Pregnancy diabetes type 1

Contents

Type 1 or Type 2 Diabetes and Pregnancy

Problems of Diabetes in Pregnancy

Blood sugar that is not well controlled in a pregnant woman with Type 1 or Type 2 diabetes could lead to problems for the woman and the baby:

Birth Defects

The organs of the baby form during the first two months of pregnancy, often before a woman knows that she is pregnant. Blood sugar that is not in control can affect those organs while they are being formed and cause serious birth defects in the developing baby, such as those of the brain, spine, and heart.

An Extra Large Baby

Diabetes that is not well controlled causes the baby’s blood sugar to be high. The baby is “overfed” and grows extra large. Besides causing discomfort to the woman during the last few months of pregnancy, an extra large baby can lead to problems during delivery for both the mother and the baby. The mother might need a C-Section to deliver the baby. The baby can be born with nerve damage due to pressure on the shoulder during delivery.

C- Section (Cesarean Section)

A C-section is a surgery to deliver the baby through the mother’s belly. A woman who has diabetes that is not well controlled has a higher chance of needing a C-section to deliver the baby. When the baby is delivered by a C-section, it takes longer for the woman to recover from childbirth.

High Blood Pressure (Preeclampsia)

When a pregnant woman has high blood pressure, protein in her urine, and often swelling in fingers and toes that doesn’t go away, she might have preeclampsia. It is a serious problem that needs to be watched closely and managed by her doctor. High blood pressure can cause harm to both the woman and her unborn baby. It might lead to the baby being born early and also could cause seizures or a stroke (a blood clot or a bleed in the brain that can lead to brain damage) in the woman during labor and delivery. Women with type 1 or type 2 diabetes have high blood pressure more often than women without diabetes.

Early (Preterm) Birth

Being born too early can result in problems for the baby, such as breathing problems, heart problems, bleeding into the brain, intestinal problems, and vision problems. Women with type 1 or type 2 diabetes are more likely to deliver early than women without diabetes.

A Personal Story

Low Blood Sugar (Hypoglycemia)

People with diabetes who take insulin or other diabetes medications can develop blood sugar that is too low. Low blood sugar can be very serious, and even fatal, if not treated quickly. Seriously low blood sugar can be avoided if women watch their blood sugar closely and treat low blood sugar early.

If a woman’s diabetes was not well controlled during pregnancy, her baby can very quickly develop low blood sugar after birth. The baby’s blood sugar must be watched for several hours after delivery.

Miscarriage or Stillbirth

A miscarriage is a loss of the pregnancy before 20 weeks. Stillbirth means that after 20 weeks, the baby dies in the womb. Miscarriages and stillbirths can happen for many reasons. A woman who has diabetes that is not well controlled has a higher chance of having a miscarriage or stillbirth.

7 Tips for Women with Diabetes

If a woman with diabetes keeps her blood sugar well controlled before and during pregnancy, she can increase her chances of having a healthy baby. Controlling blood sugar also reduces the chance that a woman will develop common problems of diabetes, or that the problems will get worse during pregnancy.

Steps women can take before and during pregnancy to help prevent problems:

  1. Plan for Pregnancy
    Before getting pregnant, see your doctor. The doctor needs to look at the effects that diabetes has had on your body already, talk with you about getting and keeping control of your blood sugar, change medications if needed, and plan for frequent follow-up. If you are overweight, the doctor might recommend that you try to lose weight before getting pregnant as part of the plan to get your blood sugar in control.
  2. See Your Doctor Early and Often
    During pregnancy, a woman with diabetes needs to see the doctor more often than a pregnant woman without diabetes. Together, you and your doctor can work to prevent or catch problems early.
  3. Eat Healthy Foods
    Eat healthy foods from a meal plan made for a person with diabetes. A dietitian can help you create a healthy meal plan. A dietitian can also help you learn how to control your blood sugar while you are pregnant.
    Tasty Recipes for People with Diabetes and Their Families “external icon
    To Find a Dietitian:
    American Dietetic Association
    1–800–877–1600
    www.eatright.orgexternal icon (click on “Find an Expert”)
  4. Exercise Regularly
    Exercise is another way to keep blood sugar under control. It helps to balance food intake. After checking with your doctor, you can exercise regularly before, during, and after pregnancy. Get at least 30 minutes of moderate-intensity physical activity at least five days a week. This could be brisk walking, swimming, or actively playing with children.
    Learn more about physical activity during pregnancy ”
  5. Take Pills and Insulin as Directed
    If diabetes pills or insulin are ordered by your doctor, take them as directed in order to help keep your blood sugar under control.
  6. Control and Treat Low Blood Sugar Quickly
    Keeping blood sugar well controlled can lead to a chance of low blood sugar at times. If you are taking diabetes pills or insulin, it’s helpful to have a source of quick sugar, such as hard candy, glucose tablets or gel, on hand at all times. It’s also good to teach family members and close co-workers or friends how to help in case of a severe low blood sugar reaction.
  7. Monitor Blood Sugar Often
    Because pregnancy causes the body’s need for energy to change, blood sugar levels can change very quickly. You need to check your blood sugar often, as directed by your doctor. It is important to learn how to adjust food intake, exercise, and insulin, depending on the results of your blood sugar tests.
    Learn how to take control of your diabetes ”

More Information

Got diabetes? Thinking about having a baby? pdf icon
View, download, and print this brochure about diabetes and pregnancy.

For information on how to keep blood sugar well controlled, visit the American Diabetes Associationexternal icon website.

When you are pregnant, your ideal scenario is to not gain too much weight, pass each milestone without worry, and have a safe, fast delivery that results in a healthy baby. When you have Type 1 diabetes, however, the ideal pregnancy may seem unattainable. Lisa Pink, a new mother, was able to manage her pregnancy along with her diabetes to have a healthy baby girl. She summed up her experience: “It’s a lot of work. However, it’s also worth it when you hold your healthy, perfect baby!”

