Understanding Diabetes and Pregnancy: Expert Q&A

Patients who have pre-diabetes or diabetes benefit from precise monitoring and specialized care, especially when they're pregnant. Regardless of the type of diabetes, high blood sugar levels can cause serious complications during pregnancy and place a baby at increased risk for health problems. Our experts, Maternal Fetal Medicine Specialist Dr. Maritza Gonzalez and Endocrinologist Dr. Laura Dickens will talk and answer questions about the new diabetes and pregnancy program designed for patients who need complex diabetes care before, during, and after the pregnancies. Our experts will tell you about the latest in care and they'll take your questions live. That's coming up right now on At The Forefront Live.

[MUSIC PLAYING]

And we want to remind our viewers that today's program is not designed to take the place of a visit with your actual physician. Let's start off with having each one of you introduce yourselves and tell us a little bit about what you do here at UChicago Medicine. And Dr. Dickens, you're actually at the desk with me, so we'll start with you.

Hi. Thanks so much. My name is Laura Dickens. I'm an endocrinologist here at the University. So endocrinologists specialize in problems of hormones and glands, including diabetes.

Great. And Dr. Gonzalez, you're actually joining us from across the room as we continue to try to social distance as we do these shows. So let's have you introduce yourself and tell us--

Thank you, Tim.

Yeah.

I'm Maritza Gonzalez. I'm a Maternal Fetal Medicine Specialist. Or, in other words, I am an OB doctor that takes care of high-risk pregnancies.

So let's talk a little bit about pregnancy and diabetes. It's a real issue that I think a lot of people probably don't think about unless it impacts them directly, but it impacts quite a few women. First of all, in our community and our neighborhood, and it's a pretty significant issue. Can you describe to us how type 2 diabetes affects women who are pregnant and their babies?

Absolutely, absolutely. So, as you said, it's a common problem. Here in the United States about 1 in 10 people have type 2 diabetes. And so many pregnancies are affected. The key thing about type 2 diabetes and pregnancy is that we want to plan ahead. So women with type 2 diabetes can have a healthy pregnancy.

It's important that this planning process begins long before you're thinking of getting pregnant. So ideally, before getting pregnant, your blood sugar should be as close to normal as possible. So all women of childbearing age should talk about this with their diabetes care team and get blood sugars under excellent control before it's even part of the equation.

So we hear about type 1 diabetes, type 2 diabetes. What are the differences?

Great question. So I guess to start out, in general, diabetes is a problem where blood glucose or blood sugars are too high. And anytime you eat, your body breaks down food into sugar. Insulin is a hormone that helps your body to use that sugar for fuel. So with diabetes, your body's either not producing insulin or not using it well.

So in type 1 diabetes, the body, all at once or over time, stops producing insulin, so you require insulin shots for your life. With type 2 diabetes, usually you're producing insulin but just not using it well. So this is where we can use other medications like pills, but many times we do end up needing insulin depending on the course of the disease.

So Dr. Gonzalez, as we talk about women who are thinking maybe about getting pregnant, and if they do have diabetes, I think sometimes people worry about just handling the pregnancy in general and then you add in this factor. Is that something that people need to be overly concerned about? Or, do diabetic women, are they fine, just go ahead and go ahead with pregnancy?

I think that's a great question. Women who have diabetes, before pregnancy or are thinking about getting pregnant, it is important that they work closely together with their obstetrical provider and their diabetic specialists. Some would say that it's best to make sure that their hemoglobin a1c is less than 7.0 in the few months leading up to preparing for pregnancy.

One of the other things that they can do is also take a prenatal vitamin and increase folic acid to help decrease some of the structural abnormalities that we see more often in women with diabetes and pregnancy when their diabetes is not well controlled. So it's fair to be concerned that having a pregnancy with preexisting diabetes is more complicated and carries more risks, but it certainly is doable, and many women can have a healthy pregnancy and postpartum period with diabetes.

How about if you're pre-diabetic? What things should you know and what things can you do?

Right. So like I mentioned before, making sure that the hemoglobin a1c is as well controlled as possible, taking medication early on to help prevent any structural abnormalities, like the folic acid helps decrease the risk of open-neural tube defects. It's one of the important nutrition factors that is required to help that development. And most women don't realize that they're pregnant until the nervous system of a baby has already been starting to form or formed.

So that's why being proactive and preparing for pregnancy really decreases those risk complications. Making sure that they have a good nutrition plan, a good exercise plan, have had their health maintenance up to date when they're getting ready for pregnancy is one of the great things that can be done.

