Hosted by Ray Shields, MD

During the last two generations, diabetes during pregnancy has increased significantly in American Indian and Alaska Native (AI/AN) women.  Hyperglycemia during pregnancy can be associated with morbidity and mortality for both the mother and her infant.  Therefore, management of diabetes in pregnancy offers a unique opportunity to affect both patients’ health positively.  Currently, women with diabetes and good glycemic control can look forward to pregnancy outcomes that are comparable to that of the general population.

Preconception Planning in Type 2 Diabetes

Pregnancy in women with type 2 diabetes is associated with an increase in risk to both the fetus and the mother.  The incidence of congenital anomalies and spontaneous abortions increases during the period of fetal organogenesis in women with poor glycemic control.  A woman may not know she is pregnant during fetal organogenesis, which is not complete until eight weeks post-conception. Therefore,  pre-conception counseling and planning are essential in women of childbearing age who have diabetes to optimize their diabetes control before becoming pregnant.

Gestational Diabetes (GDM)

AI/AN women are at increased risk for developing gestational diabetes (GDM), as are women with certain other risk factors, including but not limited to the following:

·  Previous gestational diabetes                  ·  Obesity

·  Previous fetal macrosomia                       ·  Insulin resistance syndrome

·  Unexplained stillbirth                                  ·  Polycystic ovarian syndrome (PCOS)

·  Congenital anomaly                                   ·  Family history of diabetes

AI/AN women should be screened for pre-existing diabetes early in pregnancy with a 50 gram 1 hour Oral Glucose Tolerance Test (OGTT).  If early screening is negative, repeat the screen for GDM at 24-28 weeks gestation.  The screening can be repeated at 32 weeks in selected cases.  A positive screening test should be followed by 100 gram 3 hour OGTT. The IHS guidelines (see references), written by Neil Murphy, MD at the Alaska Native Medical Center, give a comprehensive outline on both the screening, testing and management of patients with GDM that is beyond the scope of this document.

Management of  Hyperglycemia during Pregnancy

The treatment of diabetes in pregnant women involves several components, including careful and frequent monitoring of blood glucose, the administration of insulin if indicated, and dietary interventions. 

Hypoglycemia, a major risk of insulin therapy,  can usually be prevented with careful self blood glucose monitoring and education of the mother.  Exercise therapy has been shown to be effective in some randomized controlled data in this field.

 Women with diabetes who are planning pregnancy or who have become pregnant (i.e., women with pregestational diabetes) should have a comprehensive eye examination and should be counseled on the risk of development and/or progression of diabetic retinopathy.  Eye examination should occur in the first trimester with close follow-up throughout pregnancy and for 1 year postpartum. Women who develop GDM during pregnancy do not require a comprehensive eye examination during pregnancy due to the short period of exposure to elevated glucose and the low risk of developing diabetic retinopathy.

Postpartum GDM Screening for Type 2 Diabetes

Women with GDM are at increased risk of developing type 2 diabetes after delivery.  About one third of all AI/AN women with GDM will develop diabetes within 5 years of delivery.  These women should be re-tested by a 75 gram 2 hour OGTT at least 6-12 weeks post delivery to determine their glycemic status.  Women with a normal postpartum OGTT should be re-tested every 1-3 years with a fasting blood glucose. Providers should monitor blood glucose in the postpartum and lactating period, as clinically appropriate.

 All women with a history of GDM should receive counseling and education regarding lifestyle modifications that will reduce or delay the development of type 2 diabetes.  Moreover, the importance of maintaining optimal glucose control prior to and during any subsequent pregnancy should be stressed.  Women with a history of diabetes in pregnancy can be offered all standard FDA-approved contraceptive agents.

Mothers should also be made aware that children of GDM pregnancies should be monitored for obesity and abnormalities of glucose utilization.