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Before conception

Lisa learned she had Type 1 diabetes when she was 25 years old. She didn’t think about pregnancy and starting a family until she reached her mid-30s. Lisa didn’t know any mothers with Type 1 diabetes, but two of her friends knew of women who had managed their diabetes throughout successful pregnancies. Encouraged, Lisa went to her doctor a year before she and her husband began trying to become pregnant, which is highly recommended. A woman with Type 1 diabetes should attain healthy blood glucose levels before conception. This is important for the baby’s health during pregnancy but also before conception. The National Institutes of Health recommends that a woman with Type 1 diabetes have blood glucose levels in the target range of 80 to 110 mg/dl before eating and 100 to 155 mg/dl one to two hours after eating for three to six months before becoming pregnant. During pregnancy, the recommended target blood glucose range is 60 to 99 mg/dl before eating and 100 to 129 mg/dl one to two hours after eating.

Safe sugar

Meeting these target ranges will help decrease the chance of too much sugar being passed to your baby. Too much sugar may cause a fetus to grow too quickly or possibly harm the early development of organs. Having a large baby was one of Lisa’s concerns, so she started using a continuous glucose monitor (CGM) to make sure her numbers were in her target range. “This helped me track trends and changes and to be better prepared for insulin needs,” Lisa said. “For the most part, everything went well. I was able to continue to exercise once the first trimester nausea subsided, and I didn’t gain too much weight, only about 20 to 25 pounds, which is good. One of the concerns was that the baby would get too big, but she was sizing well throughout and weighed 7 pounds, 2 ounces, at birth.”

Complications and concerns

It is important to ask your doctor about setting goals in an appropriate range. Eating healthy and getting enough exercise can also help you manage blood glucose levels and lessen your need for insulin. And finding an obstetrician who is sensitive to the monitoring and needs of a woman with Type 1 diabetes is essential. Lisa felt she needed extra assurance that everything was going well and that her concerns about the effect of high blood sugar on the fetus were considered. “So I got extra tests,” she said. “I had a harmony DNA test done at about 16 weeks to test for the chance of chromosomal abnormalities, tests for neural tube defects and spina bifida, and a fetal EKG to check for heart abnormalities. Obviously, each test added stress at the possibility of something being wrong with the baby, but everything turned out fine. Additionally, my condition required fetal monitoring once a week after 30 weeks and that increased to twice a week after 36 weeks. It was at one of these fetal monitoring sessions where they noticed the baby’s movement was not optimal and my high blood pressure put me into the hospital to deliver early.”

Early delivery is one of the main concerns for woman with Type 1 diabetes. Being pregnant and having Type 1 diabetes means that you have to be more vigilant. All pregnancies can have complications, but Type 1 makes you more vulnerable to specific issues like preeclampsia, which is gestational hypertension or high blood pressure. In general, women with Type 1 are susceptible to this because they often have high blood pressure before they get pregnant. Many pregnant women with Type 1 diabetes also worry about developing insulin resistance. During pregnancy, the placenta provides the fetus with nutrients and water. The placenta also makes a variety of hormones to help you stay pregnant. In early pregnancy, hormones can cause increased insulin secretion and decreased glucose production by the liver, which can lead to hypoglycemia, or low blood glucose. In later pregnancy, hormones like estrogen, cortisol, and human placental lactogen can have a blocking effect on insulin, a condition called insulin resistance. As the placenta gets bigger, more of these hormones are made, and insulin resistance becomes greater.

Women with Type 1 diabetes have a lot to consider when trying to conceive as well as during pregnancy and delivery. Unexpected things can happen during delivery, and having a birth plan in place may help. Lisa learned some important steps during her delivery when the unexpected happened to her. It started when her doctor’s office was acquired by another hospital, so her endocrinologist was not able to see her in the hospital. She had to deliver at the hospital affiliated with her obstetrician. Fortunately, the hospital’s endocrinologist was able to help make sure her blood sugar was in control during and after labor. When Lisa’s numbers climbed during labor, she realized she did not have a specific plan for blood sugar control while she was in the hospital or a plan for her pump settings. So this was all done on the fly with a doctor she had never met. Fortunately, the new doctor communicated with her regular doctor during this time to keep him updated and help get Lisa’s settings right after delivery. “As a 35-year-old Type 1 diabetic, my birth plan really was whatever needed to be done to keep me and the baby healthy, so I was willing to do whatever was necessary for that,” Lisa said. “Any plans I may have had went out the door when my blood pressure was high and I had to go into labor 12 days before my due date. Preeclampsia is a risk for diabetic mothers, and so I had to be aware of that throughout the pregnancy. My blood pressure was creeping up toward the end, but didn’t really become an issue until that 38th week. I was feeling well for most of the pregnancy, but really started to feel sluggish the last two months, with my ankles swelling, and that’s when my blood pressure was increasing.”

Breastfeeding

After her early but successful labor and delivery, Lisa faced a new challenge: would she be able to breastfeed her beautiful daughter? “Absolutely! I was told that it would not be an issue. They test a baby’s blood sugar as part of the standard post-delivery tests, and I don’t think having diabetes necessarily increases her chances by that much, and there’s no deficiency or issues with my breastmilk despite my diabetes. I had difficulty getting her to latch on, but we definitely tried and I was able to breastfeed some of the time, but mostly pumped milk for her, especially when I went back to work. Regardless of my condition, breastfeeding is hard, and your baby needs to eat, so please don’t be afraid to ask for and feed your baby formula if you need to, despite how much breastfeeding pressure there is. Your baby’s health is the most important thing. Our baby was not getting enough food and so was jaundiced and had high bilirubin levels because she was not eating and therefore not expelling waste. Although we were in the hospital four days postpartum, due to my high blood pressure treatment…we had to go back to the hospital two days later for her to get light therapy treatment for her jaundice. This was not necessarily related to my diabetes, but still is a concern I was not really aware of.”

