Not even 20 years ago, it was uncommon for a woman with diabetes to choose to have children of her own. Many doctors discouraged attempting pregnancy based on the high incidence of complications that both a mother and an infant could suffer due to poor blood glucose control.
Complications of pregnancy can now be avoided with minimal risk to mother or baby as long as appropriate steps are taken prior to and during the pregnancy. Infant survival rates for pregnant women with diabetes are now nearly identical to those for nondiabetic women.
While it is much more likely today that a woman with diabetes will have a healthy pregnancy, risks are still an issue. Poorly controlled diabetes prior to and during pregnancy increases the risk of birth defects and miscarriages. Uncontrolled blood glucose can lead to the baby being too large (macrosomia) because extra glucose crosses the placenta. This makes delivery hard on both mother and child.
The baby may have problems with low blood glucose at birth as its pancreas has been making extra insulin to compensate for all the extra available glucose if the mother has been experiencing high blood glucose levels. Mothers with poorly controlled blood glucose are at risk for high blood pressure, kidney infections, preterm labor and delivery and Cesarean deliveries.
The complications associated with diabetes and pregnancy can in large part be avoided if mothers are willing to make an extra effort. Lois Jovanovic, MD, an internationally recognized endocrinologist specializing in diabetes and pregnancy, recommends taking control of your diabetes at least a three to six months before you become pregnant, so that when you conceive you will know that you have already laid a good foundation for a healthy delivery.
See your endocrinologist for an assessment and check some lab values. Your A1C should be 6.5% or less prior to getting pregnant, according to many experts. A 24-hour urine test will assess kidney function. Make sure that it is safe to continue your medications during pregnancy. ACE inhibitors and ARBs, blood pressure medications used to improve kidney function, are contraindicated during pregnancy. Oral diabetes medications are not currently approved by the FDA for use during pregnancy or lactation. In most cases, women with type 2 diabetes have to switch to insulin therapy during pregnancy and breastfeeding.
If blood glucose levels aren’t in the goal range, talk with your diabetes educator. Perhaps an insulin pump would improve your control, or you may need to increase insulin doses, or possibly improve your carbohydrate counting skills. Plan to meet with a dietitian to design an appropriate eating plan during pregnancy.
See an ophthalmologist to evaluate your eyes for retinopathy prior to pregnancy. You may need to continue seeing a specialist for eye care during the pregnancy. And be sure to choose an obstetrician who has experience dealing with diabetes.
Once you are pregnant, plan to keep seeing your endocrinologist and diabetes educator regularly. Blood glucose levels are variable during pregnancy and can drop significantly in the first trimester. Be aware that hypoglycemia will almost certainly be an issue. Keep an emergency glucagon kit on hand at all times along with glucose tablets or glucose gel, and carry snacks in the car, in your purse and anywhere else you might suddenly need one. Plan to check blood glucose before meals and one hour after meals, at bedtime and possibly in the middle of the night.
Lois Jovanovic, MD, recommends fasting blood glucose levels of less than 90 mg/dl and less than 120 mg/dl one hour after meals. The American Diabetes Association recommends blood glucose levels less than 140 mg/dl one hour after meals during pregnancy. Ultimately, the more tightly controlled your blood glucose, the better your chance of a healthy outcome.
With weight gain and increased placental hormones, you will become more resistant to insulin, and your insulin needs will gradually rise until they are almost double by the time you are 36 weeks along. Your endocrinologist and diabetes educator can help you adjust insulin doses to keep up with your increasing needs.
Exercise is appropriate during pregnancy and will help to keep your blood glucose under control. The more consistent the exercise, the better for blood glucose control. However, do not try to add intense exercise once you are pregnant. Simply walking for 15 to 20 minutes a day will improve blood glucose. Again, be aware of possible hypoglycemia and carry a snack when you exercise. Check with your doctor to see what types and amounts of exercise are safest for you during pregnancy.
Tests ordered by your physician will help to ensure a healthy birth. Ultrasound will allow your perinatologist to assess the fetus’s health and development. Non-stress tests use two monitors on the mother’s abdomen; one records fetal heart rate and the other detects contractions. The heart rate should increase with activity and stimulation. Amniocentesis may be performed to assess lung maturity if induction of labor or elective Cesarean section is planned prior to 39 weeks.
Labor and Delivery
You have worked hard for nine months in preparation for this remarkable moment, and it is finally here. In the hospital, typically an IV is started which will provide glucose as well as insulin. Insulin pump therapy has been used successfully during labor and delivery, but you and your doctor should determine the best way to keep your blood glucose under control during delivery. The real key to a safe delivery is frequent blood glucose testing, which will indicate whether insulin or glucose is necessary throughout labor.
Once the Baby Arrives
Once the baby is born and the placenta is delivered, hormone levels change and your insulin need will be cut in half. You may not even need any insulin for the first 24 to 48 hours following delivery. Again, your endocrinologist and diabetes educator will help you adjust your insulin as needed.
Hypoglycemia is again a risk as your insulin needs change and as your first instinct is to take care of the baby rather than yourself. If you do get low, care for yourself first and then the baby. In the long run, your baby will be better off with a healthy mother.
Many of the medications that are not recommended while you are pregnant continue to be off limits if you choose to breast feed. However, breastfeeding is strongly encouraged as it provides health benefits for both the baby and the mother.
