Timing And Route Of Delivery
In gestational diabetes, shoulder dystocia is the complication most anticipated at the time of delivery. In one study,36 this complication occurred in 31 percent of neonates weighing more than 4,000 g who were delivered vaginally to unclassified mothers with diabetes. No prospective data support the use of cesarean delivery to avoid birth trauma in women who have gestational diabetes. One remaining limiting factor is the 13 percent error rate in estimating fetal weight by ultrasonography.37
A decision analysis38 that evaluated the cost and efficacy of a policy of elective cesarean delivery for an estimated fetal weight of 4,500 g in mothers with diabetes found that 443 cesarean deliveries would need to be performed to prevent one case of brachial plexus injury, at a cost of $930,000. A reasonable approach is to offer elective cesarean delivery to the patient with gestational diabetes and an estimated fetal weight of 4,500 g or more, based on the patientâs history and pelvimetry, and the patient and physicianâs discussion about the risks and benefits. There are no indications to pursue delivery before 40 weeks of gestation in patients with good glycemic control unless other maternal or fetal indications are present.
Tips For Taking Insulin During Pregnancy
- Change insulin sites to prevent soreness from repeatedly using the same area move an inch or two away from the original site
- Inject insulin at the same time every day if you feel unwell, inform your diabetes specialist
- Consult your doctor before altering your exercise routine or diet
- Store the bottle of insulin at room temperature
- Track the amounts of insulin you are taking, especially if you take two different types
- Dispose the needle in a container meant for sharp objects that is separate from other waste
Are there any side effects of taking insulin during pregnancy?
The main insulin side effect during pregnancy is that it could cause low blood sugar levels in case you missed/delayed a meal or injected excess insulin.
My doctor alerted me of the signs to watch out for and how to treat low blood sugar during pregnancy, says Priya.
What are the symptoms of low blood sugar in pregnancy?
If you are hypoglycemic or your blood sugar is low , you may experience these symptoms:
- Sweating, dizziness, feeling shaky
What You Need To Know About Diabetes When Is Insulin Prescribed For Gestational Diabetes
One of the most common signs of diabetes is excessive thirst. You may also feel more hungry and pee more than usual. Its important to check your blood sugar as soon as you start to notice these symptoms. If your blood sugar drops below 70 mg/dL, you should immediately eat 15 grams of carbohydrates. Then, check it again fifteen minutes later. If you cant eat that much carbohydrate at once, you can try oral glucose.
Despite the many complications of type 1 diabetes, you can still find ways to manage it. By reading about diabetes, youll be better prepared to live a healthy and happy life. You can avoid diabetes by making healthy choices. In fact, there are many treatments available for type 1 diabetes. In some cases, a patient may even experience an improvement in their overall health after the transplant. In some cases, you can even reverse your diabetes through a simple procedure.
Type 2 diabetes is the most common type. Most people with type 1 diabetes have type 2 diabetes. They both require insulin to regulate their blood sugar. If youre overweight, you may have type 2 diabetes. If youre concerned about diabetes, its important to learn about it. Your doctor can provide you with more information on your condition, including tips on how to cope with it. You should never be afraid to ask questions. Just remember, youll have to answer them. Youre not alone.
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Insulin Dosing In Pregnancy
Insulin has long been considered the standard of care to attain optimal glucose control in pregnancy, although multiple methods are available to initiate insulin. Weight-based dosing, weight plus gestational agebased dosing, and even a one-dose-for-all type of dosing have been used . Without clear evidence for one approach over another, the choice of protocol usually is based on clinician comfort and preference.
Although there are several methods for initiating insulin, the national guidelines lack an algorithm for adjusting doses in pregnancy. Adjustments outside of pregnancy are made in small increments over a long period of time. Pregnancy does not have the luxury of time because the risk of fetal harm develops rapidly, and quick control is imperative. The CDAPP Sweet Success program offers some guidance on adjustments, suggesting changes by 24 units in short- and intermediate-acting insulins every 23 days. Women with GDM or type 2 diabetes rarely have hypoglycemia unawareness they quickly recognize and treat hypoglycemic events. Therefore, the most aggressive adjustments can safely be made in this population. In practice, adjustments can be made every couple of days until control is attained, if personnel and time allow.
What Causes Gestational Diabetes
Gestational diabetes occurs when your body cant make enough insulin during your pregnancy. Insulin is a hormone made by your pancreas that acts like a key to let blood sugar into the cells in your body for use as energy.
During pregnancy, your body makes more hormones and goes through other changes, such as weight gain. These changes cause your bodys cells to use insulin less effectively, a condition called insulin resistance. Insulin resistance increases your bodys need for insulin.
All pregnant women have some insulin resistance during late pregnancy. However, some women have insulin resistance even before they get pregnant. They start pregnancy with an increased need for insulin and are more likely to have gestational diabetes.
About 50% of women with gestational diabetes go on to develop type 2 diabetes, but there are steps you can take to prevent it. Talk to your doctor about how to lower your risk and how often to have your blood sugar checked to make sure youre on track.
