Managing diabetes in pregnancy: to deliver a healthy baby, a woman with diabetes must control and manage her diabetes well, both before conception and throughout her pregnancy, says a diabetes nurse specialist.

Diabetes nurse pregnancy specialist at Waikato District Health Board (DHB), Elizabeth Johnson, is passionate that women with diabetes (both pre-existing types I and 2, and those who develop diabetes during pregnancy) should receive optimal care during their pregnancies. "They should be given the same chance of having a healthy baby as pregnant women without diabetes."

Over the years, the odds of that happening have improved greatly, but there are still many women who are unaware of the health complications they and their babies may face if their diabetes is not properly controlled. At the same time, a lot of women with undiagnosed type 2 diabetes are slipping through the net

Diabetes is the most common pre-existing medical disorder complicating pregnancy in the Waikato. Women with pre-existing diabetes are much more likely to lose their baby than women who do not have diabetes--during pregnancy as a result of a miscarriage, intrauterine death or after birth. Congenital foetal abnormalities are more common and macrosomia (large babies) can result in injury to both the baby and mother during delivery. After delivery, the main risk to the baby is hypoglycemia. Pregnant women with diabetes also face increased risks of retinopathy and nephropathy, pre-eclampsia, hypertension and placental insufficiency. Outcomes can be improved if women plan their pregnancies and gain good blood glucose control before and throughout their pregnancies, done in conjunction with a multi-disciplinary diabetes and pregnancy team.

Numbers of women developing gestational diabetes mellitus (GDM), usually in the third trimester, are growing. "Between two and 12 percent of women develop GDM. These women are likely to have macrosomic babies. Usually, their blood glucose levels return to normal after the pregnancy, but they do have an increased risk of developing type 2 diabetes later in life, particularly if they are Polynesian, Maori or Asian, the high-risk populations. It is critical we increase women's awareness of the risks of having diabetes during pregnancy and their need to take more responsibility for their own health." Johnson has been nursing since 1972, having trained at Wellington Hospital. Work both in New Zealand and overseas has included intensive and coronary care, and surgical nursing. It was during her years as a district nurse in the Huntly, Ngaruawahia and Te Kauwhata areas that Johnson really became aware of the health complications caused by diabetes. Many of the patients she visited were Maori, with a high incidence of chronic renal failure and cardiac disease, and diabetic ulcers, often leading to foot deformities and amputations.

"I experienced first hand the relationship between poor wound healing and poor diabetic control. After about ten years, I grew tired of being the ambulance at the bottom of the cliff, so became the diabetes nurse educator for the same area, with the aim of helping people prevent these complications. One of the problems with diabetes is that it is a silent condition, with major factors being obesity and lifestyle. I continue to grapple with the issue of how to help people come to grips with this disease and learn to make changes in their lives in order to manage it better."

Four years ago, Johnson took over the diabetes in pregnancy nurse specialist role within the Waikato Diabetes Service where she works fulltime with a multi-disciplinary team of 38 people. This includes a dietitian, podiatrist, researcher and psychologist. Just prior to joining the team, her daughter was facing a risky birth and Johnson experienced personally the uncertainty and heartache that mothers in such vulnerable situations go through, particularly the trauma of being separated from their babies. The experience helped her empathise with women who faced pregnancy and birthing complications because of diabetes.

At present, Johnson has around 38 pregnant women on her books with either type I or type 2 diabetes or GDM. The key to a healthy pregnancy and safe delivery for these women is to for them to manage their pregnancies and to ensure their HbA1C blood glucose levels remain below seven percent, even three months prior to conceiving.

"Having good blood glucose control is a major factor in preventing miscarriages and birth defects," she said. "During the first eight weeks of pregnancy, the baby's major organs develop, so having tight control of blood glucose levels as soon as possible is important. Maintaining good control can be stressful and demanding for many women, because insulin doses will need to be adjusted constantly throughout the pregnancy, with rising needs as the pregnancy progresses. Near the end of the pregnancy, a woman may need three times the normal amount of insulin. "A number of women with type 1 diabetes are now using insulin pumps. These can give them easier and more accurate control than multiple daily injections. Those with type 2 diabetes who take tablets to control the disease move to insulin injections. Prior to insulin being available, women with type I diabetes were unable to have a baby; now they can have two or three children and through normal deliveries. It gives me enormous pleasure to see these women delivering healthy babies."

Johnson is concerned that numbers of women developing GDM are escalating. Risk factors include the age of first-time mothers (over 25); ethnicity (risks are higher among Maori, Polynesian and Asian populations); having a family history of diabetes; and being overweight. Johnson believes midwives should monitor women's weight during pregnancy, with an optimal increase being between 10 and 11 kilos for a healthy woman.

