The Nuts and Bolts of Monitoring a Diabetic Pregnancy

A pregnancy with pre-existing diabetes is automatically deemed “high risk”.

There is no point in getting upset over semantics. Despite how it may sound, I’m generally fit and well. On a day to day basis I’m healthy. I’d like to have a “normal” pregnancy, and honestly I do have a good chance of a perfectly “normal” pregnancy with a lovely, healthy baby at the end and no additional complications or surprises.

But there are increased risks, both to mum and baby, when the pregnancy is complicated by pre-existing diabetes. And really all that “high risk” means is that I’m being closely monitored with the aim of preventing potential complications and also so that if any of them should arise, we can do the very best to minimise them.

In early pregnancy, women with diabetes have an increased risk of miscarriage – although increased by how much is debatable, given how common miscarriage unfortunately is. The risk of birth defects is also increased – although by how much depends quite a lot on how close to non-diabetic your blood sugars. Prolonged high blood sugars in the first trimester increase the risk, as this is when all the baby’s organs and systems are forming.

Women with diabetes are also much more at risk of macrosomic – or big – babies. This one is practically a cliché. Again, it is very much affected by blood glucose control. Once the baby has a functioning pancreas of its own, any excess sugar in the mother’s blood stream, which passes to the foetus, will cause more insulin to be produced. Insulin behaves rather like a growth hormone, and this contributes to the baby growing larger. Of course, many women have large babies without being diabetic, and many diabetic women have babies of perfectly normal size, so none of this is a certainty. The main problem for a very big baby is delivery!

Conversely, women with diabetes can be at increased risk of intra-uterine growth restriction, causing a small baby. This may be attributable to early placental breakdown, which may also cause still birth ad is the reason why many women with diabetes are advised to consider early induction of labour.

Scary list, but it goes on. There are also specific risks to the woman herself. In early pregnancy insulin needs can be dramatically reduced and coupled with the goal of tight control this can increase the risk of severe hypoglycaemia. Pregnancy itself may contribute to changes in the warning symptoms of low blood sugars, and frequent blood sugars can dull these warning symptoms further leading to an increased possibility of passing out or seizures. In later pregnancy, pre-existing diabetes is also a risk factor for pre-eclampsia, which unmanaged can itself be life threatening to both mum and baby.

Pregnancy itself may accelerate any long term complications of diabetes, especially diabetic retinopathy. Part of the mechanism for this is related to pregnancy hormones, but it’s also in part down to the irony that a rapid improvement in how tightly blood sugars are controlled can cause a rapid deterioration in retinopathy.

It would be easy to find this all totally and utterly depressing. It is pretty depressing. But it’s also important to remember that these are all just raised risks. There are no certainties and the idea of the “high risk” label is so that everyone can work together to keep how much the risks are raised to the absolute minimum. Ideally to prevent all of these things from happening.

What this means in terms of pregnancy care is appointments. Lots of them. Throughout the first two trimesters, I’m scheduled to be seen in a diabetes and pregnancy clinic at least every two weeks – more often if there are specific problems. These appointments involve a raft of medical professionals – a diabetes consultant, a diabetes specialist nurse and a nutritionist if required as well as an obstetrician specialising in pregnant women and a similarly specialised midwife. In addition, there is close email and telephone contact between visits. There will be additional scans to spy on the baby and check for problems, including a foetal echocardiogram to check on the baby’s heart during the second trimester, and fortnightly growth scans from the late second trimester onwards. This is in addition to the routine scans and midwife care offered to pregnant women without diabetes.

My eyes will also be under closer scrutiny than normal to look out for any changes. In a non-pregnant diabetic with no previous problems, retinal exams would be once a year. Now, my retinas will be photographed once per trimester, in addition to having been examined just a few months before the pregnancy began.

It’s a demanding schedule and in the third trimester, things step up even more. The growth scans continue and the visits become once-twice weekly. But whatever it takes to keep baby and mum healthy – it’s got to be done.

The final part of the equation is everything that goes on in between all those appointments. Managing blood sugars is the biggest part of managing the risks of a diabetic pregnancy, and managing blood sugars tightly can be a full time job. No amount of time spent at the hospital will make a real difference if I’m not able to keep on top of things for all the other hours in the week. Whereas the healthy body has all the tools to continually sense and respond to changes in blood sugar levels, I need to get that information for myself and act on it. What this all means is lots and lots of blood glucose tests, and for me, wearing a continuous glucose monitoring system and an insulin pump, which is the best tool for me to be able to respond to rapidly changing insulin requirements.

No one said a pregnancy with diabetes would be easy. But I’m sure that it will all be completely and utterly worthwhile when hold our child in our arms for the first time.


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