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Diabetes poses challenges during pregnancy
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In this issue, Susan Weiner, MS, RDN, CDE, CDN, talks with Marina Chaparro, RDN, CDE, MPH, a diabetes educator who specializes in pediatric nutrition. She has lived with type 1 diabetes since age 16 years. She has a healthy 2-year-old daughter and is currently pregnant with her second child.
How common is diabetes during pregnancy?
Chaparro: The prevalence of diabetes in pregnancy is increasing at an alarming rate. Approximately 1.3 million women of reproductive age have diabetes. Type 1 diabetes affects a very small percentage — 0.1% to 0.2% — of all pregnancies. Most cases of diabetes in pregnancy — around 90% — are gestational diabetes and the remainder are pre-existing type 2 diabetes. Excess weight is related to gestational diabetes, with greater risk seen in pregnant women with obesity. It comes as no surprise as the rise in gestational diabetes is parallel to the rise in the obesity epidemic.
What do diabetes educators need to know about the difference s among the types of diabetes in pregnancy?
Chaparro: There are three classifications of diabetes during pregnancy: gestational diabetes, pregestational type 1 diabetes and pregestational type 2 diabetes. Understanding the differences is key to providing appropriate education. Gestational diabetes refers to glucose intolerance or hyperglycemia that occurs only during pregnancy. Women who develop gestational diabetes usually do so by the 24th to 28th week of pregnancy, and the condition subsides after giving birth.
Pregestational diabetes refers to either type 1 or type 2 diabetes that is diagnosed before pregnancy. Pre-existing type 2 diabetes can be managed with diet, oral medications or insulin; however, during pregnancy, insulin is usually needed and at higher doses in order to achieve glycemic targets. In the case of type 1 diabetes, women often face unique and greater challenges due to the physiologic changes that affect blood glucose control. Pregnancy is a ketogenic state that puts women with type 1 at higher risk for diabetic ketoacidosis as well as hypoglycemia. Insulin doses increase significantly, up to 200% by the third trimester, and constant insulin adjustments are needed in maintain glycemic targets and prevent worsening complications. Women with pre-existing diabetes face greater comorbidities and have a fourfold increase in perinatal mortality.
What are some of the challenges women with type 1 diabetes have during pregnancy?
Chaparro: Pregnancy is a time of many challenges, even without diabetes. For women with pre-existing diabetes, the struggle to achieve tight blood glucose control becomes even greater. This entails frequently adjusting insulin doses, measuring blood glucose up to 12 times per a day, waking up in the middle of the night to have a snack, monitoring carbohydrate intake very closely, managing nausea while preventing hypoglycemia, and so forth. This takes an emotional toll on women. Women often feel guilt, anxiety and frustration as they work constantly to maintain blood glucose levels less than 120 mg/dL. Women with type 1 diabetes who are pregnant struggle not only with the physiologic and metabolic changes occurring in their body, but many also face a lack of resources. Pregnancy guides for women with type 1 diabetes are limited, partly because the condition is so specific, but it doesn’t make it less important.
Why did you become interested in this topic?
Chaparro: It’s not until you live it that you really understand it. I am a registered dietitian and diabetes educator who has lived with diabetes since I was 16 years old. In the past year I gave birth to a healthy baby girl while successfully managing my diabetes. If there is something I learned during my pregnancy, it is how to control my numbers. As a nutrition expert and diabetes educator, I was able to try different techniques for delivering insulin via my pump, test specific carbohydrate meals on my blood glucose as well as evaluate my continuous glucose monitor to make adjustments. Yet, like many women with type 1 diabetes, I had a lot of doubts about what do before and during pregnancy. I realized there is need for more tailored resources and access to experienced health care providers. Fortunately, I was able to use my expertise to my advantage; but not without hurdles.
What advice would you give to other providers who care for women with type 1 diabetes?
Chaparro: Not all diabetes in pregnancy is the same. Pre-existing type 1 and type 2 diabetes in pregnancy are treated differently. Second, health care providers need to know how to make frequent and appropriate insulin dose changes in relation to meal times, pathophysiology and trimester of pregnancy, exercise and so forth. The use of CGM and insulin pumps should be second nature, as more and more women are depending on these tools to manage their diabetes. It may sound obvious, but some health care providers might not feel comfortable operating an insulin pump or know how to interpret continuous glucose reports. If you are dealing with women with pre-existing diabetes, you need to understand the tools and technology available. Lastly, planning is key. More emphasis should be given to preconception because many of diabetes complications can be avoided if glycemic control is achieved before conception.
Where do you see the future of care in women with pre-existing diabetes during pregnancy?
Chaparro: Definitely more research is needed in the areas of counseling and education. The medical community has a very good understanding on what the glycemic targets and pregnancy goals should be; however, we still don’t know how to effectively help clients reach those goals. In other words: I know my HbA1c should be less than 6%, but how do I get there? I expect the use of CGM will become the mainstream for women with pre-existing type 1 diabetes as more individuals are using this technology to effectively manage diabetes. I personally see a bigger shift to insulin pumps compared with multiple daily injections, and I expect more studies to demonstrate the benefits. To date, there are no randomized control studies that show the benefit of using an insulin pump vs. multiple daily injections during pregnancy; there are only observational studies. Artificial pancreas systems are being tested in women with type 1 diabetes during pregnancy with positive outcomes. I see this as an additional tool to help women control their diabetes with less human error.
References:
American Diabetes Association. Diabetes Care. 2016;doi:10.2337/dc16-S015.
Feldman AZ, et al. Curr Diab Rep. 2016;doi:10.1007/s11892-016-0765-z.
For more information:
Marina Chaparro, RDN, CDE, MPH, is a registered dietitian nutritionist and certified diabetes educator. She is spokesperson for the Academy of Nutrition and Dietetics and founder of Nutrichicos, a bilingual children and family nutrition practice in Miami. She can be reached at marina@nutrichicos.com.
Susan Weiner, MS, RDN, CDE, CDN, is the 2015 AADE Diabetes Educator of the Year and author of The Complete Diabetes Organizer and Diabetes: 365 Tips for Living Well. She is the owner of Susan Weiner Nutrition PLLC and is the Endocrine Today Diabetes in Real Life column editor. She can be reached at susan@susanweinernutrition.com.
Disclosure: Chaparro reports no relevant financial disclosures. Weiner reports she is a clinical adviser to Livongo Health.