SHERRI
SHAFER, R.D.,
Certified Diabetes Educator
Diabetes
and Pregnancy: Twice as important
Pregnancy
is a wondrous and exciting time. It’s a time of change, both
physically and emotionally. With the proper attention and prenatal
medical care, most women with diabetes can enjoy their pregnancies
and welcome a healthy baby into their lives. Why
Tight Blood Sugar Control Is Critically Important
Blood sugar control is
important from the first week of pregnancy all the way until
delivery. Organogenesis takes place in the first trimester.
Uncontrolled blood sugar during the early weeks of pregnancy
increases the risk of miscarriage, and birth defects. (Women
don’t develop gestational diabetes until later in pregnancy,
which means they don’t share these early pregnancy risks.)
Later in the pregnancy,
uncontrolled blood sugar levels can cause fetal macrosomia, which
may lead to shoulder dystocia, fractures, and the need for
Cesarean section deliveries. Very high blood sugar levels can
increase the risk of stillbirth.
Maternal
hyperglycemia can stimulate fetal hyperinsulinemia, and lead to
neonatal hypoglycemia when the glucose supply (umbilical cord) is
cut.
Because of all these increased
risks, home deliveries are not typically recommended for women
with any form of diabetes.
As many as two thirds of all
women with diabetes have unplanned pregnancies and most women
don’t realize that they’re pregnant until six or more weeks
into the pregnancy. That’s why it’s critically important for
women who have diabetes to use contraception and achieve tight
blood sugar control prior to conception. Many health-care
providers suggest at least three to six months of stable blood
sugar control prior to attempting to conceive. Hemoglobin A1c
should be within 1 percentage point above the lab normal, which
means striving for a HbA1c of less than 7 percent.
Women using oral agents should
be switched to insulin prior to becoming pregnant. Oral agents are
contraindicated in pregnancy. It's also important to make sure
that any other prescription drugs or over-the-counter medications
that are being used are safe for pregnancy. Typical
Blood Sugar Targets During Pregnancy Fasting
blood sugar:
< 95 mg/dl if meter reads
whole blood.
< 105 mg/dl if meter is
plasma calibrated. Blood
sugar level measured 1 hour after the meal:
< 140 mg/dl if meter reads
whole blood.
< 155 mg/dl if meter is
plasma calibrated. Dietary
Management
Calorie requirements increase
by 300 calories per day during months 4-9. Most women end up
needing a total of about 2,000-2,200 calories per day. Weight
should be monitored and calories adjusted to ensure appropriate
weight gain.
A minimum of 1,700-1,800
calories per day is recommended during pregnancy. Eating too few
calories or too few carbohydrates can cause the production of
ketones. Ketones can pass through the placenta and may have a
negative impact on the fetus.
Diabetes during pregnancy is
one situation when a slightly lower carbohydrate intake may be
prudent. I usually recommend that 40-50 percent of the calories
come from carbohydrate. I have women start with the lower end and
move up as tolerated. (Women using insulin often tolerate 45-50
percent, as insulin can be adjusted to cover.) Excessive
carbohydrate intake may make it difficult to maintain the strict
blood sugar control required during pregnancy. It’s equally
important to ensure adequate carbohydrate intake. If too little
carbohydrate is eaten, then important nutrients from the
carbohydrate food groups may be lacking. Grains, milk, and fruits
are each important components of a healthful diet. Calorie
Level
Grams of carbohydrate needed to provide 40-50 % of total
calories 1,700
170-213 1,800
180-225 1,900
190-238 2,000
200-250 2,100
210-263 2,200
220-275 2,300
230-288 2,400
240-300 2,500
250-313 2,600
260-325
Once carbohydrate goals are
determined, it’s important to distribute the carbohydrate intake
throughout the day. Eating too much at one time can cause the
blood glucose to go dangerously high. It works best to split the
carbohydrate budget between three meals and two to four
snacks--for example, 45-60 grams of carbohydrate for each main
meal and 15-30 grams of carbohydrate for each snack. (Note: some
women do best to limit breakfast to 30 grams of carbohydrate
secondary to hormonally mediated glucose intolerance that commonly
occurs in the morning.) Dietary
Strategies for Controlling the Blood Sugar *Distribute
carbohydrate between three meals and two to four snacks.
Distributing the carbohydrate throughout the day allows the body
to process it one batch at a time. *Milk
and fruit are both healthful choices. However, they tend to digest
rather quickly, which means that the glucose derived from those
foods enters the bloodstream rapidly. To prevent spiking post-meal
blood sugar levels, it’s recommended to eat those foods one
portion at a time. *Avoid
fruit juices, regular soft drinks and sugary beverages. *Avoid
added sugars. That includes natural sugars, honey, and syrups.
Every bite should count toward good nutrition *Breakfast
matters: Because of hormones, blood sugar levels can be especially
difficult to control at breakfast time. For women with elevated
post-breakfast blood glucose values, it helps to avoid milk,
fruit, and refined breakfast cereals at the breakfast meal (since
those foods digest so quickly). Milk and fruit should still be
included, but at meals or snacks other than breakfast. A breakfast
that consists of starch plus protein may be better tolerated.
Another option is to limit breakfast to 30 grams of carbohydrate
and distribute the remaining carbohydrate between the other meals
and snacks. But don’t skip breakfast. Blood glucose monitoring is crucial. If the above dietary guidelines are being followed, and blood glucose cannot be maintained within target levels, then insulin should be added or adjusted until control is achieved.
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