Type 2 Diabetes And Pregnancy

Diabetes mellitus, more commonly referred to as just diabetes, affects more than 37 million Americans, with around 90–95% of cases being type 2 diabetes. Although there is a higher incidence of type 2 diabetes among women 35 to 44¹ compared to women 18–24, more and more cases are developing in children, teenagers, and young adults every day.

With more cases of diabetes among women developing before and around reproductive years, it's important to understand what to expect with type 2 diabetes and pregnancy.

This article will look at how diabetes can affect pregnancy, the diagnosis process, potential complications, management, and when to speak to your healthcare providers. 

How does type 2 diabetes affect pregnancy?

Type 2 diabetes is a condition in which your cells don't normally respond to insulin under a process known as insulin resistance. Insulin is a hormone your pancreas produces that regulates blood sugar levels and allows cells to take up sugar or glucose from the bloodstream to use as energy.  When cells, for many reasons, are no longer responsive to insulin, your blood sugar levels rise, leading to type 2 diabetes. 

During pregnancy, people with type 2 diabetes are affected differently than pre-pregnancy and often need to change their management routines. 

Will it affect me?

Yes, type 2 diabetes will affect you during pregnancy, which is why it is so important to not only tell your healthcare provider as soon as you get pregnant but discuss your intentions to get pregnant first. Proper management and preparations can be followed to ensure a safe and healthy pregnancy. 

Preparations for women with diabetes often include preconception care. Participating in diabetes care before conception reduces the risks of congenital anomalies, congenital malformations, and other diabetes complications in infants. This is significant news since congenital anomalies are more common in cases with type 2 than with type 1. 

Preconception care includes diabetic mothers receiving assistance with self-management skills, meeting with a diabetes educator, and access to additional support for medical, nutritional, and physical well-being. This ensures their glucose level is under control and health is optimal before getting pregnant.  

Will it affect my baby?

Yes, this type of diabetes during pregnancy can also affect your baby. The Centers for Disease Control and Prevention² (CDC) reports that high blood sugar levels during conception can compromise the health and development of the baby. Their report also notes an increased risk of type 2 diabetes diagnoses in children of mothers with the condition.

Infants of mothers with diabetes may also be born prematurely and via cesarean birth.

How is diabetes during pregnancy diagnosed?

If you don't have a clinical diagnosis of diabetes before becoming pregnant, screenings for gestational diabetes mellitus are often implemented in the sixth and seventh months of pregnancy (24 to 28 weeks). The most common approach in the US³ is a 2-step process that consists of an oral glucose challenge test followed by an oral glucose tolerance test.

However, other screenings may include fasting plasma glucose measurement or only taking an oral glucose tolerance test. 

About 6–9% of women develop gestational diabetes in the last few months of pregnancy. Unfortunately, around 50% of these women develop permanent type 2 diabetes within 5–10 years after giving birth. 

On the other hand, 1–2% of US women are diagnosed with either type 1 or 2 diabetes during pregnancy. This group doesn’t have gestational diabetes as their high sugars have been picked up at the first onset of pregnancy and therefore are more likely to be undiagnosed type 1 or type  2 diabetes.

Unlike gestational diabetes mellitus, once you are diagnosed with type 1 or type 2 diabetes, you will have it for the rest of your life. 

Unless there are reasons you should be tested early, you will likely not receive any other screening than the traditional blood tests taken in the beginning. 

Risks of diabetes increase among women who are obese (categorized by a body mass index higher than 30), of certain ethnicities such as Asian or Hispanic,  and those with family history and/or medical history of diabetes. Unless you have these risks, have abnormally high blood pressure, and your glucose levels are not in the normal range, you will likely not be screened for diabetes until 24–28 weeks. 

What are the complications of type 2 diabetes in pregnancy?

Having type 2 diabetes while pregnant can cause many complications for a mother and her unborn child. While these complications are mostly preventable with the right medical, nutritional, and physical guidance from your healthcare providers, people with diabetes are still more at risk.

