Diabetes and Pregnancy

“Giving birth and being born brings us into the essence of creation, where the human spirit is courageous and bold and the body, a miracle of wisdom”. ~Harriette Hartigan

Pregnancy is a special time for women – one also filled with great change. If you have Type 1 or Type 2 diabetes, having a baby requires some special planning to keep you and your baby healthy and to minimize the potential complications.

If you’re not ready to raise a family, talk with your doctor about how to delay getting pregnant until you are ready.

Before you get pregnant, schedule an appointment to talk with your doctor about having a baby. If you have diabetes, your pregnancy is considered high risk, which means you have an increased risk of problems during your pregnancy. You need to pay special attention to your health, and you may need to see doctors who specialize in treating diabetes or its complications.

Already existing diabetes-related health problems can affect your pregnancy. And pregnancy can make some diabetes health problems worse. Your doctor can talk with you about how pregnancy might affect any previous or ongoing problems you have.

  • Before you get pregnant, talk with your doctor about
  • Getting your vaccinations up to date [link to article on vaccines and immunizations]
  • Having a gynecological exam and Pap test to be certain everything is healthy
  • Get checked for sexually transmitted diseases and HIV

Your doctor should also check for:

  • High blood pressure
  • Eye disease, also called diabetic retinopathy
  • Cardiovascular disease
  • Nerve damage
  • Kidney disease
  • Thyroid disease

It’s especially important to effectively manage your glucose levels and excess weight before your pregnancy and to discuss a planned pregnancy with your doctor as early as possible because glucose targets are different for women who are trying to get pregnant. This is because high glucose levels can be harmful to your baby during the first eight weeks of pregnancy when a baby’s brain, heart, kidneys, and lungs form — even before you know you are expecting, because many women don’t realize they’re pregnant until 5 or 6 weeks after conception.

Target Blood Glucose Numbers (mg/dL) for Women with Diabetes Planning to Become Pregnant

  • Before meals and when you wake up 80 to 110
  • 1 to 2 hours after eating 100 to 155

If you have diabetes and are already pregnant, don’t panic! Millions of high-risk pregnancies, including women with diabetes, produce perfectly healthy babies without affecting the mother’s health.

Just make sure you are doing everything you can to take care of yourself and your diabetes during your pregnancy.

Pregnancy causes many changes in your body, so your diabetes management may need to change too. Even if you’ve had diabetes for years, you may need to change or fine tune your meal plan, physical activity routine, and medicines. As you progress through the various stages of pregnancy your needs could change frequently.

Just like with regular diabetes management, keeping your blood glucose as close to normal as possible before and during your pregnancy is the most important thing you can do to stay healthy and have a healthy baby.

Your health care team can help you learn how to use meal planning, physical activity, and medicines to reach your blood glucose targets. Together, you’ll create a plan for taking care of yourself, your diabetes and your baby.

How Diabetes Affects You and Your Baby

Glucose in a pregnant woman’s blood passes through to the baby. If your blood glucose level is too high during pregnancy, so is your baby’s glucose level before birth.

High blood glucose levels before and during pregnancy can:

  • Contribute to the mother’s diabetes complications, such as eye problems, heart disease, and kidney disease
  • Increase potential problems for your baby including: premature birth, weighing too much, having breathing problems or low blood glucose right after birth
  • Increase the risk of losing your baby through miscarriage or stillbirth
  • Increase the risk of your baby having birth defects. However, research has shown that when women with diabetes keep blood glucose levels under control before and during pregnancy, the risk of birth defects is about the same as in babies born to women who don’t have diabetes.

Having diabetes can also increase your chances of developing the following conditions:

  • Preeclampsia causes high blood pressure and excess protein in the urine and can be life-threatening to you and your baby. The only “cure” for preeclampsia is to give birth. If you develop preeclampsia early in your pregnancy you may be put on bed rest and medicines, or even have to be hospitalized, to allow your baby time to grow before delivery. If you develop preeclampsia late in your pregnancy, you may need to deliver your baby early through a common surgical procedure called a cesarean section, or c-section.
  • Depression is a potential issue for all people with diabetes but pregnant women with diabetes need to be vigilant about depression because it can cause you to lose good glucose management and control.

