Management Of Pregnancy In Diabetes

Diabetes has been characterized as one of the most psychologically and behaviourally demanding of the chronic illnesses14, and in women with diabetes who are pregnant, the demands of diabetes self-management are increased further. The experience of pregnancy for a woman with diabetes is strongly influenced by the increasing demands of the diabetes treatment regimen, concerns about the health of her baby and the impact of the pregnancy on her own health. While most pregnant women with diabetes would seem intrinsically motivated to comply with the medical recommendations in order to reduce the risk of birth defects, actually performing the required self-care behaviours throughout pregnancy is a difficult task15.

Pregnancy is in itself an emotionally stressful period, during which the woman is confronted with various psychological and physical challenges. For a woman with diabetes the 'developmental tasks' related to pregnancy are essentially the same as for any woman, i.e. developing attachment to the fetus, preparing for separation, and adopting a realistic relationship with the newborn1617. Pregnancy in a woman with pre-existing diabetes is usually accompanied by a great deal of medical attention, which may lead women with diabetes to feel that their pregnancy is medicalized and being 'taken over' by health professionals, with much of the attention focused on the fetus and its growth. Already existing feelings of ambivalence and fragility in the woman may be strengthened, and complicate the process of developing attachment to the fetus and preparing emotionally for motherhood. The health risks associated with diabetic pregnancy can trigger overprotective-ness in the patient's partner and family members, thereby unintentionally contributing to her sense of vulnerability18. Unplanned pregnancy may cause emotional stress in women with diabetes and fears of criticism and abandonment.

Women striving for 'perfect' diabetes control may find it extremely difficult to accept any elevated blood glucose levels and become highly frustrated by the day-to-day variability in blood glucose levels that is likely to occur in insulin-dependent diabetes, regardless of pregnancy. Receiving feedback of a lowering of glycated haemoglobin can help to decrease stress levels and improve self-esteem. On the other hand, failure to improve glycaemic control can easily lead to feelings of guilt and an increase of psychological distress and, eventually, to diabetes 'burn-out'19.

A complicating factor in diabetic pregnancy that has attracted increasing attention concerns the risk of (severe) hypoglycaemia in strictly regulated diabetic pregnancy, partly related to the suppression of counter-regulatory hormones20. Severe hypoglycaemia, be it as a result of pregnancy or improved metabolic control, can cause high levels of anxiety, confronting the mother-to-be with a serious dilemma. On the one hand, she strives for optimal glycaemic control to reduce the risk of birth defects; on the other hand she is fearful of hypoglycaemia, both for herself and because of the possible harm that hypoglycaemia may cause to the fetus. Impaired hypo-glycaemia awareness and related worries about severe hypoglycaemia can lead the pregnant woman to accept 'safe' levels of blood glucose, thereby compromising glycaemic control. Hypoglycaemia may be one of the major reasons why women do not reach near-normal glycaemic control during pregnancy21. This may be particularly true for women for whom work and/or family commitments make it extremely difficult to have low blood glucose levels. In a retrospective study of 30 patients by Gold and associates22, women who had had previous pregnancies indeed had poorer glycaemic control, particularly during the latter part of the pregnancy. An alternative explanation for their poorer control could be that these women may have experienced a previous successful pregnancy, making them overconfident, resulting in a degree of complacency in their self-management.

For every parent, delivery is a stressful event. In the case of a mother with diabetes, stress levels may be increased in view of the risk of obstetric complications related to macrosomia and pregnancy-induced hypertension (pre-eclampsia). Clinical studies indeed suggest a higher occurrence of premature labour and preterm delivery in diabetic pregnancies23. Little is known about how diabetic pregnancy, in both type 1 and gestational diabetes, affects the development of the maternal-infant relationship. There is some research to suggest that children from diabetic mothers are at increased risk for a variety of behavioural disturbances, partly related to the children's obesity24.

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