Diabetes and pregnancy

Diabetes can develop during pregnancy - a danger to the unborn child

Approximately every 20th pregnant woman develops diabetes during pregnancy, gestational diabetes. It is known that some pregnant women are at higher risk of gestational diabetes, for example because of diabetes in the family. In most cases, however, doctors cannot predict exactly which woman will be affected. The consequences for the child can be significant. Early detection is possible - but not within the framework of the prenatal care funded by the health insurances, as emphasized by the Maternofetal Medicine Working Group (AGMFM) of the DGGG and the Working Group on Diabetes and Pregnancy of the German Diabetes Society.

The infants in the womb become overweight from the increased sugar content of the maternal blood that nourishes them. The overweight of the children increasingly leads to difficult birth processes, more often to caesarean sections. Undiscovered gestational diabetes is at least involved in around every 10th child who dies before birth, as Dr. Ute Schäfer-Graf, specialist at the maternity clinic of the Vivantes Clinic Berlin-Neukölln and spokeswoman for the working group, emphasizes. It is estimated that around 300 to 400 stillbirths per year in Germany are caused by undetected gestational diabetes. Many children have to stay longer in the children's hospital after such pregnancies because of blood sugar fluctuations. Children whose sugar metabolism was already stressed in the uterus - the most sensitive developmental phase in humans - have an increased risk of later developing obesity and diabetes.

In order to detect pregnant women at risk of gestational diabetes, the urine of every pregnant woman is examined for its sugar content with a diagnostic strip during the preventive examinations. However, this test is not reliable because sugar in the urine does not appear until the disease is advanced and the amount of sugar excreted in the urine during pregnancy varies greatly from person to person. A more reliable method is to determine the amount of sugar in the blood after a sugar stress test. As an alternative, an addiction test can be carried out first, for which the woman does not have to be sober and the blood sugar is only measured after one hour. If this blood sugar level is increased, the suspicion of gestational diabetes must be confirmed or eliminated via the stress test. In this stress test, blood is taken from the pregnant woman on an empty stomach in the morning; then she is given a sugar drink, and after an hour or two the blood sugar is measured again. Excessive rise in blood sugar levels indicates a diabetic metabolism. Therapy can then be initiated with a changed diet and lifestyle and, if necessary, also with insulin, which in the right hands is not a danger for the child but a great blessing.

The blood sugar load test (also known as the glucose load test = GTT) is currently not paid for by the health insurances as part of the normal preventive examinations. The German Diabetes Society and the Working Group for Maternal-Fetal Medicine (AGMFM) of the German Society for Gynecology and Obstetrics (DGGG) have been working intensively for a long time to change the maternity guidelines so that the glucose load test - once at 24 - 26 weeks of pregnancy - can be carried out into the Pregnancy screening included and thus also eligible for reimbursement.

In November 2003 the Federal Committee of Doctors and Health Insurance Funds decided to postpone negotiations on the inclusion of reliable diagnostics for gestational diabetes in the German maternity guidelines. This decision caused a lack of understanding among gynecologists, diabetologists and paediatricians as well as those affected. Because the urine sugar screening misses 9 out of 10 cases of gestational diabetes.

The Federal Committee of Doctors and Health Insurance Funds rejected a blood sugar screening on the grounds that there are currently no sufficiently reliable data on the benefits of this examination. The examination procedure was based on the principle of "evidence (= proof) based medicine". This means that only what is proven and true is what has been proven by studies at a very high scientific level. These would be, for example, studies that withhold therapy from some of the pregnant women in order to prove by comparison with the treated group that the therapy is beneficial for mother and child. However, this is not ethically justifiable. In addition, a considerable part of our - meaningful and necessary - routine examinations during pregnancy would never have been included in the maternity guidelines had one always judged according to the strict criteria of evidence-based medicine.

Negotiations on the inclusion of blood glucose tests in maternity guidelines are due to resume after the results of a large global study examining the effects of gestational diabetes are available. However, there is a fear that these results - contrary to the assumptions of the Federal Committee - will not be available until 2006/7 at the earliest; until then, 90% of all gestational diabetes cases will continue to go undetected, with all of its consequences for the children and their mothers.

As long as the examination for pregnancy-related diabetes is not paid for by the health insurances, doctors are allowed to provide this service, but the pregnant women have to pay for it themselves. The costs are 15 - 35 euros for the glucose stress test including advice.

Source: Berlin [DGGG]