 How diabetes can affect the baby’s health

High blood glucose levels can cause the baby to grow very large (9 pounds or more). Being very large makes it hard for the baby to be born through the birth canal. Blood sugar that remains high in a pregnant woman can also cause her baby to have the following health problems:

  • Birth defects, especially of the brain, spine, and heart
  • Nerve damage to the baby’s shoulder during delivery
  • Low blood sugar after birth
  • Increased chance of overweight, obesity, and/or diabetes later in life

Your health care team

Regular visits with members of a health care team who are experts in diabetes and pregnancy will ensure you get the very best care. Your health care team should include:

  • A medical doctor who specializes in diabetes care, such as an endocrinologist. You will need monitoring and advice on glucose control during and after your pregnancy.
  • An obstetrician-gynecologist (OB/GYN)who also has experience treating women with diabetes. You may be referred to a maternal-fetal medicine specialist, also called a perinatologist. These doctors have had special training to take care of women with high-risk pregnancies. You will see your OB/GYN regularly throughout your pregnancy.

Your health care team may also include:

  • A nurse educator or nurse practitioner, who provides prenatal care and advice on managing diabetes.
  • A registered dietitian to help with meal planning. A healthy diet—for glucose control and nutrition—has never been more important than now. The phrase “You’re eating for two” is not about quantity as much as making good food choices.
  • Medical specialists who treat diabetes complications such as: ophthalmologists and optometrists for vision problems, nephrologists for kidney disease, and cardiologists for heart disease. If you are already experiencing complications from diabetes, you’ll need those conditions monitored throughout your pregnancy.
  • A social worker or psychologist can help you cope with stress, worry, and the extra demands of pregnancy. If you become overly anxious or depressed be sure to tell your OB/GYN and ask for a referral to a social worker or psychologist.
  • A doctor who cares for newborn babies, called a neonatologist. The hospital will assign a neonatologist if urgent care for your baby is needed at the hospital.
  • A lactation consultant, who is trained to help with breastfeeding. She can give you the information and support you need to start breastfeeding your baby. You can give your baby a healthy start by breastfeeding. Breastfeeding is highly recommended for the babies of women with diabetes. Breastfeeding provides the best nutrition and helps your baby stay healthy. Babies who breastfeed are less likely to become overweight and develop diabetes later on.

Even with all those medical professionals at your side, You are still the most important member of the team. Your health care team can give you expert advice, but you’ll be responsible for keeping your diabetes under control every day.

What can be done to prevent health problems related to diabetes during pregnancy?

  • See your doctor(s) and medical team members regularly. Your doctor needs to evaluate how the pregnancy is affecting your diabetes and make changes to your diabetes self-care routine.
  • Monitor your glucose levels regularly and often. Pregnancy affects your blood sugar control. You will need to check your blood sugar more often than when you are pregnant. Talk with your doctor about how often to check your blood sugar.
  • Take your medications on time. If medications are ordered by a doctor, take them as directed.
  • Check Ketone Levels. If your blood glucose levels rise above a certain level, such as 200 mg/dL or if you use an insulin pump, your doctor might recommend that you test for ketones. Your doctor will recommend a ketone testing regimen. If your ketone levels are too high your doctor might suggest making changes in the amount or times when you take your diabetes medications.
  • Control and treat low blood sugar quickly. Having tight blood sugar control can result in low blood sugar at times. Keep a ready source of sugar, such as glucose tablets or gel or hard candy, on hand at all times.

Eating, Diet, and Nutrition

Healthy eating is important during pregnancy to help you manage your blood glucose levels and weight and provide your growing baby with the nutrition it needs to develop properly.

If you don’t see a dietitian, or haven’t seen one in a while, you should schedule an appointment before you get pregnant. During pregnancy, many women need changes in their diet, such as extra calories and protein. Together, you and your dietitian will create a healthy eating plan tailored to your needs, usual schedule, food preferences, medical conditions, medicines, and physical activity routine.

Once you are pregnant, your healthy eating plan will be based on how many calories you need for pregnancy and your goals for weight gain during the pregnancy. Your dietitian can discuss the best foods to eat, portion sizes, and when to eat to reach or maintain a healthy weight.

You might need to see your dietitian every few months during pregnancy as your body changes.

