Edited by Frank J. Snoek and T. Chas Skinner
Psychological Issues in the Management of Diabetes and Pregnancy
Pregnancy has a significant impact on most women with diabetes mellitus.
Diabetic women who become pregnant are faced with increasing demands in managing their diabetes as it responds to the pregnancy. In addition, they are subjected to intensified medical care focused on possible foetal problems, such as birth defects and mal-development, and diabetes-related complications.
Diabetes mellitus in pregnancy is associated with an increased risk of preeclampsia, spontaneous abortions, foetal malformations, stillbirths, macrosomia and related neonatal morbidity. In the last decades, it has become clear that poor glycemic control is an important determinant of these problems.1,2 Achieving and maintaining optimum glucose regulation is considered of high relevance in minimizing the risk of these complications.
Unfortunately, diabetic women with good glycemic control before and during pregnancy generally should not expect a normal rate of perinatal complications. In a prospective cohort study of 323 Dutch women with type 1 diabetes and overall good glycemic control (HbA1c less than 7%), it was noticed that the rates of congenital malformations, macrosomia and perinatal death were still increased 3.5- to 4.5-fold as compared with national data.3
Next and related to medical problems, important psychological issues may arise and need to be addressed as part of a multidisciplinary team approach.
This chapter will highlight some of the psychological issues involved in diabetes care throughout different stages of pregnancy, from planning conception to delivery and beyond.
In general, maternal and perinatal complication rates are lower in diabetic women with lower HbA1c levels.1–3 In this respect, it is considered important to counsel diabetic women who are planning to become pregnant about the reduction in complications that may be achieved by (further) improvement of glycemic control.4–6 Fertile women with diabetes should be strongly encouraged to use effective contraception until optimal glycemic control has been established.
Research suggests that most women with diabetes tend to seek medical care after they have discovered they are pregnant. In the Maine study, in which health care providers in a state-wide network were trained in preconception care and attempts were made to contact diabetic women before pregnancy, only one-third of the diabetic pregnancies occurred in women who had received preconception counselling.7
Lower income, unemployment, less education and unmarried status are known factors to have a major impact on whether or not women seek preconception care.8
Large individual differences may be observed in how diabetic women and their partners cope with the need for ‘preconception watchfulness’ and pregnancy planning. While some women or couples may be ‘unrealistically’ optimistic regarding the health risks involved, others may react over-anxiously, and develop a phobia of hyperglycemia, leading to excessive blood glucose monitoring and very frequent consultations of the diabetes health care team.
Unplanned pregnancy may cause emotional stress and fears of criticism.
In a recent study, it was found that women who felt their doctor discouraged pregnancy were more likely to have an unplanned pregnancy than women who had been reassured they could have a healthy baby.9 This finding underscores the importance of the doctor-patient relationship.10
Social support appears to play a significant role as well. In the same study, women with unplanned pregnancies reported to be less satisfied with their partner relationship than those who planned their pregnancies. Most of the women with unplanned pregnancies felt that their partners were not well informed about the possible risks or were not able to understand the amount of effort required to achieve a good diabetes control.9
For a woman with diabetes the ‘developmental tasks’ related to pregnancy are essentially the same as for any woman, i.e. developing attachment to the fetus, preparing for separation and adopting a realistic relationship with the newborn. 11,12
It is thought, however, that women with diabetes have a different mood profile compared with non-diabetic women. In a study of pregnant women with preexisting diabetes mellitus and non-diabetic controls, maternal characteristics and test results on the Profile of Mood States-Bipolar form were reported. Women with diabetes displayed a greater anxiety and hostility in comparison with nondiabetic women with no association to their level of glycemic control. Their psychological profile was not associated with the severity of the disease as reflected by the diabetes classification.13
By contrast, in a prospective longitudinal study using Mental Health Inventory (MHI-5) forms and the Spielberger State–Trait Anxiety Inventory (STAI) during pregnancy, women with gestational diabetes expressed no higher anxiety scores than glucose-tolerant women.14 In a study measuring bipolar subjective mood states, the mood profile in such women was significantly associated with their level of glycemic control.15 Thus the degree of metabolic control appears of psychological importance in women with gestational diabetes. Continuous reassurance regarding metabolic control in women with gestational diabetes may enhance their confidence and ability to cope with their temporary disease state.16
The experience of pregnancy for a woman with diabetes is strongly influenced by the increasing demands of the diabetes treatment regimen, concerns about the health of her baby, and the impact of the pregnancy on her own health.
For women who are in poor metabolic control, the requirements of more intensive self-care and medical management can give way to worries and increased stress levels.