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What Is Gestational Diabetes
Gestational diabetes is a type of diabetes that happens during pregnancy. Unlike type 1 diabetes, gestational diabetes is not caused by having too little insulin. Instead a hormone made by your placenta keeps your body from using the insulin as it should. This is called insulin resistance. Blood sugar then builds up in your blood instead of being absorbed by the cells in your body.
The symptoms of gestational diabetes often go away after delivery. But sometimes they don’t. Or you may have a greater risk of developing type 2 diabetes later.
The Initial Causes When Is Insulin Prescribed For Gestational Diabetes
Type 2 diabetes is a common condition in many people. This type is caused by a lack of insulin and is a result of an unhealthy lifestyle. The bodys inability to process glucose from the blood can damage many parts of the body, including the eyes, kidneys, and nerves. Fortunately, there are some things you can do to avoid diabetes. Here are five tips to help you lower your risk: Eat more vegetables and fruits, get regular exercise, and avoid smoking.
High levels of triglycerides in the blood are another factor that can cause diabetes. These triglycerides are caused by a buildup of cholesterol in the blood. A high triglyceride level causes the body to misrepresent insulin as a molecule, which causes glucose to build up in the blood. A simple blood glucose test can confirm your diagnosis of type 2 diabetes. By following these tips, you can begin living a healthy life and avoid the complications of diabetes.
A person with type 2 diabetes must consume less sugar. Glucose causes thirst and dehydration because the body releases energy stores into the bloodstream instead of using insulin. If untreated, diabetes can lead to weight loss and diabetic ketoacidosis, a dangerous condition whereby the cells are deprived of energy. To prevent the condition, you must make sure that your diet is low in glycemic load and that you exercise regularly.
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How Do I Check My Blood Sugar Levels
Checking your blood sugar levels involves pricking the side of your finger with a special device called a lancet, and putting a drop of blood onto a test strip. This is then read by a blood glucose meter which tells you your blood sugar levels.
You should be given a blood glucose meter and taught how to check your blood sugar levels. If this hasnt happened, ask your care team for one straight away.
Your care team will tell you when to check. This is likely to include when you wake up in the morning and one hour after meals. If youre having two or more insulin injections, youre likely to be told to check before meals, one hour after meals and also at bed time.
What Is Gestational Diabetes Mellitus
Gestational diabetes mellitus is a condition in which a hormone made by the placenta prevents the body from using insulin effectively. Glucose builds up in the blood instead of being absorbed by the cells.
Unlike type 1 diabetes, gestational diabetes is not caused by a lack of insulin, but by other hormones produced during pregnancy that can make insulin less effective, a condition referred to as insulin resistance. Gestational diabetic symptoms disappear following delivery.
Approximately 3 to 8 percent of all pregnant women in the United States are diagnosed with gestational diabetes.
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Exercise As Treatment For Gestational Diabetes
Regular physical activity is important to help keep your blood glucose under control.
Women with gestational diabetes should get at least 30 minutes of moderate to intense exercise at least five days a week, according to the Centers for Disease Control and Prevention.
This can include walking briskly, swimming, dancing, low-impact aerobics, or actively playing with children.
Potentially dangerous activities including basketball and soccer , horseback riding, and downhill skiing should be avoided.
During the first trimester of your pregnancy, you should also avoid exercises that require you to lie on your back, which could put pressure on certain blood vessels and accidentally limit blood flow to your baby.
Ask your doctor before lifting weights, jogging, or performing other muscle- and bone-strengthening exercises during your pregnancy.
Checking Your Blood Sugar
Your body changes as the baby grows. Because you have diabetes, these changes will affect your blood sugar level. Pregnancy can also make symptoms of low blood sugar hard to detect.
During pregnancy, your diabetes control will require more work. The blood sugar checks you do at home are a key part of taking good care of yourself and your baby before, during, and after pregnancy.
Blood sugar targets are designed to help you minimize the risk of birth defects and miscarriage, and help prevent your baby from getting too large. If you have trouble staying in your target range or have frequent low blood sugar levels, talk to your health care team about revising your treatment plan. Target blood sugar values may differ slightly in different care systems and with different diabetic teams. Work with your health care team on determining your specific goals before and during pregnancy.
We suggest the following targets for women with preexisting diabetes who become pregnant. More or less stringent glycemic goals may be appropriate for each individual.
- Before a meal and bedtime/overnight: 60-99 mg/dl
- After a meal : 100-129 mg/dl
- A1C: less than 6%
*Postprandial glucose measurements should be made one to two hours after the beginning of the meal, which is generally when levels peak in people with diabetes.
Check your blood sugar levels at the times your diabetes care team advises this may be up to eight tests daily and will probably include after-meal checks.
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Maternal Complications Associated With Insulin Therapy
3.8.1 Maternal hypoglycemia
Hypoglycemia threshold is specific for every individual. In pregnancy, there is a reduction of this threshold by 20% . Patients with GDM that are treated with insulin must maintain a glycemia above 3.7 mmol/l according to CDA, or above 3.9 mmol/l according to ADA .
