• Baby on the Way
• Diabetes
• Labor and Delivery
• Prenatal Care

Healthy Pregnancy With Diabetes: You Can Do It!

So you have diabetes and you want to get pregnant. The good news is that with some planning, preparation and commitment, you can have a healthy pregnancy and a thriving baby. The time to start planning is now!

The most important thing you can do is keep your blood glucose (blood sugar) in the target range — before, during, and after pregnancy. Target blood glucose level ranges before getting pregnant are:

• Before eating: 80-110 mg/dl
• One hour after meals: less than 155 mg/dl
• Or two hours after meals: less than 140 mg/dl

If your blood glucose levels are not in your target range, you need to bring your diabetes under control before getting pregnant, ideally three to six months in advance.

To reduce the risk of complications and improve your baby’s health, it’s also important to establish a set of positive lifestyle habits. Maintain a fit body weight, eat an optimal diet and exercise. You should have a pre-pregnancy exam to make sure that you are doing these things properly. And if you smoke, stop. For women with diabetes, smoking can increase diabetes-related health problems such as eye disease, heart and kidney disease, nerve damage and poor blood circulation.

The Risk of High Blood Glucose Levels

Blood glucose levels that are too high during pregnancy pose many possible risks to the baby and mother.

Since the baby’s organs — the brain, heart, kidneys and lungs — are completely formed by seven weeks after your last period (a time when you may have just realized you are pregnant), it's crucial to get your blood glucose levels under control before getting pregnant.

Christine M. Kovac, MD, a Premier Health specialist in maternal-fetal medicine, warns of the risks. ”In moms who have pre-existing diabetes, especially if not well controlled, there is a higher risk of stillbirth [a baby who dies in the womb after surviving at least 28 weeks of pregnancy], miscarriage [loss of the baby before 20 weeks], birth defects such as spina bifida, kidney abnormalities and heart defects.”

In addition, there is a higher risk of having a baby that is too big, which carries its own danger of newborn complications such as hypoglycemia (low blood glucose), jaundice (yellowing of the skin), and respiratory distress syndrome (difficulty breathing).

Dr. Kovac continues, “With long-term diabetes there is a risk of poor growth in the baby. Later in life, the children of mothers with diabetes have a higher risk of obesity and various medical problems, such as diabetes and high blood pressure.”

If blood glucose levels are not kept under control, risks for the mother include:

• Premature delivery, difficult delivery or Caesarean section
• Worsening of diabetic eye problems
• Worsening of diabetic kidney problems and heart disease
• Infections of the bladder and vaginal area
• Preeclampsia (high blood pressure, usually with too much protein in the urine)

Read on to find out how you can minimize your risks and maximize a successful pregnancy.

Your Pre-Pregnancy Exam

The pre-pregnancy exam by your doctor typically includes the A1C test (also called the hemoglobin A1c, HbA1c, or glycohemoglobin test). This blood test provides information about your average blood glucose levels over the past three months. The American Diabetes Association recommends that most women with diabetes aim for an A1C target as close to normal as possible — below 6.5 percent and ideally below 6 percent — before getting pregnant and during pregnancy.

Other aspects of a pre-pregnancy exam include:

• Assessing any complications, such as high blood pressure, heart disease and kidney, nerve and eye damage
• Checking the function of your thyroid if you have type 1 diabetes
• Reviewing your medications and supplements to make sure they are safe to continue using during pregnancy

Drugs commonly used to treat diabetes and its complications may not be recommended in pregnancy, especially statins, ACE inhibitors, ARBs and most noninsulin therapies.

Dr. Kovac stresses the importance of using a reliable form of birth control until your blood glucose levels and your healthy lifestyle habits are in place. If you have any concerns, bring them up with your health care team.

