It is important to manage your pregnancy if you have pre-existing type 1 or type 2 diabetes.
Good News:
With planning and blood glucose in the target range during pregnancy, the majority of women with diabetes can expect to have a normal pregnancy and a healthy baby!
Bad News:
This is a lot of work!
If there were ever a time in life when one should pay extra attention to their diabetes, it is when planning a pregnancy. Prior to pregnancy, it is important to be under the care of a team that has expertise in diabetes and pregnancy. It is essential that blood sugars are at target prior to getting pregnant, with an A1C of less than or equal to 7% (or 6.5% if it can be done without significant hypoglycemia). The developing fetus is very sensitive to elevated blood sugars and birth defects can happen very soon after the baby is conceived, if the blood sugars are elevated. Stillbirths and miscarriages are more common with elevated sugars. As well, later in pregnancy, if blood sugars are not well controlled, the baby will put on extra fat that can make the delivery more difficult.
Women should have an assessment for complications of diabetes such as eye, kidney and circulation disease prior to getting pregnant. For example, in a small number of women, eye disease may worsen during pregnancy if eye complications are not treated prior to getting pregnant.
This is the time for teamwork! You and your baby are the centre of this team. The team needs to include those who support you on a daily basis, your primary care team, your obstetrical team, and your diabetes team. Communication amongst the team members is essential to help ensure a smooth pregnancy.
Type 2 Diabetes and Pregnancy
Pre- planning
If you are on oral medications for type 2 diabetes, you may be switched to insulin to stabilize your sugars prior to pregnancy. The medication, metformin, may sometimes continue until conception, or for a while after, especially if it is being used to treat a condition called polycystic ovarian syndrome (PCOS), a clinical syndrome with some of the following features: obesity, infertility issues, irregular periods, increased facial hair, acne or ovarian cysts. It is important that if metformin is stopped and insulin started that sugars are brought to the target range quickly and there is not a gap in time from stopping the metformin to starting insulin. The amount of testing of blood sugars will increase when planning a pregnancy to ensure that all the blood sugar levels are at target. For some people, a continuous glucose monitor may be recommended.
Medications
It is recommended that women with pre-existing diabetes take folic acid (a vitamin) prior to getting pregnant and during the first part of the pregnancy. Some medications that control blood pressure (ACE inhibitors or ARBs) can cause birth defects and need to be discontinued prior to or once diagnosed with a pregnancy. If needed, other medications can be started that are safe to use during pregnancy to treat blood pressure. Statin medications which help to control cholesterol must be stopped prior to pregnancy.
Management
A meal plan to ensure that the baby gets enough nutrition, while not encouraging extra weight gain for you, is essential and is best done by the diabetes team, which will include a dietitian. If you are using insulin, you will meet regularly with the team for adjustments. Usually there is a substantial increase in insulin requirements in pregnancy. It is not unusual for the amounts to double or triple as the hormones of pregnancy block the action of insulin.
Blood glucose monitoring during pregnancy
Blood glucose needs to be monitored both prior to and after meals, if on insulin. A check in the middle of the night may also be important. There is evidence that real-time continuous glucose monitoring (rtCGM) should be used in women with type 1 diabetes during pregnancy to improve blood glucose levels, and to reduce the risk for large birthweight infants, hypoglycemia at birth and NICU admissions.
Blood glucose targets
Targets for blood sugars for all pregnant women are as follows:
- Fasting and before meal: <5.3 mmol/L
- 1 hour postmeal: <7.8 mmol/L
- 2 hour postmeal: <6.7 mmol/L
Type 1 Diabetes
Insulin and blood glucose levels
Insulin routines should be optimized prior to getting pregnant. If women are not on multi-dose insulin routines (basal/bolus- usually 4 injections per day) or on an insulin pump, this is the time to get this going and learn how to fine tune blood sugar control prior to getting pregnant.
There are many hormonal changes that happen in pregnancy and these affect blood sugars. In the middle of the first trimester (1-13 weeks), there may be a drop in insulin requirements and sometimes women have to decrease their dose of insulin, or they will have sudden and unexpected lows. Woman often find that they do not notice their low sugars until their blood sugars are lower than usual, so frequent testing is a must during pregnancy. After the first trimester, the requirements go up slowly over the pregnancy.
Finally, there are changes in insulin requirements after pregnancy. Immediately after delivery, women are unusually sensitive to insulin and may need substantially less insulin after delivery. This may last a few days, weeks or even months. Typically, as well, women may have less insulin requirements when they are nursing, so constant vigilance and adjustments are necessary.
In addition, women with type 1 diabetes are more susceptible to thyroid disease and this may develop after having a baby. It is therefore important to follow up with a blood test for thyroid function in the months after delivery.
All of this sounds like a lot of work, but by planning for a pregnancy when you have diabetes, you will ensure the best start for your baby!
