Life with Diabetes

Diabetes and Pregnancy

If you have diabetes, a healthy pregnancy and baby is possible when you take steps to follow a healthy eating plan, stay physically active, and manage your blood glucose (blood sugar). 

To protect your baby, it’s important to get a good handle on your diabetes management before you become pregnant and very early in your pregnancy while major organs are forming, less than eight weeks after your last menstrual period. Some of these organs include your baby’s neural tube, which includes the brain and spinal cord, and the heart. 

Planning ahead for each stage of pregnancy, including preconception and the first, second, and third trimesters, will help you know what to expect and create a game plan to ensure your health and the health of your baby. 

Before You Are Pregnant

Because your baby starts developing so early, talking to your health care provider a few months or more before you try to become pregnant will help to make sure you have a healthy pregnancy. This will allow you take steps to bring your blood glucose (blood sugar) into your target range and reduce your A1C, if needed.  

Worried that your A1C is too high? This is the time to work with your diabetes care team to change your treatment plan. Changes could include to your eating plan, physical activity, and medications you take. And no matter what your A1C is, taking prenatal vitamins with folic acid early will lower your child’s risk of birth defects.

This is also the time to make sure you have the right health care providers lined up for your care during your pregnancy. If parts of your diabetes care team don’t have a lot of expertise with diabetes and pregnancy, think about looking for ones that do. 

For the best prenatal care, your care team should include:

  • A doctor, trained to care for people with diabetes and has cared for pregnant women with diabetes
  • An obstetrician gynecologist (OB/GYN) who handles high-risk pregnancies and has cared for other pregnant women with diabetes
  • A pediatrician (children's doctor) or neonatologist (doctor for newborn babies) who knows and can treat problems that can happen in babies of women with diabetes
  • A dietitian who can change your meal plan as your needs change during and after pregnancy
  • A diabetes care and education specialist who can help you manage your diabetes during pregnancy
  • An eye doctor (optometrist or ophthalmologist) who can be sure your eyes are in good shape for pregnancy

It’s important to remember that you are the most important member of your health care team. Keep track of any questions you have so that you have them ready at your appointments.

What to Be Checked For

Before you’re pregnant is the time to ask your health care provider to be tested for type 2 diabetes if you don’t have it and you’re at risk. The American Diabetes Association (ADA) recommends testing for diabetes during your first prenatal visit. Not sure if you’re at risk? Take the Type 2 Diabetes Risk Test.

Having obesity or overweight can negatively impact your baby by raising your risk for complications. Talk to your health care provider about if you are currently at a weight that is healthy for you and the steps to take to reach it, if necessary.  

Your OB/GYN or endocrinologist should test your thyroid function. The risk of thyroid disorders is higher in women with diabetes, and having the right levels of thyroid hormone are important for your baby’s development while you’re pregnant.

Visit your eye doctor (optometrist or ophthalmologist) so they can check to see if you have diabetes-related retinopathy or assess the level of your retinopathy if you’ve already been diagnosed. This is important because retinopathy can worsen during pregnancy. If you have retinopathy, have your eyes rechecked each trimester. Diabetes-related kidney disease (nephropathy) can also worsen, so make sure you’ve been screened prior to pregnancy.

Checking Your Blood Glucose (Blood Sugar)

Blood glucose targets are usually lower during pregnancy because high blood glucose poses such a great risk to the baby. The fact that your blood glucose target during pregnancy is lower than what you might be used to also raises your risk for low blood glucose. 

Your body changes as the baby grows. Because you have diabetes, these changes will affect your blood glucose level. Pregnancy can also make symptoms of low blood glucose hard to detect.

During pregnancy, you’ll need to work harder to manage your diabetes. Checking your blood glucose checks at home is a key part of taking good care of yourself and your baby before, during, and after your pregnancy.