Women striving for ‘perfect’ diabetes control may find it extremely difficult to accept any elevated blood glucose level and become highly frustrated by the day-to-day glucose variability that is likely to occur in insulin-dependent diabetes regardless of pregnancy. Lowering of glycosylated hemoglobin can help to decrease stress levels and improve self-esteem. Failure to improve glycemic control can easily lead to feelings of guilt and an increase of psychological distress and eventually diabetes ‘burn-out’.17
Strict glycemic control increases the risk of (severe) hypoglycemia. It was found that in about two-thirds of diabetic pregnancies that were regulated by intensive insulin therapy, at least one episode of severe hypoglycemia occurred during the first 20 weeks.18 In a recent cohort-study, a mean of 2.6 episodes of hypoglycemia was reported during the first trimester. A lower HbA1c level and a higher total daily insulin dose were predictive for severe hypoglycemia.19
Severe hypoglycemia can cause high levels of anxiety, confronting the mother-to-be with a serious dilemma. On the one hand she strives for optimal glycemic control to reduce the risk of birth defects; on the other hand she wants to minimize the risk of hypoglycemia because of the possible harm that it may cause to herself and the fetus. To date, the adverse effects of (periods of) maternal hypoglycemia to the fetus’s health are not well established. Impaired hypoglycemia awareness and related worries about severe hypoglycemia can lead the pregnant woman to accept higher levels of blood glucose, thereby compromising glycemic control.20 This may be particularly true for women for whom work and/or family commitments make it extremely difficult to have low blood glucose levels.
Obstetrical care in the first and early second trimesters is largely concentrated on detecting birth defects. In the late second and third trimester, the obstetrical focus is on assessing fetal growth and development, and maternal health.
The revelation of fetal anomalies, abnormal fetal growth and/or development in women with poor metabolic control may cause feelings of guilt and distress, resulting in further glucose dysregulation.
Clinical studies suggest a higher occurrence of premature labor and preterm delivery in diabetic pregnancies.21,22 The imminent birth of a preterm infant and a (long) period of hospital stay preceding this event may induce anxiety and feelings of separation in women concerned. This emotional stress can have a negative impact on their metabolic control and vice versa.
Delivery is a stressful event to all women and their partners. In general, women are in fear of the possible pain that delivery may cause. Women may be anxious whether they will be able to cope with this pain if analgesia is not available soon or is not effective enough. In women with diabetes, stress levels may be increased in view of the possible complications of delivery related to macrosomia. Shoulder dystocia due to macrosomia is a major clinical problem which may cause irreversible physical damage to the newborn and secondary surgical complications to the mother. Feelings of anger, doubt and anxiety may persist for many years thereafter. In this respect, it is important to discuss prenatally the procedures and possible complications of either vaginal or caesarean delivery.
Little is known about the psychological implications of breastfeeding in women with diabetes other than in non-diabetic women. Diabetic women may find it stimulating that breastfeeding appears to be an independent protective factor against type 1 diabetes in their children.23
Little is known about how diabetic pregnancy, both in type 1 and gestational diabetes, affects the development of the maternal-infant relationship. There is some research to suggest that children from diabetic mothers are at increased risk for a variety of behavioral disturbances, partly related to the children’s obesity.24
In an Israeli study, one-year-old infants of women with diabetes mellitus had lower scores on the Bayley Scales of Infant Development and revealed fewer positive and more negative behaviors than infants of mothers in the non-diabetic group. Infant outcomes in the maternal diabetic group were associated with maternal metabolism.25
Prepregnancy counseling has so far shown to have a limited effect in changing contraceptive behavior in women with diabetes. Unplanned pregnancies therefore remain a major problem. Further research into possible ways of improving the efficacy of prepregnancy programs are warranted. Such studies should take into account socio-economic, cultural and ethnic factors, that can strongly influence a woman’s acceptance, understanding and adherence to restrictions imposed by a diabetic pregnancy.26
Education is a prerequisite for adequate diabetes self-management, but by no means a guarantee that patients will indeed adhere to the diabetes regimen. In order to help women to cope more effectively with their diabetes, it is essential to identify their specific psychological and behavioral barriers, such as low diabetes identify their specific psychological and behavioral barriers, such as low diabetes self-efficacy, fear of hypoglycemia and lack of social support. Customized psychosocial interventions should prove helpful in improving the outcome of diabetic pregnancies as well as the women’s quality of life.
New technologies in monitoring glycemic control should be evaluated regarding their psychological implications. Continuous glucose monitoring (CGM) is a promising technique that appears useful in detecting high postprandial blood glucose levels and nocturnal hypoglycaemic events that are unrecognized by intermittent blood glucose measurements.27 The psychological consequences of CGM in pregnant diabetic women who are confronted with concealed high and low levels of blood glucose despite tight monitoring should be a subject of future studies.
The importance of a follow-up protocol after delivery is emphasized by the observation that glycemic control often quickly deteriorates after delivery, returning to suboptimal prepregnancy levels.
In the last decades, much progress has been made in the medical management of diabetic pregnancy. A large number of health care professionals is involved in medical care for pregnant women with diabetes. Dedicated medical specialists (obstetricians, endocrinologists, ophthalmologists, nephrologists, neonatologists), diabetic nurses and dietary consultants have their specific shares in the prevention, diagnosis and treatment of maternal and perinatal complications. In daily practice, it appears difficult to attune the activities of these different professionals to each other. In Amsterdam (VU medical center), an integrated pregnancy and diabetes clinic was started in April 2004 to overcome these problems and improve the care for the pregnant woman with diabetes and her child (to-be). The rates of complications and women’s satisfaction with the provided care will be evaluated and used to further improve the quality of care.
Next to the medical aspects of diabetic pregnancy, psychological and social issues appear to be important determinants of pregnancy outcome and possibly provide a key to further enhancement of diabetes care in pregnancy. The integration of psychological expertise with specialized medical care may provide a substantial contribution to a further improvement of multidisciplinary diabetes management in pregnancy.
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Copyright © 2005 by John Wiley & Sons, Ltd.