Planning a pregnancy: the importance of getting slim before you get started

newborn baby

In Europe the World Health Organisation estimate that more than 50% of men and women are overweight or obese and 23% of women are obese.

In a pregnant woman obesity raises her chances of gestational diabetes and pre-eclampsia. She is also more likely to get metabolic syndrome and type two diabetes later in life. The resulting children are more likely to come to harm in utero and at birth and also more likely to become fat children. They are then more likely to develop higher blood pressure and excess weight in early adulthood.

Despite the push to improve the outcome for the babies in utero, lifestyle changes and medical interventions have largely proved unsuccessful.

Women with a BMI over 25 find it more difficult to conceive in the first place and then are more likely to miscarry compared to their slimmer sisters. The miscarriage rate is 1.67. Congenital abnormalities become more common.

The placenta responds to maternal insulin levels. In normal weight women they become 40-50% less sensitive to insulin but this bounces back within days of delivery. Obese women show greater decreases in insulin sensitivity, this affects lipid and amino acid metabolism. African Americans and Southern Asians get these changes at lower body masses than Europeans.

Obese women are more likely to go into labour early. They also may need to be delivered early. They have a higher rate of failed trial of labour, caesarean sections and endometritis and have five times the risk of neonatal injury.

Anaesthetic complications are more common. The Royal College of Obstetrics and Gynaecology recommend that women with a BMI over 40 see an obstetric anaesthetist before going into labour. Epidural failure is more common. The woman may have lower blood pressure and respiratory problems and the baby may have more heart rate decelerations in labour.

Broad spectrum antibiotics are recommended for all caesarean sections. Despite this, overweight women get more post- operative infections. The wounds are also more likely to come apart.

Obese pregnant women are obviously at even more risk.

Babies of obese mothers are usually fatter at birth compared to other babies. Obese mums tend to put on more weight than average during the pregnancy and then find it even harder to lose weight after delivery.

Recent randomised controlled trial  have shown that interventions started after pregnancy have little or no effect. These include increasing the mum’s physical activity and cutting the dietary glycaemic load. These things reduced the weight gained in pregnancy a little but did not affect adverse pregnancy outcomes and the birth of fat babies. Thus there is now a bigger push to intervene before pregnancy.  

Currently between ten and twenty percent of obese women lose weight between pregnancies. This has been found to reduce weight gain in the next pregnancy and also the risk of pre-eclampsia.  Supervised intensive lifestyle interventions can be done, work and are safe, even in breast feeding mothers. Pre-pregnancy classes to get women fit for pregnancy would help improve the outcome for the babies of the future.  The metabolic environment, a mixture of inflammation, insulin resistance, lipotoxicity, and hyperinsulinemia,  can then be optimised prior to conception. After this, it is really too late.

 

Adapted from Obesity and Pregnancy. Patrick M Catalano and Kartik Shankar from Cleveland Ohio and Little Rock Arkansas Universities.  BMJ 18 February 2017 BMJ 2017;356;j1

Planning a pregnancy: how tight does blood sugar control need to be?

 

At what level do pregnancy complications begin?7241780178_d6f12e91cd_o

    December 17th, 2016  Diabetes in Control

 

 

The results from a new study show that risk increased in women with an early HbA1c of at least 5.9% regardless of a gestational diabetes diagnosis later in pregnancy.

Risk of obstetric complications increases linearly with rising maternal glycemia. Testing HbA1c is an effective option to detect hyperglycemia, but its association with adverse pregnancy outcomes remains unclear. Emerging data sustains that an early HbA1c≥5.9% could act as a pregnancy risk marker.

The purpose of the study was to determine, in a multi-ethnic cohort, whether an early ≥5.9% HbA1c could be useful to identify women without diabetes mellitus at increased pregnancy risk. Primary outcome was macrosomia. Secondary outcomes were pre-eclampsia, preterm birth and Caesarean section rate.