A team effort

When asked if she had any advice for other women with Type 1 diabetes who are considering having children, Lisa stated, “The main thing, as with all diabetes care, is that you have to have your team — endocrinologist, nutritionist, diabetes educator, if necessary, and obstetrician. They all have to be working together and communicating to make sure you are taking care of yourself and that your numbers are on track. This is in addition to all the other pregnancy milestones that other women need to worry about, because you have to be in the best condition possible before you get pregnant. It’s a lot of work, and my husband was also a big part of that team to make sure I was on track and keeping all my appointments and taking my vitamins, etc. It definitely takes a lot of people.”

Want to learn more about pregnancy with diabetes? Read “Pregnant and Pumping” and “Pregnancy With Diabetes.”

Also in this article:

  • Diabetes Preconception Tips
  • Diabetes Pregnancy Complications and Concerns

Pregnancy was hard but worth every moment

With the insulin pump and some amazing support from the consultants and diabetes nurses at King’s, I was able to get fantastic HbA1c levels that were simply not possible for me when using injections.

My pregnancy progressed without any major complications and although I was busy at work, my bosses were very supportive and understood that my hospital appointments would mean I was out of the office for half a day each week. Being diabetic felt like a full-time job in itself during pregnancy!

As well as obsessive testing, I counted carbs meticulously and tried to work out exactly what kind of foods worked at what time of day to avoid any big blood sugar peaks. It turns out a cheese croissant for breakfast worked perfectly, while an evening pizza was absolutely impossible to manage. Having a target for post-meal blood sugar levels is one of the big differences during pregnancy, as well as having lower targets overall.

The other tricky thing with pregnancy is the huge increase in the amount of insulin required, and it keeps on going up throughout. By the end of my pregnancy I needed more than twice the amount of insulin I do now.

I went on a DAFNE course when I was around five months’ pregnant and the other participants were a bit shocked at what huge doses I was taking, and that I was happily walking around with blood glucose levels between 3.5 and 4!

Being diabetic had its advantages

The plan with most Type 1 diabetics is to induce labour at about 38 weeks as there is a risk that the placenta can deteriorate if pregnancy continues to 40 weeks.

A few weeks before I was due to go in for induction I was getting high blood pressure readings at clinic. I was admitted to the antenatal ward for overnight monitoring because the doctors were concerned that I may have pre-eclampsia (as with so many other things, more likely if you’re diabetic).

I realised then that being diabetic did have its advantages: it meant I was getting much more care throughout my pregnancy so if anything were to go wrong it would be picked up quickly.

At 38 weeks pregnant I went into hospital for my induction. The first dose of hormones didn’t have any effect, so the next day I was given a second dose. I still thought nothing much was happening so sent my husband home late in the evening to get some rest.

Of course as soon as he’d gone I started experiencing labour pain and when I got to 2cm dilated I had my waters broken. However, something was amiss with the baby’s heart rate so the decision was made to go for an emergency Caesarean. I was prepared that I might need a Caesarean as it’s quite common for diabetics, but the fact that the baby might be in danger was pretty scary. Fortunately my husband just got back in time – five minutes more and I think he’d have missed me going into theatre.

The Caesarean went to plan, but with the concern over the baby’s heart he was taken to the Special Care Baby Unit (SCBU) to be monitored. When he was born he needed resuscitation, and I only got to see him for a couple of seconds before he was taken away, which was extremely distressing.

I didn’t get to meet my son properly until he was about seven hours old because I was in the recovery room following the C-section. I’d so looked forward to the first few hours with him.

The paediatricians quickly established that the baby’s heart was fine, but he ended up staying in the neonatal unit for five days. Despite all my best efforts to get good glucose levels during pregnancy, baby James was born with hypoglycaemia, which is very common with diabetic mothers.

Unfortunately treating hypoglycaemia in a newborn is not as simple as giving them glucose so their sugar levels get back to normal levels quickly, because their body continues to produce too much insulin for a few days. To get baby James’s glucose levels up, he had to be tube fed every hour and his heel pricked to test his blood.

It was upsetting having him in the SCBU and I struggled to get breastfeeding established as he was being tube fed. At the same time I had to keep going back to the postnatal ward as there were concerns over my high blood pressure.

However, slowly but surely things got better. After five days, baby James was discharged to join me on the postnatal ward and I got to enjoy spending time bonding with him and getting to know him properly. And then a few days later I was discharged myself to begin our new life in the family home.

Without a doubt my pregnancy was the hardest thing I have ever done. But it was so incredibly worth it.

How to Get Pregnant with Type 1 Diabetes (All the Lifestyle Tips)

Why?

The doc, also known as a high-risk obstetrician, spent our appointment telling me all the terrible things that could happen in a pregnancy complicated by diabetes. Yes, tight blood sugars were necessary. Without them, the chances of having a pregnancy colored by complications, both for me and for the unborn baby, were high. The visit was a long list of all the potential things that could go wrong, from the pregnancy itself, to actually giving birth, to the health of my future child: birth defects. Potential miscarriage. Pre-ecclampsia. Vision issues. Kidney complications.

Oy.

And yet, I had a handful of friends, longtime type 1 women like me, who were in our 30’s and had had their own healthy beautiful children. They were not hobbled by illness or problems throughout. They may have had an issue here or there, but they managed things and got through them. And they were able to do it with the tight blood sugar control recommended for women with pre-existing diabetes. The truth is, with average hemoglobin A1C numbers in the 4-7 percent range, women with diabetes are no more likely to have pregnancy complications than are women without diabetes. This was recently proven by research in the journal Diabetes Care that found women diabetes who had A1C numbers 6.9 percent or lower had no more risk of “serious adverse outcome” than the non-diabetics did.

