A Healthy Pregnancy for Women With Diabetes

If you have type 1 or type 2 diabetes mellitus, you need to plan for pregnancy. Women with poorly controlled diabetes are at risk of several pregnancy problems. These risks can be greatly reduced if you take steps to become as healthy as you can before pregnancy and manage your health during pregnancy.

This pamphlet explains

• types of diabetes
• how diabetes can affect your pregnancy
• the importance of preconception health care
• controlling diabetes during pregnancy
• what to expect during labor, delivery, and after the baby is born

Types of Diabetes

Pregnancy health care providers often call diabetes that is present before pregnancy “pregestational diabetes.” Diabetes is caused by a problem with insulin. Insulin moves glucose out of the blood and into the body’s cells where it can be turned into energy.

There are three types of diabetes: type 1, type 2, and gestational diabetes. In type 1 diabetes, the body makes little or no insulin on its own. In type 2, insulin is produced, but the body does not respond to it the way it should. The third type, gestational diabetes, is diabetes that is discovered for the first time during pregnancy.

When the body does not make enough insulin or does not respond to it, glucose cannot get into cells and instead stays in the blood. As a result, the level of glucose in the blood increases. Over time, high blood glucose levels can damage the body and cause serious health problems, such as heart disease, vision problems, and kidney disease.

Women with diabetes need to regularly check and control their blood glucose levels to prevent these serious health problems. Type 1 diabetes is treated with insulin. A healthy diet and regular exercise also help keep blood glucose levels under control. Type 2 diabetes often can be managed with a program of weight loss, diet, and exercise. Oral medications or insulin sometimes may be needed.

How Diabetes Can Affect Your Pregnancy

If you have diabetes, controlling your blood glucose level before and during pregnancy is key for your health and the health of your unborn baby. If your diabetes is not managed well, you are at increased risk of several of the complications associated with diabetes. These complications, in turn, can have a serious effect on pregnancy and your unborn baby. The following problems can occur in women with diabetes:

• Birth defects—Birth defects occur in 6–12% of women with pregestational diabetes. Defects of the heart, brain, spine, and skeleton can occur in the early weeks of pregnancy when these organs are developing.
• High blood pressure—Women with diabetes may have problems with high blood pressure, which can cause complications during pregnancy. High blood pressure during pregnancy increases the risk of preeclampsia, a serious condition that can lead to seizures and kidney or liver problems in the mother. Preeclampsia also increases the risk of stillbirth.
• Hydramnios—In this condition, there is an increased amount of amniotic fluid in the amniotic sac that surrounds the baby. It can lead to preterm labor and delivery.
• Macrosomia (very large baby)—The baby receives too much glucose from the mother and can grow too large. A large baby can make delivery more difficult. The baby may be at increased risk of injury. A large baby also increases the risk of having a cesarean delivery.

Pregestational diabetes also can cause problems after the baby is born. Babies born to mothers with pregestational diabetes may have problems with breathing, low glucose levels, and jaundice. Most babies do well after birth, although some may need to spend time in a special care nursery. The good news is that with proper planning and control of your diabetes, you can decrease the risk of these problems.

The Importance of Preconception Health Care

If you have diabetes and are planning to become pregnant, it is important to talk with your health care provider. Schedule a preconception appointment with your health care provider so that you can learn the steps to take before pregnancy that can decrease the risk of problems later.

Your health care provider will help you get your blood glucose level under control before you become pregnant (if it is not already). Having a stable glucose level is important because some of the birth defects caused by high glucose levels happen when the baby’s organs are developing in the first 8 weeks of pregnancy—before you may know you are pregnant. Getting your glucose level under control may require changing your medications, diet, and exercise program.

In addition to keeping your glucose level in the normal range, preconception care also allows your health care provider to do the following:

• Diagnose and treat any medical problems you may have because of your diabetes, such as high blood pressure, heart disease, kidney disease, and eye problems
• Give you general information about how to lose weight if necessary through a healthy diet and exercise
• Advise you about taking multivitamin or prenatal vitamin supplements containing at least 400 micrograms of folic acid to help prevent neural tube defects

Controlling Diabetes During Pregnancy

Managing your diabetes while you are pregnant is a must. You can control your glucose levels with a combination of eating right, exercising, and taking medications as directed by your health care provider.

