Urinary Problem of Women with Diabetes
Dr. Tony Bazi
Associate Professor of Obstetrics and Gynecology at AUB
Certified, American Board of Obstetrics and Gynecology
Certified subspecialty Female Pelvic Medicine and Reconstructive Surgery
A common and true belief is that diabetics produce more urine than non-diabetics, and consequently have to make more trips to the toilet. While this is true, especially with poor diabetes control, producing a lot of urine (polyuria) constitutes only one of many aspects of urinary problems in diabetics.
The bladder is a “reservoir” that stores urine produced by the kidneys, and expels the urine when appropriate, i.e. when ordered by the brain. The filtration of urine by the kidneys may be affected after longstanding diabetes, but this by itself is not related to the bladder problems as discussed below.
The function of the bladder itself may be affected in the following ways:
- Frequency: going too often to the toilet, even when passing small amounts.
- Urgency: sudden desire to pass urine that cannot be postponed.
- Incontinence: involuntary loss of urine before reaching the toilet.
- Nocturia: waking up at night because of the need to go to the toilet.
These symptoms (frequency, urgency, incontinence, nocturia) are collectively known as “overactive bladder”. Why does this happen? The affection of nerves that supply the bladder in both the sensation and the function may cause a hyper excitatory state so your bladder feels it is full. In addition, there could be delayed sensation so you may have a short warning time before you actually lose the urine.
What can be done? First, do not be tempted to avoid drinking water, you always need it. Second, go to the toilet regularly (for example every two hours during the daytime) before the full sensation; remember, the warning time is short. This by itself may improve your condition tremendously. Third, exercise your pelvic floor muscles by contracting them regularly. Your doctor or physiotherapist should teach you how to do these (kegel exercises). A word of caution: do not perform these exercises during urination. To decrease the impact of nocturia, avoid eating late and minimize fluids before bedtime. This would prevent overfilling of the bladder when you are asleep. If you have varicose veins, stockings in the evening would help reduce the amount of urine manufactured after you lie down. Finally, there are some safe medications that can be taken either continuously or when needed (for example before going on trips or to long social events). Incidentally, make sure you do your “bathroom mapping”,as in you first locate the toilet in any public place you go to.
In addition to overactive balder, susceptibility to frequent bladder infections (cystitis) is common in diabetic patients. This is mostly due to decreased immunity. Symptoms of infections include pain during urination, intermittency and smelly urine. Antibiotics should be taken in these situations. When the symptoms go away, it is not necessary to repeat the urine test to demonstrate that the infection is gone.
It is important to note that one cannot attribute all bladder symptoms to diabetes. A woman may have stress incontinence (losing urine during cough or activity), uterine prolapse or bladder descent due to other factors, the most common of which is childbearing.
In conclusion, while there are many bladder problems peculiar to diabetics that can be efficiently identified and treated, the presence of diabetes should not pose an obstacle to treating other common bladder problems.
Management of Diabetes in Pregnancy
Anwar Nassar, MD
Professor of Obstetrics and Gynecology
Interim Chairman, AUBMC
Most cases of diabetes in pregnancy (90%) are gestational diabetes (GD), which begins or is first recognized during pregnancy. The remaining are patients diagnosed with diabetes before pregnancy. Tight blood sugar control during pregnancy is the key for an optimal pregnancy outcome in either type of diabetes since poor blood sugar control can have serious short- and long-term consequences for both the mother and the baby.
GD affects ~7% of expectant mothers, making it one of the most common health problems of pregnancy. For few moms-to-be, the pancreas can’t keep up with the increased insulin demand during pregnancy, and therefore blood glucose levels rise too high, resulting in GD, which usually has no symptoms. That’s why pregnant women are usually screened for diabetes at 24-28 weeks. In those at high risk for diabetes (obese, GD in a previous pregnancy, family history of diabetes and sugar in their urine test), screening is done at the 1st prenatal visit and repeated at 24-28 weeks. If the screening test is positive, a confirmatory test is then performed. Most women with GD go on to have healthy babies. Dietary changes and exercise may be enough to keep the blood sugar levels under control, but sometimes medications are needed. Artificial sweeteners may be safely used in moderate amounts. Complications of uncontrolled GD include overly large babies where the baby’s shoulders may get stuck during delivery. This can result in a fractured bone or nerve damage, both of which heal without permanent problems in the majority of babies. That is why some doctors may recommend that women with suspected large babies give birth by cesarean section. Shortly after birth, some babies may have low blood sugar (hypoglycemia), jaundice, polycythemia (an increase in the number of red cells in the blood), hypocalcemia (low calcium in the blood), breathing problems at birth (the lungs of babies whose mothers have diabetes tend to mature a bit later) and even stillbirth (death of baby before delivery) in the last two months of pregnancy. Finally, women with GD are at increased risk for developing preeclampsia, a disease characterized by high blood pressure and edema. GD goes away after birth, but it does increase the risk of a woman for developing diabetes later in life. One third of women who had GD will continue to have diabetes.
