Outlook for Pregnant Diabetics Improved

In the 1970s, diabetic women were discouraged from becoming pregnant due to adverse effects to the mother and fetus as well as a lack of accurate information for the health care professional. Before insulin became available, the maternal mortality rate for women with diabetes was greater than 30 percent and the perinatal mortality of infants of diabetic mothers was greater than 60.

Now, with improvements in care, including insulin therapy, monitoring, and prenatal testing, maternal mortality is minimal and perinatal mortality is less than 5 percent. This is still high, however, compared with the perinatal mortality rate of less than 1 percent for the general population. With proper glycemic control, planning, and medical follow up, it is possible to have a healthy pregnancy and baby.

In diabetic women, pregnancy has the potential for increased complications due to drastic changes in the mother's carbohydrate metabolism. A growing fetus is dependent on the mother's nutrient supply of glucose, amino acids, and lipids. To a large extent, this supply is regulated by insulin. In the early stages of pregnancy, insulin sensitivity is normal or enhanced, which, in addition to morning sickness, accounts for a decrease in insulin needs.

In later pregnancy, the hormonal changes associated with fetal growth, such as the rise in estrogen, progesterone, prolactin, cortisol, and human placental lactogen, or HPL, are all associated with insulin resistance. The biggest contributor to this resistance is most likely the hormone HPL, which is very similar to growth hormone, a known insulin antagonist. This resistance is maximized in the third trimester. Also, during the latter part of the pregnancy maternal insulin levels reach a plateau, leading to an increase in free fatty acids, which further aggravates insulin resistance.

All of these changes in insulin sensitivity and in glucose and lipid levels have profound implications for the diabetic mother and the growing fetus. Good control of diabetes, prior to conception and throughout pregnancy, is the cornerstone for optimal maternal and neonatal outcomes.

The overall outlook for the pregnant diabetic patient has improved enormously over the last few decades. The most important aspect of diabetic care for the mother is the need to maintain good glycemic control, with the goal of lessening the risk for congenital malformations and other, later fetal complications. If no major complications are present, good glycemic control and careful monitoring can result in a healthy neonate, with minimal long-term health risk to the mother.

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©2006 Texas Medical Center

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