WELCOME

Hello and Welcome,

We have prepared this guide to help you to stay healthy during your pregnancy.
It contains general information on gestational diabetes, as well as dietary advice, specific recommendations for lifestyle adjustments, explanations on blood glucose control, practical advice and a log book.

The Diabetes Clinic team is a multidisciplinary unit made up of diabetology specialists who work closely with your gynaecologist and others such as the vascular surgery, cardiology, ophthalmology, nephrology and chiropody departments, as well as our social and psychological departments at the Kirchberg Hospital Centre.

We will make sure to offer our support throughout your pregnancy and we make every effort to provide you with high-quality service and health care.

The Diabetes Clinic Team

INTRODUCTION TO THE DIABETIC CLINIC

OUR PRIMARY DUTIES

To provide information and instructions regarding diabetes, including symptoms, treatments, nutrition, education, injections and glucose-measuring techniques, additional analyses and examinations.
To provide medical supervision to help manage your diabetes.
To recommend therapeuticy education to help you manage the disease, its treatment and prevent complications.
To make sure that you have the appropriate equipment and the necessary information.

OUR MAIN ACTIVITIES AND SERVICES

Phone and email access in the event of an emergency for all patients under the Clinic’s supervision.
A consultation service for outpatient diabetics or in-patients at the Robert Schuman Hospitals.
Instruction for pregnant women with diabetes or with gestational diabetes.
Specific instructions and training for patients on insulin pumps.
An instructional program for newly-diagnosed diabetics and their families.
Development of your glucose profile.
Personalised dietary management

MISSION OF PREVENTION

The Diabetes Clinic actively participates in diabetes prevention by organising special events, open-days, etc.

WHAT IS GESTATIONAL DIABETES?

“Gestational diabetes” or “pregnancy diabetes” means a glucose intolerance which may occur during pregnancy and which in most cases subsequently disappears. It is important to screen for and treat this form of diabetes as it can lead to complications for the baby and the mother.

As sugar can pass through the placenta, high glucose levels in the mother lead to high glucose levels in the child which exposes the child to the risk of excess weight, malformations, neonatal hypoglycaemia as well as the risk of being overweight and diabetic later in life. Effective treatment of maternal blood glucose will reduce this risk. Complications for the mother can include frequent infections, (pre)eclampsia, miscarriage, a more difficult delivery and the need for a caesarean section. The mother also has the risk of developing chronic diabetes after her pregnancy. Some women have a higher risk of developing gestational diabetes.
This is linked to age, overweight, family history, ethnic origin, frequent multiple pregnancies, a history of hyperglycaemia (high blood glucose) or prior instances of gestational diabetes. However, every woman can be affected, and the number of sufferers is on the increase. That said, gestational diabetes exhibits few symptoms and often goes unnoticed. In order to determine the high-risk patients, the Kirchberg Hospital Centre offers screening to all expectant women between the 24th and the 28th week of pregnancy at the Bohler Clinic.
Screening for pregnancy diabetes is carried out by means of a test known as the “Glucose Tolerance Test”. The fasting patient must drink a sugary solution and her blood glucose levels are then measured 1 and 2 hours afterwards to see how the body responds to this high quantity of sugar. If one of the values is too high, the patient is at risk of developing gestational diabetes and requires closer supervision: blood glucose tests before and after meals, additional blood tests and regular consultations at a specialist centre.
The basic treatment for gestational diabetes consists of a carbohydrate-controlled diet as well as an adjustment in lifestyle including an increase of physical activity for the mother. This treatment can if required be supplemented by oral antidiabetic drugs or insulin.
If you are affected, you will be guided by our multidisciplinary team of physicians, nurses and specialist dieticians.
They will explain your pathology, its consequences and possible treatments, and advise you on how to modify your lifestyle and eating habits during pregnancy. In addition, they will teach you how to test your blood glucose levels on your own before and after each meal. These efforts will normally be sufficient in balancing your blood glucose levels. If, despite adequate dietary and lifestyle habits, your blood sugar is still high, we will initiate a suitable medicine-based treatment and, in a case where insulin becomes necessary, we will teach you how to inject yourself and manage the doses.

NURSING CARE

HOW TO MONITOR CAPILLARY BLOOD GLUCOSE

At the first consultation, the nurse at the Diabetes Clinic will give you a device for monitoring your blood sugar level.

When to take blood glucose measurements

You will be asked to measure your blood glucose 6x/day to get an overview of your glucose levels throughout the day
Namely:

• the first test on awaking on an empty stomach
• 2nd test 2 hours after the start of breakfast
• 3rd test before lunch
• 4th test 2 hours after the start of lunch
• 5th test before dinner
• 6th test 2 hours after the start of dinner

Blood glucose targets

• During pregnancy: fasting: < 95 mg/dl
• before each meal: < 120 mg/dl
• 2 hours after the beginning of the meals: < 120 mg/dl

How to measure your blood sugar level

It is important to wash your hands with soap and water, rinse and dry them prior to taking each measurement.