So Dr. Dickens, I wondered if we could talk a little bit about food types, and I know you have a graphic that we can take a look at too, which would be kind of neat. I think we can do that. One of the challenges that I think a lot of people face, women particularly in this area, in our neighborhood, we hear about food deserts, and that's a real issue. I don't know if you could talk a little bit about that and then kind of discuss healthy food types.

Yeah, absolutely. You're right. That's a big challenge. And many of our patients are facing that. We can start by describing a little bit--

Sure, let's go ahead and pull that up, John, if we can.

On the graphic. So this is a method, I guess, that I suggest to a lot of my patients. It's called the plate method. And the reason I like it is because it doesn't require necessarily measuring cups or detailed knowledge about portion sizes. You can use your regular 9-inch plate to help guide you in your food choices.

So the idea here is that half of your plate should be made up of non-starchy vegetables. A quarter of the plate, so the top right is your starch portion, and 1/4 of the plate, so the bottom right, is a lean protein. And this is a nice graphic to give some examples of what could fit into each of those categories. But using this as a guide, it helps to limit your carbohydrates, which carbohydrates are an important component of the diet for women affected by diabetes.

Carbohydrates raise your blood sugar. So we want to make sure we choose healthy ones and limit the portion. And then be sure to get lean protein chicken, fish, particularly when you're pregnant. And then the vegetable portion. Many of us are guilty of not getting enough vegetables. Filling half your plate is a good way to start.

And one of the things that we will do commonly. We work with registered dieticians who are experts in food and nutrition and can help when you're dealing with a tight budget or feeding a family with some practical solutions for how to get to this endpoint, things like farmers markets, employing canned or frozen vegetables. There are a lot of ways to get that healthy nutrition that doesn't have to be very expensive.

One of the things that I saw that was pretty neat that happens on the south side of Chicago are these neighborhood gardens. And I was really blown away by the quality of the food and the organization that was happening. I mean, these are folks that are basically urban farmers, but they give away the produce to folks in the neighborhood. And I thought that was really a neat idea and just a wonderful way to kind of share and get the very best in vegetables.

Yeah, that's fantastic. So great to know about those resources.

Yeah, it really. We need more things like that, because I do think it is difficult a lot of times for folks to get what they need. So Dr. Gonzalez, you had some statistics, I think, you wanted to share on pregnancy and diabetes. I don't know if you wanted to throw any of those out.

Well, I think--

Putting you on the spot here.

A little bit. I think an important one is that all women are at risk for diabetes in pregnancy if they don't have pre-existing diabetes. And if you were to develop gestational diabetes, which is what we call diabetes only pertaining to pregnancy, you do have around 50% risk of developing type 2 diabetes in your after-pregnancy. So that's anywhere between 5 to 20 years after the pregnancy that was affected with gestational diabetes.

So I think that's important to remember, that having gestational diabetes, and if you don't still have diabetes in the postpartum period, you continue to be at higher risk. But the good thing is that it's a very modifiable risk, meaning there's a lot of things that you can do to decrease that risk.

The other piece is-- [? an ?] important statistic to think about when talking about diabetes and pregnancy is that as the obesity rate in all populations, in particular, reproductive women or women of reproductive age, the rates of gestational diabetes are also rising. So we see a pretty clear pattern with increased pre-pregnancy weight and pregnancy weight, increased rates of gestational diabetes. So those are important to remember and why we test all women to see if they have diabetes in pregnancy.

And if there are some patients who have higher risk factors, we actually will test them earlier in the pregnancy. And then also between the second and third trimester as we normally do for everyone.

So let's go back to that for a moment, because I think that's interesting. You mentioned that even without pre-diabetes there still is a pretty high risk factor. Why is that? What causes that?

It's part of the natural process in pregnancy, actually. There are hormones that the placenta produces that later in pregnancy can mimic insulin resistance, and it's important for the development of the pregnancy. So I describe it as a natural process of the pregnancy. Some women have some risk factors that makes them a little higher or a little bit more challenging for them to overcome the insulin resistance and, thus, have what's called gestational diabetes. And so require a little closer monitoring in their pregnancy to make sure that their glucose is well controlled to avoid any complications in the pregnancy that are associated with diabetes and pregnancy.

And are we seeing more evidence of gestational diabetes in the past decade or so?

