In our last discussion, we spoke of the problems and possibilities of childbirth for the mother who has diabetes. There are some mothers for whom diabetes is not an event known or even suspected before conception. In approximately 2% of otherwise normal pregnancies (one pregnancy in fifty) diabetes comes on by the 28th week. This type of “gestational diabetes” carries all the somber risks and tribulations of a mother with poorly controlled insulin-dependent diabetes prior to conception, namely large babies, premature babies, nonfunctioning lungs and increased risk of death or abnormal delivery.
The challenge for Texas lies for those whose family backgrounds puts them at uniquely high-risk for non-insulin dependent or maternity onset diabetes. For those of Mexican-American background, statistics from Monterey, Mexico suggest that gestational diabetes, or the diabetes of pregnancy, may be present in as high as 13% (one mother in eight) by the 28th week. For these mothers, the family tendency towards diabetes is brought out some ten to fifteen years earlier by the pregnancy. It is for them especially that the American Diabetes Association makes the recommendation for the screening of pregnant mothers between the 24th and 28th week.
Fortunately for many mothers the diabetes of pregnancy is readily controlled by careful adherence to a calorie restricted program. Only enough calories for the baby and then a little for the mother are advised. Careful monitoring of blood sugar for adequate control is what the mother can contribute to a successful birth and delivery. Occasionally her body may need additional assistance. Because diabetes tablets will cross the placenta and alter the babies sugar control, this is one time in non-insulin dependent diabetes when insulin may be needed to guarantee a successful outcome.
Clearly from many Texans the challenge lies in knowing whether diabetes of the mild maturity onset variety is a trait within the family. Once again it is most important for these mothers to be tested between weeks 24 and 28 of their pregnancy. Others who are at risk include those who are overweight, those who have lost babies during previous pregnancies and those whose earlier children weighed in excess of nine pounds. In other words, the challenge for Texans is the detection of the problem. Once this is discovered, the pregnancy is properly monitored and the blood sugar is kept within the normal range for the non-diabetic mother, the baby’s chances of normal birth, delivery and prognosis are excellent.
For most mothers with the diabetes of pregnancy, the arrival date of the child is an especially happy one since the end of the pregnancy is also the end of the state of abnormal blood sugar levels. Long term follow up of ladies who have experienced the diabetes of pregnancy is an important precautionary detail. If they allow themselves become overweight, some 40 to 60% of these women will develop classic, non-insulin-dependent (Type II) diabetes within 10 years.
This group of mothers who are overweight after their gestational diabetes is a unique high-risk group, in whom the natural history of Type II diabetes is being studied. Some fascinating results have been noted in Scandinavia, were mothers given sulfonylureas (diabetes tablets generally used for Type II patients) have led to a removal of the 40 to 60% risk of diabetes development. The debate still continues for those others at high risk for developing diabetes after the birth experience. Should they arise to the challenge of their genes and take an “anti-diabetic” tablet, even though they do not have diabetes? To what extent does the ten years of freedom from the family risk belie future changes in health in later life? Only time will tell.
In the meantime, for those of us with Mexican-American heritage, overweight or of Native American background, the chances of developing diabetes at pregnancy remains maybe one in eight. A special early reminder to the family physician, and adequate screening with a simple glucose load could become very important present to the new family arrival. For those who rise to the challenge and successfully conquer the risks, the reward of a perfect child with a normal birth weight and physiological function can be well worth the extra concerns taken.
Of the many ways to a happy family, enlightened planning, adequate testing and collaborative teamwork for the baby’s management before arrival can be the best response to the increasing challenge of Texans with a proud heritage.
Authored by: Brian Tulloch, M.D.