Type 1 Diabetes Pregnancy and Management

Table of content

1. An overview

Pregnancy is a stage that arrives in almost every woman’s life with mixed feelings of pride, joy, expectation, emotion, and also anxiety. A recent study suggests that almost 20% of women suffer from mood or anxiety disorders during pregnancy. A typical pregnancy lasts 40 weeks from the 1st day of LMP (Last menstrual period) till the birth of the baby). Everyone desires an ideal pregnancy (It is a full-term pregnancy without having any health hazards that end with the birth of a healthy baby keeping the mother also in good health).

2. Health hazards including type-1 diabetes during pregnancy

Diabetes is the most common medical complication during pregnancy (found in the case of 3.3% of all live births). Both hyperglycemia (it occurs when the blood glucose level is too high. It is triggered by unbalanced food consumption/ insulin need not well satisfied/ stress/ sickness/ unhealthy lifestyle) and hypoglycemia (It occurs when the blood glucose level is too low. At this too low blood glucose level, the body cannot get the energy it needs) are found common in women with preexisting diabetes. 

Besides diabetes, some women experience various health hazards during pregnancy. These complications can put the fetus and the health of the pregnant mother as well as the incoming baby at higher risk. Even the women who were quite healthy before getting pregnant can experience various health complications which include:

• High blood pressure
• Infection
• Preeclampsia (it is a serious condition where the woman has high blood pressure and at the same time has a high level of protein in the urine)
• Preterm labor (it is the labor that begins before the 37th week of pregnancy. Any infant born before 37 weeks, is at higher risk of health problems in most cases.)
• Stillbirth (it is the death of a baby in the uterus usually after the 20th week of getting pregnant)
• Miscarriage (it is the loss of a fetus before the 20th week of pregnancy. The medical term for miscarriage is spontaneous abortion)
• Gestational diabetes (it is a condition during pregnancy when blood sugar rises to a high level without having any diabetes at all).

3. Management of type-1 diabetes in pregnant women

Type 1 diabetes accounts for only 5% of total diabetic patients and affects a few of all pregnancies. 

Type-1 diabetes is a condition in which the body does not make enough insulin to control blood sugar levels. Type-1 diabetes was previously called insulin-dependent diabetes. It is an autoimmune disease that requires the daily use of insulin.

Type 1 diabetes pregnancy symptoms:

• Increased thirst and urination
• constant hunger
• weight loss
• blurred vision
• extreme fatigue.

Pregnant women with type-1 diabetes (during preconception/ pregnancy/ postpartum period which is commonly defined as 6 weeks after childbirth) have unique needs. These are stated below.

3.1) Preconception counseling is essential for women with type-1 diabetes (also known as T1DM i.e. Type-1 Diabetes Mellitus) to mitigate adversities. Preconception care should be comprehensive. The goal of preconception care should be right glycemic control with a hemoglobin A1C less than 6% without any significant hypoglycemia. This will lower the risk of

• congenital malformations
• preeclampsia
• prenatal mortality

Glycemic control is a medical term referring to the desired level of blood sugar in a patient with diabetes mellitus. For people without diabetes, the normal range for hemoglobin A1C level lies between 4%- 5.6%. A hemoglobin A1C level between 5.7%- 6.4% means one has a higher chance of getting diabetes. A1C level 6.5% or higher means one has diabetes. A1C is a common blood test used to diagnose type-1 and type-2 diabetes. It monitors how well the patient is managing the blood glucose level. 

Congenital malformations refer to congenital disorders or birth defects that affect the baby from birth. Preeclampsia is a serious condition where women develop high blood pressure and also have a high level of protein in the urine. Whereas previously they had no high blood pressure Prenatal mortality, according to the definition given by the World Health Organization, is the number of stillbirths and deaths in the 1st week of life per 1000 total births. The prenatal period commences after completing 22 weeks of gestation and 7 days after birth).

3.2) Again the safety of medications must be assessed before conception. Also, optimal control must be achieved of

• retinopathy
• hypertension
• nephropathy

Retinopathy refers to any damage to the retina of the eyes which may cause vision impairment. Often, retinopathy is caused by abnormal blood flow. Hypertension is a condition of excessively high blood pressure. And nephropathy is a common complication related to type-1 and also type-2 diabetes. Over time, high blood sugar associated with untreated diabetes causes high blood pressure. This, in turn, damages the kidneys by increasing pressure on the delicate filtering system of the kidneys.

3.3) Frequent eye exam is essential due to the risk of progressive retinopathy during pregnancy.

3.4) The pregnant woman must have chronic hypertension treatment goals. These are: 

• Systolic blood pressure range: 110-129 mm Hg
• Diastolic blood pressure range: 65-79 mm Hg 

3.5) Labor and delivery target plasma glucose levels: 80- 110 mg dL An insulin drip is recommended to achieve these targets during active labor.

3.6) Postpartum insulin doses must be reduced and blood glucose levels must be monitored in women with type-1 diabetes because of enhanced insulin sensitivity after delivery (Insulin sensitivity describes how sensitive the body is to the effects of insulin. Some having high insulin sensitivity will require a smaller amount of insulin to lower blood glucose levels as compared to the person who has low insulin sensitivity). 

3.7) Breastfeeding is recommended and highly encouraged both for the maternal and infant benefits (Maternal benefit includes increased insulin sensitivity and healthy weight. Infant benefit includes the reduced prevalence of overweight).

3.8) Nutrition: Medical nutrition therapy is needed to optimize glucose management focusing on consistent timings and quality of healthy meals and snacks as well as accurate carbohydrate counting. Prenatal vitamins with folic acid reduce the risk of congenital malformations in infants of diabetic mothers.

3.9) Regular checkup for pregnant diabetic women is essential. Regular monthly visits to the doctor should continue without fail.

3.10) Obesity is highly correlated with T1DM in the case of pregnant women. It is well-advised to fight obesity as it is a great risk factor for

• preterm delivery
• preeclampsia
• prenatal mortality
• intra-urine fetal demise

It is the clinical term for stillbirth that describes the death of a baby in the uterus.

3.11) Autoimmune thyroid is common in women with T1DM. Even the pregnant women without known thyroid should have TSH level checked during preconception

Conclusively, treating diabetes is of prime importance in consideration of the health of both the pregnant mother and the incoming baby (irrespective of whether one is trying to get pregnant or already got pregnant).

4. Concluding remarks

4.1) To improve pregnancy outcomes, healthcare education /effective contraceptive/ preconception planning/ ideal glycemic control /comprehensive medical care is essential. These can decrease maternal mortality and pregnancy risks associated with type-1 diabetes.

4.2) Approximately, 40% - 60% of the patients report that their pregnancies were not planned. Factors associated with planned pregnancies are higher education / higher income level/ private health insurance/ endocrinology care before pregnancy. Planning is therefore important to ensure that pregnancy is safe and healthy both for the pregnant mother as well as the incoming baby.