Better vigilance could stem pregnancy-linked diabetes
Many women miss prenatal deadlines to best control blood sugar, an expert says. Perils affect both prospective mother and fetus.
Child-bearing years are likened, with opportunity and finality, to a ticking clock. Women who are diabetic confront an additional deadline in motherhood, with their health and that of the fetus in the balance.
Lamentably, about 90 percent of them miss the deadline.
Such is the experience of Dr. Zane Brown, a UW Medicine perinatologist who since 1974 has treated diabetic women in pregnancy almost exclusively – more than 4,500 cases.
“Once a patient is pregnant and diabetic, she's already missed the point at which we can do a lot for her. She needs to enroll into care prior to conception. When that happens, we can prevent a lot of early pregnancy loss, birth defects. Later on it’s simply a matter of controlling her blood sugars to control babies’ weight and to permit a normal delivery.”
Brown estimated that only 10 percent of his patients seek guidance before conception. The rest present at two or three months along, sometimes farther, unwittingly raising their risk of hypertension, stroke, placental abruption and fetal loss, or a child born with deficits.
He wished more family practitioners and primary-care physicians communicated the benefit of family planning to women of child-bearing age who are diabetic or at heightened risk for pre-diabetes.
“As physicians, we need to talk to women about pregnancy and getting blood sugars normal before conception,” he said. “Once you are pregnant, the meter is running very quickly. When a new patient is [several months pregnant], we can't take weeks or months to bring those levels down. They have to be hospitalized immediately to save the pregnancy, and we might have two or three days to normalize blood sugars.”
Rapid normalization of blood sugars is possible, he said, but often at the cost of the woman developing proliferative retinopathy, in which the blood vessels in the eye weaken and bleed.
“If that patient comes in before conception, we can take three or four months to get blood sugars down,” Brown said, comparing the more gradual normalization to underwater divers’ slow ascent to avoid “the bends.”
When glucose becomes poison
By definition, gestational diabetes is spurred by, or first recognized during, pregnancy. In the vast majority of cases, “mild diabetes has probably been present for years, and if not for the test at 24 weeks would go unrecognized,” he said.
Women’s insulin needs rise during pregnancy, but diabetics cannot produce enough to meet the need. Glucose can rise to two to three times its norm, morphing from an essential fuel into a broad-spectrum teratogen – an agent able to poison virtually any organ in the fetus.
“It's worse than radiation, X-ray or cigarette smoking,” Brown said.
As a result, “maybe a heart valve is not in place or a part of the brain doesn't develop.” For the mother, longer term, high levels of blood glucose can destroy tissue within an organ – perhaps the functional part of the kidney, leading to renal failure.
The Maternal and Infant Care Clinic at UW Medical Center delivers babies for the majority of the state’s patients with insulin-requiring diabetes, Brown said.
“We’re one of the largest diabetes-in-pregnancy practices in the country, probably, by pure numbers. I don't think there's ever a time when there aren't several patients on the labor unit who have insulin-requiring diabetes. Our nurses, anesthesiologists and pediatricians are spectacularly aware and adept at treating these patients.”
To refer a patient or learn more, contact the Maternal and Infant Care Clinic at 206.598.4070.
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