A Guide to Pregnancy With Diabetes
For a healthy mom and baby, the planning starts now
Pregnancy is a time of wonder and amazement—and lots of bodily changes that seem to defy explanation. (Think of the bizarre cravings and food aversions. The weird skin and hair changes. Oh, and your feet will probably get bigger, too.) Many pregnant women experience caroming hormonal mood swings, but for women with preexisting diabetes, those nine months are also packed with crazy blood glucose ups and downs. "I spent the entire first trimester with my face buried in the fridge," says Kerri Sparling, 31, who has type 1 diabetes and whose daughter was born in April. "I was low all the time. It wasn't until probably the second trimester that the insulin resistance kicked in. Everything I ate, the insulin didn't cover it."
It's true that diabetes makes pregnancy more complicated. But it's just as true that, with good care and planning, women with both type 1 and type 2 can have safe pregnancies—and healthy babies.
First Things First
Before you get down to baby-making business, there are a few lifestyle changes you may need to make. Here are some ideas for how you can reach your pre-pregnancy goals.
- Stop Smoking Pick up a hobby that keeps your hands busy when cravings hit.
- Get Your A1C Under 7% Test often—and review the results with your doctor.
- Prevent Birth Defects Take 400 to 800 micrograms of folic acid daily.
- Eat Nutrient-Rich Foods Book an appointment with a registered dietitian to learn about healthy eating.
- Ditch Alcohol Instead of wine, for example, try a nonalcoholic spritzer made from seltzer water and a splash of juice.
- Skip possibly Unsafe Foods Swear off raw meat, lunch meat, raw fish and smoked seafood, soft cheeses like brie and gorgonzola, fish with high mercury levels (like tuna), and unpasteurized milk.
- Exercise More Take a 30-minute walk at lunchtime.
Stage 1: Before You Begin
It may seem counterintuitive, but you'll actually want to see your doctor before you start trying to get pregnant. This is called a "preconception visit," and it's where you'll get a lot of information about what pregnancy may bring (remember to take notes!). It's also a chance for your doctor to assess your general health and adjust your regimen accordingly. Depending on how you manage your diabetes, you may need to see both an endocrinologist and an ob-gyn at this point. Preexisting diabetes automatically makes your pregnancy "high risk," even if it goes along without a hitch. An obstetrician who specializes in such pregnancies will be more accustomed to treating women with diabetes. And remember, you'll probably be coming into the office a lot once you get pregnant (as much as once or even twice a week in the third trimester), so if you're choosing new docs you may want to consider how convenient they are to where you live or work.
In addition to a higher chance of miscarriage, there are two major types of risks that a mother's diabetes poses to a developing baby. The first occurs in the earlier part of the pregnancy, when organs are beginning to grow and serious birth defects can occur. The second concern comes later in the pregnancy, when babies of diabetic mothers run a risk of growing too big (this is known as macrosomia), which can create problems for delivery and harm the newborn.
All of these problems are best prevented, first and foremost, by keeping your blood glucose in check. This is why your A1C (average blood glucose over the past two to three months) should be below 7 percent before you conceive. Some doctors advise going lower, say 6.5 or 6. During the pre-conception visit, you and your doctor will determine a safe A1C goal and devise a way to get there before pregnancy. If you have type 2 diabetes that is treated with diet and exercise, oral medications, or a combination, you may need to go on insulin for the duration of the pregnancy, or even before.
Your doctor may also discuss whether you need to lose weight. If so, "that's probably the best thing besides getting blood sugar under control," says Deborah L. Conway, MD, assistant professor in the Department of Obstetrics and Gynecology at the University of Texas Health Sciences Center in San Antonio. "[For obese women,] any amount of weight loss prior to pregnancy is going to reduce the impact that just the obesity alone has on pregnancy." Obesity increases pregnancy complications like high blood pressure and can also up a woman's chances of having a cesarean section. Your doctor will advise you on how much to lose before trying to get pregnant.