"Being overweight puts a huge strain on the pancreas. If blood glucose levels are not controlled, women with GDM can have problems at birth, and newborn babies can experience feeding and breathing difficulties. Babies may also inherit the gene for diabetes, thus having a higher risk of becoming obese and developing diabetes in later life. Women who have had GDM have a 50 percent risk of developing type 2 diabetes within the next 20 years.

"A large baby, born at term or prematurely, may have low blood glucose levels at birth. Hypoglycaemia in the neonatal period can affect the newborn, particularly brain development."

Waikato DHB nurse practitioner Deborah Harris is currently conducting a study looking at the effects of low blood sugar and brain function in newborn babies. Last year, over 100 babies suffering from hypoglycaemia were admitted to the newborn unit. Harris is seeking to enrol 200 babies for her PhD study, which she expects will take a number of years to complete. Although the majority of these babies are born from mothers with diabetes, a number have mothers with other conditions, eg hypertension.

Shortly into her new role, Johnson discovered a real lack of knowledge and even fear about diabetes among the 100 or so midwives working at the DHB. The increasing number of midwives with no nursing background and consequently little understanding of diabetes was exacerbating this situation. The protocols and guidelines for managing pregnant women with diabetes were out of date and women were being diagnosed very late in their pregnancies, allowing little time for them to achieve control.

"I set up some study days, using a whole team approach and with the help and backing of the midwifery educator. The midwives were enthusiastic about these sessions, as they said learning about the issues facing mothers with diabetes and their babies was a real awakening for them--like having the film fall from their eyes. These sessions are now held regularly.

"The study days were then opened up to the 120 or so lead maternity carers (LMCs) working in the community where we discovered a wide variance in practice. A questionnaire sent to these midwives showed only about 22 percent of those surveyed did universal screening for diabetes, with 77 percent using risk factors only. The majority were not well informed about the risk factors, resulting in the low number of women in the Waikato region being screened for GDM.

Undertaking universal screening is now becoming accepted practice, with most women being offered a blood glucose test between 24 and 28 weeks of pregnancy. Our universal screening rates are improving but they are still low compared to other areas of the country. With obesity and type 2 diabetes rates becoming more prevalent, universal screening is now an important public health initiative.

"Staff from the diabetes and pregnancy service spend half a day with second-year midwifery students at the Waikato Institute of Technology. The diabetes service also runs courses for practice nurses on managing type 2 diabetes, which includes a slot with me. Practice nurses and midwives in the community are key to controlling this disease."

Two years ago, the diabetes team launched its Diabetes in Pregnancy Protocols and Guidelines booklet. This aims to increase awareness among midwives, GPs, obstetricians and all main maternity carers of the problems associated with the condition and to assist them identify and actively manage women with known diabetes and those who develop GDM during and after pregnancy.

Johnson is pleased there is now less separation shortly after birth of mothers with diabetes and their babies. This has resulted in improved breastfeeding rates, as midwives and postnatal staff appreciate the extra help these women may need to establish successful breastfeeding. Breastfeeding within 30-60 minutes of birth can reduce the risk of babies experiencing low blood glucose levels.

Johnson has been a catalyst for many positive changes at the DHB and has much to be proud of. She attributes many of the service's successes, however, to the dedicated work of the various members of the diabetes team. "They are a really awesome group to work with and give me tremendous collegial support."

Johnson sees an increasing number of high-risk patients each year (150 in 2006 compared to 100 three years ago). She is involved in three clinics each week, one of which is a combined clinic where patients are seen by both obstetric and diabetes team members. The rest of the week is spent telephone counselling, keeping up with the paper work, visiting wards and the delivery suite ensuring protocols are being followed, monitoring and adjusting patients' insulin levels after they have given birth (using standing orders), working with the dieticians and ensuring patients receive follow-up from their GPs. "I use many skills and assume many different roles. On top of that I have to maintain my diabetes nurse specialist accreditation. I have just been reaccredited for the next five years."

This year, Johnson is hoping to have a midwife join the diabetes in pregnancy team, working alongside her. Auckland and Middlemore Hospitals have midwives who specialise in diabetes care, but in the rest of the country, the roles are usually taken by diabetes nurse educators or specialists working part-time in pregnancy services. Johnson enjoys networking through the Australasian Diabetes in Pregnancy Society, attending (and often presenting at) its annual conferences. She would also like the opportunity to get together with other nurses in New Zealand working in this area.

Although kept going by her successes, Johnson still struggles to find ways to empower women to take responsibility for their own health. She has much sympathy for pregnant women who discover they have GDM, women who expected their pregnancy would be normal and who then have to cope with the medicalisation of birth, possibly having to take insulin and realising their babies could be at risk of birth complications. A GDM diagnosis can result in a kind of grief.

"I am a great proponent of universal screening, not just screening of women with high-risk factors or from high-risk ethnic groups, as the sooner women are picked up, the more time they will have to prepare well for their births. Good control and good management are the keys to a good outcome for everyone."