The rates are increasing, yes. I think, going back a few years, the data usually lags current times, but I think the risk had been around 6%, or the prevalence was 6% in all pregnancies, and that is increasing across essentially all ethnicities and all groups in the past 10 years.

So if somebody has diabetes, they have to really monitor their sugar levels. That's very important-- or their blood sugar. That's very important. And you have some show and tell for us, which we always love, to kind of demonstrate one of the methods that's used. We'll talk about a couple of different things here in a moment, but can you show us-- what do you have there?

Sure, absolutely. This is a glucometer or a blood sugar meter, which is what we use to test blood sugar. I'll walk you through how it's used. So before we're going to test, we're going to get everything set up, test strip, insert into the meter, that turns it on. I'm going to use an alcohol swab to clean my finger.

This is where we're going to get a drop of blood. You can wash your hands, too. That works perfectly well. This is a lancing device.

Contains a very tiny needle. Going to stick the side of my finger, which is a little bit less painful than the pad. All right, little prick. And we'll see a drop of blood.

A teeny tiny needle because you don't need a lot, obviously.

Exactly. All right. So we had a nice drop of blood here, apply it to the strip. And it'll count down, 5, 4, 3, 2, 1. Blood sugar reading is 87. Normal.

And what's a good number?

So it can depend on the time of day and how recently you've eaten. I'll tell you, during pregnancy, we're shooting for essentially normal blood sugars. So this means first thing in the morning before you've eaten, less than 90 to 95. One hour after eating, less than 140, 2 hours after eating, less than one 120.

So you have to check multiple times a day. And there's different ways to test. We discussed this a little bit before the show. And the reason I bring this up is I think everybody's seen the commercials. So can you talk a little bit about that and where we are with using those technologies with pregnant women?

Sure. So what we've been discussing is the continuous glucose monitor. So this is a sensor that's worn on the belly or the back of the arm, usually for 10 to 14 days, and it's continuously monitoring the blood sugar level. Not directly from the blood, actually, but from sort of the fluid and the tissue that lives right underneath your skin.

So it can send those numbers either to a cell phone app or to a little device that looks pretty similar to a meter and is essentially continuously tracking your blood sugar throughout the day. There are a couple of advantages to this. Obviously, it gives us a lot of numbers. So the process I just went through, we're usually asking women to do this four to six times a day. A continuous glucose monitor will give many more readings with, essentially, less hassle.

It also allows us to get readings during times like exercise or sleep when it may not be convenient to stop and prick your finger. So those are the great benefits. I will say this technology is not FDA-approved for use in pregnancy, but it is fairly commonly used and advocated for by professional societies and experts. So it's an exciting thing that we use in our practice and certainly are happy to talk with patients about.

Dr. Gonzalez, we were talking about that before the program as well. That's something that you all, your team, is working on to try to get that approval, which is a fairly lengthy process.

Well, more of we're trying to show the benefits of use in pregnancy and so we can work together with other groups to see if it's something that can be approved, but it certainly, just like Dr. Dickens mentioned, we see the benefit. There's a lot of societies who support the use of it. And especially because a lot of our patients have pre-existing diabetes and it's been part of their care. And it really helps us as providers have a better understanding about what their glucose pattern is like and helps us adjust their medication and follow their pregnancy a lot in a way that's a lot easier for families.

But yes, it is something that we're interested in. We have used it in patients and we want to compare and see how they have done and then hopefully encourage other providers to do as well.

That's great. And so when you're talking about looking at the different trends for the blood sugar, why is that so important?

It's actually one of the main tools that we have to monitor how well-controlled the diabetes is in the pregnancy and how to adjust any medication that they might need. And it really helps us determine what are the risk of complications with either delivery method, delivery timing, need for surgical procedures for delivery, that sort of information. Also, we know that the better control the glucose is throughout pregnancy, the less these complications are. So it really gives us an idea and pattern of how well they're doing day to day, actually.

Great. So Dr. Dickens, if somebody has gestational diabetes during pregnancy, is it likely they will become diabetic after giving birth? What do mothers need to know there?

Yeah, that's a great question and something we always want to talk about with our mothers before they have their baby. So the lifetime risk after having gestational diabetes of type 2 diabetes can be up to 50%, so a coin flip of whether you'll later develop type 2 diabetes. And in many cases, immediately after the baby is born and the placenta is delivered, those hormones that cause insulin resistance clear from your system and blood sugars can return to normal.

