Diabetes: Risk Factors during Pregnancy

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Guest: Dr. Roger Newman – Obstetrics and Gynecology

Host: Dr. Linda Austin – Psychiatry

Dr. Linda Austin: Dr. Newman, I know you have a very strong interest in complications of pregnancy and one of those that is so common, especially here in South Carolina, is a woman with diabetes who is pregnant. Why is diabetes a risk factor in pregnancy?

Dr. Roger Newman: Well, you are right. It is very common here at the Medical University. Somewhere between five and seven percent of our obstetrical patients are complicated by either preexisting diabetes or the diabetes that develops during pregnancy that we refer to as gestational diabetes. Diabetes presents multiple risks during pregnancy that primarily have to do with the altered metabolic environment.

Dr. Linda Austin: Meaning?

Dr. Roger Newman: Well, for women who have preexisting diabetes who are in poor control, that results in various changes in metabolic features that their fetus is being exposed to. Women in poor control tend to be hyperglycemic, high blood sugar. They also, because of the lack of insulin, use other sources for energy, particularly fat. When they metabolize fat, they create high levels of what are called keto acids and these probably, in too high of levels, are teratogenic to developing embryos.

Dr. Linda Austin: Meaning?

Dr. Roger Newman: Well, what we see in poorly controlled diabetics is that they have much higher rates of fetal malformations and, unfortunately, those are all preventable. Women who get control or take control of their diabetes prior to pregnancy and normalize their blood sugars, they can go through the first two, three months of pregnancy with the exact same risk of having a fetal malformation as anyone else.

Dr. Linda Austin: So, your advice, then, to a woman with diabetes who is thinking about getting pregnant is what?

Dr. Roger Newman: Well, if you are considering pregnancy, there is no more important condition that requires preconceptional care than diabetes. If you are diabetic, considering pregnancy, you need to find a specialist in diabetes or a medical internist, or an obstetrician who is interested in preconceptional care and start seeing them to plan your pregnancy. Part of that planning is going to be an intensive effort to normalize your blood sugars prior to conception.

Dr. Linda Austin: Some women do not become diabetic until they become pregnant. Those women are also at risk for difficulties.

Dr. Roger Newman: Yes they are and this, again, would also apply to the woman who has pregestational diabetes as well. But, as you go through pregnancy and your diabetes is not well controlled, the high glucose levels provide excessive fuel for the baby. The mother’s excess glucose is transported across the placenta to the baby. The baby has to metabolize that glucose, but it also stores the extra glucose and it stores the extra glucose in its body in different forms. The result is that those babies become overgrown and overgrown babies are not necessarily healthy babies.

Dr. Linda Austin: That can then lead to preterm labor, something we have talked about in another podcast.

Dr. Roger Newman: Excessively large babies are predisposed to early delivery. They are more prone to experience distress. They can literally outgrow the supply of oxygen. The demands of a baby that weighs 11 pounds are substantially greater than the normal size baby that weighs 7.5 pounds. If the baby outgrows the mother’s ability to provide it with oxygen, the baby can experience distress or, unfortunately, the ultimate tragedy of pregnancy which is a stillbirth. Late stillbirth in diabetic pregnancies is still a too common complication.

Dr. Linda Austin: I am concerned that a woman with diabetes, who is pregnant and listening to this, might become extremely alarmed. Could you talk to that woman and tell her what she can do and what she expect if she does take very good care of herself?

Dr. Roger Newman: Well, first of all, if she takes very good care of herself, the outcomes for diabetics can be essentially the same as for a woman without diabetes. So, that is really the goal, which is to normalize your blood sugar control and that will normalize your pregnancy even late in the game. If a woman has had trouble controlling her diabetes, she can still gain great advantages by getting that diabetes under control and by getting the appropriate care for a woman who has diabetes. You can eliminate that risk of fetal distress and stillbirth late in pregnancy by simply getting your blood sugars into a normal range.

Babies that are too large or babies that are in distress can be detected by techniques such as ultrasound or fetal heart rate testing. So, as long as we recognize that a woman is diabetic and is at risk for some of these things, obstetrical surveillance can be undertaken that will prevent these really adverse outcomes. So, while there are reasons to be concerned, there are things that you can do for yourself to lower your risk and there are things that your obstetrician can do for you to lower your risk to help you have a safe and successful pregnancy.

Dr. Linda Austin: I would imagine that delivering a very large baby might pose challenges and complications as well.

Dr. Roger Newman: Yes, that is absolutely right. One of the greatest concerns for an obstetrician is taking care of the woman with diabetes during labor. We have limitations in our ability to identify accurately this size of a baby but we know that women who are diabetic are at greater risk of having not only larger babies but babies that have different shapes. What we found is that women who have diabetes have babies that have much larger shoulders than a woman who is non-diabetic, even if the baby is the same size. You can have two eight pound babies but you can look at the baby of a mother who has diabetes and be able to identify it because they just have a different physical shape. They put on their weight differently and as a result, those babies can be very difficult to deliver. There is a disorder called shoulder dystocia where the baby’s head delivers but you cannot get the shoulders delivered and that becomes a real emergency.

Dr. Linda Austin: And, leads to Cesarean section?

Dr. Roger Newman: Well, in that case it is too late for a Cesarean section because the baby is partially delivered. So, there are other procedures that we do to try to relieve a shoulder dystocia but they are dangerous. Cesarean section is much more common in women who have diabetes, primarily related to the size of their baby. Sometimes we electively do C-sections when we know a baby is excessively large and the mother has diabetes. Sometimes just due to the size of the baby, labor becomes stalled and we end up having to do a C-section because a woman cannot successfully deliver.

Dr. Linda Austin: Dr. Roger Newman, thank you so much for talking with us today.

Dr. Roger Newman: Thank you very much.

If you have any questions about the services or programs offered at the Medical University of South Carolina or if you would like to schedule an appointment with one of our physicians, please call MUSC Health Connection: (843) 792-1414.

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