Get Your Team in Place

Dr. Kovac advises that once a woman with diabetes becomes pregnant, she should be followed closely by a health care team with experience in managing diabetes in pregnancy. The members of the team include:

• A doctor trained to care for people with diabetes who has cared for pregnant women with diabetes
• An obstetrician who handles high-risk pregnancies and has treated pregnant women with diabetes
• A pediatrician or neonatologist (doctor for newborn babies) who knows how to address special problems that may occur in babies of women with diabetes
• A registered dietitian who can help you alter your meal plan as your needs change during and after pregnancy
• A diabetes educator who can help you manage your diabetes during pregnancy

A caveat: because of the high level of care needed for both mom and baby during and after delivery, home births are not advised for women with diabetes.

You’re Pregnant – Now What?

During pregnancy, controlling your diabetes requires continued careful monitoring. Your body is changing as the baby grows, and because you have diabetes these changes will affect your blood glucose levels.

“Some of the normal physiologic changes that occur in pregnancy can make it more difficult to keep sugar levels in the necessary narrow range,” Dr. Kovac cautions. “As the placental hormones in pregnancy increase, blood sugars can go higher after meals. On the other hand, between meals and snacks blood sugars can drop more drastically as the baby and placenta take away some of the mother’s sugars.”

The American College of Obstetricians and Gynecologists recommends the following blood glucose targets during pregnancy:

• Before a meal (preprandial) and bedtime/overnight: 95 mg/dl
• After a meal (postprandial): 70-120 mg/dl; measure one to two hours after the beginning of the meal, generally when levels peak in people with diabetes.
• A1C: less than 6%

Check your blood glucose levels at the times your diabetes team advises; this may be up to eight tests daily and will probably include after-meal checks. Track your results in a blood glucose record form, like this one from the National Institute of Diabetes and Digestive and Kidney Diseases.

What About Diabetes Medications?

Insulin is the traditional first-choice drug for blood glucose control during pregnancy. Most effective for fine-tuning blood glucose, insulin doesn’t cross the placenta and thus is safe for the baby. Insulin can be injected with a syringe, an insulin pen, or through an insulin pump.

If you have type 1 diabetes, pregnancy will affect your insulin treatment plan. During the months of pregnancy, your body's need for insulin will go up, especially during the last three months.

The need for more insulin is caused by hormones that the placenta makes to help the baby grow. At the same time, these hormones block the action of the mother's insulin. As a result, your insulin needs will increase.

If you have type 2 diabetes and are taking diabetes pills to control your blood glucose, you may not be able to take them when you’re pregnant. Because the safety of using diabetes pills during pregnancy has not been established, your doctor will probably immediately switch you to insulin. In addition, the insulin resistance that occurs during pregnancy often decreases the effectiveness of oral diabetes medication.

Unlike insulin, oral medications cross the placenta to the unborn baby in varying degrees. For these reasons, the American Diabetes Association does not recommend their use in pregnancy, although oral medications are now used more frequently than before by some health care providers to manage blood glucose levels not controlled by diet and exercise alone during pregnancy. Whether the medications you are taking are safe during pregnancy should be discussed with your doctor.

Eating a Healthy Diet

During pregnancy your dietitian or doctor may need to change your meal plan to help you avoid problems with low and high blood glucose levels. This is the most important reason for keeping track of your blood glucose results.

For most women, the focus of a good meal plan during pregnancy is improving the quality of foods you eat rather than the quantity of food eaten. A good meal plan is designed to help you avoid high and low blood glucose levels while providing the nutrients your baby needs to grow.

Including a variety of different foods and watching portion sizes are keys to a healthy diet. Of course healthy eating is not only important before and during pregnancy, but also throughout your life. A healthful diet includes a wide variety of foods, including vegetables, whole grains, nonfat dairy products, fruits, beans, lean meats, poultry and fish.

Many mistakenly think eating for two means eating a lot more than you did before. You only need to increase your calorie intake by about 300 calories each day.

If you start pregnancy weighing too much, you should not try to lose weight. Instead, work with your dietitian or doctor to curb how much weight you gain during pregnancy. Your dietitian will help you keep track of your weight gain.

