The prevalence of diabetes worldwide is on the rise, with the World Health Organisation (WHO) reporting a significant increase among adults from 4.7% in 1980 to 8.5% in 2014. Diabetes is a chronic disease whereby either the pancreas does not produce enough insulin or the body fails to use the insulin that it produces effectively. The former describes type 1 diabetes mellitus (T1DM) which is managed by daily administration of insulin. Most women with diabetes will have a healthy baby, but there are potential complications women should be aware of, ideally before conception. The midwife is well positioned to provide important education to women on how their condition will affect their pregnancy and aid them in the management of such.
In this assignment, I will discuss the risks associated with a diabetic pregnancy, the management of diabetes during pregnancy and the importance of empowering women with information.
There are several risks associated with diabetes in pregnancy, to both the woman and her baby. She should be informed of these risks whilst assured there are ways to reduce them greatly. Diabetic women are more likely to have a larger baby, which can lead to a difficult birth, induction of labour or caesarean section. Women with diabetes are unfortunately at a higher risk of having a miscarriage. Pregnancy can also increase the risk of developing diabetes related problems or exacerbate existing ones. For example; diabetic nephropathy, diabetic retinopathy or diabetic ketoacidosis.
The baby may be at higher risk of health issues such as respiratory or cardiac problems soon after birth, resulting in the need for transmission to the neonatal unit and extra care. The child also has a higher risk of developing diabetes, obesity or both later in life. Diabetes slightly increases the chances of birth defects, stillbirth or dying shortly after birth (NHS, 2018).
Well controlled diabetes prior to pregnancy as well as during, along with regular monitoring of ketones and blood glucose for example, will help to reduce these risks. It is the midwives’ responsibility to ensure that the woman is aware of the day to day self-management she will need to undertake as a pregnant diabetic woman. The midwife must also ensure that the additional antenatal care necessary, such as extra ultrasounds, are arranged. Arming women with information and guidelines allows them to take active control of their diabetes and pregnancy and recognise deviations that call for adjustments or medical attention.
While 40-60% of women with pre-existing diabetes including T1DM report that their pregnancies were unplanned, the planned pregnancies have several better outcomes such as reduced congenital malformations, caesarean deliveries and perinatal mortalities. Planned pregnancies also reach a greater gestational age at delivery (Feldman and Brown, 2016). This highlights the importance of preconception care and planned pregnancies in diabetic women, it is needed to minimize the risks.
Counselling about the possible adverse effects to both the woman and her baby is essential, whilst emphasising the extra time and effort she will need to manage her diabetes and in turn reduce these risks. She should be informed that associated risks increase with the longer the woman has had diabetes and that while risks can be reduced, they cannot be eliminated (NICE, 2015).
During the preconception period, there are several tests and assessments the woman will be offered. At the first preconception care appointment, midwives should offer a retinal assessment as well as a renal assessment. Due to the increased risk of diabetic retinopathy in pregnancy, unless a woman with T1DM has had a retinal assessment in the previous 3 months, she should be offered one following her first antenatal clinic appointment and again at 28 weeks into the pregnancy. Frequent screening ensures early detection and treatment. Likewise, if a renal assessment hasn’t been undertaken in the previous 3 months it will be arranged at first contact. Referral may be made to a nephrologist if needed (NICE, 2016).
Haemoglobin A1C (HbA1C) level is measured at booking and monthly during pregnancy. The midwife will also offer a meter for self-monitoring blood glucose as well as blood ketone testing strips to test for ketoaemia. If the woman was to be suspected of having diabetic ketoacidosis in pregnancy she would need immediate medical and obstetric care (NICE 2015). The midwife must provide support to ensure the woman has the equipment and knowledge she needs to self-monitor her blood glucose levels. A woman with T1DM will have already been monitoring herself before becoming pregnant whilst for some women with type 2 diabetes and all with gestational diabetes, this is a new task and habit to be formed. It is the role of the midwife to educate the woman on her target blood glucose and offer evidence based advice on how to reach those targets optimally.
Women should be advised to use contraception until good blood glucose control has been established. The method must fit the woman’s lifestyle and be used reliably. There are several options including barrier methods, pills, implants, intrauterine devices, vaginal rings and injections. All come with their own risks that the midwife may discuss with the woman. For the majority of women, the risks of an unplanned pregnancy outweigh any risks involved in contraception. Once the desired blood glucose level is reached, the woman should come off of contraception and aim to maintain said level (Feldman & Brown, 2016).
Blood glucose is assessed by HbA1C level. The woman should be informed that glucose monitoring and medicines for treating diabetes as well as its complications will need to be reviewed both before and throughout the pregnancy.
Goals of preconception care should be tight glycaemic control with a HbA1C <6.5%. This is because the prevalence of congenital abnormalities rises with elevated blood glucose levels at conception and early on in the pregnancy. Higher A1Cs early in pregnancy are also associated with preeclampsia, intrauterine fetal demise and preterm deliveries (American Diabetes Association). Women with T1DM whose HbA1c level is above 10% should be strongly advised by the midwife not to get pregnant and the midwife should help to develop individualised targets of blood glucose with the woman, reassuring her that any reduction towards the HbA1C level of 6.5% is highly beneficial for the baby and overall pregnancy outcome (NICE, 2015). The midwife must convey the importance of glycaemic control to the woman and support her choice of contraception whilst achieving a stable, safer blood glucose.
Individualised dietary advice should be offered, with the aim of optimizing glucose management through consistent timing and quality of meals (Feldman & Brown, 2016). Women with a BMI above 27kg/m2 should be offered advice on how to lose weight; it is ideal for women to be within a healthy weight range before becoming pregnant. Obesity is becoming more common in those with T1DM and is associated with an increased risk of fetal demise, preeclampsia, perinatal mortality and preterm delivery. It is imperitive to address obesity with lifestyle changes (Feldman & Brown, 2016).