To ensure your pregnancy is as safe and healthy as possible, you must:

• Consult your doctor before getting pregnant if possible (make an appointment immediately if it is unexpected)

• Maintain a healthy weight by eating a balanced diet and increasing safe physical activity (i.e., brisk walking, prenatal yoga, etc.)

• Prioritize blood sugar control

• Meet with a diabetes educator if you haven't already

• Discuss your family history, medical history, insulin during pregnancy, and more with your gynecologist

In the meantime, here are some potential complications individuals with type 2 diabetes may experience during pregnancy if it is not adequately monitored and managed. 

Complications for the mother

Pregnant women with type 2 diabetes are at an increased risk of developing one or more of the following problems:

Preterm birth or cesarean delivery

Pregnant women with type 2 diabetes have higher risks of complications and longer recovery times than natural births. 

Eye disease

Damage to the small blood vessels in your eye could worsen if you already had problems with it beforehand. 

Kidney disease

Previous damage to your kidneys can worsen and often be irreversible in damage. However, kidney damage that occurs during pregnancy has the potential to get better. 

Infections

Infections are more common among pregnant women with type 2 diabetes (and other types of diabetes) compared to pregnant women without diabetes. Major infections⁴ associated with diabetes during pregnancy include:

• Respiratory infections 

• UTIs 

• Gastrointestinal and liver infections

• Soft tissue and skin infections

• Neck and head infections 

• Other infections, including the human immunodeficiency virus

Preeclampsia

Although preeclampsia only affects about 4–5%⁵ of global pregnancies, the risk of developing it is 2–4 times higher among women with type 1 and 2 diabetes. The condition is a potentially dangerous pregnancy complication most widely characterized by persistently elevated blood pressure levels, typically beginning after 20 weeks.

While pregnancy outcomes can be serious or fatal for the mom and the baby, proper monitoring and management can prevent it. 

Complications for the baby

Pregnancy in women with diabetes isn't just a risk for the mother. Complications for the baby can include:

Macrosomia

Fetal macrosomia is a high-risk condition during pregnancy where the infant's gestational weight range is not the same as average, often landing in the 90th percentile (birth weight at 9 pounds, 15 ounces (4,500 grams) or more). 

Approximately 7.8%⁶ of babies born in the US were more than 4,500 grams at birth, with 22.3% of pregnant mothers with diabetes having a high birth weight baby compared to just 13.6% of pregnant mothers without diabetes. Symptoms of an abnormally large baby include excessive amniotic fluid or abnormal measurements identified in fundal height and fetal size in an ultrasound. 

Premature birth

If glucose during pregnancy isn't controlled, the baby can grow big and lead to an increase in amniotic fluid. This, in turn, can trick the body into thinking it is further along than it really is, resulting in preterm birth in many cases.

A 2014 study linked type 2 diabetes to premature births finding that previously having a preterm birth was strongly associated with a 29% higher risk of being diagnosed with type 2 diabetes. The report also noted that pregnant mothers with gestational diabetes before 32 weeks had a 55% higher risk of type 2 diabetes. 

Stillbirth

Stillbirth refers to the death of a baby in the womb after 20 weeks, occurring before or during delivery. One study⁷ noted that babies at extremes of weight centiles were the most at risk, with body mass index and maternal blood glucose level playing a role. The report found that participants with type 1 diabetes had a 6-times higher risk of their child being stillborn, while women with type 2 had a 3-times higher risk. 

Women with type 2 diabetes, in particular, saw an additional risk for stillbirth among male infants. They also found that the highest rate of stillbirths was at 38 weeks, which researchers concluded could potentially suggest that routine care and delivery policies could act as a preventative.

Fetal and neonatal loss

While stillbirth refers to the death of an infant after 20 weeks and before or during delivery, neonatal loss refers to the loss of a fetus in the first 28 days of life. Neonatal loss is one of the most common fetal adverse outcomes among pregnancies with diabetes.

Congenital disorders or birth injury

The risks of developing major congenital disorders in pregnancy are significantly higher among women with a pre-existing diagnosis of diabetes. According to the CDC,⁸ the strongest associations were detected between pre-existing diabetes and a congenital disability of the lower spine (sacral agenesis), limb defects, and a brain defect (holoprosencephaly). Other potential congenital disorders include heart abnormalities. 