Vitamin and Mineral Supplements

Your doctor will tell you whether you need to take a vitamin and mineral supplement before and during pregnancy. Many pregnant women need supplements because their diets don’t supply enough of the following important vitamins and minerals:

  • Iron—to help make extra blood for pregnancy and for the baby’s supply of iron
  • Folic acid—to prevent birth defects in the brain and spinal cord
  • Calcium—to build strong bones
  • Vitamin D – Studies suggest that having enough vitamin D in your blood may help maintain healthy blood glucose levels.

 Physical Activity

If you have been physically active before your pregnancy you should be able to continue with a more moderate version of your exercise routine during pregnancy. Though you should give up activities that increase your risk of falling such as inline skating or skiing.

If you are already pregnant and haven’t been active, start with an activity such as walking.

Regardless of your physical activity levels before pregnancy, walking and swimming, are low impact activities most pregnant women can participate in. Swimming (or floating), particularly in late stages of pregnancy can be great for relieving lower back pain and swollen feet.

Diabetes Medications

Some medicines are not safe during pregnancy and may even need to be stopped before you get pregnant. Talk to your doctor about all the medicines you currently take, such as those for high cholesterol and high blood pressure. Your doctor will advise you which medicines to stop taking.

The literature is mixed regarding the use of oral medications such as Metformin during pregnancy. It is, oddly enough, a drug that is used for women with poly cystic ovarian syndrome to help them get pregnant and reduce miscarriages in the first trimester.

Because of concern of the impact of oral medication such as Metformin or glyburide on the developing fetus, and lack of FDA approval, most doctors prescribe insulin if glucose levels are poorly controlled through diet and exercise.

Although the Food and Drug Administration (FDA) has not yet approved glyburide and Metformin for use in gestational diabetes, professional opinion about these drugs is changing as more studies are completed.

However, the safest diabetes medicine is insulin. If you’re already taking insulin, you might need to change the kind, the amount, or how and when you take it. Your insulin needs may double or even triple as you get closer to your delivery date. Your doctor will work with you to personalize your insulin routine.

Labor and Delivery with Diabetes

Your health care team will consider your health, your baby’s health, and any pregnancy complications in deciding how and when delivery should occur. You’ll want to talk with your health care team about your options well ahead of time so you can be prepared for all contingencies.

Your doctor may recommend inducing labor before your due date or delivering the baby surgically using a cesarean section. However, most women with diabetes have the option of regular child birth.

The factors your health care team will consider in deciding what type of delivery is best for you and your baby may include:

  • Baby’s size and position
  • Baby’s lung maturity
  • Baby’s movements
  • Baby’s heart rate
  • Amount of amniotic fluid
  • Your blood glucose and blood pressure levels
  • Your general health

Blood Glucose Control during Labor and Delivery

Keeping your blood glucose levels under control helps ensure your baby won’t have low blood glucose right after birth. You will be physically active when you’re in labor, therefore you may not need much insulin. Hospital staff will check your blood glucose levels frequently. Some women are given insulin and glucose, as well as fluids, through an intravenous (IV) line during labor to provide control of blood glucose levels during labor. If you are using an insulin pump, you might continue to use it throughout labor.

If you are having a c-section, your blood glucose levels may increase because of the stress of surgery. Your health care team will closely monitor your blood glucose levels and will likely use an IV for insulin and glucose to keep your levels under control.

After Delivery

After you’ve given birth, you might need less insulin than usual for several days. Breastfeeding can also lower the amount of insulin you need. You’ll be at increased risk for low blood glucose after delivery, especially if you’re breastfeeding. Diabetes medicines other than insulin are not recommended during breastfeeding.

If you’re breastfeeding, you might need more calories each day than you needed during your pregnancy. You might need to have a snack before or after you breastfeed your baby. Your dietitian can provide personalized recommendations and answer any questions you have about what, when, and how much to eat.

Remember, to be a good mom, you have to take good care of yourself by having good glucose control, eating healthy and being physically active. You are now responsible for a new life, in addition to your own – you need to provide a good example for your children to follow. With a little extra care you and your baby can have a healthy life together.

You can use the planning checklist “My Plan to Prepare for Pregnancy with Diabetes” to help you plan for and have a safe and healthy pregnancy.

Sources

NIDDK

NIH

CDC

Pharmacy Times Oct 2005

Everyday Health