Diabetes in Pregnancy

So–you may be a known diabetic, or just found out you didn’t pass the glucose test, so you are now labeled GESTATIONAL DIABETIC.  Let’s all hope it goes away after the baby is born!

You will need to be checked again at your 6 week post partum visit to make sure you are not still diabetic!

Because we have some of the fluffiest people in Canada living in our area–we screen everybody.  The Society of Obstetricians in Canada recommends screening everybody—there are some centres in Saskatchewan and Ontario that do not do this.

You can be diabetic even if you are healthy beforehand–that darn placenta just can work 100% against you–no matter how healthy you eat, how much you exercise —- the “elephant in the room” is that PLACENTA!!!   The placenta makes hormones that can make you diabetic.   BUT   if you are diagnosed with diabetes early in the pregnancy–you can CALL it gestational diabetes—but you are very likely TYPE 2 diabetic.

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TESTING!!!

The preferred approach to test for diabetes in pregnancy is to begin with a 50 g glucose challenge test (that sickly sweet orange drink).

You do not have to FAST for the 50 gram test–but this is NOT the morning to hit House of Pancakes and load up on syrup!  Have some ham and eggs—much better!

If you fail this 50 gram test, you will have to do the 2 hour test, with a 75 g oral glucose drink.   THIS one you FAST for!

IF YOUR ONE HOUR  BASIC SCREEN IS7.8 mmol/liter (  ≥ 140 mg/dl) YOU JUST FAILED AND NEED THE TWO HOUR TEST.

TWO HOUR TEST:

You are considered diabetic if you have ONE NUMBER ABNORMAL:

fasting       ≥5.3 mmol/L     (95mg/dl)

(  ≥ is read as greater than OR EQUAL TO)

1 hour        ≥10.6 mmol/L

2 hours       ≥9.0 mmol/L)

GOALS OF DIET AND MEDICATION ARE SUGARS THAT ARE:

fasting                                        < (less than)5.3mmol/L,(95 mg/dl)

I hour postprandial (after eating)   <7.5 mmol/l(140 mg/dl)

and 2 hours postprandial                 <6.7 mmol/L.(<120mg/dl))

What are the complications of being diabetic in pregnancy?

  1.  higher birth weight baby, so more trouble getting shoulders delivered, and higher chance of  C. Section
  2. C. Section on fluffy women don’t heal as well, and it is not unusual to spend weeks having your wound packed–while you are trying to care for a newborn
  3. increase in death for baby–uncontrolled diabetes has a higher death rate, and stillborn rate.  This is NOT a higher risk if you are DIET CONTROLLED!!!   Diet controlled is same risk of a normal pregnancy—-so try really hard to do your BEST with diet—there’s no “do-overs” for making this baby.
  4. problems  with the sugar control in the baby after birth
  5. a mom who is at risk for continued diabetes after delivery (you need to be checked after delivery to make sure you don’t need to continue with medications etc.
  6. diabetes is bad for your heart and your brain–heart attacks and strokes–we NEED you around to get this baby through life!

If women with GDM (gestational diabetes mellitus), do not achieve sugar targets within 2 weeks from diet  alone, insulin therapy should be initiated.  Sometimes, if there is just a problem with fasting sugars, or sugars are still high wtih decent diet, the option of the pill Glyburide is one I discuss.  Although not generally done here, there is plenty of literature abut its use in pregnancy.   I used it quite a lot when practicing in the USA.  I will use it when a woman refuses insulin.

Glyburide is safe and effective in controlling glucose levels in >80% of patients with GDM and does not cross the placenta.

Women who are older, who are diagnosed earlier than 25 weeks, and have higher fasting and postprandial glucose values on their OGTT (oral glucose tolerance test–that 75 gram drink and 2 hour test), are less likely to respond to glyburide.  I find it best when the morning sugar alone is the highest.

The use of Glyburide can lead to increase compliance with care–women are more accepting of a pill than a needle!  If, however, you are told you need insulin–you need insulin—time to put on the grown-up panties, and do what you can to keep this pregnancy going well.   It’s a tiny needle—-and YES–you CAN do it!!