About three months before you start attempting to conceive, you will also need to begin taking 400 to 800 micrograms of folic acid daily, which prevents birth defects like spina bifida. You can find folic acid supplements in the vitamin aisle, or you can get a prescription from your doctor. Some prenatal vitamins don't have enough folic acid, so check before you use one as your only source of the essential nutrient. Your doctor will also advise you about which current medications you need to quit because they pose a risk to the baby. Statins, ACE inhibitors, and many other drugs—including some over-the-counter meds, like ibuprofen—aren't considered safe for use in pregnancy. When in doubt, ask your doctor or nurse if a particular medication or supplement is OK.
Before you become pregnant, you will need certain tests. Some of these apply to any woman contemplating pregnancy. For example, your doctor will want to make sure that you've had immunizations. And you and the baby's father may choose to undergo genetic testing, to see if you carry predispositions to any conditions. For women with diabetes, there are some additional screenings. Besides an A1C test, you should have your cholesterol, thyroid function, and blood pressure checked. Hypothyroidism, or abnormally low thyroid function, is quite common, especially in people with type 1 diabetes, and may affect the developing baby's nervous system. It should be treated before you conceive; if you take thyroid hormone replacement, you will probably need a higher dose during pregnancy. Also, talk with your doctor about safe blood pressure–lowering medications since many are off limits to expectant mothers.
Women with diabetes should also get a comprehensive eye exam before conceiving. Pregnancy can stimulate the development of the eye disease retinopathy, a common complication of diabetes. If the disease becomes too advanced, it can prevent a vaginal delivery, because pushing during labor can further damage the eyes. Women with diabetes will also have their kidney function tested before pregnancy. Since pregnancy can harm their kidneys, women with advanced kidney disease may be advised to avoid pregnancy. Women with both diabetes and heart disease may also be poor candidates for pregnancy.
Finally, while diabetes itself doesn't affect fertility, polycystic ovary syndrome (PCOS), which is associated with type 2 diabetes, can. If you're having trouble getting pregnant, your doctor can recommend fertility treatments, which are as safe for women with diabetes as they are for women without.
Stage 2: The Nine-Month Stretch
Pregnancy changes the body in many ways. For one thing, you'll see your blood glucose can behave like never before. (Management gets extra tricky if you have morning sickness and can only eat a few foods.) In the first trimester, you might not notice much difference, though some women with diabetes actually experience hypoglycemia (low blood glucose) during this time. Around week 20, a woman's insulin resistance increases, raising her blood glucose. Insulin resistance builds as pregnancy continues; by the end of the third trimester, insulin needs may be double what they were before pregnancy.
What Is Gestational Diabetes?
About 4 percent of all pregnant women without preexisting diabetes will develop gestational diabetes sometime around the 28-week mark. While the cause is not yet understood, gestational diabetes occurs when the mother's body becomes resistant to insulin, causing glucose levels to build up in the blood. As with type 1 and type 2 diabetes, high blood glucose levels can cause problems for both mother and baby. Women with gestational diabetes usually get a special meal plan and are encouraged to exercise; they also have to test their blood glucose and may need to inject insulin. Gestational diabetes usually goes away after pregnancy, but brings an increased risk for the condition in other pregnancies—and for type 2 in the future.Because your blood glucose levels will be in a state of flux, and because you'll want to maintain tight glucose control, your doctor may advise you to test more often. Your results directly affect your baby, so it's important to not only read the numbers but use them to make any necessary changes to your diet or your insulin regimen.
Monitoring your weight is also important, whether you have diabetes or not. According to Institute of Medicine recommendations, underweight women should gain 28 to 40 pounds over the course of a pregnancy; normal-weight women should gain 25 to 35; overweight women should gain 15 to 25; and obese women should gain 11 to 20.
Gaining the weight is easy for most women. Making sure you don't top those recommended numbers might be tougher. Contrary to what you may have heard, a pregnant woman doesn't need to eat for two. In fact, you need only about 300 extra calories per day (depending on your activity levels and weight) to nourish a growing baby. But you'll want them to be the "best" calories possible—fruits and vegetables, whole grains, lean proteins—since they are building the new little being inside of you. A registered dietitian can help you create a meal plan.
