting blood glucose test should be taken. If such a test shows increased blood glucose upon fasting diabetes should be assumed and treated. (Feinbloom, 2000, p. 15)

Implications for pregnancy:

If the complications created by hyperglycemia are significant and persistent during pregnancy the individual woman is at risk for accelerated progression of the secondary complications of diabetes, including high blood pressure, heart disease, vision decrease or blindness and increased weight gain. Preeclampsia, and severely increased level of blood pressure during pregnancy is also much more likely in women with diabetes during pregnancy, and this in and of itself creates extreme duress on the mother and possibly the infant and complications that must be treated, often with bed rest and pharmacological treatment, specific to pregnancy.

Diabetic mothers are more prone to toxemia and infection during pregnancy (Hotchner, 1979); one-fourth to one-half of all diabetic mothers can expect to experience preeclampsia, eclampsia, or hypertensive disease during pregnancy (Moore, 1983; Ziegel & Cranley, 1984). Eclampsia is a leading cause of maternal death. In the early decades of this century in the United States, death from eclampsia accounted for one-quarter of all maternal deaths (Slemons, 1941). Thus, the diabetic mother is also at risk during pregnancy. (Mansfield, 1986, p. 95)