It is certainly an added challenge to have diabetes during pregnancy, but a few extra visits to the doctor and some extra blood glucose testing are a small price to pay when you finally see the baby you have been carrying for nine months. Suddenly, you have a wonderful reward, and all your hard work and effort were worthwhile.
When Diabetes First Appears During Pregnancy
In about four percent of pregnancies, gestational diabetes occurs. Women at high risk for developing gestational diabetes are overweight, have a history of glucose intolerance, a family history of diabetes, are 25 years or older or have had diabetes during a previous pregnancy.
• Blood glucose control is the key to a healthy pregnancy for women with diabetes, and it should be tested before meals, one hour after meals and at bedtime.
• Target blood glucose goals are the same for any woman with diabetes during pregnancy, regardless of type of diabetes.
• It is critical to have a healthy meal plan with consistent carbohydrate intake and to consult regularly with a dietitian.
• Adding moderate exercise to your routine, even just a daily 20-minute walk, will significantly improve blood glucose levels.
• Insulin therapy may become necessary at some point during your pregnancy, because blood glucose levels continue to rise with decreased insulin sensitivity and increased placental hormones as your pregnancy progresses.
• Once your baby arrives, it is wise to check your blood glucose levels several times. You may be one of the 2 percent of women who had undiagnosed type 2 diabetes prior to getting pregnant. Ask your healthcare team when your follow-up glucose tolerance test will be scheduled.
• Breastfeeding benefits both the baby and the mother, and it is strongly encouraged by healthcare professionals.
Top 10 Ways to Improve Your Odds for a Healthy Pregnancy
10. Choose an obstetrician who has experience working with women with diabetes.
9. See an ophthalmologist to screen for retinopathy before conception.
8. Review all of your medications to determine their safety during pregnancy.
7. Keep your blood pressure under control.
6. Continue to do safe exercise on a daily basis.
5. See a registered dietitian to review your eating habits.
4. Follow up with your diabetes educator.
3. See your endocrinologist regularly.
2. Keep your A1C at 6.5% or less.
1. Do your best to keep your blood glucose in line with your goal for pregnancy.
Maternal Nutrition During Pregnancy
By Lois Jovanovic, MD
The old adage “You are what you eat” can also be applied to a developing fetus; you might say, “Your baby becomes what you eat.”
Medical nutritional management is the primary intervention that can result in improved outcomes in pregnancy. Examples include folate supplementation to prevent neural tube (birth) defects, protein supplementation in the case of malnutrition and iron supplementation for anemia.
Pregnant Women With Diabetes Need to Count Carbs
Diabetic women have special needs, and the mainstay of treatment during pregnancies complicated by diabetes—type 1, type 2 and gestational—is attention to the carbohydrate content of the meal plan.
Meticulous awareness of the types and quantities of carbohydrates is important because fetal growth is directly dependent on the metabolism of carbohydrates, both simple and complex, that then appear in the blood stream and compose more than 90 percent of the peak after-meal blood glucose.
Some fetuses are more sensitive to minor elevations in blood glucose than others. When the carbohydrate content of a meal plan has more than 40 percent of the total calories, then the peak after-meal levels may be markedly elevated.
Examples of foods to avoid and foods that may be eaten because they do not affect the after-meal glucose levels are listed in Table 1.
What Is Overnutrition?
Overnutrition of the fetus occurs when the mother’s blood glucose is elevated above the normal range for a pregnant woman.
Normal pregnant women have a blood glucose level that is 20 percent below that of nonpregnant women. Thus the normal pregnant fasting blood glucose is 60 to 90 mg/dl, and no blood glucose is ever higher than 120 mg/dl, even one hour after eating. When the blood glucose levels are elevated, the fetus is force-fed too many calories.
The after-meal glucose levels are more potent than the fasting or the average blood glucose levels. Thus, attention to meal planning is even more important during pregnancy than even the treatment of diabetes in general, for the sake of the healthy growth pattern of the unborn child.
When the mother’s blood glucose levels are elevated, there is an increased risk of complications for the infant (see Table 2).
Table 1 Impact of Foods on After-Meal Glucose Levels
|Foods to avoid or restrict portion size|
|Simple Sugars||Complex Carbohydrates||Fruits|
|Cookies||Rice (brown and white)||Melons|
|Sodas with sugar||Tortillas||Bananas|
|Foods with minimal impact on after-meal glucose levels|
|Raw carrots||Tofu, bean curd|
Table 2 Consequences of Fetal Overnutrition Mediated by Elevated Maternal Glucose
Note: Goal maternal blood glucose levels are less than 90 mg/dl for before-meal glucose levels and less than 120 mg/dl for peak after-meal glucose levels at one hour after the first bite of food.
Fetal and Neonatal Complications of Maternal Hyperglycemia
- Birth defects
- Spontaneous abortion
- Fetal obesity
- Onset of insulin resistance syndrome before birth and sustained after birth (metabolic problems and concentration of fat in the abdominal cavity that is associated with an increased risk of blood pressure elevation, heart disease and liver problems)
- Hypoglycemia (low blood glucose)
- Hyperinsulinemia (high insulin levels)
- Hypocalcemia (low blood calcium)
- Hyperbilirubinemia (yellow jaundice)
- Erythrocytosis (high red blood cell count)
- Birth trauma (shoulder and clavicle damage)
- Respiratory distress (difficulty breathing)
- Cerebral anoxia (lack of oxygen to the brain and risk of cerebral palsy and mental retardation)