You can help keep your weight (and blood glucose) down by exercising. Most pregnant women can safely work out with a doctor's go-ahead. Skip high-impact exercises like kickboxing or contact sports. And avoid activities that require you to lie on your back during the second and third trimesters; that can reduce blood flow to the fetus. Bike riding, swimming, and walking "are fine to continue through pregnancy," says Jennifer Wyckoff, MD, a clinical assistant professor of internal medicine at the University of Michigan Health System. Prenatal yoga classes can be a great place to strengthen muscles in the company of other pregnant women. Whatever you choose, take plenty of breaks, stay hydrated, and stop if you feel pain or discomfort.
During pregnancy, you'll review your blood glucose log on a regular basis with your doctor or nurse and get an A1C test every few weeks. You'll also have general check-ups monitoring blood pressure and weight gain on a schedule set by your doc. All pregnant women get an ultrasound around week 18 to monitor the baby's development; women with diabetes usually get additional ultrasound scans at other times in the pregnancy. Sometime between weeks 20 and 22, your obstetrician will order a more detailed scan called a fetal echocardiogram, to make sure the fetal heart is growing correctly. If you have retinopathy, you'll also get follow-up eye exams every trimester. You may need to check fasting urine ketones in the morning if you're sick or if your blood glucose is persistently high.
And yes, all those tests and scans and appointments may leave you feeling overmonitored—even annoyed—at times. But remember that it's all to ensure a safe delivery and a healthy baby.
Stage 3: Labor and Delivery
Most women look to this moment with equal parts fear, dread, and excitement. While many women with diabetes have a vaginal birth without complications, the chances of having a cesarean section or having labor induced before your due date are increased. That's partly because women with diabetes are more likely than others to have large babies, in which case vaginal delivery can damage the baby's collarbone or shoulders. It's also because diabetes and obesity increase a woman's risk for high blood pressure and a condition called preeclampsia (see box). These conditions often require early delivery to prevent harm to the mother and baby. The upside is somewhat more control of the circumstances around labor and delivery; the downside is that induction often leads to more intense, painful contractions that come faster, plus an increased chance of having a cesarean section.
About 18 to 30 percent of pregnant women with diabetes develop pre-eclampsia, a condition marked by high blood pressure and proteins in the urine that shows up after the 20-week mark. (The risk is higher with preexisting high blood pressure or kidney disease.) Other symptoms include blurred vision, sudden weight gain, and swelling. Untreated, preeclampsia can harm the baby and put the mother at risk for stroke and seizures. The only way to get rid of it is to deliver the baby, but if you're too early in your pregnancy, your doctor might put you on bed rest and prescribe medication to lower your blood pressure and help the developing baby's lungs mature. Doctors may induce labor in a woman diagnosed with preeclampsia once the fetus has gotten big enough.
Whether you are expecting to have a vaginal birth or a cesarean section, you should talk to your obstetrician about your diabetes management plans during labor and delivery to make sure the doctor and nurses who will be delivering your baby are familiar with diabetes. Women who have a cesarean section usually receive intravenous infusions of insulin and glucose, and have their blood glucose monitored by hospital staff. If you take multiple daily injections, chances are you'll have the IVs during vaginal delivery, too. Women who use an insulin pump and have a vaginal birth are often able to keep the pump on during labor and delivery, but talk with your doctor to determine if this is an option for you.
Testing during labor is important because, says Wyckoff, "you can't really predict what's going to happen to the blood glucose during the delivery. You just have to act and react." Depending on your hospital's and doctor's preferences, you may be able to monitor your own blood glucose if you give birth vaginally.
Post-delivery, your blood glucose levels will drop, and so will your insulin needs. Women can typically cut their insulin dose by a third or a half following delivery, to near pre-pregnancy levels—or even lower for a day or two. Talk to your doctor before you go into labor to make a plan for how you will adjust your dosing and avoid hypoglycemia. Don't rely on the hospital docs and nurses to manage your insulin and eating regimen after childbirth.