Women with diabetes need to see their health care providers more often than other pregnant women. Your health care provider will schedule frequent prenatal visits to check your glucose level and for other tests.

Your Glucose Goals

Many women with diabetes who have never been pregnant are surprised at how low the recommended blood sugar level is for pregnancy. Your health care provider likely will recommend that you check your blood glucose level several times a day to make sure it is in the normal range and meets the following goals:

• Fasting level = below 100 mg/dL
• 1 hour after eating = below 140
• 2 hours after eating = below 120

Keep a log that lists your glucose levels with the time of day and share your log with your health care provider at each prenatal visit.

A blood test called a hemoglobin A1C may be used to track your progress. This test result gives an estimate of how well your blood glucose level has been controlled during the past 4–6 weeks. Your hemoglobin A_1C should not be higher than 6%.

Be aware that even with careful monitoring, women with diabetes are more likely to have low blood glucose levels, known as hypoglycemia, when they are pregnant. Hypoglycemia can occur if you do not eat enough food, skip a meal, do not eat at the right time of day, or exercise too much. Symptoms of hypoglycemia include the following:

• Dizziness
• Feeling shaky
• Sudden hunger
• Sweating
• Weakness

If you think you are having symptoms of hypoglycemia, check your blood glucose level right away. If it is below 60 mg/dL, eat or drink something, such as a glass of milk, a few crackers, or special glucose tablets. Make sure your family members know what to give you as well.

Your blood glucose level also can get too high, which is called hyperglycemia. When your glucose level is too high, your body might make substances called ketones that can be harmful to your baby. Hyperglycemia can happen if you eat more food than usual, are sick, or are less active than normal. If you have hyperglycemia, talk to your health care provider. You may need to change your diet, exercise routine, or medications.

Eating Right

Eating a well-balanced, healthy diet is a critical part of any pregnancy because your baby depends on the food you eat for its growth and nourishment. In women with diabetes, diet is even more important. Not eating properly can cause your glucose level to go too high or too low.

The number of calories you should consume every day depends on your weight, how far along you are in your pregnancy, your age, and your level of activity. Your health care provider may recommend that you see a dietitian or diabetes educator to help with planning your meals. In most cases, your meal plan will include eating several small meals and snacks throughout the day and before bedtime.

During your pregnancy, it is important to watch how much weight you gain. The amount of weight you should gain depends on your weight before pregnancy. If you are a normal weight before pregnancy, you should gain 25–35 pounds. If you are underweight, you will need to gain more weight. If you are overweight, you will need to gain less.

You may be asked to keep a log of what you eat for several days so that it can be compared with your medication dosage, exercise, and glucose levels.

Exercise

Another key part of a healthy pregnancy is exercise. Exercise helps keep your glucose level in the normal range and has many other benefits, including controlling your weight; boosting your energy; aiding sleep; and reducing backaches, constipation, and bloating. Work with your health care provider to decide what type and how much exercise is right for you. It is best to aim for at least 30 minutes of exercise on most days of the week.

Medications

If you took insulin before pregnancy to control your diabetes, your insulin dosage usually will increase while you are pregnant. Insulin is safe to use during pregnancy and does not cause birth defects. If you used an insulin pump before you became pregnant, you probably will be able to continue using the pump. Sometimes, however, you may need to switch to insulin shots.

If you normally manage your diabetes with oral medications, your health care provider may suggest a change in your dosage or that you take insulin while you are pregnant.

Special Tests

As your pregnancy progresses, your health care provider will likely order special tests to check the size and well-being of the baby. These tests can help your health care provider detect possible problems and take steps to manage them.

A targeted ultrasound exam may be done in the second trimester to check for visible birth defects. Ultrasound exams may be repeated in later weeks to track the baby’s growth.

