Complications of Diabetes

Two aspects of diabetes complications need to be considered when a woman is contemplating pregnancy. First, there is the impact of the pregnancy on diabetic corn-

Table 13-1 Glucose Targets During Pregnancy

Fasting and premeal blood glucose levels 60 to 100 mg/dl Peak glucose levels after meals Less than 130 mg/dl

Bedtime and 2 a.m. glucose levels 100 mg/dl

Table 13-2 Risk of Fetal Malformation with Elevated HbAlc

HbA1c Level

Fetal Malformation Rate

Less than 6% is normal

Less than 6.9%

No increase in rate

7 to 8.5%

5%

Greater than 10%

22.4%

Source: Miller E, Hare JW, Cloherty JP, Dunn PJ, Gleason RE, Soeldner JS, Kitzmiller JL. "Elevated maternal hemoglobin A1c in early pregnancy and major congenital anomalies in infants of diabetic mothers." N Engl J Med 1981 May 28; 304 (22): 1331-34.

plications and maternal health, and second, the effects of diabetic complications on fetal health.

• Diabetic retinopathy: New diabetic retinopathy can suddenly appear during pregnancy, and retinopathy that is already present can get worse. There are two possible reasons for the deterioration: First, if your diabetes control has been poor and you suddenly tighten it over a short period of time (such as getting ready for pregnancy), the rapid improvement itself can cause a flare-up of the retinopathy. Second, the hormonal and circulatory changes that occur in pregnancy may worsen the retinopathy. If you have significant retinopathy before you become pregnant, you might require treatment during the pregnancy. Therefore, you will need to see an ophthalmologist before and during the pregnancy. The retinopathy usually improves after the pregnancy.

• Diabetic kidney disease: If you have kidney disease secondary to your diabetes, pregnancy can make the kidney disease worse. Often the kidney disease will recover after delivery, but it may not if the prepregnancy kidney failure is more severe. Women with diabetic kidney disease who are contemplating pregnancy should therefore consider getting an opinion from a nephrologist (kidney doctor).

• Preeclampsia: Preeclampsia is a serious condition where there is severe elevation in blood pressure, fluid retention, and protein loss. It occurs more often in women with diabetes. About 15 to 45 percent of women with diabetes who have microalbuminuria (see Chapter 3) develop preeclampsia. Hospitalization and early delivery may be necessary.

• Blood pressure medications: If you are taking ACE inhibitors to control your blood pressure, your doctor will switch you to other blood pressure medicines because ACE inhibitors cannot be taken during pregnancy.

Heart disease: During pregnancy, there is increase in blood volume and blood flow, and this causes the heart rate to go up. A normal heart handles this increased demand without any problems, but it can be a problem in women with heart disease. The risk of heart disease is higher in women with long-standing, poorly controlled type 2 diabetes who also have high lipid levels and high blood pressure; and in women with type 1 diabetes who have multiple complications with autonomic neuropathy and kidney disease. If you have any of these risk factors for heart disease, you should get an evaluation from a cardiologist before becoming pregnant.

• Lipid therapy: The FDA has not approved cholesterol-lowering medicines for use during pregnancy, and if you are taking any of these drugs, you should discontinue them. Women with diabetes who have high triglyceride levels can develop pancreatitis during pregnancy. Therefore, if you have high triglycerides before you become pregnant, you should work with your nutritionist to take whatever measures are necessary to lower the triglycerides.

Thyroid disease: You should be screened for thyroid disease before becoming pregnant. If you are hypothyroid, your thyroid hormone replacement medication will need dose adjustments during pregnancy.

• Gastroparesis: In the first trimester, diabetic gastroparesis can worsen the nausea and vomiting of pregnancy, and sometimes women will need to be admitted to a hospital for intravenous fluids and nutrition because they get dehydrated and malnourished. Occasionally this problem continues throughout the pregnancy.

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