1,228 pregnancies were included for outcome analysis. Women with HbA1c≥5.9% (n= 48) showed a higher rate of macrosomia (16.7% vs. 5.9%,p= 0.008) and a tendency towards a higher rate of preeclampsia (9.32% vs. 3.9% ,p= 0.092). There were no significant differences in other pregnancy outcomes. After adjusting for potential confounders, an HbA1c≥5.9% was independently associated with a three-fold increased risk of macrosomia (p= 0.028) and preeclampsia (p= 0.036).

They evaluated data on 1,228 pregnant women from April 2013 to September 2015 to determine whether an early HbA1c of at least 5.9% can identify women at increased risk for adverse pregnancy outcomes.

Participants were screened for gestational diabetes at 24 to 28 weeks’ gestation, and HbA1c measurement was added to first antenatal blood tests. The primary outcome of the study was macrosomia, and secondary outcomes included rates of preeclampsia, preterm birth and caesarean section.

Compared with participants with an HbA1c less than 5.9% (n = 48), participants with an HbA1c of at least 5.9% (n = 1,180) were more often members of ethnic minorities, had higher pre-pregnancy BMI, were more likely to have anemia and microcytosis, and were more likely to be diagnosed with gestational diabetes.

The rate of macrosomia was increased nearly threefold in participants with HbA1c of at least 5.9% compared with participants with HbA1c less than 5.9%; there also was an increased tendency toward preeclampsia. The rates of preterm birth and caesarean section did not differ significantly between the two groups.

Among participants with HbA1c of at least 5.9%, 22 were diagnosed and treated for gestational diabetes.

From the results of the study it was concluded that, in a multiethnic population, an early HbA1c ≥5.9% measurement identifies women at high risk for poorer pregnancy outcomes independently of GDM diagnosis later in pregnancy. Further studies are required to establish cutoff points adapted to each ethnic group and to assess whether early detection and treatment are of benefit.

In an earlier study published by the American Diabetes Association (Diabetes Care, 2014) they demonstrated that a simple A1c blood test can uncover hidden type 2 diabetes in expectant mothers. The study found that the A1c test can accurately detect undiagnosed type 2 and prediabetes in pregnant women.

The hemoglobin A1c done early in pregnancy may be a convenient and effective way to identify women with pre-existing type 2 diabetes or who are at greater risk of worse pregnancy outcomes.

In this study, researchers examined the use of an A1c measurement done during the first trimester as a screening tool for pre-existing diabetes. The test was performed on more than 16,000 pregnant women and compared with the results of a 2-hour oral glucose tolerance test (OGTT), which is performed after an overnight fast, and is the gold standard diagnostic test for type 2 diabetes.

The study found that the hemoglobin A1c test was able to identify all the women with pre-existing type 2 diabetes when an A1c cutoff point of 5.9 percent was used, said Dr. Florence Brown from Joslin Diabetes Center in Boston.  “In addition, even if women did not have pre-existing diabetes, the A1c cutoff point of 5.9 was able to identify a population of women at greater risk for adverse pregnancy outcomes, including some women with gestational diabetes.”

This is an important finding because 5.9 percent is considerably lower than the value of 6.5 percent currently used to diagnose patients with type 2 diabetes who are not pregnant, she adds. The 6.5 percent threshold would have missed almost half of these women and is therefore too high for screening purposes, the study authors conclude.

This study also found that an early pregnancy A1c of 5.9 percent to 6.4 percent was associated with a greater risk of worse pregnancy outcomes, including birth defects, preeclampsia and perinatal death.

Given that the prevalence of type 2 diabetes is increasing, the A1c test done as early as possible could identify women at high risk and improve pregnancy outcomes. “This study supports the use of an A1c test in the first trimester and ideally with the first prenatal visit as one possible screen for pregnant women,” said Dr. Brown.

Practice Pearls:

  • A1c test in the first trimester and ideally with the first prenatal visit is one possible screen for pregnant women.
  • An A1c test done as early as possible could identify women at high risk and improve pregnancy outcomes.
  • All pregnant women should undergo screening for diabetes and prediabetes at initial appointment and also later in their pregnancy.

Mañé L, et al. J Clin Endocrinol Metab. 2016;doi:10.1210/jc.2016-2581.