For women diagnosed with diabetes before pregnancy, medical help should be sought before getting pregnant. This preconception visit is essential since high dose folic acid should be started and tight blood sugar control (glycosylated hemoglobin levels Hb A1C <6.1%) should be ensured before pregnancy. Women with pregestational diabetes are at increased risk of abortion, polyhydramnios (excessive amniotic fluid), birth defects, stillbirth, and several complications in their babies like hypoglycemia, respiratory problems, growth restriction (low birth weights), hypoglycemia, hypomagnesemia, polycythemia, hyperbilirubinemia (high bilirubin levels), and increased risk for the baby of inheriting diabetes. Women are at increased risk of delivering by cesarean and of having preterm labor and preeclampsia. To help reduce these risks, the patient should follow a meal plan and a liberal exercise program and should test blood sugar and take her medications, usually insulin and more recently oral hypoglycemics. She will have to come for more frequent prenatal visits than the usual. The recommended daily caloric intake is 30 kcal/kg and may be distributed as: 10–20% at break- fast; 20–30% at lunch; 30–40% at dinner; and up to 30% for snacks, especially a bedtime snack to reduce hypoglycemia at night. The goals of blood sugar control are 60-90 mg/dl before breakfast and 120 mg/dl 2 hours after meals. In case of hypoglycemia, a glass of milk is preferable to fruit juices containing high levels of glucose. A fetal ultrasound and echo-cardiogram (an ultrasound that focuses on the baby’s heart) are usually ordered because the risk of birth defects, especially heart defects. Other tests include: fetal heart monitoring (non-stress tests) to check for his well-being and one or more ultrasounds during 3rd trimester to monitor baby’s growth.
Nowadays, with adequate follow up and tight blood sugar control, favorable pregnancy outcomes can be attained in women with pre-gestational and gestational diabetes.
Long-term Impact of Gestational Diabetes on Maternal & Child Health
Antoine Abu-Musa, MD, PhD
Department of Obstetrics and Gynecology, AUBMC
Gestational diabetes mellitus (GDM) complicates 1%–16% of pregnancies. GDM is associated with several poor short-term maternal and fetal outcomes, and treatment of GDM improves pregnancy outcome. GDM is confined to the pregnancy state and in most cases resolves itself spontaneously in the postpartum period. Nevertheless, women with GDM during pregnancy were found to be at an increased risk for future adverse outcome. GDM is increasing in prevalence, driven by greater maternal obesity and weight gain during pregnancy.
RISK FOR THE MOTHER
One of the most common long-term complications of GDM is the development of subsequent type 2 diabetes mellitus. At least half of the women with GDM will develop type 2 diabetes mellitus later in life. In addition, GDM is associated with future cardiovascular disease (CVD). Studies have reported a 66% to 85% higher risk of CVD, including coronary artery disease, myocardial infarction, and/or stroke. Another important recent finding is the association between GDM and adverse urinary system-related long-term outcomes.
GDM was associated with both stress urinary incontinence and mixed urinary incontinence up to 2 years following delivery with more profound symptoms in those who required insulin during pregnancy. Moreover, in pre-menopausal women, a history of GDM was found to be associated with almost doubled risk for overactive bladder.
RISK FOR THE OFFSPRING
The intrauterine environmental or nutritional status seems to be involved in the fetal programming and offspring exposed to maternal hyperglycemia are prone to develop mainly metabolic-related diseases later in life. The offspring are at increased risk of developing impaired glucose tolerance, hypertension, overweight and obesity, and dyslipidemia. It is well documented that the offspring of women with GDM are at considerable risk for diabetes at a young age, with an almost 8-fold increased risk of diabetes. Also GDM is associated with increased future risk of obesity, adiposity and increased abdominal circumference in children ages 5-7 years. Moreover, offspring of women with GDM have higher systolic blood pressure compared with controls. This could lead to future hypertension.
PREVENTION AND RISK REDUCTION
GDM has significant implications not only for the outcome of pregnancy, but certainly also for the future of both mother and child. Lifestyle intervention has been documented to prevent or limit the development of these severe conditions. It is therefore mandatory to diagnose and treat GDM and, furthermore, to follow mothers and their offspring after pregnancy, given their increased risk of diabetes. Maternal glycemic control may help to prevent adverse long-term outcome of the offspring, lowering the risk of being overweight. Other factors of prevention, for example weight control, special diet, and regular exercise are recommended to both the mother and her child as part of a comprehensive management plan. Finally, breastfeeding (for at least 6 months) compared with formula feeding has shown to have beneficial effects on glucose tolerance, hypertension, dyslipidemia, and obesity for both mother and offspring.