Based on your body mass index, the American Diabetes Association suggests the following averages for how much weight you should gain during pregnancy:

Pre-pregnancy weight	Pounds to gain
Underweight	28-40
Normal	25-35
Overweight	15-25
Obese	11-20

Why Daily Physical Activity Matters

Exercise is key to diabetes treatment, and your plans for physical activity should be discussed with your diabetes team. Regular physical activity is not only safe for pregnant women, it also benefits health by offsetting such problems of pregnancy as varicose veins, leg cramps, fatigue and constipation.

For women with diabetes, exercise — especially after meals — may help the muscles use the glucose in the bloodstream and help keep your blood glucose levels in your target range. However, if you have any of the following conditions, you should talk to your diabetes team about the risks of exercise during pregnancy:

• High blood pressure
• Eye, kidney or heart problems
• Damage of the small or large blood vessels
• Nerve damage

It’s generally not a good idea to start a new, strenuous exercise program during pregnancy. Good exercise choices for pregnant women include walking, low-impact aerobics, swimming, and water aerobics.

Activities to avoid during pregnancy are:

• Activities that put you in danger of falling or receiving abdominal injury, such as contact sports
• Activities that put pressure on your abdomen (as while lying on your stomach)
• Scuba diving
• Vigorous, intense exercise, such as running too fast to carry on a conversation
• Activities with bouncing or jolting movements (horseback riding or high-impact aerobics)

It’s Showtime!

Your labor may start on its own, or you may decide, with the advice of your health care team, to have labor induced or have a planned Caesarean section (C-section). No matter how you deliver your baby, your doctors will be working during labor and delivery to keep your blood glucose level under control.

At the start of active labor, your insulin needs will drop. You will most likely not need any insulin during labor and for 24 to 72 hours after delivery. Your blood glucose will be checked every few hours, and your insulin and glucose regimen will be tailored to your needs.

Managing Well After Delivery

Some new mothers have better blood glucose control in the first few weeks after delivery. For many, it's a period of odd blood glucose swings. Check your blood glucose levels frequently following delivery to avoid either high or low blood glucose levels until you get an idea of how much insulin your body needs. It’s important to check your blood glucose often during this time, keeping records of your levels to help you and your team adjust your insulin dose.

“Some of the normal physiologic changes that occur in pregnancy can make it more difficult to keep sugar levels in the necessary narrow range,” Dr. Kovac cautions.

If you have type 2 diabetes, your doctor will decide which medication you should take after delivery. You will usually be able to go back to the same medications you were taking before pregnancy, as long as they were controlling your diabetes well. This may be modified if you are breastfeeding.

Continue your healthy habits that kept your blood glucose levels on target during pregnancy. Eat healthy meals and get proper nutrition. Watch for signs of depression and talk to your doctor or health care provider if you think you are experiencing symptoms. Rest whenever your baby is sleeping.

Be good to yourself: take a warm bath, read, walk with a friend and accept offers of help.

Breastfeeding is good for women with diabetes, but it may make your blood glucose more unpredictable. To help prevent low blood glucose levels due to breastfeeding, try these tips:

• Have a snack before or during nursing
• Drink enough fluids (sip a glass of water or a caffeine-free drink while nursing)
• Keep something to treat low blood glucose handy when you nurse, so you don't have to stop a feeding to treat low levels

Breastfeeding may also help you lose the weight you gained during pregnancy, although you shouldn’t try to lose too quickly. While you are breastfeeding, it’s important that you get the right amounts of fluids, protein, vitamins and minerals. Work with your dietitian to develop a meal plan that will allow you to achieve gradual weight loss and still be successful at breastfeeding.

If you have type 1 or type 2 diabetes and use either insulin or oral blood glucose lowering-medications, understand that most of these medications can be safely used during breastfeeding. Check with your doctor for specifics.

Source: American Diabetes Association; National Institute of Diabetes and Digestive and Kidney Diseases; Christine Kovac, MD, Perinatal Partners