MDNews - Cleveland-Akron-Canton

++++++++++++++++++++++++ + +++ + WOMEN'S HEALTH U +++ ++++++++++++++++++++++++ Care for Women with Pregestational Diabetes By Katherine Wolfe, DO A CCORDING TO THE American Diabetes Association, 25.8 million Americans have diabetes, which accounts for 8.3 percent of the American population. Already at risk for numerous health complications, diabetic women who desire pregnancy warrant careful monitoring during the preconception, prenatal and peripartum periods. Risks and Complications One common misconception regarding pregestational diabetic women is that the main result will be a large baby. These babies are actually at risk for both extremes of growth disturbances. Macrosomia can occur with suboptimally controlled glucose. Growth restriction can complicate the pregnancy, especially if vascular disturbances exist from diabetes. In addition, there is an increased risk of miscarriage, stillbirth and birth defects. The risks continue after delivery. Babies born to diabetic mothers can suffer from hypoglycemia, hypocalcemia, hypomagnesemia and hyperbilirubinemia. Uncorrected disorders can cause seizures. Breathing problems (respiratory distress syndrome) are more common, even in full-term babies, compared to the babies of nondiabetic mothers. Uncontrolled diabetes can cause the neonatal blood to have more red blood cells than normal and can cause the blood to become more viscous. The baby's heart can become thickened and not work as well (hypertrophic and congestive cardiomyopathy). 34 | Cleveland/Akron/Canton MD NEWS Diabetic mothers are also at risk for complications. Diabetes may affect a woman's kidneys, eyes and heart. Pregnancy may worsen these complications. Additionally, these women are more likely to develop pregnancy-specific complications such as preeclampsia. Precautions and Management Given the risk of serious complications for mother and baby, diabetes in women who desire pregnancy should be optimized prior to conception, with careful management throughout pregnancy. The best time to prevent birth defects is prior to conception. A woman can lower her chance of having a baby with a birth defect if she controls her blood glucose (hemoglobin A1C level less than 6.5 percent), starts 1 milligram of folic acid three months prior to conception and avoids teratogens (including certain medications such as ACE inhibitors or lipid-lowering medications, alcohol and tobacco). Diabetes management during pregnancy should include medical nutrition therapy, counseling with a dietician, 30 to 60 minutes of physical activity daily, psychosocial assessment to identify any barriers to care, patient monitoring of blood glucose and insulin therapy when indicated. Placental hormones cause insulin resistance, so typical insulin requirements increase during the course of the pregnancy, and rapidly decline after delivery. Exposure to commonly used medications in pregnancy (steroids, betamimetics) will temporarily increase insulin requirements as well. I MDNEWS.COM I SEPTEMBER- OCTOBER 2013 Due to the risk of kidney injury in diabetic patients and the increased risk of preeclampsia, physicians should check a 24-hour urine for creatinine, creatinine clearance and total protein early in pregnancy. Antihypertensive therapy should be used to reach a goal of 130/80 for diabetic patients with hypertension and 130/75 for patients with diabetic nephropathy. Diabetes can cause proliferative retinopathy that may worsen during gestation, potentially causing permanent vision loss. This is treatable with laser photocoagulation. Ophthalmological exams are recommended upon entry to care. Coronar y arter y disease affects diabetic women at a mean age of 34 years. Consider ordering an EKG and echocardiogram if the patient has had diabetes for more than 10 years, has known heart disease or is over the age of 35. Optimistic Outlook Advances in managing the pregnancies of women with diabetes have reduced the mortality rate for mothers and infants. Subsequently, advances in maternal and fetal care have improved the outlook of the babies of these mothers to the point where most can expect to deliver a healthy child when they have received appropriate prenatal care. Dr. Katherine Wolfe is a perinatologist with the Akron Children's Hospital Center for Maternal Fetal Medicine. I

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