Blood glucose targets are designed to help you minimize the risk of birth defects and miscarriage and help prevent your baby from getting too large. If you have trouble staying in your target range or have frequent low blood glucose levels, talk to your health care team about changing your treatment plan. Blood glucose targets may differ slightly in different care systems and with different health care teams. Work with your health care team on what targets meet your goals before and during pregnancy.

Generally, to make sure your blood glucose stays as close to target range as possible, check it when you wake, before you eat, and one or two hours after meals. You might need to check at different times depending on your lifestyle, so ask your doctor or diabetes educator about times that are right for you.

The Standards of Care in Diabetes recommends:

  • A fasting glucose 70–95 mg/dL
  • Under 140 mg/dL an hour after eating
  • Under 120 mg/dL two hours after eating 

If you’re having trouble reaching your targets, work with your doctor or diabetes educator to review your targets and adjust your treatment plan.

Continuous glucose monitors (CGMs) are being used more frequently during pregnancy. A CGM will monitor your glucose 24/7, and if it drops while you’re sleeping, an alarm will wake you. That’s an important benefit—especially for people with type 1 who are more likely to have low blood glucose.

A diabetes educator or registered dietitian can help you adjust your diet. For the most part, the same well-balanced eating plan that was recommended before you were pregnant is what you can follow. But an expert can help you make changes or start you on a new eating plan if you need it.

Also, it’s important to know that you’re not exactly “eating for two.” In fact, during the first trimester, you don’t need any extra calories at all.

While blood glucose and nutrition are probably your main focus, you’ll also want to start taking steps to prevent preeclampsia—a late-pregnancy complication where you experience very high blood pressure that can lead to organ damage. Women with any type of diabetes are at high risk for preeclampsia, but taking a baby aspirin daily after the 12-week mark will lower your risk.

Whatever you do, don’t stop taking your diabetes medication(s) unless you’ve been told to. Some diabetes medications might not be officially approved for use during pregnancy, but none of them have been linked with major complications. It’s much worse to stop your medication and have your blood glucose suddenly increase.

That said, according to the ADA’s Standards of Care in Diabetes, insulin is the preferred medication for managing your blood glucose while you’re pregnant—no matter what type of diabetes you have. Because insulin doesn’t cross the placenta, it’s the safest option for your baby. Plus, other diabetes meds usually aren’t enough to manage higher blood glucose from insulin resistance if you have type 2 diabetes. It’s likely that your doctor will switch you to insulin even if your blood glucose was managed well before you were pregnant.

Whether you’re new to insulin or have been on it since childhood, you’re going to need to keep tweaking your dose throughout your pregnancy. In the first trimester, if you have type 1 diabetes, your insulin needs might actually decrease. Adjusting your dose is key—you risk hypoglycemia (low blood glucose) otherwise. That’s dangerous to you, of course, but regular hypoglycemia events can also be harmful to your baby’s developing brain. 

The morning sickness and fatigue you might have had during the first trimester will start to lift, which means you should be able to eat a little more. That’s largely a good thing—but you don’t want to overdo it. Most women only need to eat about 300 extra calories a day during the second and third trimesters.

Now that you’re feeling a bit better, you’ll be able to move more, too. Physical activity will help your stress level, blood glucose levels, and make your labor easier. So stay as active as possible. You can take a short walk 15 minutes after a meal or do a more intense activity, it’s up to you. Just be sure that you were able to do that level of activity before. Shoot for at least 150 minutes of moderate activity, such as brisk walking, per week. For example, walking 30 minutes a day for five days of the week.

A few things about physical activity to keep in mind: 

  • Now isn’t the time to start training for your first marathon. 
  • Avoid: 
    • Contact sports
    • Activities that put you at risk for falls (such as riding a bike outside)
    • Anything that raises your temperature too high (think hot yoga or running outdoors on a sweltering day)
    • Heavy weight lifting (switch to lighter weights)

If you want to be sure an activity is okay to do, consult your doctor.

