Having a chronic condition such as diabetes (diabetes mellitus) means careful monitoring of your health at the best of times, and this becomes even more crucial during pregnancy.
Most women who have pre-existing diabetes who become pregnant have type 1 diabetes (once called insulin-dependent or juvenile diabetes), although some may have type 2 (once called non-insulin dependent) diabetes.
Another type of diabetes called gestational diabetes is a temporary type of diabetes that occurs in pregnant women who have never had diabetes before and it usually goes away after the baby is born, although it does lead to an increased risk of developing diabetes in the future. This article deals only with pre-existing diabetes — also known as ‘pre-gestational diabetes’.
If you have diabetes, there’s no reason that you can’t have a healthy and successful pregnancy and deliver a healthy baby. What it does mean is that you will probably have to work closely with your doctor and other healthcare professionals to ensure you manage your diabetes well during your pregnancy.
I have diabetes and want to become pregnant: what should I do?
For women with type 1 or type 2 diabetes seeing your doctor and diabetes healthcare professionals for pre-pregnancy planning 3-6 months before you start trying to get pregnant is an important step in ensuring the best outcome for you and your baby.
You can discuss with your doctor what you need to do before you become pregnant, and what you can do to manage your diabetes during pregnancy.
It’s important to get your blood glucose levels within a recommended target range before you get pregnant. The NDSS recommends that you have an HbA1c of 6 per cent or less for the 3 months before you get pregnant.
Your doctor will recommend you take a high-dose folate supplement starting at least 1 month before conception. Folate is a vitamin that helps reduce the risk of some birth defects. This is important for all women planning a pregnancy, as the fetus needs adequate levels of folate during the first few weeks (when you may not even know you are pregnant) for normal development of the nervous system.
All pregnant women are recommended to take folate, but women with diabetes are recommended to take a higher dose than other women. Your doctor can advise you about supplements. All pregnant women are also recommended to have a flu vaccination and a whooping cough vaccination, and this is especially important for women with diabetes.
If you have diabetes and fall pregnant unexpectedly, contact your doctor and diabetes team straightaway for help and advice.
Are there increased risks to my baby if I have diabetes?
If you have diabetes, you have a slightly higher risk than other women of your baby:
- having a birth defect (congenital abnormality);
- being born prematurely;
- weighing too much or weighing too little;
- having jaundice; or
- having dangerously low blood sugar levels after birth.
However, you can minimise these risks by planning ahead and gaining the best possible control of your blood sugar at the time of conception and throughout pregnancy, especially the first 2 months (when your baby’s major organs are developing). This will also help to lower the risk of miscarriage and birth defects in your baby.
Are there increased risks to me of having a baby?
Will I need to change my diabetes medicines during pregnancy?
You should have a review of all your medicines before you get pregnant. Some medicines will need to be stopped or replaced before you get pregnant and then resumed after your pregnancy or after you finish breastfeeding.
Metformin is an oral medicine (tablet) used to treat type 2 diabetes. It is considered safe in pregnancy. If you have type 2 diabetes and are taking other tablets to help control your blood sugar (oral hypoglycaemic medication), your doctor will probably recommend you switch to something else.
If you use insulin, your doctor / diabetes healthcare professional can discuss the type of insulin and dose you should take in pregnancy.
If you have high blood pressure (hypertension) now is the time to get your blood pressure under control using medicines that are safe to continue once you are pregnant.
You may need to stop taking some medications, such as certain cholesterol-lowering medicines, while you are pregnant — check with your doctor.
Your doctor can also advise you about a folate supplement.
How will pregnancy affect my insulin requirements?
Like any woman who becomes pregnant, your hormones behave differently during pregnancy than at other times. What this means for you is that you have to be aware of the impact of these possible changes to your hormones and your metabolism so that you can adjust your diabetes management accordingly. Your insulin requirements are likely to change throughout the period of your pregnancy and shortly after delivery.
For example, early in your pregnancy, your body might start using glucose more effectively than usual, which means you need less insulin. You may be more at risk of hypoglycaemia (low blood sugar) during this time, particularly if morning sickness or nausea affect your intake of carbohydrates.
Maintaining optimal blood sugar levels early in pregnancy can be difficult due to the hormonal and physical changes taking place.
You might also find that your usual symptoms of hypoglycaemia change during this period so be aware of any signs that you are experiencing a hypo. Common signs of hypoglycaemia include shaking, sweating, headache, confusion, paleness, and changes in mood or behaviour.