Birth injuries, on the other hand, refer to the injuries that occur during birth. This can include bruising, clavicle or collarbone fracturing, broken bones, etc. 

Neonatal hypoglycemia

Hypoglycemia happens when your blood sugar level is lower than normal. This condition is a preventable cause of brain injury. In neonatal hypoglycemia, the diagnosis is most widely given with a glucose concentration of less than 47 mg/dl. However, neonatal hypoglycemia is still very controversial and requires more research. 

How to manage type 2 diabetes while pregnant

Even if you're familiar with managing your type 2 diabetes before getting pregnant, pregnancy symptoms can impact your ability to continue managing the condition properly. The right medical care and guidance will ensure your pregnancy is safe and successful. 

The following management methods are advised for pregnant women with pre-existing type 1 or 2 diabetes. 

Diabetes education

First and foremost, you must meet with a diabetes educator to ensure a thorough understanding of the condition, its risks (especially in pregnancy), and the importance of following guidelines and advice from medical experts. Your pregnancy can still be a safe journey. As the saying goes, knowledge is power. 

Nutrition and exercise 

Nutrition and exercise are vital to a healthy pregnancy, even among those not considered obese. Any weight gain beyond the recommended targets can worsen perinatal outcomes, leading to macrosomia, neonatal hypoglycemia, and more. 

Medical experts recommend special attention to food intake to ensure strict glycemic control, preferably through registered dietitians familiar with individualized medical nutrition therapy (MNT). 

Glucose monitoring

Monitoring is very important. Fetal monitoring plays an important role in ensuring your baby stays safe. A close glucose monitoring will also ensure glycemic goals are achieved, any potential adjustments to your nutrition plan or medications are informed, and any needed changes in insulin requirements are identified.

Insulin requirements, insulin management, and non-insulin medication

People with type 1 diabetes are typically more insulin sensitive than type 2. However, insulin resistance among all people with pre-existing diabetes can still increase as the pregnancy progresses, requiring close glucose monitoring.

Women with type 2, in particular, are often required to take basal insulin and/or oral agents to reach their glycemic control targets. Education and awareness on this topic are extremely important among those who primarily manage their diabetes with diet alone before pregnancy. Pregnancy will lower glucose levels, so insulin management is essential to the success of having a healthy and safe pregnancy.

On another note, women with type 2 diabetes taking oral agents, such as metformin, are advised to switch to insulin when they get pregnant. This is because insulin is the first-choice drug for management during pregnancy per the American Diabetes Association's (ADA's) Standards of Medical Care in Diabetes. 

When should I see a doctor?

You should consult your healthcare provider or OBGYN for any concerns or questions about type 2 diabetes during pregnancy. If you've already been diagnosed with type 2, you should consult your doctor before trying to get pregnant. Taking the time to prepare yourself will ensure that you and your baby are safe throughout your pregnancy. 

If you're already pregnant, make an appointment to see your doctor as soon as possible. Complications of pregnancy with diabetes do not have to be severe or fatal. Many healthy babies are born every year among pregnant mothers with the condition. Staying in constant contact with your doctor will allow them to provide you with the most responsible diabetic care specific to you and your circumstances. 

The lowdown

When combined, type 2 diabetes and pregnancy don't have to be dangerous for the mother or the baby. However, the condition will affect both.

There are several risks and complications that you should be fully aware of. Type 2 diabetes may put you at risk for preterm birth, C-section, eye disease, infections, kidney disease, and preeclampsia. Babies may also be at risk for macrosomia, premature birth, stillbirth, neonatal loss, congenital disorders, birth injury, and neonatal hypoglycemia.

With that being said, there is also plenty of specialized expertise and research on the effects of diabetes in pregnancy. These studies allow your healthcare provider to care for you and your baby in the best ways possible. Typically, this means meeting with a diabetes educator, monitoring your glucose, and managing/adjusting your insulin accordingly throughout your pregnancy.

Diabetes management in pregnancy will not be the same for everyone, so ensure you work closely with your healthcare providers who can help you follow a pregnancy and delivery plan just right for you.