Insulin analogs are superior to human insulin because the hypoglycemic events are less frequent in type 1 diabetic pregnancies . The use of multiple daily injections is as effective as continuous subcutaneous insulin infusion .
Maternal hypoglycemia affects the fetus just in severe cases when is associated with loss of consciousness or secondary to trauma. Also, it was observed that repeated episodes could lead to growth over the 90th percentile . These episodes are more likely to be present in the first trimester in women who had pregestational diabetes than in GDM .
3.8.2 Hypertension
There is moderate quality evidence that indicates higher hypertension associated hypertension without giving details in insulin-treated GDM. This fact should be further researched because it is in contradiction with a non-modified risk for pre-eclampsia .
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Intermediate Insulin And Long
Insulin isophane is a U-100, intermediate-acting insulin. It is produced in E. coli. It is identical to human insulin and is in a suspension. Its onset of action is 12 hours, with an average peak of 4 hours . Duration of action is 1020 hours. Vials are good for 31 days at room temperature, and pens are good for 14 days .
Insulin detemir is a long-acting analog produced in S. cerevisiae. This can potentially cause a reaction for patients who are allergic to yeast. Detemir lacks a defined peak and lasts for up to 20 hours. Its time to onset of action can be 12 hours. The pen and vial last up to 42 days at room temperature while in use . Detemir has less incidence of hypoglycemia compared to NPH in pregnant women .
Insulin glargine is a long-acting analog produced in E. coli and has a unique distribution mechanism. The acidic solution is neutralized in subcutaneous tissue and microprecipitates are formed. These microprecipitates slowly release glargine over 24 hours, resulting in no peak. Its onset of action is 12 hours, and its duration of action is 24 hours. Vials and pens are good for 28 days at room temperature while in use .
Benefits Of Physical Activity
Activity helps to manage your gestational diabetes because it increases the amount of glucose used by your muscles for energy, so it helps to lower your blood sugar levels. Also, being active helps the body use insulin more efficiently. And, regular activity can help reduce the amount of insulin you need.
There are lots of other health benefits of being active with gestational diabetes too.
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Checking Your Blood Sugar Level
You’ll be given a testing kit that you can use to check your blood sugar level.
This involves using a finger-pricking device and putting a drop of blood on a testing strip.
You’ll be advised:
- how to test your blood sugar level correctly
- when and how often to test your blood sugar you’ll usually be advised to test before breakfast and 1 hour after each meal
- what level you should be aiming for this will be a measurement given in millimoles of glucose per litre of blood
- how to share your blood sugar levels with your care team, to help you get the right advice and treatment
If you take insulin and have problems with low blood sugar or your blood sugar is not stable, your care team might offer you a continuous glucose monitor .
This is a small sensor you wear on your skin that sends data wirelessly to a receiver or a mobile phone, so you can see your blood sugar level at any time.
Birth Complications Associated With Insulin Therapy
3.7.1 Cesarean section
A Cochrane analysis of 1481 women with GDM showed that in the treatment group there was a higher number of induced labors versus the group with standard antenatal care, but with no difference regarding the number of births by CS . Another meta-analysis did not demonstrate a correlation between the use of different types of insulin-like aspart, lispro and the birth by CS . Although the risk is not influenced by insulin treatment, it can be reduced by induction of labor in 38th39th week of gestation with better outcomes for the fetus .
3.7.2 Vacuum-assisted birth
Although pre-gestational diabetes raises the risk for vacuum assisted birth , in GDM the risk was similar to that in the general population and could not be related to insulin therapy . A particular situation is with GDM that appeared in pregnancies obtained by assisted reproductive technology where the risk for perinatal and obstetrical complications is probably increased by the adverse effect of hyperglycemia, not by insulin treatment .
3.7.3 Fetal morbidity
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Pregnancy And Drug Considerations
In normal pregnancy, blood pressure is lower than in the nonpregnant state. In a pregnancy complicated by diabetes and chronic hypertension, target goals for systolic blood pressure 120160 mmHg and diastolic blood pressure 80105 mmHg are reasonable . Lower blood pressure levels may be associated with impaired fetal growth. In a 2015 study targeting diastolic blood pressure of 100 mmHg versus 85 mmHg in pregnant women, only 6% of whom had GDM at enrollment, there was no difference in pregnancy loss, neonatal care, or other neonatal outcomes, although women in the less intensive treatment group had a higher rate of uncontrolled hypertension .
During pregnancy, treatment with ACE inhibitors and angiotensin receptor blockers is contraindicated because they may cause fetal renal dysplasia, oligohydramnios, and intrauterine growth restriction . Antihypertensive drugs known to be effective and safe in pregnancy include methyldopa, labetalol, diltiazem, clonidine, and prazosin. Chronic diuretic use during pregnancy is not recommended as it has been associated with restricted maternal plasma volume, which may reduce uteroplacental perfusion . On the basis of available evidence, statins should also be avoided in pregnancy .
Suggested citation: American Diabetes Association. Management of diabetes in pregnancy. Sec. 13. In Standards of Medical Care in Diabetes2017. Diabetes Care 2017 40:S114S119