• Never use alcohol to disinfect your hands, to avoid errors in the results.
• Prior to each test, use a new needle and a new test strip.
• Select the depth of your needle on the finger-pricker.
• Prepare your reader by inserting the test strip.
• The thumb and index finger are never pricked, nor the pads of the fingers; this is to avoid loss of sensitivity and pain during self-testing. It is advisable to prick the side of the finger.
• Apply the drop of blood to the test strip.
• Write down the result in the logbook and ensure to also include any event which may account for this value (stress, illness, fever, overeating).
• Dispose of the needle in a sharp container (a special yellow container for needles) provided free of charge by the pharmacy (putting needles in the bin is prohibited).

How do you inject your insulin

• Prepare your equipment. Wash your hands with soap and water and dry them thoroughly.
• Screw the needle onto the insulin pen.
• Prepare 2UI (turn the knob on the end of the pen), inject into the air and repeat until you get a drop.
  Prepare the insuline dosis to inject
• Choose the injection site.
  • Make sure the skin is in good condition (no scars, wounds, bruises, eczema, allergies, tattoos).
  • Change the site for each injection.
• If you use needles 4 mm or 5 mm long, it is not necessary to make a fold. If in doubt, consult your diabetes nurse.
• Prick vertically (90°) to the skin.
• Inject gently, without moving the needle under the skin.
• After injection, wait 10 seconds before removing the needle from the skin. A compress is not necessary.
• Dispose of the needle into your sharps box (yellow container).
• Keep the insulin pen at room temperature until the next injection (use an insulated bag for transport in case of very hot weather or temperatures). Once opened, your Pen can be used for one month.

DIETARY MANAGEMENT NUTRITIONAL RECOMMENDATIONS

Introduction

In addition to regular blood glucose monitoring, what are the dietary measures to adopt after testing positive on the glucose tolerance test? In the following section we will focus on the important nutritional recommendations in this regard. All of the nutritional recommendations for avoiding toxoplasmosis or listeriosis (for example), during pregnancy, are always in effect; however, they are not explicitly covered here.

NUTRIENTS AND NUTRITION

Our goal is for you to have a balanced diet, with an appropriate carbohydrate content, which helps to manage blood glucose (glycaemic) levels. You should try to have 3 balanced meals a day and maybe an afternoon snack.
The various foods supply the body with substances that are necessary for it to function properly. This includes nutrients such as: water, proteins, carbohydrates, fats, fibre, minerals and vitamins.

Nutrients that do not affect blood glucose

WATER:

The body is made up of mostly water. Water eliminates waste (sweat, urine), controls body temperature (perspiration) and carries substances within the body. The daily recommendation for intake of water is 1.5 to 2 litres.
Food sources: mineral water, tea, herbal teas, coffee (decaf), soups, etc.

PROTEINS :

Proteins can be compared to building bricks for a house. In fact, proteins are the foundation for the body’s growth and structural development. They are animal-derived (meat, fish, eggs, etc.) or plant-derived (pulses, soya and their by-products).

FATS :

Fats are a major source of energy and the foods containing them can be very high in calories. However, besides this high caloric content, they also contain fat-soluble vitamins (vitamins A, D, E and K), which are important particularly for vision, bone development, strengthening of the immune system and blood coagulation.
As with proteins, there are animal-derived and plant-derived fats.
As part of a healthy, balanced diet, plant-derived fats (oils) would be preferable in order to have an optimal intake of polyunsaturated fatty acids and essential fatty acids (omega-3 and omega-6) which are essential for proper development of the nervous system and the brain as well as for strengthening the immune system.
Food sources:

• Oils
• Margarine
• Butter
• Oily fruits (nuts, hazelnuts, cashew nuts, almonds, pistachios, etc.)

PROTECTIVE NUTRIENTS:

MINERALS AND VITAMINS

Even in small quantities, mineral salts, trace elements and vitamins are essential for ensuring various bodily functions (good bones, proper functioning nervous system, red blood cell formation, enhancement of the immune system, etc.).
They do not provide energy. A varied diet provides you with the recommended supply of mineral salts and vitamins.

Water, proteins, fats, vitamins and minerals do not directly affect blood glucose levels.
The following nutrients, however, will require attention due to the fact that they do directly influence blood glucose levels.

Nutrients affecting blood glucose levels

Carbohydrates:

Carbohydrates are the sugars contained in food. They have a direct effect on blood glucose levels and are a main source of energy for the human body.
They help us to move around, run, think, etc. Carbohydrates are essential for life, thus the importance of choosing them wisely.

What happens during digestion? (in very simple terms):

• The greater the amount of simple carbohydrates, the shorter the digestion time and the faster the effect on blood glucose levels.
  Therefore: Sucrose and glucose are more quickly digested and absorbed, and blood glucose levels increase rapidly.
• The greater the amount of complex carbohydrates, the longer the digestion time and the slower the effect on blood glucose levels.
  Therefore: Starch takes longer to digest and be absorbed, and blood glucose levels take longer to rise.

Other factors that speed up or slow down digestion :

Meal variety: the more varied the components of your meal (proteins, fats, carbohydrates and fibre) the more slowly it will be digested.
Example: a dish of pasta vs a complete meal of meat, vegetables and starch.

