Diabetes and pregnancy

Pregnancy in diabetic patients is associated with a high risk of stillbirths, fetal malformations, abortions, macrosomia, neonatal mortality and morbidity. Several studies have demonstrated that near- normal glycaemia in early pregnancy reduces the frequency of spontaneous abortions and congenital abnormalities to a level close to that of infants of non-diabetic women.

During the different stages of pregnancy starting from planning conception to delivery and beyond, diabetes has a significant impact and probes important psychological issues that needs to be addressed in diabetes care.

In the starting stage, women with established diabetes may experience the increased stress levels related to their worries about possible birth defects that may interfere with family planning.

Pregnant diabetic women are faced with increasing scrutiny regarding fetal development, managing their diabetes as it responds to the pregnancy, and increased medical management.

Women are confronted with a serious health problem that may involve insulin therapy, and elicit anxieties regarding the impact of the diabetes on the health of both the unborn child and the mother, in case of gestational diabetes.

Planning pregnancy :

Nowadays, there are in principle no medical reasons for a woman with established diabetes not to become pregnant, provided she takes adequate care of her blood glucose control before conception and throughout the pregnancy. In some occasions doctors may advise against pregnancy, like, as when the women with diabetes has seriously advanced microvascular complications, and the pregnancy may accelerate these complications and cause severe disability or even death in the diabetic woman.

Health care professionals have taken the attitude that women with diabetes have it in their hands to prevent birth defects by maintaining optimal blood glucose levels before conception and throughout pregnancy.

But, is known yet about the heredity of type 1 diabetes, the issue of passing the disease to the unborn child appears of increasing concern for women with diabetes who are planning a family.

Psychologically some women or couples may be unrealistically optimistic regarding the health risks involved and others may react over anxiously and develop a phobia of hyperglycaemia, leading to excessive blood glucose monitoring and very frequent consultations of the physician.

From a psychological point of view, we would be subjected to advise couples struggling with infertility to take a more general attitude towards pregnancy. This approach may be less useful in women with diabetes. Because developing a more accepting attitude may be incompatible with staying adherent to the diabetes regimen.

Research suggests that most women with diabetes tend to seek medical care after they are pregnant, when damage to the fetus may already have occurred. It has been found that most unplanned pregnancies are not contraceptive failures, but may have been consciously or subconsciously intended.

Social support appears to play a significant role, as women with unplanned pregnancies are reported to be less satisfied with their partner relationship than those who have planned their pregnancy.

It is shown that the two most important factors influencing contraceptive use among diabetic women would be

1. attitudes towards contraception and
2. perception of the extent to which significant others want the woman to use contraception.

Management of pregnancy in diabetes :

Diabetes is one of the most psychologically and behaviourally demanding of the chronic illness. In women with diabetes who are pregnant, the demands of diabetes self-management are increased further. 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 task.

Pregnancy is an emotionally stressful period, during which the woman is confronted with various psychological and physical challenges. For a diabetic woman, the developmental tasks like developing attachment to fetus, preparing for separation, adopting a realistic relationship with the newborn, which are related to pregnancy are essentially the same as for any other woman.

Already the 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 over protectiveness and unplanned pregnancy may cause emotional stress in women with diabetes and fears of criticism and abandonment.

Receiving feedback of a lowering of glycated haemoglobin can help to decrease stress levels and improve self-esteem and also failure to improve glycaemic control can easily lead to feelings of guilt and an increase of psychological distress.

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. Hypoglycaemia may be one of the major reasons why women do not reach near-normal glycaemic control during pregnancy.

Delivery is a stressful event for every parent. For 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).

Indeed, clinical studies suggest a higher occurrence of premature labor and preterm delivery in diabetic pregnancies. Some research suggests that the children from diabetic mothers are at increased risk for a variety of behavioural disturbances.