You don’t have to give your shot in the same place every time.  This is an example of a”grid” system.  You can think of your belly like this–just move along every day, and you won’t hit the ame area for at least another month.

HEMOGLOBIN A1C  (HGB A1C)

Hgb A1C is a blood test that shows the average blood glucose level over the previous two to three months.   It does not matter if you fast for this test—it is a way to see how your sugars are, even if you have been really good for a day or two before you are tested.

If your sugars have been high we will know!   We may test this monthly if we have trouble with control.  We are very happy if under 6.7–and pretty well over the moon if under 6!

DIET

Miserable thing–but there are no good cereals, no good cookies, no good cakes, and no good rice or pasta–and no good juices or sodas.  I hear –well eat BROWN rice—there is VERY little difference between white and brown rice.  A serving of rice is HALF A CUP (leveled off)—like WHO eats just that—-they bring 4 cup servings in most restaurants!

There are no good juices–well maybe tomato juice — and although milk is fine–CHOCOLATE milk is NOT!

Calories per day are typically divided over three meals, and two to four snacks.   In general, the calories are divided up so that  40 percent of calories come from carbohydrate, 20 percent protein, and 40 percent fat.  Some experts feel that 40% carbs is one of the reasons we have this obesity epidemic–and suggest 35% carbs, 40% protein, and 25% fat.

Try to eat as many veggies as you can—-use vinaigrettes for dressing.

You need to pay attention to labels, and to the GLYCEMIC INDEX of foods.  Some foods will really push up your blood sugar.   You also need to pay attention to GLYCEMIC LOAD.

The glycemic load is calculated by multiplying the grams of a carbohydrate in a serving by that food’s glycemic index, then divide by 100.

A glycemic load of 10 or below is considered low.Thumbs up sign

A glycemic load of 20 or above is considered high.

A glycemic INDEX–GI  is rated:

0-55 is low           56-69 is medium         70 and over is high

Two foods with the same amount of carbohydrates can have different glycemic index (GI)numbers.   Also, if you are cooking pasta–the longer you cook it, the higher the glycemic index (GI).

Very ripe fruits tend to have a higher glycemic index.  That’s why you use very ripe bananas in banana bread!

You want to avoid foods with high GI, and high GL (glycemic load).

Math Clip Art

HOW TO DO THE MATH–and we tend to eat the same foods so you can keep a log in a book or on your smart phone under notes app.

LINKS TO SITES WITH APPS YOU MAY LIKE

There are free apps that will tell you the GI of most foods (and you have to try to use food that is not processed–that means put in a can, or a box, or a bottle).

As long as you know the glycemic index of a food and the grams of available carbohydrates (total carbohydrate minus fiber) in that food, you can figure out that food’s glycemic load.

GLYCEMIC LOAD = Glycemic index x Grams of carbohydrates / 100

Image result for raw carrots

1/2-cup serving of raw carrots, which have about 8.6 grams of available carbohydrates and a glycemic index of 45.

AVAILABLE carbs is number of carbs per serving MINUS number of grams of fiber per serving.

45 (G.I.)x 8.6 (# of available carbs per 1/2 cup serving) = 387 / 100 = 3.9 glycemic load

YAAAAHHH    stuff your face on carrots!!!  Please–SHOOT me!!

 

So  ONE CUP of red kidney beans has 37 grams of carbs and 9 grams of fiber–

so AVAILABLE carbs is 28 grams.  Now that sounds like a lot.   The G.I.  (from charts available on the internet or on apps you can get) is 27.

The G.L. (glcemic load) is:

27(glycemic index) x 28 (number of carbs in one cup)/100= 7.56

Half a cup is 27 x 14(half of 28)/100 = 3.78  — a really LOW glycemic load!

Want to calculate the glycemic load of instant white rice instead?

