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SEVEN. Diabetes and Special Situations

I have diabetes and want to get pregnant. What should I do?

I will be traveling. How do I handle the time changes with my insulin shots?

My child has diabetes and is about to start school. What steps should I take and how will the school help to ensure that things go well?

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I have diabetes and want to get pregnant. What should I do?

When a woman of childbearing age has diabetes, it is very important to plan the pregnancy ahead of time for a number of reasons. The first reason is that studies have shown that the risk of birth defects (called congenital malformations) is much higher if the diabetes is not well controlled at the time of becoming pregnant. Improving control of the diabetes as quickly as possible after discovering the pregnancy will not fully reverse this risk, which in some studies has been found to be as high as one in five. Therefore, it is important to establish and confirm that your diabetes is in the best possible control before proceeding with a plan to become pregnant.

The second issue is that women with longstanding diabetes who suffer from its microvascular complications (see Questions 32, 33, and 34 for discussion of these) are more likely to have a complicated pregnancy and will need to be reassessed prior to and during the pregnancy. Of particular importance are the possibility of progression of retinopathy and nephropathy during the course of pregnancy.

Finally, it may be necessary to change the type of treatment during the pregnancy, and this may require some forward planning. For example, pills are generally not used during pregnancy. Therefore, a woman with type 2 diabetes will almost always need to learn how to take insulin and it may be more convenient to do this as part of pre-pregnancy planning.

I am scheduled to have an operation.

How do I prepare my diabetes for this?

The extent to which you and your physician prepare for your operation depends on the extent of the operation, the severity of the condition that has led to it, and the treatment that you are taking for your diabetes. The fact that your operation is planned means that it is not urgent nor an emergency. However, many people with diabetes will experience surgical emergencies for which no preparation is possible. In general, the outcome will depend on the underlying emergency, with the overall management being made somewhat more complex by management of the diabetes during and after the operation. However, in recent years, studies have shown that very careful management of the blood sugar is very important in the days immediately following an operation. However, there is less convincing evidence that blood sugar management prior to and during an operation is quite as important.

In general, your surgeon will request assurance from the medical doctor caring for your diabetes that your blood sugar is under fair overall control, especially in the days and weeks running up to the operation. The severity of any large vessel complications, such as heart and other vascular disease, will need to be evaluated. Your blood pressure will need to be well controlled, as high blood pressure (hypertension) is a frequent accompaniment to diabetes and can lead to surgical complications if unregulated. Of the small vessel complications of diabetes, your kidney function will need to be evaluated and the result taken into account, as abnormal kidney function can affect blood pressure, lead to retention of intravenous fluids, and alter the rate of removal of certain medications from the body.

In general, your surgeon will request assurance from the medical doctor caring for your diabetes that your blood sugar is under fair overall control, especially in the days and weeks running up to the operation.

If you are taking pills and the operation is relatively minor and brief and your diabetes is under good control, not taking your medication on the night prior to and/or the morning of the operation may be all that is needed and the medication can be resumed after surgery, with your first main meal. People who are taking insulin will generally be instructed to take a reduced dose of the longer-acting insulin the night prior to surgery and to take no set dose of shortacting insulin after the last meal has been eaten before surgery. Upon arrival at the hospital, the glucose will be monitored frequently by the hospital staff and insulin will be given if you need it. This is especially true for longer and more complicated operations. In all cases, you should monitor your blood sugar carefully at home in the days leading up to your operation.

 
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