I knew I could try to do it, too.

Soon, I started blogging about my efforts to get and stay pregnant, while managing my type 1 diabetes. I liked the support I received from commenters. Plus, I wanted to connect with others who were pregnant, had given birth, or who were trying to conceive, all with type 1 diabetes.

At the same time, I found that there were no insider’s guides to pregnancy with pre-existing diabetes that were told from an actual woman with diabetes’ perspective. The books sanctioned by official diabetes organizations were written by health care professionals, and not by people with diabetes (as far as I could tell). I found Kathryn Gregorio Palmer’s excellent book, When You’re A Parent With Diabetes, which touches on pregnancy, hadn’t been published yet. And while I found an out-of-print Australian book that interviewed women with type 1, but it was actually pretty dry and clinical.

I began slowly finding other bloggers writing about pregnancy and diabetes. I found the great website DiabeticMommy.com, which is a sprawling bulletin board devoted to all things pre-pregnancy, pregnancy, and parenthood, with type 1, type 2 and gestational diabetes. There are some excellent Yahoo Groups devoted to these issues as well, particularly PositiveDiabeticPregnancies and PregnantPumpers.

Super-tight control for pre-pregnancy, as defined by my docs in my hospital’s diabetes and pregnancy program at the Joslin Diabetes Center, is having blood sugars of about 70-100 mg/dl before meals, about 120-140 mg/dl one hour after meals, and 100-140 mg/dl before bed. Once pregnant, those numbers dip even more, to 60-90 mg/dl before meals, with 120 mg/dl an hour after meals and 100-140 mg/dl before bed.

Huh?

It took a lot of trial and error, along with constant blood sugar testing (sometimes once an hour, up to 15 times a day), but I was able to figure out which foods I could eat that wouldn’t spike me too high after a meal (hello, oatmeal and whole grains, particularly mixed with some low-fat protein; goodbye, white bread). Exercise—even a stroll after a meal or a walk to my local train station—always helped smooth things out. And this was in the days before I had a continuous glucose monitor. I recently started using one and it’s sometimes really surprising to see how some meals show a nice slow and unpronounced rise in numbers after a meal, and how some meals really sent things flying high (oy, French fries, what did I ever do to you?)

Of course, everyone is different, and what works well for me, food-wise, might send another person’s numbers soaring. SO much about diabetes is trial and error, and figuring out what works for you, pre-pregnancy, can make actual pregnancy and its inevitable changes and challenges (hello, hormones and insulin resistance) easier to handle.

I’m pleased that after many long months, I finally got pregnant and knock on wood, had a pretty healthy and normal pregnancy (the details are all on my blog.) Our healthy son, known online as Toddler L, was born two years ago without any problems and thrives today as his chatty and mischievous self.

I’m also facing another kind of birth. After an equally long process, the guide I wished I had back in the day will be published in early 2010. My book, “Balancing Pregnancy with Pre-Existing Diabetes: Healthy Mom, Healthy Baby,” (see above link) will be published by Demos Medical Publishing in early 2010. It gives the insider details of pregnancy and type 1 or type 2 diabetes, using both my own experience and insights from dozens of other women who have been there. I hope it will give future readers the kind of information I was so hungry for and that it will give them the sense that a pregnancy with diabetes doesn’t have to be the horror show some doctors (or the technically accurate but extremely dated film Steel Magnolias) would lead you to believe.

Instead, pregnancy with pre-existing diabetes is a challenge and a boatload of work, no doubt, but it can be a pregnancy where the end result is a fantastically healthy and happy new mother and baby.

Prenatal vitamins: At least one month before you get pregnant, start taking a daily vitamin that has folic acid. It’s been shown to lower the risk of having a baby with a neural tube defect like spina bifida, a serious condition in which the brain and spinal cord don’t form normally. The CDC recommends you take 400 micrograms of folic acid daily before conception and throughout pregnancy. Most drugstores sell over-the-counter prenatal vitamins that don’t require a prescription.

Your blood sugar: The doctor will check to see if your blood sugar is in control. This is key, because you may not know you’re pregnant until the baby has been growing for 2-4 weeks. High blood sugar during the first 13 weeks can cause birth defects, lead to miscarriage, and put you at risk for diabetes complications.

Your medications: You’ll need more insulin during pregnancy, especially the last 3 months. The doctor will tell you how to adjust your dose. If you take diabetes pills, the doctor may switch you to insulin, because some of these drugs can harm the baby. So can some high blood pressure treatments used with diabetes. Bottom line: Discuss all medications you take with your doctor.

Meal planning: You’ll need to make some changes while you’re pregnant to avoid swings in blood sugar levels. You’ll also need to take in more calories to feed your growing baby.

Pregnancy if You Have Diabetes

  • a social worker or psychologist to help you cope with stress, worry, and the extra demands of pregnancy
  • You are the most important member of the team. Your health care team can give you expert advice, but you are the one who must manage your diabetes every day.

    Talk with your health care team before you get pregnant.

    Get a checkup

    Have a complete checkup before you get pregnant or as soon as you know you are pregnant. Your doctor should check for

    • high blood pressure
    • eye disease
    • heart and blood vessel disease
    • nerve damage
    • kidney disease
    • thyroid disease

    Pregnancy can make some diabetes health problems worse. To help prevent this, your health care team may recommend adjusting your treatment before you get pregnant.

    Don’t smoke

    Smoking can increase your chance of having a stillborn baby or a baby born too early.2 Smoking is especially harmful for people with diabetes. Smoking can increase diabetes-related health problems such as eye disease, heart disease, and kidney disease.

