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Pregnancy with diabetes not necessarily risky by Dick Peterson Public Relations “If you have diabetes, don’t get pregnant. If you do, you might....”  The advice echoes from the past, but today’s reality about diabetes and pregnancy no longer carries “don’t” and “if you do...” warnings.  But do prepare. Reality is that prospective moms—with preparation—can look forward to nine months of pink and blue joy, complete with morning sickness and food cravings, without the fear of birthing an overweight baby or experiencing dangerous complications. “The most important time is prior to conception,” said high-risk pregnancy specialist Ruth Anne Queenan, M.D. “A woman with diabetes should have good control of her blood sugar levels at the time of conception.”  Queenan, an MUSC assistant professor of obstetrics and gynecology, said that neglecting good control could lead to birth defects. Queenan calls Terry Stephenson her “poster mom,” but actually she’s just among the latest Queenan has seen from preconception through a successful birth.  Terry Stephenson gave birth to “a beautiful and healthy (eight pounds, eight ounces) baby girl on Feb. 17. My husband and I named her Hallie Grace Stephenson.” Terry says by all indications up to her birth, Hallie was expected to be a baby boy. You guessed it, the nursery’s blue, the baby clothes are blue, but little Hallie’s in the pink. Stephenson, 40, who first discovered her diabetes about four years ago when she gave birth to her first child, has been conscientiously treating her condition with four to six daily blood tests and insulin injections to keep her blood glucose level within a normal range.  “I evidently had diabetes for several years before it was diagnosed,” Stephenson said. “A routine screening seven months into my first pregnancy disclosed the high blood sugar and I was initially treated for gestational diabetes.”  Gestational diabetes is a less serious condition, caused by hormones made in the placenta that work against insulin. Stephenson said that when she, with her husband, Brian, and son Kyle, now 4, moved to Charleston about two years ago, she began seeing MUSC endocrinologist John Colwell, M.D. Colwell directs a team approach to intensive diabetic management. It is called IDEAL for Intensive Diabetic Education, Awareness and Lifestyle.  The team consists of a physician, nurse clinician (Denise Wood, R.N., MSN, CDE, or Jane Parker, R.N., MSN, CDE), a nutritionist (Betty Johnson, R.D.), and a counselor (Sara Vale, Ph.D.). The IDEAL tight blood glucose control policy for treating diabetes fit perfectly with Queenan’s recommendations to ensure fetal well-being in pregnancies complicated by diabetes.  “Pregnancy in diabetes was the first condition in which intensive blood sugar control was proved to affect the outcome,” Colwell said. He explained that within the past decade scientific studies have proven what endocrinologists have suspected for years—that intensive control by testing blood sugar and administering insulin as frequently as needed helps avoid many of the devastating complications of diabetes. Complications include blindness, kidney failure, hypertension, heart disease and neuropathy. Stephenson tests her blood sugar and injects insulin from four to six times daily, regulating the amount of insulin to counteract glucose levels in her blood. Critical to the pregnancy-diabetes-healthy baby equation is the case-by-case collaboration between MUSC endocrinologists and the Prenatal Wellness Center. Patient care teams meet regularly to review each patient’s progress and discuss concerns.  “We have a smoothly paved road of communication here,” Queenan said. “Patients with complicated medical problems that can lead to tragic outcomes need a team to look at the whole picture.” Tragic things? Often the result of delayed care or neglect of the diabetes, those tragic things can catch a mother in the midst of a high-risk pregnancy from both sides—from both the diabetes and childbirth.  Uncontrolled diabetes allows an excess of unmetabolized glucose to remain in the mother’s blood, which flows to her baby. The baby’s insulin helps the fetus metabolize glucose and stores it as fat, increasing the baby’s birth weight often beyond nine pounds. Unchecked diabetes can also result in fetal cardiac defects, central nervous system malformations, skeletal and genitourinary abnormalities, Queen-an said. “Insulin is one of the best growth factors,” Queenan said, “and when a baby gets too big, it runs the risk of outgrowing its blood supply in utero. Large infants can experience birth trauma during delivery.” The mother too is in danger. Pre-eclampsia—high blood pressure in pregnancy, protein in the urine, multi-system organ failure —puts a woman in extreme danger and was probably a prime reason women with diabetes were told not to have children. “But with good care, we can expect good outcomes,” Queenan said. All people with diabetes —male, female, pregnant or not—need to maintain as tight a control on their blood sugar as possible, Colwell said. And tight control is something Stephenson takes in stride. She carries with her an insulin auto-injector that allows her to dial up a precise amount of insulin. A glucose monitor tests a drop of blood from a finger prick and in seconds she can know how much insulin to inject. Colwell said that improvements on the traditional syringe for administering insulin include devices that can be worn and measure out a predetermined amount of insulin at timed intervals. One newly developed device measures blood glucose every six seconds from an implanted glucose sensor. The information is downloaded to a pager-sized computer and yields a three-day record of glucose levels on which to base insulin needs. All new devices being developed are based on maintaining tight blood glucose control.  Further development is even looking into a fast-acting insulin that can be inhaled, he said. “We already have a faster absorbing ‘designer insulin’ that can be taken to cover a meal as a person eats.” “Tight glucose control has become a standard of care,” Colwell said, “on the basis of evidence in non-pregnancy cases.” He said that studies have confirmed that development of diabetes-related complications are slowed 50 to 75 percent due to tight blood glucose management. Because frequent communication and feedback are critical, a team approach, such as is the case in IDEAL, is necessary.