Trends in standards of care for pregnant diabetes patients in the UK

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Are care standards for diabetic pregnant patients being achieved?The short answer to the question is NO. The National Diabetes Audit indicates that while the diabetes epidemic continues to grow, medical care continues to fall way short of the standards devised to reduce the burden of complications both on individuals and the economy.

Women who are pregnant tend to get off to a bad start by not being on the right dose of folic acid before they embark on the pregnancy. They are advised to take 5mg of the vitamin a day in order to reduce the chance of their baby developing spina bifida. Of the type one diabetic women 45%  met this standard but only 24% of type two diabetic women did so.

In order to eliminate foetal abnormalities related to hyperglycaemia the HbA1c should be preferably below 6.0 in the first trimester and  yet only 8% of women with type one and 22% of those with type two managed a HbA1c of 6.1% (43 mmol/mol) or less. Pregnancy is advised to be avoided all together if the HbA1c  is over 10% (86) but 12% of type ones and 8% of type two women were over this. The women most adversely affected tended to be living in the greatest areas of deprivation, and also of Asian or Black ethnicity.

Oral glucose lowering drugs apart from metformin are advised for women trying for a baby and insulin should be used if necessary to achieve blood sugar targets. Statins, ACE inhibitors (prils), and ARBS (sartans) should be stopped prior to pregnancy as these can be teratogenic.  But 57% of type two diabetic women were on at least one of these drugs at the onset of pregnancy.

Hypoglycaemia, severe enough to need hospital treatment, was experienced by 9.3% of pregnant women with type one diabetes.

Currently 67% of type one women have a caesarean section compared with 52% of type twos. The rates of stillbirth for offspring are almost 12.8 per 1000 births compared to 4.7 for the general population. Neonatal deaths are 7.6 per 1000 compared to 2.6 for the general population. The rate of congenital abnormalities approximately double that for the general population at 44.2 per 1000 compared to 22.7.  Adverse pregnancy outcomes of all types are related to the HbA1c particularly in the first and third trimesters.

Despite the growth of specialist diabetic-obstetric teams there has been very little improvement in these outcomes over the last ten years. How can we help diabetic women prepare for their pregnancies? Why are so many women and babies not getting the medical care that could help them?

Some basic advice: see your GP well before you plan a pregnancy if you have diabetes and tell them that you are planning for having a baby.

Use effective contraception until your glycaemic goals have been met. For most women this means a Hba1c of 6.5% or under and ideally under 6.0%.

Start folic acid 5mg daily.

Stop statins, ACE inhibitors, ARBs and seek alternative blood pressure control drugs instead, if you have high blood pressure.

Get your weight down to normal if at all possible.

Start a gentle exercise regime if you haven’t already started.

If you have type two diabetes discuss moving onto insulin with your consultant diabetologist.

If you have type two diabetes you will usually continue metformin but stop other drugs on the advice of your consultant diabetologist or GP.

 

Based on Analysing newly-published diabetes audits: are care standards being achieved? Written by Steve Chaplin B Pharm MSc Medical Correspondent in Practical Diabetes March 2016

What can diabetic women expect when they are expecting?

NICE have come up with some sensible improvements for the management of diabetic pregnancies that should reduce complications for mothers and babies in the future. None of these changes are radical and indeed they are already considered best practice, but what is different is that they want to see if best practice can be made routine.

Frequency

Approximately 700,000 women give birth in England and Wales each year, and up to 5% of these women have either pre‑existing diabetes or gestational diabetes. Of women who have diabetes during pregnancy, it is estimated that approximately 87.5% have gestational diabetes (which may or may not resolve after pregnancy), 7.5% have type 1 diabetes and the remaining 5% have type 2 diabetes. The prevalence of all 3 types of diabetes is increasing. The incidence of gestational diabetes is also increasing as a result of higher rates of obesity in the general population and more pregnancies in older women.