From the second trimester, insulin requirements usually start to increase.
Later in your pregnancy your placenta will have grown in order to provide your baby with the nutrition needed to develop. Unfortunately, it also starts producing hormones that adversely affect the ability of insulin to do its job properly, which can result in a state of insulin resistance from about the fifth or sixth month of your pregnancy. This means that you might need to take more insulin: more mealtime, rapid-acting insulin. Some mums-to-be need as much as twice their usual insulin dose by around 30 weeks.
In the final 4 to 6 weeks of pregnancy, your need for insulin might change again and you might need slightly less insulin at this time. A rapid fall in requirements at this stage can be a sign of a problem. Contact your diabetes healthcare team immediately if this happens.
Once the baby is born, your insulin needs will fall dramatically, compared with what they were while you were still pregnant. This can make controlling your blood sugar levels challenging.
What all these changes mean is that you will have to be extra-vigilant in monitoring your blood sugar levels, and work closely with your doctor and other healthcare professionals to ensure you keep your diabetes under tight control.
What are the recommended blood glucose targets during pregnancy?
The current recommended targets in clinical guidelines for blood glucose during pregnancy for women with type 1 and type 2 diabetes are shown in the table.
|Recommended blood glucose targets in pregnancy (source: NDSS)
|2 hours after meals
Ask your doctor or diabetes educator how often you need to test your blood glucose. You will need to test it multiple times per day (before meals and 1-2 hours after meals), and overnight, on occasions. This will help you to monitor your condition and help you and your doctors adjust your insulin dosage, if necessary.
There are no hard and fast rules about your insulin regimen: your doctor will be best placed to recommend what’s suitable for your condition and circumstances. Some mums-to-be can keep tight control of their blood glucose levels on their usual twice-daily insulin, while others might have to change their routine to include multiple doses of insulin.
I have some complications of diabetes: how does this affect my pregnancy?
It is important to have your kidneys, eyes and nerves checked for complications of diabetes before you get pregnant. This is referred to as a baseline screening.
You will need to have a urine test to check the amount of protein passing through your kidneys and a blood test to check your kidney function.
It’s also important to have the back of your eyes checked by an optometrist or ophthalmologist.
Your nerves can be checked for damage by your doctor, podiatrist or diabetes educator.
If you have kidney problems as a result of diabetes (a condition known as diabetic nephropathy), you will need to be monitored carefully during your pregnancy.
Mild nephropathy usually causes few problems, but severe kidney disease is a cause for concern, especially when associated with high blood pressure and proteinuria (protein in the urine).
Unfortunately, any diabetes-induced renal disease can deteriorate during a pregnancy, but fortunately, things usually return to normal after the delivery (unless the kidney disease is severe).
You might find that you are susceptible to urinary infections during pregnancy so ensure you tell your doctor if you have any symptoms or feel feverish for any reason. Any urinary tract infection in a pregnant woman must be treated because there is a risk of the bacteria ascending from the bladder to the kidneys.
Most pregnant women are at risk of conditions such as high blood pressure and swollen ankles as a result of fluid build-up, especially in the later stages of pregnancy, so your doctor will be monitoring you carefully for any signs such as these.
If you have kidney problems and/or high blood pressure, there is a risk of pre-eclampsia, (also known as toxaemia of pregnancy), a condition in which your blood pressure increases, there is protein in the urine and you experience fluid retention resulting in swelling of the limbs, face and hands. If you have preeclampsia during pregnancy, your doctor may recommend medications, bed rest, early admission to hospital or early delivery of your baby, depending on the severity of the condition.
Eye problems (diabetic retinopathy) frequently get worse during pregnancy (although this may reverse after the baby is born). If you’re planning to become pregnant, you should have your eyes assessed beforehand and get treatment before you become pregnant. However, if your eye problems need treatment during pregnancy, you should be able to have laser treatment without damaging your baby.
Nerve problems as a result of diabetes (diabetic neuropathy) don’t usually cause additional problems during pregnancy.
One common concern is carpal tunnel syndrome (a condition in which the nerve that travels through the wrist becomes compressed, resulting in numbness, tingling and pain) but this often resolves after delivery.
What if I become ill during pregnancy?
If you have an illness during pregnancy you should see your doctor as soon as possible. This is because illness might make you more susceptible to losing control of your blood glucose levels. For example, your risk of hyperglycaemia (high levels of blood glucose, characterised by symptoms such as increased thirst, urinating frequently, and fatigue) is also increased if you are stressed or suffer from a cold or ‘flu.