    If you smoke or use other tobacco products, stop. Ask for help so you don’t have to do it alone. You can start by calling the national quitline at 1-800-QUITNOW or 1-800-784-8669. For tips on quitting, go to Smokefree.gov.

    See a registered dietitian nutritionist

    If you don’t already see a dietitian, you should start seeing one before you get pregnant. Your dietitian can help you learn what to eat, how much to eat, and when to eat to reach or stay at a healthy weight before you get pregnant. Together, you and your dietitian will create a meal plan to fit your needs, schedule, food preferences, medical conditions, medicines, and physical activity routine.

    During pregnancy, some women need to make changes in their meal plan, such as adding extra calories, protein, and other nutrients. You will need to see your dietitian every few months during pregnancy as your dietary needs change.

    Be physically active

    Physical activity can help you reach your target blood glucose numbers. Being physically active can also help keep your blood pressure and cholesterol levels in a healthy range, relieve stress, strengthen your heart and bones, improve muscle strength, and keep your joints flexible.

    Before getting pregnant, make physical activity a regular part of your life. Aim for 30 minutes of activity 5 days of the week.

    Talk with your health care team about what activities are best for you during your pregnancy.

    Physical activity can help you reach your target blood glucose numbers.

    Read tips on how to eat better and be more active while you are pregnant and after your baby is born.

    Avoid alcohol

    You should avoid drinking alcoholic beverages while you’re trying to get pregnant and throughout pregnancy. When you drink, the alcohol also affects your baby. Alcohol can lead to serious, lifelong health problems for your baby.

    Adjust your medicines

    Some medicines are not safe during pregnancy and you should stop taking them before you get pregnant. Tell your doctor about all the medicines you take, such as those for high cholesterol and high blood pressure. Your doctor can tell you which medicines to stop taking, and may prescribe a different medicine that is safe to use during pregnancy.

    Doctors most often prescribe insulin for both type 1 and type 2 diabetes during pregnancy.3 If you’re already taking insulin, you might need to change the kind, the amount, or how and when you take it. You may need less insulin during your first trimester but probably will need more as you go through pregnancy. Your insulin needs may double or even triple as you get closer to your due date. Your health care team will work with you to create an insulin routine to meet your changing needs.

    Take vitamin and mineral supplements

    Folic acid is an important vitamin for you to take before and during pregnancy to protect your baby’s health. You’ll need to start taking folic acid at least 1 month before you get pregnant. You should take a multivitamin or supplement that contains at least 400 micrograms (mcg) of folic acid. Once you become pregnant, you should take 600 mcg daily.4 Ask your doctor if you should take other vitamins or minerals, such as iron or calcium supplements, or a multivitamin.

    What do I need to know about blood glucose testing before and during pregnancy?

    How often you check your blood glucose levels may change during pregnancy. You may need to check them more often than you do now. If you didn’t need to check your blood glucose before pregnancy, you will probably need to start. Ask your health care team how often and at what times you should check your blood glucose levels. Your blood glucose targets will change during pregnancy. Your health care team also may want you to check your ketone levels if your blood glucose is too high.

    During your pregnancy, you may need to check your blood glucose levels more often.

    Target blood glucose levels before pregnancy

    When you’re planning to become pregnant, your daily blood glucose targets may be different than your previous targets. Ask your health care team which targets are right for you.

    You can keep track of your blood glucose levels using My Daily Blood Glucose Record (PDF, 44 KB) . You can also use an electronic blood glucose tracking system on your computer or mobile device. Record the results every time you check your blood glucose. Your blood glucose records can help you and your health care team decide whether your diabetes care plan is working. You also can make notes about your insulin and ketones. Take your tracker with you when you visit your health care team.

    Target blood glucose levels during pregnancy

    Recommended daily target blood glucose numbers for most pregnant women with diabetes are

    • Before meals, at bedtime, and overnight: 90 or less
    • 1 hour after eating: 130 to 140 or less
    • 2 hours after eating: 120 or less3

    Ask your doctor what targets are right for you. If you have type 1 diabetes, your targets may be higher so you don’t develop low blood glucose, also called hypoglycemia.

    A1C numbers

    Another way to see whether you’re meeting your targets is to have an A1C blood test. Results of the A1C test reflect your average blood glucose levels during the past 3 months. Most women with diabetes should aim for an A1C as close to normal as possible—ideally below 6.5 percent—before getting pregnant.3 After the first 3 months of pregnancy, your target may be as low as 6 percent.3 These targets may be different than A1C goals you’ve had in the past. Your doctor can help you set A1C targets that are best for you.

    Ketone levels

    When your blood glucose is too high or if you’re not eating enough, your body might make ketones. Ketones in your urine or blood mean your body is using fat for energy instead of glucose. Burning large amounts of fat instead of glucose can be harmful to your health and your baby’s health.

    You can prevent serious health problems by checking for ketones. Your doctor might recommend you test your urine or blood daily for ketones or when your blood glucose is above a certain level, such as 200. If you use an insulin pump, your doctor might advise you to test for ketones when your blood glucose level is higher than expected. Your health care team can teach you how and when to test your urine or blood for ketones.

    Talk with your doctor about what to do if you have ketones. Your doctor might suggest making changes in the amount of insulin you take or when you take it. Your doctor also may recommend a change in meals or snacks if you need to consume more carbohydrates.

    What tests will check my baby’s health during pregnancy?

    You will have tests throughout your pregnancy, such as blood tests and ultrasounds, to check your baby’s health. Talk with your health care team about what prenatal tests you’ll have and when you might have them.

    Clinical Trials

    The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and other components of the National Institutes of Health (NIH) conduct and support research into many diseases and conditions.

    What are clinical trials, and are they right for you?