Well, a portion size of around 2/3 cup of white rice has about 36 grams of available carbohydrates and a glycemic index of 72. Here’s the math:

72 (GI) x 36 (carb content) = 2,592 / 100 = 26 glycemic load—–NOT GOOD!!!!

If you HAVE to have rice, then make it a brown rice BUT consider mixing in Quinoa, lentils, chia seeds. millet–or other grains etc— make it more tasty.  COOLING the rice actually will slightly lower the GI, since the sugars in the rice will “crystallize” and become less digestible—at least that is what dieticians (they’re the experts!!) are telling us.

The glycemic load uses a specific calculation. So as long as you know the glycemic index of a food and the grams of available carbohydrates (total carbohydrate minus fiber) in that food, you can figure out that food’s glycemic load. Here’s the calculation:

Glycemic index x Grams of carbohydrates / 100

LIST OF GLYCEMIC INDEX OF COMMON FOODS

GLYCEMIC LOAD AND INDEX –LIST by HARVARD UNIVERSITY

article that explains, pretty well, how to put it all together

 

KRAFT DINNER each box is supposed to have THREE SERVINGS   hahahahahahahahaha—yeah    right

ONE SERVING IS  1/3 cup (level) unprepared has 27G of carbs in 52 grams– and 1Gram of fiber so subtract 1—-so 26 grams of available carbs per serving—we’ll forget the cheese for now and just do the macaroni.

Related image

From printed charts we know the GLYCEMIC INDEX of macaroni is 50 per 100 grams–so we will use

50 (the GI) x 26 (grams of carbs per serving-which is ONE THIRD OF THE BOX!)=1300 then divide by 100 = 13 GLYCEMIC LOAD    This is medium GLYCEMIC LOAD—now—let’s get REAL—-you are going to eat at least half the box!

So–  half a box has 54 grams of carbs, so now

GI (50) x 54 /100 = 27      HIGH GLYCEMIC LOAD

Oh   –now add on the cheese!!!—look!!—just FORGET this meal as an option!

SERIOUSLY!!   Look at doing zucchini pasta–it holds up well to thick sauces.  Spaghetti squash is an option but it is a bit watery in my opinion.

Remember that even though bottled spaghetti sauces look healthy (they are red so tomatoes and tomatoes are healthy)–there is a bucketload of sugar in them—that’s why they burn in the pot so easily–the corn syrup caramelizes!!!  Just read the ingredients on your next bottle—-there will be a maltOSE or a fructOSE or a sucrOSE–some OSE (code word for SUGAR)!!   MAKE YOUR  OWN SAUCE!!

ENOUGH!!!!!!   GET AN APP ALREADY!!!!!  OR  remember—no bread, no cookies or cakes or cracker or cereals.  No pasta. No candy, chocolate….basically–if it looks delicious…DON’T EAT IT!!!!

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WHAT TO EXPECT during pregnancy if you have diabetes.

If your get your sugars controlled with diet alone, then no special testing needs to be done–you are at no higher risk than a normal pregnant woman.

IF you need insulin or meds, then things are done!

At about 32-34 weeks we start doing NST (non stress tests).  This is where you are put on a monitor to graph out the baby heart beat for about 20-30 minutes.  We look for the heartbeat to go up when the baby moves.  We may do NST weekly or twice a week–depending on your medical situation.

For instance, diabetics are way more prone to high blood pressure in pregnancy–so if we have you on insulin AND we have to start blood pressure pills, you will get tested more than someone who has normal blood pressure.

If there is excessive fluid around your baby (polyhydramnios–poly=too much   hydra= water  amnio= fetus sac), you may get more testing done.

Your risk is highest if your average sugars are over 180 mg/dl (10 mmol/l), and your Hgb A1C is over 8%.

We try to aim for a normal vaginal birth, but diabetics do have a higher chance of a C. Section due to size of baby, and increased risk of other complications such as high blood pressure, too much fluid, etc.

We are not here to give you a hard time—but we are not your best friend—we are your doctors/practitioners–and you might not like what we say—but DON’T SHOOT THE MESSENGER!   PLEASE!!!!

 

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