To Inject or Not To Inject
Labib Ghulmiyyah MD, FACOG
Assistant Professor, Clinical Obstetrics & Gynecology Residency Program
Director Maternal-Fetal Medicine, AUBMC
It is a well known fact that high blood sugar can cause a baby to grow unnaturally large, a most common problem with gestational diabetes or diabetes that develops during a pregnancy. And a baby that is too big can cause problems during delivery and even cause the baby problems at birth. Complications that can occur to the baby are the possibility of breathing difficulties, jaundice or low blood sugar. High blood pressure is also common in women with gestational diabetes.
However, most women with gestational diabetes can give birth to healthy babies. The key is to keep blood sugar levels under control.
You are probably wondering how can this be done?
Most women can control their gestational diabetes by strictly following a diabetes meal plan, being more active and consulting a diabetes educator or a dietician, as they are experts in nutrition and meal planning. Controlling blood glucose may require daily tracking of glucose levels, eating healthy foods, exercising regularly, and sometimes, taking medication. As a mother with gestational diabetes, you will probably need more frequent prenatal care visits to monitor your health and the health of your baby. In doing so, you will reduce risks and complications that may arise. Later in the pregnancy, you should also be doing special tests for the baby’s well being in order to make sure everything is ok.
Gestational diabetes can usually be controlled through diet and exercise, but if that doesn’t work pharmacologic therapy may be required to control blood glucose levels. Until recently, pharmacologic therapy was limited to insulin, a drug that is injected under the skin (in the fat). (Health care providers or diabetes educators can teach you how to give yourself insulin shots).
The use of oral medication was not common throughout the history of diabetes treatment, with a few attempts in the 1960s to popularize it. In 2000, a new study conducted in the United States revived the interest in oral medications. The daily sugar levels as well as the well being of mothers and babies did not differ significantly between those taking the injections of insulin and those taking the oral medication.
Having said that, insulin injections are still considered to be the standard treatment today although it is now accepted that oral medication might be an alternative option for some patients.
In both cases, if you are prescribed medication, you need to keep monitoring your blood glucose level as recommended by your health care provider. They will review your glucose log to make sure that the medication is working.
Bear in mind that changes in your medications may be needed to help keep your blood glucose level in the normal range. There is the unfortunate possibility that gestational diabetes may cause long-term health effects in women, and they are at higher risk of having diabetes in the future, as are their children.
Women with gestational diabetes will need to have regular diabetes testing after pregnancy. Their children will also need to be monitored for diabetes risks. Control is the key before, during and after the pregnancy!
Gestational Diabetes in Pregnancy (GDM)
Elie Hobeika MD, FACOG
Assistant Professor, Clinical Obstetrics & Gynecology, AUBMC
Medical Director, Department of Obstetrics & Gynecology, KMC
Diabetes complicates 2-3% of pregnancies. Most cases of diabetes complicating pregnancy are GDM that begins or is first recognized during pregnancy with an incidence of 1-14%.
The American College of Obstetricians and Gynecologists (ACOG) recommends universal screening for pregnant women using 50 grams oral glucose tolerance test between 24 and 28 weeks. If the number is above 140 mg/dl, a diagnostic test consisting of 100 grams of glucose, with a 3-hour oral glucose tolerance test is needed. Two abnormal values are needed to make the diagnosis of gestational diabetes mellitus (GDM).
Unlike women with pre-pregnancy diabetes, fetal anomalies are not increased in infants of mothers with GDM. Nonetheless, fetal death is a little higher than the general population.
Macrosomia (large baby) has been observed in as many as 50% of pregnancies complicated by GDM.
Women with GDM are more likely to develop hypertensive disorders and be delivered by cesarean section compared to women without GDM.
The mainstay of treatment of GDM is nutritional counseling and dietary intervention.
The recommended daily caloric intake is 30 kcal/kg based on pre-pregnant body weight for non-obese and 24 kcal/kg for obese patients.
The caloric composition includes 40– 50% from complex, high-fiber carbohydrates; 20% from protein; and 30–40% from primarily unsaturated fats.
Surveillance of blood glucose level is necessary. Fasting plasma glucose levels should be maintained below 95 mg/dl and below 120 mg/dl 2 hours after eating, in women with GDM.
When standard dietary management does not maintain these glucose levels, medications are needed in the form of pills (glyburide or metformin) or, if insufficient, shots (insulin) are then recommended.
For well-controlled GDM, antepartum testing is not needed and vaginal delivery can happen at term with cesarean section reserved for large babies above 4500 grams. For uncontrolled GDM or GDM requiring medications to control the blood sugar, antepartum testing is needed and early delivery might be helpful.
It is recommended that women with GDM receive a post-partum evaluation with a 75-g glucose tolerance test. This is based on the 30- 50% likelihood of such women developing diabetes within 20 years of delivery.