    Clinical trials are part of clinical research and at the heart of all medical advances. Clinical trials look at new ways to prevent, detect, or treat disease. Researchers also use clinical trials to look at other aspects of care, such as improving the quality of life for people with chronic illnesses. Find out if clinical trials are right for you.

    What clinical trials are open?

    Clinical trials that are currently open and are recruiting can be viewed at www.ClinicalTrials.gov.

    Having a Healthy Pregnancy With Type 1 Diabetes

    “The most important thing for type 1 diabetics is that if they consider pregnancy, they should make sure blood glucose control is under optimal conditions,” advised obstetrician and gynecologist Raul Artal, MD, a professor and chairman of the obstetrics and gynecology department at St. Louis University in Missouri.

    It is important to work with both an ob/gyn — one who’s experienced in caring for women with type 1 diabetes — and an endocrinologist to make sure that you’re achieving your blood sugar goals.

    Insulin generally doesn’t pose a risk to your baby, but high blood sugar does. “The number one concern is congenital malformations,” Artal explained. Neural tube defects (such as spina bifida) and congenital malformations of the heart are both possible when blood sugar is high. Low blood sugar (hypoglycemia) poses a different kind of threat by limiting the mother’s amount of glucose stores, which transfers to the developing infant and puts the child at risk for various long-term conditions, such as cognitive deficits, developmental abnormalities, and hypertension.

    A research review in the Cochrane Database System Review looked at three published studies of pregnancy and birth outcomes for 223 women with pre-existing diabetes. The researchers compared the outcomes of those who had poor control of blood sugar with those who had tight or tight-to-moderate control. Women with poorly controlled blood sugar were at greater risk for fetal death, pre-eclampsia, delivery by C-section, and birth weights above the ninetieth percentile for infants.

    Babies born to women with pre-existing diabetes are also more likely to have breathing problems, jaundice, and low blood sugar levels, although these tend to be temporary complications.

    Steps to a Healthier Pregnancy With Type 1 Diabetes

    In addition to working closely with your medical team, the following strategies will help ensure a healthy pregnancy and healthy baby:

    • Discuss needed medication changes. Pregnant women are more likely to experience low blood sugar levels and to potentially need more insulin throughout their pregnancy. Ask your doctor what signs to look for and a medication strategy to put in place.
    • Use a continuous glucose monitor. This device will give you speedy feedback on your blood sugar levels and rates of change. Sparling attributed much of her success to the use of her Dexcom CGM.
    • Plan for life with baby. Sparling said, only half joking, that she was so focused on managing her diabetes and her pregnancy that she hadn’t given much thought to baby care. Managing diabetes can be tough, but learning about the needs of an infant will keep you focused on the fun and joy to come.
    • Use adequate birth control after delivery. Diabetic women must regain control of their blood sugar before getting pregnant again. Discuss the family planning methods you prefer with your doctor so they can be put in place after delivery.

    Finally, Sparling suggests setting aside time to relax, especially if you often stress out about your blood sugar levels. Occasional spikes aren’t going to harm your baby if your A1C number is good, she said.

    Even without diabetes, “It takes a lot of work for your body to make a baby,” Sparling noted. But if you do have type 1 diabetes, just take extra care to stay closely attuned to your blood sugar levels, and you’ll soon have a happy, healthy baby.

    Pregnancy in Women with Type 1 or Type 2 Diabetes

    Uncontrolled high blood sugar poses many risks to mother and baby.

    Being well-prepared for pregnancy can help reduce the risk of complications, keep you healthy throughout your pregnancy, and give your baby a good start in life.

    Blood glucose (sugar) control is a daily challenge for people with diabetes. Hormonal changes during pregnancy make diabetes even more challenging.

    The majority of women who properly control their diabetes before and during pregnancy have successful pregnancies, and give birth to beautiful, healthy babies.

    Risks and potential complications

    Women with diabetes have a higher risk of miscarriage and of having a baby with birth defects (heart and kidney defects, for example). This risk significantly increases if blood glucose (sugar) control is not optimal, especially at conception and during the first 3 months of pregnancy, when the baby’s organs are forming.

    If your blood glucose (sugar) levels are poorly controlled, you should avoid becoming pregnant until your healthcare team has helped you improve your blood sugar control.

    Risks for the mother:

    • Miscarriage
    • Rapidly worsening retinopathy (damage to the retina caused by diabetes)
    • Rapidly worsening nephropathy (kidney damage caused by diabetes) and kidney failure
    • A more difficult vaginal delivery (because of the baby’s weight) requiring special maneuvers by the obstetrician or the use of forceps or suction
    • Caesarean delivery
    • Gestational hypertension and pre-eclampsia (a pregnancy complication characterized by high blood pressure and significant swelling)
    • Excess amniotic fluid, which can cause premature labour

    Risks for the baby:

    • Defects (especially if the diabetes is poorly controlled in the first 3 months of pregnancy) of the heart, kidneys, urogenital tract, brain, spinal cord and backbone
    • Higher-than-average birth weight (more than 4 kg or 9 lbs.) or, conversely, sometimes stunted growth and low birth weight
    • Premature birth
    • Difficulty breathing at birth because of delayed lung maturity, among other factors
    • Hypoglycemia at birth, all the more severe if the mother’s diabetes was poorly controlled in the days/weeks prior to the birth
    • Jaundice
    • Calcium deficiency in the blood at birth
    • Malfunction in the production of red blood cells (polycythemia or hyperviscosity)
    • Perinatal death

    All of these complications occur almost exclusively when the mother’s diabetes has been poorly controlled.

    With the intensification of treatment for women with diabetes, the mortality of newborns has decreased significantly, but remains slightly higher in women with poorly controlled diabetes, especially if they have episodes of ketosis, ketoacidosis or hypertension during pregnancy.

    How to reduce the risks

    Strict blood sugar control from preconception to delivery and close monitoring by a multidisciplinary team in a specialized centre can greatly reduce most of these risks.

