14 February 2011

Never say never

Diabetic? Epileptic? TB? That's no reason to not have a baby - but you do have to plan more carefully, warns Toni Younghusband


Diabetic? Epileptic? TB? That's no reason to not have a baby - but you do have to plan more carefully.

Nancy Taylor* is tough, uncompromising and a wizard at her job as marketing director in Johannesburg for pharmaceutical company. The discipline she imposes in every sphere of her life is most clearly defined in her attitude to the diabetes she's had since childhood - especially since deciding to have a baby.

"I suppose some people think I'm a bit of a neurotic diabetic, but I like to feel in control of my body at all times, " she yells, over the shrieks of her toddler, James. Nancy is eight months pregnant with her second baby, and is every bit a vigilant with this pregnancy as she was with the first.

"This one has obviously been a lot easier because I knew what to expert and what I could and couldn't eat without having to experiment first," she says.

Fellow diabetics call her "extreme": she admits to checking her sugar levels seven to nine times a day, but Nancy is determined this pregnancy will go a smoothly as the last.

Why it's so dangerous
High blood glucose levels during the first trimester can cause birth defects or miscarriages, so Nancy worked hard at keeping hers as near as possible to normal for three months before conception, and at maintaining those levels during the first trimester.

She's discovered that during pregnancy her body is far more sensitive to certain foods that when she isn't pregnant, especially food with high fat content, like chips.

"I find higher fat content is worse than sugar," she says. However, far from feeling deprived when dining out, Nancy says she now knows what's good and what's not, and would rather do without the French fries than suffer the symptoms of surging blood glucose levels (nausea) or injure her baby.

She carries her blood testing kit with her at all times. It's a simple procedure: she pricks her finger and puts the blood on a paper strip - during pregnancy the reading should be between four and seven. She also injects herself routinely with insulin.

Diabetics have, on average, bigger babies and they may need a Cesarean delivery. A pregnant diabetic may also have extra amniotic fluid. "When my doctor noticed a fluid build-up, I tightened up my sugar control even more and it went back to normal fairly quickly," says Nancy.

Regular exercise important
She hasn't had any undue swelling with this pregnancy, or put on much weight, but complains of tiredness and lethargy and admits she does stress about her diabetes. However, because diabetics are encouraged to excise, Nancy, a keen runner, ran until she was nearly five month pregnant. "I'm generally quit fit and I'm still very active and I'm sure that help."

Regular exercise increases the efficiency or potency of your body's own insulin which may allow you to keep your blood sugar levels in the normal range while using less insulin.

Moderate exercise also helps blunt your appetite, keeping weight down, which is essential in preventing high blood sugar levels. However, if you are insulin-dependent, remember that both insulin and exercise lower blood sugar levels, and the combination can result in hypoglycemia or low blood sugar.

Always be meticulous in managing your diabetes. Keep ready sources of carbohydrates with you at all times, including glucose tables. You may also need to eat small snacks between meals. Pre-pregnancy bicycling and jogging are good exercises to keep up.

Common complications for diabetics
It is advisable for diabetics wanting to get pregnant to talk to their doctor before conception. He may want to conduct a thorough physical examination to ensure that your body can take on the demands of pregnancy. Some of the common complications of diabetes can be affected by pregnancy, or can affect its outcome.

These include hypertension, and women who are contemplating pregnancy or who are pregnant should not take certain anti-hypertensive drugs. Diabetic retinopathy (damage to the blood vessels of the eye which can lead to a loss of vision) may develop or worsen during pregnancy. Have an eye exam during pregnancy.

Approximately 2 to 5% of all non-diabetic pregnant women develop what is called gestational diabetes. This will usually right itself after the birth.

Co-incidentally, one of Nancy's closest friends also has a medical condition which required pre-conception planning and close monitoring during pregnancy.

Epilepsy and pregnancy
Helen Michaels* is seven months pregnant with her first child, and epileptic. Her epilepsy has been carefully controlled through drugs since her diagnosis as a teenager, but before falling pregnant, she was advised by her doctor to switch medication.

Why it's dangerous
Neurologists warn that some epilepsy drugs taken during pregnancy may impair children's normal brain development, and there is some risk of foetal abnormality. "Getting pregnant was a slow process," Helen reveals, "because I had to be weaned off one medication and put onto another."