The key thing is that that doesn't happen all the time, so we do need to do some follow-up testing pretty soon after delivery to check and be certain there's not still pre-diabetes or diabetes. So this is a follow-up glucose tolerance test usually around six to eight weeks after having the baby. That's the first step. If that test is normal, you still should be screened every one to three years for developing type 2 diabetes.

I think Dr. Gonzales alluded to this, but the 50% can be a scary statistic to hear when you're dealing with gestational diabetes, but we have ways that we can significantly decrease that risk. And some of it we've alluded to, things like healthy eating and physical activity. Breastfeeding can lower that risk. And certain medications in different scenarios, like using metformin, can also decrease that risk. So I think it's important for women to have this knowledge and to see their providers and see what their options are to live a healthy life beyond this.

Dr. Gonzalez, that's one thing you really work with your patients on is giving them that knowledge and that information, and that's very critical. Can you talk to us a little bit about just, postpartum care, what do mothers need to know? What kind of tips do they get for living the healthiest life they can?

That's great. So I actually encourage my patients to continue to do as well as they were doing with their exercise and diet after delivery. Dr. Dickens mentioned breastfeeding also helps decrease the lifetime risk of type 2 diabetes. So continuing to stay active, continuing to monitor their diet and make sure that they're focusing on good carbohydrates, lean proteins. And continuing to have regular check ins with a health care provider, or their obstetrical provider, after pregnancy is going to help give the patients the knowledge and empower them to take care of their health long-term.

And so I love to encourage my patients to continue to do kind of what they're doing. They just don't need to check their sugar as often if they're not a known diabetic. Four times a day can be a lot.

So if they don't need to continue to do that, that's great, but certainly need to continue on their path of better health, better nutrition. It helps more than just decreasing the risk of diabetes. We're talking about decreasing the risk of heart disease and maintaining a healthy weight.

So we talk about prenatal care all the time, but postpartum care is so important as well.

Absolutely.

And moms need to continue to care for themselves because they're pretty busy at that point.

That's right. And it's hard. And it's hard for our patients. I believe that if we're serious about population health, then we should be serious about maternal health. So in order to be well and healthy for your family, you need to be well and healthy yourself as well.

So it's interesting that we have both of you on the program today. And it's one of the things that I think that I'm always impressed whenever we do these programs and we talk with various physicians and caregivers just about this multidisciplinary team approach that we take to care. And I wonder if we could get each one of you to kind of talk a little bit about that, because, I think, truly, when we talk about caring for the patient, it's so important to have many people involved from different areas. And I don't know, Dr. Dickens, maybe we can start with you, since you're right here, and then, Dr. Gonzalez, have you chime in as well.

You're exactly right. Especially for complicated medical conditions, diabetes and pregnancy being one of them, it's helpful to have a multidisciplinary team that brings together the different providers. Women in pregnancy are also asked to make a lot of doctors visits.

They're seeing their OB frequently. They're getting ultrasounds frequently. And we have a program where we've combined these resources into one physical location.

So we see patients together. They see our nutritionist, our diabetes educators. They receive their ultrasounds in one place. And their care team is working together as well. So we're in regular communication, making sure that things are seamless between their obstetric and their diabetes care. So it's a model that works really well, and we enjoy working together.

Dr. Gonzalez?

Yeah, just like Dr. Dickens said, it's great that we work in the same space. We were talking a little bit about postpartum care, how it's hard for patients to get that for themselves when they're busy with their children. Well, it doesn't mean that they're not busy before delivery. So by being able for our patients to see us in the same space, it decreases an additional appointment on a different day and the need to use those resources to get all those appointments.

Having diabetes in pregnancy does require more frequent visits than if you didn't. It does require a few more ultrasounds and closer monitoring. So this is one of the ways that we've helped make that easier for patients.

And being in the same physical space when we see our patients, we learn from each other as well. We help teach our learners. We help teach our patients. And so I think it's a great model that helps kind of debunk some of the myths about having diabetes in pregnancy and makes empowering women to be able to take care of themselves better a little bit easier for everyone.

That's perfect. And we want lots of healthy moms and healthy kids. So this is very important. And you all are-- it looks like you do a great job working together on this. So that's really nice.

We are out of time. Special thanks to our physicians for being with us today. And a big thank you to those of you who watch the program. Please remember to check out our Facebook page for our scheduled programs that are coming up in the future. To make an appointment, go online to UChicagoMedicine.org or you can call 888-824-0200

Thanks again for being with us today. And I hope everyone has a great week.

Thank you.

Thank you.