Stage 4: A New Life
A newly born baby of a mother with diabetes will undergo extra scrutiny. For one thing, the newborn is at an increased risk of hypoglycemia after being in the glucose-heightened environment of the mother's womb. At birth, the baby may still produce extra insulin to cover the mother's added glucose. Any low blood glucose usually goes away within a couple of days, but if left untreated it can lead to seizures. Jaundice, a common condition in newborns, is also more frequent when the mom has diabetes, but it's not serious and, with treatment, is resolved within a few days. (Be prepared, though: If your baby is still being treated for jaundice after a couple of days, you may have to go home while he or she is still at the hospital, which can be upsetting.)
While blood glucose numbers stabilize and return to pre-pregnancy levels quickly after delivery, mothers should pay especially close attention to their glucose readings if they're breast-feeding. "We strongly encourage women with diabetes to breast-feed," says Wyckoff, although she cautions that "women with diabetes who are breast-feeding do have a tendency for hypoglycemia." If you tend to go low, have a snack before, during, or after breast-feeding. If you're nursing your baby, you should eat the same number of calories post-pregnancy as you did while expecting since breast-feeding requires added calories and nutrients.
Breast-feeding your child can reduce his or her risk of type 1 diabetes. "The baby gets immune antibodies from the breast-feeding," says Lois Jovanovic, MD, MACE, head of the Sansum Diabetes Research Institute in Santa Barbara, Calif. "On the flip side, drinking cow's milk before the six-month mark may raise a baby's chances of developing type 1 diabetes later on." Since most infant formulas are made from cow's milk, Jovanovic recommends that women who are unable to breast-feed pick soy formula, even though it is more expensive.
Some research suggests that bottle-fed babies have a higher risk of childhood obesity—and therefore type 2 diabetes—than breast-fed babies. But Jovanovic says the link is in how much the babies eat, not what they eat. Mothers tend to feed a baby the entire bottle while breast-fed babies stop eating when they're no longer hungry; the result is more calories for bottle-fed babies. If you're bottle-feeding, look for cues that your baby is full, then put aside the bottle even if it isn't empty.
Women with diabetes who have poorly controlled blood glucose may have a harder time producing milk right away, according to Pat Shelly, IBCLC, RN-C, MA, director of the Breastfeeding Center in Washington, D.C., who works with many type 1 and type 2 women and sees a link. "I tell them, 'Oh, no wonder your milk isn't coming in. You're diabetic. Keep nursing,' " she says. "It's going to take an extra day or two." That might mean supplementing with formula in the meantime, which can be frustrating if you are trying to exclusively breast-feed. A lactation specialist can help you through this transition period. To prevent a delay in lactation, keep your blood glucose tightly controlled during pregnancy and while you're breast-feeding. And speak with a lactation consultant if you have PCOS; women with that condition have an even greater chance of breast-feeding problems.
It's natural to feel overwhelmed by the thought of caring for your new baby, especially if you're a first-time mom. But keep in mind that you still need to take care of yourself, too. Don't lose sight of your own diabetes management while you're tending to your baby's every last coo. And remember: It's OK to ask for help. Enlist family and friends to watch the baby or make dinner or straighten up the house.
While women with diabetes aren't at an increased risk for postpartum depression, the extra work of managing your diabetes when you have a newborn (who sleeps only a few hours at a time) can be made near impossible if you're also facing the "baby blues." Postpartum depression can bring sadness, anxiety, mood swings, insomnia, and loss of appetite. More serious signs include thoughts of hurting your baby or yourself. If you suspect you have postpartum depression, talk to your doctor right away. Reaching out to your partner or other family members, too, can help alleviate feelings of being overwhelmed.
The nine months of pregnancy can be a challenge to any woman, but the stakes are higher for women with diabetes. And so is the motivation. "Once a woman is pregnant, she'll go to the moon and back because she really wants this baby," says Jovanovic. In fact, many women with diabetes find that they have the best glucose control of their life during pregnancy. "I didn't want to screw this up," says Sparling. "This was so, so important to me that I was willing to do whatever to make sure she came out right." After months of constant blood glucose checks, intense carb counting, and endless doctor appointments, Sparling says the preparation and tight control paid off. "It's so worth it."
Real real women's stories about pregnancy and diabetes by clicking here.