Maternal Health, Diabetes and Autism

In September 2010, a cover for the Time magazine showed a pregnant woman completely naked.  The photograph was supposed to open dialogue on “How the first nine month shape the rest of your life”.  The heading accompanying the photograph could have been more specific as the health status of a mother during pregnancy defines both her own future as well as that of her child.  This is of importance to our readers as obesity and diabetes during pregnancy increases the risk of a child having autism by three to four times that of the general population (see my previous blog https://corticalchauvinism.com/2017/11/27/exercise-and-autism/).

It is a well-known fact that our population is becoming more obese and that the prevalence of diabetes is on a steep rise; I call this the “diabesity” (“diabetic“ + ”obesity”) epidemic. Since women are becoming pregnant at younger ages there is an urgent need for pre-conceptual counseling for teenagers, the creation of a multidisciplinary management team to treat obese diabetic women during pregnancy, and for good follow-up care.

Diabetes affects 6-9% of pregnancies. In ninety percent of these cases the woman suffers from gestational diabetes, that is, glucose intolerance with onset or recognition during pregnancy.  The other ten percent suffer from either type II (insulin resistant) or type I (insulin dependent) diabetes.  Women diagnosed with gestational diabetes have a 50% lifetime risk of developing Type II diabetes later on in life, often within 4-5 years of their pregnancy.

You should be aware of an increased risk of developing diabetes during pregnancy if:

  • You are over 25 years of age
  • Your ethnicity is Hispanic, African, Native American, Asian, or Pacific Islander
  • You are obese (defined by a body mass index [BMI] >30)
  • If you experience excessive gestational weight gain
  • If you have a family History of diabetes
  • If the birth weight of your baby was >4100 gms or 9 pounds
  • If in a previous delivery your infant weighed >4100 gms
  • Previous unexplained perinatal loss or birth of a malformed infant

GestaDiabetes-Fig1

Being aware of risk factors and having good medical care for diabetes during pregnancy will avoid complications.  Some fetal and maternal complications of diabetic mothers are listed below:

Fetal complications

  • Macrosomia (a newborn who is significantly larger than normal)
  • Low blood glucose during the first month of life (neonatal hypoglycemia)
  • Hyperbilirubinemia
  • Hypocalcemia
  • Erythema (irritation of the skin causing reddening in patches)
  • Respiratory distress syndrome
  • Stillbirth
  • Birth injuries

Maternal Complications

  • Operative delivery (using forceps, vacuum or cesarean section to terminate labor)
  • Gestational hypertension/Preeclampsia (these are kissing cousins that tend to occur concurrently) -As an aside aspirin is usually given in these cases as it helps prevent preeclampsia.
  • 15-50% risk of Type II diabetes
  • Increased risk for cardiac disease
  • Your stomach’s motility may decrease (gastroparesis)

Note: Diabetic retinopathy is the leading cause of blindness in reproductive years. Furthermore, diabetic nephropathy occurs in 5-10% of pregestational diabetics

Given the health hazards of gestational diabetes during pregnancy The American Congress of Obstetricians and Gynecologists (ACOG) has provided recommendations as to proper treatment. Be careful and review their recommendation as they are updated regularly, every 2 or so years. These recommendations call for early screening and diagnosis. As to treatment, the first-line of intervention is dietary modification (remember to include folic acid and multivitamins) and to increase the activity level of the patient when adequate. Blood glucose monitoring should include fasting levels (<90-95) and 2 hours postprandial (<120). For values 25% and over normal levels, the patient needs to followed on a weekly basis.  Repeated growth scans of the baby are often required. Oral agents are no longer recommended in preference to insulin. Otherwise those using metformin need to be titrated slowly (I can personally vouch for the GI side effects of the medication).

Management+of+Gestational+Diabetes

Care is also required after conception. Some type of birth control is usually recommended to prevent unintended pregnancy, a rapidly repeating pregnancy or abortion.  Long acting reversible contraceptives (LARC) provide effective contraception over long periods of time. They are the first-line of recommendation for all women, especially adolescents.

 

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