Uncontrolled blood sugar during pregnancy can also place you at risk of high blood pressure, and can worsen the diabetic complications you may already have, such as eye disease (diabetic retinopathy).
How can I keep my baby healthy during pregnancy?
Any woman who is pregnant is usually concerned about keeping her growing baby healthy and if you have diabetes you are likely to have to be even more vigilant. For example, if your blood sugar is too high in the first 8 weeks of your baby’s development, the time when your baby’s major organs such as the heart, lungs, brain and kidneys are developing, your baby has a higher-than-normal risk of having birth defects.
Also, you have a higher-than-usual chance of having a miscarriage if you have a high blood acid level (ketoacidosis) as a result of poorly controlled diabetes. Later in your pregnancy, poorly controlled blood glucose levels could result in premature birth, stillbirth, or death shortly after birth.
You can increase your chances of having a normal pregnancy and birth if you keep tight control of your blood glucose both before and during your pregnancy.
Excess blood glucose as a result of diabetes can increase your chances of having a baby with macrosomia (an overly large body), which can cause complications during delivery. But by keeping good control of your blood sugar in the second half of your pregnancy, you can minimise your chances of having a large baby.
As with other pregnancies, your baby’s health will be monitored by healthcare professionals throughout its development and especially in the last 4 to 6 weeks before birth.
In addition to the routine ultrasounds that all pregnant women are offered, women with diabetes may be recommended some extra scans. Having ultrasounds helps in monitoring your baby’s development, and can help doctors check if there are any possible abnormalities, such as kidney problems or problems with your baby’s heart or nervous system. The additional ultrasounds can also help monitor the growth of the baby and estimate its size.
Will my diabetes affect how I give birth?
In the past it was traditional, if you had diabetes, to deliver the baby about 2 weeks before full-term (at about 38 weeks). Nowadays, however, pregnancy often goes to full-term, although you may still be required to plan the date of delivery, rather than waiting to go into labour ‘naturally’.
If the baby is becoming too large or your doctor has concerns about its wellbeing, or you have high blood pressure or pre-eclampsia, your doctor may recommend early delivery and/or delivery by Caesarean section.
In general, it’s safer to deliver your baby in a hospital setting rather than at home, due to the increased potential for problems as a result of your diabetes. Also, your baby will need close monitoring after birth for problems such as excessively low blood sugar levels.
Your diabetes shouldn’t pose any barriers to the method of delivery you choose, whether it be vaginal delivery or a Caesarean section, as your healthcare professionals should be able to administer the insulin and glucose you need intravenously, if necessary. However, if the baby is large your doctors may advise you have a Caesarean section. Your doctors will be able to advise you about what’s right for your individual circumstances.
What happens after the birth of my baby?
After the birth of your baby, the metabolic changes that affected your insulin levels go into reverse. Your need for insulin is likely to drop for 2 or 3 days after delivery. After this, your insulin requirements will gradually adjust again and should go back to about the same level as you had before becoming pregnant. The process of readjusting your insulin dose and stabilising your diabetes could take several weeks, so follow the instructions of your doctor closely at this time. It is especially important to avoid having a hypo at this time when you have a new baby to look after.
Your baby’s health
There is a chance that your baby may be born with low blood sugar (hypoglycaemia), or your baby may have jaundice (characterised by a yellowish skin tone) as a result of old blood cells building up because your baby’s liver can’t clear them away fast enough.
Your baby will be carefully assessed for any signs of hypoglycaemia and jaundice, as well as breathing problems, especially if your baby is born prematurely. If your baby has low blood sugar (hypoglycaemia), your baby may need extra feeds or hospital staff can give your baby glucose intravenously.
Can I breastfeed my baby if I have diabetes?
Most women with diabetes will be able to breastfeed their baby, although there is sometimes a delay with the milk coming in.
It is safe to use insulin while breastfeeding. Breastfeeding seems to have a favourable effect on insulin sensitivity and some women find that their insulin requirements are reduced when they are breastfeeding compared with before they were pregnant. It’s important to be aware that you might be at greater risk of hypoglycaemia at this time.
Some oral hypoglycaemic medicines may not be suitable to take while breastfeeding. Some are passed through into breast milk and could affect the baby’s blood glucose level, but your doctor or specialist will advise what is best for you and your baby.
You should not resume your cholesterol-lowering medication while you are breastfeeding, unless your doctor says it is safe. Similarly, some blood pressure medicines are not recommended while breastfeeding.