    It is advisable for diabetic women who want a child to keep their glycated hemoglobin (A1C), below 7.0 % (even below 6.5 % if possible) to reduce the risk of complications and deformities. This may seem a tall order, but it is achievable. If you can’t reach that number, remember that any decrease in A1C whatsoever improves your chances of having a healthy baby.

    Note: women with A1C above 10.0% should seriously consider delaying pregnancy until they reach their blood glucose (sugar) targets.

    To help you succeed, your doctor may suggest increasing or modifying your current treatment. For some women with type 2 diabetes, it is sometimes advisable to start insulin treatment prior to pregnancy to ensure better blood glucose (sugar) control.

    Be aware that stricter control of blood glucose using antidiabetic medication or insulin may increase the risk of hypoglycemia. In short, women with diabetes who are planning a pregnancy and who need antidiabetic medication or insulin should monitor their blood glucose (sugar) levels more frequently to avoid hyperglycemia and hypoglycemia.

    Women with type 1 diabetes are also advised to test for ketones in their urine or blood when their blood glucose (sugar) level stays high for several hours. Ask your healthcare provider to show you how to do this test.

    Attaining a healthy weight

    Overweight women are more at risk for fertility problems and pregnancy complications. Before becoming pregnant, all overweight women should try to reach a healthy weight (a BMI between 18.5 and 25), particularly women with type 2 diabetes.

    Losing 10% of your body weight at a slow and gradual pace, even if you don’t reach your healthy weight, will still have a positive impact on your fertility and limit birth complications. Overweight women are advised to seek advice from a dietitian or kinesiologist to help them lose weight and increase their physical activity.

    Care of the eyes and kidneys

    People with diabetes are at risk of developing eye and kidney complications, and these risks increase during pregnancy. That is why diabetic women wishing to become pregnant should have an eye exam and their kidney function tested prior to conception. It is recommended that you see your ophthalmologist or optometrist if you have not had an eye exam in the last six months.

    If you suffer from eye or kidney complications, they should be treated and controlled before conception so that they do not become worse.

    Before becoming pregnant, it is also important that your blood pressure (hypertension) is properly controlled. Hypertension causes a rise in the pressure of the small blood vessels in the eyes and kidneys, which makes them fragile. It can also have a negative impact on the development of the placenta during pregnancy and cause complications.

    Folic acid

    Folic acid (folate) is an important vitamin in the prevention of brain and spinal-cord defects (spina bifida) in babies. Most women get their daily requirement of folic acid by eating a varied diet.

    Folic acid is found in leafy green vegetables, fruits, nuts, bread and cereals. In addition to eating a balanced diet, it is recommended that all diabetic women who want a child start taking a supplement of 1 mg per day of folic acid at least three months before conception and continue taking this supplement for at least the first 3 months of pregnancy.

    Consult your pharmacist for advice about taking a folic acid supplement.

    See the list of high-risk pregnancy clinic .

    Research and writing: Team of Diabetes Quebec Health Professionals.

    Excerpted from: Diabetes Québec (2013), Diabète et grossesse.

    Other reference: Feig D, Berger H, Donovan L et al. Diabetes Canada 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada: Diabetes and Pregnancy. Can J Diabetes 2018; 42 (Suppl 1): S255-S282.

    Lat update: July 2018

    Diabetes During Pregnancy

    What is diabetes?

    Diabetes is a condition in which the body can’t make enough insulin, or can’t use insulin normally. Insulin is a hormone. It helps sugar (glucose) in the blood get into cells of the body to be used as fuel. When glucose can’t enter the cells, it builds up in the blood. This leads to high blood sugar (hyperglycemia).

    High blood sugar can cause problems all over the body. It can damage blood vessels and nerves. It can harm the eyes, kidneys, and heart. In early pregnancy, high blood sugar can lead to birth defects in a growing baby.

    There are 3 types of diabetes:

    • Type 1 diabetes. Type 1 diabetes is an autoimmune disorder. The body’s immune system damages the cells in the pancreas that make insulin.

    • Type 2 diabetes. This is when the body can’t make enough insulin or use it normally. It’s not an autoimmune disease.

    • Gestational diabetes. This is a condition in which the blood glucose level goes up and other diabetic symptoms appear during pregnancy in a woman who has not been diagnosed with diabetes before. It happens in about 3 in 100 to 9 in 100 pregnant women.

    What causes diabetes during pregnancy?

    Some women have diabetes before they get pregnant. This is called pregestational diabetes. Other women may get a type of diabetes that only happens in pregnancy. This is called gestational diabetes. Pregnancy can change how a woman’s body uses glucose. This can make diabetes worse, or lead to gestational diabetes.

    During pregnancy, an organ called the placenta gives a growing baby nutrients and oxygen. The placenta also makes hormones. In late pregnancy, the hormones estrogen, cortisol, and human placental lactogen can block insulin. When insulin is blocked, it’s called insulin resistance. Glucose can’t go into the body’s cells. The glucose stays in the blood and makes the blood sugar levels go up.

    Who is at risk for diabetes during pregnancy?

    The risk factors for diabetes in pregnancy depend on the type of diabetes:

    • Type 1 diabetes often occurs in children or young adults, but it can start at any age.

    • Overweight women are more likely to have Type 2 diabetes.

    • Overweight women are more likely to have gestational diabetes. It’s also more common in women who have had gestational diabetes before. And it’s more common in women who have a family member with Type 2 diabetes. Women with twins or other multiples are also more likely to have it.

    What are the symptoms of diabetes during pregnancy?

    There are no common symptoms of diabetes. Most women don’t know they have it until they get tested.

    How is diabetes during pregnancy diagnosed?