While it’s natural to put on weight, aim to gain no more than 25–30 pounds during your pregnancy if you don’t have overweight or obesity. If you have overweight or obesity, try to stay at the weight you are now.

Obesity Risks and Pregnancy

Obesity raises your risk for pregnancy complications, this includes preeclampsia, stillbirth, and having a baby that’s very large (fetal macrosomia). Studies have also found that children of mothers who had obesity during pregnancy are more likely to develop heart disease, asthma, and type 2 diabetes later in life.

Keep in mind that as your baby grows, so will the amount of insulin you will need to take. Being pregnant creates more insulin resistance because of hormones that are needed for your baby.

The second trimester is also when several important screening tests are done, including: 

  • At 18 weeks, you’ll have a fetal echocardiogram to make sure the baby’s heart is healthy.
  • You’ll get regular ultrasounds, including the anatomy scan at 18–22 weeks, which provides a detailed look at all your baby’s body parts.

You may end up needing as much as double your insulin dose by late in the third trimester. Keep working closely with your doctor to adjust your medication as needed.

Starting at 28 weeks, your doctor will probably recommend a growth scan every four weeks. Your baby’s size is a major concern because women with diabetes are more likely to have a baby that’s larger than normal (fetal macrosomia). This can complicate a vaginal delivery. The baby’s shoulders can get stuck in the mother’s pelvis, making a C-section necessary. Babies that are very large at birth are also more likely to have obesity during childhood and develop risk factors for type 2 diabetes, heart disease, and stroke.

Growth scans also look at amniotic fluid, which surrounds the growing fetus in the uterus. It increases when a mother’s blood glucose high, because the fetus is trying to flush out the extra glucose. Too much amniotic fluid can trigger pre-term labor. If your level is high, you may need more testing.

At 30 to 32 weeks, you’ll also start getting nonstress tests to check your babies heart rate. 

Women with diabetes are often induced earlier, at 37 to 38 weeks. Inducing labor slightly early reduces the risks to you and your baby, including the chance of stillbirth—especially if the baby is showing signs of distress, if you aren’t able to reach your blood glucose targets, or you have preeclampsia

Postpartum

Right after you give birth—ideally at a hospital with a good neonatal intensive care unit in case your baby requires any special monitoring—a pediatrician will check your baby for low blood glucose. Your baby was getting blood glucose from you (and making extra insulin to compensate) and will need time to adjust.

Your insulin needs will also drop—a lot—which puts you at risk for hypoglycemia too. Within just a few hours, your body may be able to manage blood glucose levels at the way it did before you were pregnant.

You should see a health care provider within two weeks for a checkup. If you have type 2 diabetes and weren’t previously using insulin, you might be able to switch back to another medication, though some women prefer to stay on insulin longer because it doesn’t get into breast milk.

Whatever treatment you opt for, breastfeeding is strongly recommended by most health care providers. It helps lower your blood glucose and children who are exclusively breastfed are less likely to develop type 2 diabetes. Not only that, but studies have found that mothers with gestational diabetes (GDM) have a lower risk of developing type 2 diabetes in the future if they breastfeed. The catch, however, is that nursing requires a lot of energy. To prevent dangerous lows if you’re still taking insulin, remember to check your blood glucose before you breastfeed and, unless it’s already high, eat a snack.

Postpartum depression is fairly common in women with diabetes. Managing your diabetes, caring for a newborn, lack of sleep, and major hormonal shifts can lead to a mood disorder. If your “baby blues” don’t improve after two weeks, or if you’re overcome by feelings of sadness or have thoughts of harming yourself or your baby, tell your health care provider or a mental health professional right away so you can get treated and start feeling better.

While this might all seem like a lot to take in, you don’t have to let diabetes keep you from your dreams of having a family. For women with diabetes, having a baby is a lot more work than it is for women who don’t have diabetes. But if you do the work, you can expect to have just as good of an outcome.