It is extremely dangerous for an epileptic to stop their medication altogether, and dangerous to both mother and baby if a pregnant epileptic stops her drugs. A sudden seizure can result in a bad fall or accident which may injure them both.

Helen's weaning process began by lessening her daily dosage of one drug and slowly building up the other. This took about two months, and her brain activity was closely monitored by EEG scans. Once her neurologist was happy that the new drug (which is safe for foetuses) was effective, he gave Helen the go-ahead to conceive.

Women with epilepsy are slightly less fertile than women who don't have it, but Helen fell pregnant within four months. International studies have shown that up to 60% of women with epilepsy who become pregnant experience a decrease or complete cessation of seizures during pregnancy. Other may experience an increase.

Thus far, Helen's enjoyed a model pregnancy. "All I've had to do is have regular blood test to monitor the drug levels. Your blood levels increase during pregnancy which means you need to increase your medication accordingly," she says. "So far the baby's fine, I'm doing well and the pregnancy's proceeding as it should."

She suggests, however, that other women with pre-existing medical disorders do substantial research and consult with a trusted doctor before considering pregnancy. "I learnt a lot of important information before I got pregnant and I shudder to think what might have happened if I had just gone ahead and conceived." she says.

The Internet has been a vital source of info and regular consultations with her gynaecologist and neurologist have all helped build her confidence. Epilepsy is associated with an increased risk of spina bifida and Helen's gynaecologist insisted on testing for this condition.

Gynaecologist and obstetrician Dr Andrew Newham who is a member of Shape's advisory board, says folic acid supplementation started at least three months before an epileptic woman becomes pregnant is essential.

"And she should continue with folic acid - 5mg a day - for three months into the pregnancy," he says. Folic acid helps protect against spina bifida.

There are several other pre-existing disorders which require additional planning and care when considering pregnancy. They include:

Tuberculosis, if confined to the lungs as is usually the case, presents little risk to the foetus. Most of the drugs used to treat TB are safe in pregnancy and should be given.

Why it's dangerous:
If the infection involves organs other than the lymph nodes, there can be effects on the foetus. A recent study published in the New England Journal of Medicine reported that pregnant women with active TB outside of the lungs and lymph nodes were more likely to need prenatal hospitalisation, and their babies were more likely to have problems after birth.

But if your infection is inactive, especially if it was confined to the lungs, you should have nothing to worry about.

A baby born to a mother infected with chlamydia has about a 25% chance of developing neonatal (newborn) conjunctivitis, which usually appears about a week after birth.

Why it's dangerous
Sometimes it causes permanent scarring. The most effective way to protect babies is to screen expectant mother and treat those found to be infected. Women with genital chlamydia infections usually have no symptoms, so all pregnant women should be screened.

Treating the mother with antibiotics is about 90% effective in preventing disease in the baby. Without treatment, however, the infection can persist through the entire pregnancy. Furthermore, since no treatment is 100% effective, repeated testing should be performed to ensure that the infection is eradicated.

And when the baby is born, eyedrops should be administered immediately by nursing staff to prevent the conjunctivitis associated with chlamydia or gonorrhoea.

In an acute asthma attack, airway inflammation or bronchoconstriction may cause respiratory distress. Ventilation rate increases and can change the acidity of the blood. If the attack worsens, further airway narrowing causes impairment of air exchange.

As the asthma attack worsens, arterial oxygen can decline. If left unchecked, the airway narrowing and the gas exchange abnormalities can be fatal.

Why it's dangerous
The main concern is adequate oxygen delivery to the mother and foetus. Maternal complications of uncontrolled asthma can include pre-eclampsia/eclampsia, vaginal haemorrhage and premature labour. Neonatal complications may include growth retardation, pre-term birth and increased risk of perinatal death.

Fortunately, scientific studies have shown no significant effects on the baby if the pregnant mother continues to use her asthma medication, although some oral corticosteroids have been associated with a higher risk of pre-eclampsia (pregnancy-induced hypertension).

Heart and kidney disease
Although rare, severe case of heart and kidney disease could seriously impact on pregnancy. Those who suffer these illnesses must consult their doctors before getting pregnant.

*Names have been changed

(Toni Younghusband, Shape magazine)

This is an edited version of an article which comes from an earlier edition.


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