    Nearly all nondiabetic pregnant women are screened for gestational diabetes between 24 and 28 weeks of pregnancy. A glucose screening test is given during this time. For the test, you drink a glucose drink and have your blood glucose levels tested after 2 hours.

    If this test shows a high blood glucose level, a 3-hour glucose tolerance test will be done. If results of the second test are not normal, gestational diabetes is diagnosed.

    How is diabetes during pregnancy treated?

    Treatment will depend on your symptoms, your age, and your general health. It will also depend on how severe the condition is.

    Treatment focuses on keeping blood glucose levels in the normal range, and may include:

    • A careful diet with low amounts of carbohydrate foods and drinks

    • Exercise

    • Blood glucose monitoring

    • Insulin injections

    • Oral medicines for hypoglycemia

    What are possible complications of diabetes during pregnancy?

    Most complications happen in women who already have diabetes before they get pregnant. Possible complications include:

    • Need for insulin injections more often

    • Very low blood glucose levels, which can be life-threatening if untreated

    • Ketoacidosis from high levels of blood glucose, which may also be life-threatening if untreated

    Women with gestational diabetes are more likely to develop Type 2 diabetes in later life. They are also more likely to have gestational diabetes with another pregnancy. If you have gestational diabetes you should get tested a few months after your baby is born and every 3 years after that.

    Possible complications for the baby include:

    • Stillbirth (fetal death). Stillbirth is more likely in pregnant women with diabetes. The baby may grow slowly in the uterus due to poor circulation or other conditions, such as high blood pressure or damaged small blood vessels. The exact reason stillbirths happen with diabetes is not known. The risk of stillbirth goes up in women with poor blood glucose control and with blood vessel changes.

    • Birth defects. Birth defects are more likely in babies of diabetic mothers. Some birth defects are serious enough to cause stillbirth. Birth defects usually occur in the first trimester of pregnancy. Babies of diabetic mothers may have major birth defects in the heart and blood vessels, brain and spine, urinary system and kidneys, and digestive system.

    • Macrosomia. This is the term for a baby that is much larger than normal. All of the nutrients the baby gets come directly from the mother’s blood. If the mother’s blood has too much sugar, the pancreas of the baby makes more insulin to use this glucose. This causes fat to form and the baby grows very large.

    • Birth injury. Birth injury may occur due to the baby’s large size and difficulty being born.

    • Hypoglycemia. The baby may have low levels of blood glucose right after delivery. This problem occurs if the mother’s blood glucose levels have been high for a long time. This leads to a lot of insulin in the baby’s blood. After delivery, the baby continues to have a high insulin level, but no longer has the glucose from the mother. This causes the newborn’s blood glucose level to get very low. The baby’s blood glucose level is checked after birth. If the level is too low, the baby may need glucose in an IV.

    • Trouble breathing (respiratory distress). Too much insulin or too much glucose in a baby’s system may keep the lungs from growing fully. This can cause breathing problems in babies. This is more likely in babies born before 37 weeks of pregnancy.

    • Preeclampsia. Women with Type 1 or Type 2 diabetes are at increased risk for preeclampsia during pregnancy. To lower the risk, they should take low-dose aspirin (60 to150 mg a day) from the end of the first trimester until the baby is born .

    Can diabetes during pregnancy be prevented?

    Not all types of diabetes can be prevented. Type 1 diabetes usually starts when a person is young. Type 2 diabetes may be avoided by losing weight. Healthy food choices and exercise can also help prevent Type 2 diabetes.

    How is diabetes during pregnancy managed?

    Special testing and monitoring of the baby may be needed for pregnant diabetics, especially those who are taking insulin. This is because of the increased risk for stillbirth. These tests may include:

    • Fetal movement counting. This means counting the number of movements or kicks in a certain period of time, and watching for a change in activity.

    • Ultrasound. This is an imaging test that uses sound waves and a computer to create images of blood vessels, tissues, and organs. Ultrasounds are used to view internal organs as they function, and to look at blood flow through blood vessels.

    • Nonstress testing. This is a test that measured the baby’s heart rate in response to movements.

    • Biophysical profile. This is a measure that combines tests such as the nonstress test and ultrasound to check the baby’s movements, heart rate, and amniotic fluid.

    • Doppler flow studies. This is a type of ultrasound that uses sound waves to measure blood flow.

    A baby of a diabetic mother may be delivered vaginally or by cesarean section. It will depend on your health, and how much your pregnancy care provider thinks the baby weighs. Your pregnancy care provider may advise a test called amniocentesis in the last weeks of pregnancy. This test takes out some of the fluid from the bag of waters. Testing the fluid can tell if the baby’s lungs are mature. The lungs mature more slowly in babies whose mothers have diabetes. If the lungs are mature, the healthcare provider may advise induced labor or a cesarean delivery.

    Key points about diabetes during pregnancy

    • Diabetes is a condition in which the body can’t produce enough insulin, or it can’t use it normally.

    • There are 3 types of diabetes: Type 1, tType 2, and gestational diabetes.

    • Nearly all pregnant women without diabetes are screened for gestational diabetes between 24 and 28 weeks of pregnancy.

    • Treatment for diabetes focuses on keeping blood sugar levels in the normal range.

    • Women with gestational diabetes are more likely to develop Type 2 diabetes in later life. Follow-up testing is important.

    Next steps

    Tips to help you get the most from a visit to your healthcare provider:

    • Know the reason for your visit and what you want to happen.

    • Before your visit, write down questions you want answered.

    • Bring someone with you to help you ask questions and remember what your provider tells you.

    • At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.

    • Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects are.

    • Ask if your condition can be treated in other ways.

    • Know why a test or procedure is recommended and what the results could mean.

    • Know what to expect if you do not take the medicine or have the test or procedure.

    • If you have a follow-up appointment, write down the date, time, and purpose for that visit.

    • Know how you can contact your provider if you have questions.

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