The midwife should encourage physical activity, specifically previous pre-pregnancy exercise habits of the woman and explain that exercise can counteract the decline in insulin sensitivity that occurs during pregnancy, whereas resting will have the opposite effect (International Diabetes Federation, 2009).
A high dose folic acid supplement (5mg/day) should be taken from at least 3 months before conception up until 12 weeks’ gestation due to the greater risk of neural tube defects in diabetic pregnancies (NICE 2016). Midwives should explain to the woman the benefits of taking folic acid as part of preconception counselling to ensure her understanding and consistent adherence.
Not every pregnancy is planned and consequently many women do not receive preconception care. The American Diabetes Association recommends that preconception counselling should be incorporated into routine diabetes care for girls starting at puberty (2017). Similarly, NICE advocates for the importance of avoiding unplanned pregnancy as an essential part of education for young women with diabetes (2015). Ideally, diabetic women who become pregnant will have some knowledge of diabetes and pregnancy but it is important that the midwife does not assume this and offers diabetic women who are planning a pregnancy or are already pregnant a structured education programme, if they have not already attended one (NICE, 2015).
Diabetic pregnant women should be offered immediate contact with a joint diabetes and antenatal clinic. Here, the women will attend for an assessment of blood glucose control every 1-2 weeks during her pregnancy. It is important that quick access to specialist care is available to ensure the woman’s diabetes is well controlled in early pregnancy, when it is of utmost importance in order to reduce risk of loss and anomalies. This is also a point of contact wherein the midwife can offer advice and obtain a comprehensive clinical history to establish the extent of the diabetes and its complications, and review medicines.
It is important to review and confirm that any medications a diabetic woman is on are safe for pregnancy.
Insulin is the preferred agent for management in T1DM as it does not cross the placenta or have any known effect on the baby. The physiology of pregnancy means that frequent titration of insulin to match changing requirements is necessary (ADA, 2018). The complexity of insulin management is another reason that it is important the woman receives specialised, team-based care. There’s no evidence that either continuous subcutaneous insulin or multiple daily injections are superior in management of a tight glycaemic control of T1DM in pregnancy (Feldman & Brown, 2016).
Due to the increased risk of preeclampsia associated with diabetes, a low aspirin dose of 60-150mg/day is recommended by the ADA from the end of the first trimester onwards.
Continuous glucose monitoring is not routinely recommended during pregnancy. However, it is considered in the case of severe hypoglycaemia (which occurs in up to 50% of pregnancies), unstable blood glucose levels or to gain information about the variability in the blood glucose levels (Feldman & Brown, 2016).
The midwife should advise the woman and people close to her of the risks of hypoglycaemia and the impaired awareness of it she may have, particularly in the first trimester and at night. With that in mind the midwife should recommend carrying a fast acting form of glucose such as dextrose tablets or a high glucose drink, something a woman with T1DM will likely already have been advised to do. Advise women to aim for the following blood glucose target levels, if possible whilst avoiding problematic hypoglycaemia; 5.3mmol/litre when fasting and 7.8mmol/litre one hour after meals and 6.4mmol/litre two hours after food. The level should always be maintained above 4 mmol/litre. Nausea and vomiting can affect blood glucose control and the midwife should inform the woman of such (NICE,2015).
There are additional assessments of the baby during a diabetic pregnancy. Ultrasound monitoring of fetal growth and amniotic fluid volume is available every 4 weeks to diabetic women from 28 weeks’ gestation onwards, in addition to the ulstrasound at 20 weeks to detect congenital abnormalities (NICE, 2015). The woman will attend the regular schedule of antenatal appointments alongside her additional care.
The place, timing and mode of birth is something that the midwife will discuss with diabetic women, usually during the third trimester. She will be advised to give birth in the hospital where advanced neonatal resuscitation skills are available, due to the higher chance of neonatal distress. A woman with T1DM and no other complications will be advised between 37+0 and 38+6 weeks of pregnancy to have an induction of labour or elective caesarean section if indicated. For example, if her baby had macrosomia, which means that their weight>400g at birth. The midwife should explain the separate risks and benefits of vaginal birth, induction of labour and caesarean section in this case to ensure the woman can make an informed decision. If the woman had T1DM plus a metabolic disorder or any other maternal or fetal complications, she and her team may consider elective birth before 37+0 weeks (NICE, 2015) During this antenatal period infant feeding should be discussed and the midwife should explain how breastfeeding is particularly beneficial to those with T1DM due to increased insulin sensitivity, among the many other benefits to both mother and baby (Feldman & Brown, 2016).
Pregnancy can be an unexpected, often overwhelming experience. For women with T1DM, there are additional responsibilities, extra time to be made for extra antenatal care and a myriad of important information to take on. During pregnancy, the midwife’s role is to be an advocate for the woman. This entails offering support in the form of advice or education, ensuring she feels comfortable managing her pregnancy, informing of and aiding in prevention of specific risks and approaching care in a holistic manor.
The midwife should keep in mind the impact that the stress of a ‘high-risk’ pregnancy may be having on the woman and ask about her support network. When providing important information, it should be supported by patient-friendly reading material and sources that people such as her spouse can also benefit from. Be sure to offer a chance for the woman to ask any questions she may have.
Effective contraception, preconception planning, education and tight glycaemic control are the key components to successfully lowering the risks brought on by diabetes in pregnancy as much as is evitable. In each of these steps the midwife has a responsibility to provide accurate evidence based information, rationale and advice. She must ensure that it is received and understood then support the woman in her choices going forward. Women should be empowered to have a positive pregnancy experience and as midwives it our role to provide women with T1DM with the support and information they need to do so.