Risks

Diabetes in pregnancy is associated with risks to the woman and to the developing fetus. Miscarriage, pre‑eclampsia and preterm labour are more common in women with pre‑existing diabetes. In addition, diabetic retinopathy can worsen rapidly during pregnancy. Stillbirth, congenital malformations, macrosomia, birth injury, perinatal mortality and postnatal adaptation problems (such as hypoglycaemia) are more common in babies born to women with pre-existing diabetes. For women diagnosed with gestational diabetes, hyperglycaemia usually resolves after pregnancy, but a proportion of these women will have type 2 diabetes after the birth. Therefore, before a woman is discharged to the care of her GP, her blood glucose levels should be tested to ensure that they have returned to normal.  Women with pre-existing diabetes will be managed in general adult diabetes services after the birth.

List of recommendations

  1. Women with diabetes planning a pregnancy are prescribed 5mg/day folic acid until 12 weeks gestation.

High-dose folic acid supplements should be prescribed for women with diabetes from at least 3 months before conception until 12 weeks of gestation, because they are at greater risk of having a baby with a neural tube defect. The benefits of high-dose folic acid supplementation should be discussed with the woman during preconception counselling as part of her preparation for pregnancy. If a woman with diabetes has an unplanned pregnancy, she should be prescribed high-dose folic acid as soon as the pregnancy is confirmed.

  1. Pregnant women with diabetes are supported to self-monitor their blood glucose levels during pregnancy.

Women with diabetes need to be able to self-monitor their blood glucose levels at an increased frequency during pregnancy. This will help them to maintain good blood glucose control throughout pregnancy, which in turn will reduce the risk of adverse outcomes such as fetal macrosomia, trauma during birth, induction of labour and/or caesarean section, neonatal hypoglycaemia and perinatal death. Support should be provided to ensure that women have access to blood glucose monitors and enough testing strips, and know how to use them.

  1. Women with pre-existing diabetes are seen at the joint diabetes and antenatal care clinic within 1 week of their pregnancy being confirmed.

Women with diabetes who become pregnant need additional care in addition to routine antenatal care. A joint diabetes and antenatal clinic is able to ensure that specialist care is delivered in order to minimise adverse pregnancy outcomes. Immediate access to a joint diabetes and antenatal clinic within 1 week will help to ensure that a woman’s diabetes is controlled during early pregnancy, when there in an increased risk of fetal loss and anomalies. It will also help to ensure that the woman’s care is planned appropriately throughout her pregnancy.

  1. Pregnant women with pre-existing diabetes have their HbA1c levels measured at their booking appointment.

A woman’s HbA1c levels can be used to determine the level of risk for her pregnancy. Women who had diabetes before they became pregnant should have their HbA1c levels measured during early pregnancy to identify the risk of potential adverse pregnancy outcomes and to ensure that any identified risks are managed.

  1. Pregnant women with pre-existing diabetes are referred for retinal assessment at their booking appointment.

Pregnant women with diabetes can have an increased risk of progression of diabetic retinopathy. Pregnant women should therefore be screened more often for diabetic retinopathy. Retinal assessment should be offered at the booking appointment unless the woman has had an assessment in the last 3 months.

  1. Pregnant women diagnosed with gestational diabetes are reviewed at the joint diabetes and antenatal care clinic within 1 week of diagnosis.

Pregnant women diagnosed with gestational diabetes should have specialist advice and treatment in a timely manner, and should be reviewed by members of the joint diabetes and antenatal care team within 1 week of being diagnosed. The joint clinic should provide the woman with advice, including why gestational diabetes occurs, potential risks and complications, and treatments aimed at reducing those risks.

  1. Women who have had gestational diabetes have annual HbA1c testing

Women who have had gestational diabetes are at increased risk of getting it again in future pregnancies. They are also at higher risk of type 2 diabetes: if they are not diagnosed with type 2 diabetes in the immediate postnatal period (up to 13 weeks after the birth), they are still at high risk of developing it in the future. Early detection of type 2 diabetes by annual HbA1c testing in primary care can delay disease progression and reduce the risk of complications. Annual testing can also reduce the risk of uncontrolled or undetected diabetes in future pregnancies.

Readers of our book can find information of the blood sugar targets that are optimal in pre-pregnancy and pregnancy and of course the type of food and menus that will help them achieve these targets. Detailed insulin administration tips are also described to optimise insulin to meal matching.