Pregnancy and the dangers of diabetes

Diabetes and pregnancy share a rocky and intimate bond.

High blood sugar level is often pointed out as one of the most serious conditions to be watched out for during pregnancy. Apart from posing the risk of developing diabetes in the mother, high fluctuating blood glucose can also lead to numerous health complications in the baby right from the fetal stage.

Diabetologists have also pointed out that sugar management has to be listed as one of the top priorities in the run-up to the delivery, as diabetes could result in drastic consequences including miscarriages in some women.

How are sugar levels and miscarriages connected?

“A pregnancy loss that occurs before twenty weeks is called a miscarriage and after twenty weeks is called a stillbirth. Women with type 1, type 2 and gestational diabetes have higher chances of miscarriages. It occurs mostly because of an undiagnosed diabetic condition or when women conceive at an older age,” says Dr Mohan K Rao, NS Diabetes and Hormone Centre, Bengaluru.

A miscarriage is generally indicated via bleeding, though in some cases, it can occur without showing any signs. This is called missed miscarriage; a mother gets to know about this only during a routine check-up. The other symptoms accompanied by bleeding are strong periods-like cramps, lower back pain and so on.

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“The chance of suffering a miscarriage becomes two times more if a comparison is to be made between a woman conceiving before 30 and a woman conceiving after 35. Older age and a prolonged diabetic history put miscarriage risk at a very high level in these women; they might develop micro-vascular disorders (disruptions in blood flow through the heart’s smallest blood vessels) even hampering embryo implantation and growth,” says Dr Sunil Eshwar, lead consultant and laparoscopic surgeon, Aster RV Hospital, Bengaluru.

Dr Eshwar further explains, “due to highly uncontrolled diabetes, a pregnant woman can at times develop infection or vasculitis which in turn leads to miscarriage. If the HBA1C levels are more than seven, it can lead to abnormalities in the baby and not necessarily a miscarriage. But if it is more than nine, there is a miscarriage risk too.” Dr Eshwar also points out that as women get older, the chance of having genetic abnormalities in babies also increases.

The retrospective study (Meriam Dalhoum et al.,2022) carried out at the National Institute of Nutrition of Tunis, analysed 50 diabetic pregnant women. The study indicated that the frequency of spontaneous miscarriage was 34 per cent with a higher incidence in type 2 diabetics, 82 per cent vs 18 per cent in type 1 diabetics. Patients with a history of spontaneous miscarriage had less controlled diabetes than others (mean hemoglobin glycated hemoglobin: 8.8 per cent vs 7.9 per cent). 

The objective of a Swedish study (Kristina Mattsson et al.,2021) published in the Fertility and Sterility journal was to analyse childbirth and the risk of miscarriage and infertility among women who have received a diagnosis of type 2 diabetes before the start of their reproductive journey. Women (ages 18 to 45) with the condition were compared with women without any type of diabetes. It was concluded that women with type 2 diabetes were more often childless compared with women without diabetes. They also had a higher risk of experiencing both miscarriage and infertility.

Diabetes management during pregnancy

Ghaziabad-based Monika Kapoor, now 41, formerly employed with a multinational company, is one of the many women with diabetes and had to resort to a very strict and disciplined lifestyle in her runup to motherhood. “I was diagnosed with diabetes at 33. Three years before the delivery of my boy, I had a vaginal infection that wasn’t healing. The doctor checked my sugar levels and found them high; that’s how the diagnosis was done. When I was expecting my son, I halted my oral medication and started taking insulin shots. Diabetes during the pregnancy was managed by four insulin shots a day, a strict diet and walking. I was walking until the day of the delivery.”

Dr Rao points out that insulin shots are preferred to oral medication as they don’t cross the placenta. “Hence, there are no impacts on the foetus,” he says.

Dr Eshwar explains that generally, diabetic pregnant women shift to insulin shots as sugar levels end up being high. It could be either because hormonal changes during pregnancy affect the metabolic rate or the individual could already be suffering from pre-existing metabolic disorders that adversely affect glucose metabolism. As a result, there will be fluctuations in blood sugar levels.

Dr Eshwar underlines the importance of exercise to manage the condition. “Cardio and weight training help maintain sugar levels. In weight training, the muscles tend to work without the help of insulin to metabolise sugar,” he says.

In addition to exercise and a nutritious balanced diet, experts also recommend vitamin folate (vitamin B9) food as they help prevent neural tube defects – defects in the brain and spine of the foetus – which could happen if the mother is diabetic. According to Harvard TH Chan School of Public Health, foods that are rich in folates (a natural form of folic acid) like green leafy vegetables, beans and eggs are often suggested as healthy choices for pregnant women.

In the mother, there can be conditions that develop because of diabetes. Ahmedabad-based Dr Banshi Saboo, diabetologist and former president of the Research Society for Study of Diabetes in India, tells Happiest Health that diabetic retinopathy is an eye complication that arises due to diabetes. “With pregnancy, it tends to worsen. Women have to be monitored regularly via fundoscopy (a process by which the pupils are dilated for a complete view of the retina) as it might lead to blindness depending on its severity,” says Dr Saboo.

Precautions before conception

Dr Eshwar says that borderline diabetes does not necessarily lead to miscarriages. “To avoid any complications, I suggest women control their sugar level before conceiving. Preferably, the fasting and after-food sugar levels should be below 100mg/dl and 150mg/dl, respectively. Also, the HBA1C should be less than six.”

According to Dr Rao, blood sugar levels should be checked at regular intervals for timely diagnosis of diabetes and gestational diabetes. “Ideally, it should be done in the first trimester, then at 24 weeks and then between 32 and 36 weeks. This should be accompanied by a healthy lifestyle which includes a balanced diet and exercise,” he says and adds that there is a need for pre-conception counselling and planned pregnancy.

Dr Saboo also stresses the need for pre-pregnancy counselling. “People aiming to be pregnant must take pre-pregnancy counselling with a diabetologist to run tests not only on sugar levels but also on other metabolic profiles. Also, ongoing medications should be scanned carefully as many medications shouldn’t be continued during the pregnancy. It is because it can have adverse effects on the baby. Counselling can help women stay healthy by fine-tuning everything, including calorie intake, medication and sugar levels.”

Conditions to watch out for during pregnancy

According to the National Institute of Diabetes and Digestive and Kidney Diseases, the doctor should check for:

• High blood pressure
• Eye disease
• Heart and blood vessel disease
• Nerve damage
• Kidney disease
• Thyroid disease

Dr Saboo also suggests regular monitoring of blood glucose levels before and during pregnancy as it will help in the timely detection and treatment of diabetes.