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What care should a diabetic take when pregnant?

Q: I am 29 years old having type 1 diabetes since the last 12 years. My wife aged 29 years is also type 1 diabetic since the age of 11. Recently, her blood sugar level became very high but her urine test was normal with no infection. We tested for pregnancy and it was positive. I am very worried about her glucose level, it is shooting more than 300 mg/dl. Is it dangerous for the baby and the mother? What is the possibility of diabetes for baby? Is there chances for abnormality in the baby due to high blood sugar level? What tests should we do to ensure/evaluate the health condition of both the baby and the mother?

A:If the father has it, the risk is about 1 in 10 (10 percent) that his child will develop type 1 diabetes and if the mother (as she is 29) has type 1 diabetes, the risk is much lower so I would estimate to be little more than 10%. Pregnant women with diabetes who have high blood glucose levels before or during pregnancy are more likely to have complications, including miscarriage, stillbirth, a large baby that requires cesarean delivery, or worsening of existing kidney function or retinopathy. Most women with good control of diabetes can expect an excellent pregnancy outcome as a result of improvements in blood glucose control; this requires frequent daily glucose testing and insulin adjustment. Most commonly 4 injections should be used to god control. Birth defects are more common in women with elevated blood glucose levels before and during the early weeks of pregnancy. There is no particular birth defect caused by maternal diabetes, though most occur by the seventh week of pregnancy. In older studies, the frequency of birth defects was approximately 8 to 13 percent among diabetic women, compared to 2 to 4 percent in the non-diabetic population. However, more recent studies have demonstrated that tight blood glucose control prior to becoming pregnant greatly reduces the risk of birth defects to a level similar to women who do not have diabetes. First or second trimester screening for birth defects such as spina bifida and Down syndrome is recommended (to all women, not just those with diabetes). Women with diabetes are not at increased risk for having a baby with a chromosomal abnormality, such as Down’s syndrome, but they are at increased risk of having a baby with a neural tube defect (e.g. spina bifida). These tests are used for screening (as opposed to diagnosis), and cannot determine with certainty if a baby has these problems. If the test is abnormal, an ultrasound examination and/or amniocentesis may be performed to determine if the abnormality is actually present. The infant of the diabetic mother is at risk for several problems in the newborn period, such as low blood glucose levels (less than 30 mg/dL [1.7 mmol/L]), jaundice, too many red blood cells (polycythaemia), low calcium level, and heart problems. These problems are more common when the mother’s blood glucose levels have been elevated during the pregnancy. Most of these problems resolve within a few hours or days of delivery. Infants of diabetic mothers are often evaluated in a special care nursery to monitor for these potential problems. Most women with good control of diabetes can expect an excellent pregnancy outcome as a result of improvements in blood glucose control; this requires frequent daily glucose testing and insulin adjustment. We use 4 injections (3 short or rapid acting and one long acting) a day, which can improve control and reduce risk to mother and baby. Target blood glucose levels during pregnancy are as follows: HbA1c level: less than 6 Fasting blood glucose: 60 to 90 mg/dL (3.3 to 5 mmol/L), before meals: less than 100 mg/dL (5.5 mmol/L), one hour after meals: less than 130 to 140 mg/dL (7.2 to 7.7 mmol/L), two-hours after meals: less than 120 mg/dL (6.7 mmol/L). Postpartum (after delivery) care for a woman with diabetes is similar to that for women without diabetes. However, insulin requirements are highly variable in the immediate postpartum period; some women require little or no insulin. Insulin requirements usually return to near-pre pregnancy levels within 48 hours. Breast feeding is strongly encouraged, and benefits both the infant and the mother. Insulin requirements may be lower while breast feeding, and frequent blood glucose monitoring is important to prevent severe hypoglycaemia. Approximately 400 additional calories are required each day while breast feeding. Breast feeding for longer than three months can aid in maternal weight loss and provides significant short and long-term benefits to the infant. A woman and her obstetrician may decide to schedule the date of her delivery (either an induction of labour or Cesarean section), especially if there are risk factors, such as poor blood glucose levels, nephropathy, worsening retinopathy, hypertension or pre-eclampsia, or limited or excessive fetal growth. Waiting for labour to start on its own is reasonable if blood glucose levels are well-controlled and the mother and fetus are without problems. However, extending pregnancy beyond 40 to 41 weeks of gestation is generally not recommended.

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