The following tests may be done starting at 32–34 weeks of pregnancy and repeated in later weeks:

• Kick count—This is a record of how often you feel your baby move. A healthy baby tends to move the same amount each day. You may be asked to keep track of this movement late in pregnancy and contact your health care provider if you note a difference in your baby’s activity. The usefulness of kick counts in reducing the risk of serious problems is not clear. Some health care providers do not use kick counts for this reason.
• Nonstress test (NST)—This test records changes in the baby’s heart rate using an electronic fetal monitor.
• Biophysical profile (BPP)—In this test, ultrasound is used to check the baby’s breathing, body movement, muscle tone, and the amount of amniotic fluid. Changes in the baby’s heart rate also are recorded with an electronic fetal monitor. Results of these tests can give detailed information about the baby’s condition.
• Contraction stress test (CST)—In this test, the baby’s heart rate is measured in response to contractions of the uterus.

Labor and Delivery

Your health care provider will discuss the timing of your delivery. You may go into labor naturally. Labor may be induced (started by drugs or other means) earlier than the due date, especially if problems with the pregnancy arise.

While you are in labor, your glucose level will be monitored closely—typically every hour. If needed, you may receive insulin through an intravenous (IV) line. If you use an insulin pump, you may use it during labor. Women who use insulin pumps may work with their medical teams throughout labor to monitor glucose levels and adjust the pump settings.

After the Baby Is Born

Experts highly recommend breastfeeding for women with diabetes. Breastfeeding gives the baby the best nutrition to stay healthy, and it is good for the mother as well. It helps new mothers shed the extra weight that they may have gained during pregnancy and causes the uterus to return more quickly to its prepregnancy size.

If you breastfeed, you will need to eat extra calories every day. Talk to your health care provider about the amount and types of foods that can give you these extra calories. Eating small snacks during the day may be helpful.

You will need to closely monitor your blood glucose level after delivery. This is essential to determine your ongoing need for medication or to decide the best medication dosage. Most women who took insulin before pregnancy are able to go back to their prepregnancy insulin dosage very soon after birth.

Before you and your partner start having sex again, it is important to choose a birth control method to avoid an unplanned pregnancy. Talk with your health care provider—preferably before you have your baby—about which method of birth control you plan to use after the baby is born. You also should discuss how long to plan between pregnancies.

Finally…

If you have diabetes and are planning to become pregnant, see a health care provider for preconception care to achieve the best possible health before pregnancy. Working closely with your health care provider and controlling your glucose level throughout pregnancy increase your chances of having a healthy pregnancy and a healthy baby.

Glossary

Amniotic Fluid: Water in the sac surrounding the fetus in the mother’s uterus.

Biophysical Profile (BPP): An assessment by ultrasound of fetal breathing, fetal body movement, fetal muscle tone, and the amount of amniotic fluid. May include fetal heart rate. Sometimes the profile includes only the nonstress test and an estimate of the amniotic fluid.

Cesarean Delivery: Delivery of a baby through incisions made in the mother’s abdomen and uterus.

Contraction Stress Test (CST): A test in which mild contractions of the mother’s uterus are induced and the fetus’s heart rate in response to the contractions is recorded using an electronic fetal monitor.

Diabetes Mellitus: A condition in which the levels of sugar in the blood are too high.

Glucose: A sugar that is present in the blood and is the body’s main source of fuel.

Hydramnios: A condition in which there is an excess amount of amniotic fluid in the sac surrounding the fetus.

Insulin: A hormone that lowers the levels of glucose (sugar) in the blood.

Neural Tube Defects: A birth defect that results from incomplete development of the brain, spinal cord, or their coverings.

Nonstress Test (NST): A test in which changes in the fetal heart rate are recorded using an electronic fetal monitor.

Preeclampsia: A condition of pregnancy in which there is high blood pressure and protein in the urine.

Preterm: Born before 37 weeks of pregnancy.

Stillbirth: Delivery of a dead baby.

Ultrasound: A test in which sound waves are used to examine internal structures. During pregnancy, it can be used to examine the fetus.