The state of the meal when eaten: raw, cooked, puréed or in juice form. The more food is manipulated (cooked, mixed, pressed) the faster it is digested.
Example: orange juice vs fresh orange.

Fibre content: the more dietary fibre the food contains, the more slowly it will be digested.
Example: wholemeal bread vs white bread.

Food sources:

Starchy foods are a source of complex carbohydrates with a slow effect on blood glucose:

• Grains: wheat, oats, rice, corn, rye, barley, quinoa
• Wheat and wheat products: bread, pasta, biscuits, pizza dough, etc.
• Grain-derived products: semolina, couscous, wheat flakes, cornflakes, rice flakes…
• Potatoes
• Pulses : kidney beans, lentils, field peas, chick peas, flageolet beans, broad beans,…
  Fruits have a moderate effect on blood glucose levels:
• These can be eaten raw, cooked (puréed or preserved fruit salad). Confectionery having a very rapid effect on blood glucose:
• Sweets
• Fizzy drinks
• Confectionery
• Juices.

Depending on the level of food process, carbohydrates in each food (raw, cooked, fresh, juice) have a different effect on the blood sugar levels

Note: Depending on the form in which the fruit or starch is consumed (raw or cooked, whole or in juice form), the effect on blood glucose levels will not be the same.
Rule: the more a carbohydrate-rich food is cooked, or refined, the faster the blood glucose level will rise.

OBSERVATIONS:

Vegetables:

Vegetables contain much fewer carbohydrates than the preceding groups and have very little effect on blood glucose levels. The nutritional recommendation will be varying your consumption of cooked vegetables (accompanied by meat, soups, gratins, soufflés, etc.), raw vegetables (salads, crudités), or as juice. Always be sure to practice proper hand hygiene and wash hands well.

Milk and dairy products:

Lactose has practically no effect on blood glucose levels. This is why natural dairy products are consumed as desired and according to habit.

DIATERY FIBRE:

These supply very little energy (2 kcal) and ought not to be missed in a healthy, balanced diet. Dietary fibre has more of a regulatory effect on blood glucose. It promotes regular bowel movements, increases the feeling of fullness, etc., slows down digestion and halts the rise in blood glucose levels.

Food sources:

• Wholemeal bread
• Pasta, wholegrain rice
• Vegetables
• Fruits.

Hence the importance of preparing varied meals comprising whole foods.

What constitutes a balanced meal and a balanced day

For breakfast

A whole starch (wholemeal bread, for example)

• Fat
• A dairy product: natural yoghurt, sliced cheese, cheese or other spread
• Possibly a protein source: cooked ham or turkey, chicken
• A piece of fruit

For lunch

A hot dish

• ½ a plate of vegetables
• ¼ plate of starch, preferably whole
• ¼ plate of a protein source: meat or fish

For the evening meal

A cold dish

• ½ a plate of vegetables
• ¼ plate of a protein source: meat, cold fish or a dairy product
• ¼ plate of starch (for example, bread), preferably whole.

Some good dietary choices

Practical application

Food-wise

In order for the physician, nurse and dietician to have a very accurate and objective idea of your measured levels:

• during the first week of testing, avoid any intake of simple sugars with a sugary taste, for example brown sugar, white sugar, honey and products containing these; these would give false positives, i.e. high readings which would be due to the consumption of sugar (when sugar is not consumed, the result would perhaps be negative, and therefore correct).
• Include fruit at the end of your meal and limit the amount of fruit juice.
  Subsequently you can have a one-on-one nutritional consultation, during which your dietetician will aim to help you manage your diet more effectively. They may customise the recommendations to suit your personal situation, requirements and expectations: for example, in relation to nutritional choices.

After delivery

On the day before delivery

In cases of scheduled delivery or caesarean section, if you are on a treatment (insulin, oral medication) your health care team will tell you the measures to follow.

On the day of delivery

The midwifery team in attendance in the delivery room will be aware of your gestational diabetes and will ensure that your blood glucose levels are monitored during labour.
If you are on medication or insulin, you must follow the instructions given by your physician at the Diabetes Clinic (usually to discontinue any treatment).
Your baby’s blood glucose levels will also be monitored at birth, and after 6 hours, 12 hours and 24 hours of life (levels should be > or = 45 mg/dl).

On the days following delivery (post-partum)

You must continue to monitor capillary blood glucose 6 times a day for two full days. You must maintain a balanced diet; however, you can reintroduce certain foods containing carbohydrates which you consumed prior to pregnancy.

The blood glucose targets after delivery are: fasting <100 mg/dl
2h after the beginning of a meal < 140 mg/dl

A nurse from the Diabetes Clinic will be advised of your delivery by the Bohler Clinic team and will visit you in your room 2 or 3 days after the birth of your baby. In most cases, blood glucose values return to normal without any special diet. At this point, you will need to return the glucose monitor loaned to you during pregnancy. Should there be any problems, the physician on duty at the Diabetes Clinic will be contacted and will decide what follow-up ought to be pursued if necessary.
It is advisable to take a follow-up blood test 3 months after delivery or at the end of lactation and to consult your attending physician once a year as a follow-up measure.
In any case, you must refer to the individual recommendations provided by your medical health care team.