The Diabetologist #10

erger State–Trait Anxiety Inventory (STAI) during pregnancy,
women with gestational diabetes expressed no
higher anxiety scores than glucose-tolerant women.14 In
a study measuring bipolar subjective mood states, the
mood profile in such women was significantly associated
with their level of glycemic control.15 Thus the degree of
metabolic control appears of psychological importance
in women with gestational diabetes. Continuous reassurance
regarding metabolic control in women with gestational
diabetes may enhance their confidence and ability
to cope with their temporary disease state.16
The experience of pregnancy for a woman with diabetes
is strongly influenced by the increasing demands of the
diabetes treatment regimen, concerns about the health
of her baby, and the impact of the pregnancy on her own
health.
For women who are in poor metabolic control, the requirements
of more intensive self-care and medical management
can give way to worries and increased stress
levels.
Women striving for ‘perfect’ diabetes control may find it
extremely difficult to accept any elevated blood glucose
level and become highly frustrated by the day-to-day glucose
variability that is likely to occur in insulin-dependent
diabetes regardless of pregnancy. Lowering of glycosylated
hemoglobin can help to decrease stress levels and
improve self-esteem. Failure to improve glycemic control
can easily lead to feelings of guilt and an increase of psychological
distress and eventually diabetes ‘burn-out’.17
Strict glycemic control increases the risk of (severe) hypoglycemia.
It was found that in about two-thirds of diabetic
pregnancies that were regulated by intensive insulin
therapy, at least one episode of severe hypoglycemia occurred
during the first 20 weeks.18 In a recent cohortstudy,
a mean of 2.6 episodes of hypoglycemia was reported
during the first trimester. A lower HbA1c level and
a higher total daily insulin dose were predictive for severe
hypoglycemia.19
Severe hypoglycemia can cause high levels of anxiety,
confronting the mother-to-be with a serious dilemma. On
the one hand she strives for optimal glycemic control to
reduce the risk of birth defects; on the other hand she
wants to minimize the risk of hypoglycemia because of
the possible harm that it may cause to herself and the
fetus. To date, the adverse effects of (periods of) maternal
hypoglycemia to the fetus’s health are not well established.
Impaired hypoglycemia awareness and related
worries about severe hypoglycemia can lead the pregnant
woman to accept higher levels of blood glucose,
thereby compromising glycemic control.20 This may be
particularly true for women for whom work and/or family
commitments make it extremely difficult to have low
blood glucose levels.
Obstetrical care in the first and early second trimesters
is largely concentrated on detecting birth defects. In the
late second and third trimester, the obstetrical focus is on assessing
fetal growth and development, and maternal health.
The revelation of fetal anomalies, abnormal fetal growth and/
or development in women with poor metabolic control may
cause feelings of guilt and distress, resulting in further glucose
dysregulation.
Clinical studies suggest a higher occurrence of premature labor
and preterm delivery in diabetic pregnancies.21,22 The
imminent birth of a preterm infant and a (long) period of
hospital stay preceding this event may induce anxiety and
feelings of separation in women concerned. This emotional
stress can have a negative impact on their metabolic control
and vice versa.
3.4 Delivery
Delivery is a stressful event to all women and their partners.
In general, women are in fear of the possible pain that delivery
may cause. Women may be anxious whether they will
be able to cope with this pain if analgesia is not available
soon or is not effective enough. In women with diabetes,
stress levels may be increased in view of the possible complications
of delivery related to macrosomia. Shoulder dystocia
due to macrosomia is a major clinical problem which
may cause irreversible physical damage to the newborn and
secondary surgical complications to the mother. Feelings of
anger, doubt and anxiety may persist for many years thereafter.
In this respect, it is important to discuss prenatally the
procedures and possible complications of either vaginal or
caesarean delivery.
3.5 La
ctation
Little is known about the psychological implications of
breastfeeding in women with diabetes other than in nondiabetic
women. Diabetic women may find it stimulating that
breastfeeding appears to be an independent protective factor
against type 1 diabetes in their children.23
3.6 Childhood
Little is known about how diabetic pregnancy, both in type
1 and gestational diabetes, affects the development of the
maternal-infant relationship. There is some research to suggest
that children from diabetic mothers are at increased risk
for a variety of behavioral disturbances, partly related to the
children’s obesity.24
In an Israeli study, one-year-old infants of women with diabetes
mellitus had lower scores on the Bayley Scales of Infant
Development and revealed fewer positive and more negative
behaviors than infants of mothers in the non-diabetic group.
Infant outcomes in the maternal diabetic group were associated
with maternal metabolism.25
3.7 Practice Implications
Prepregnancy counseling has so far shown to have a limited
effect in changing contraceptive behavior in women with
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