Pregnancy and Diabetes

Contents

• What do I need to know before planning to get pregnant?
• What happens at a pre-pregnancy assessment?
• What about blood glucose control?
• What if I have a hypo when I'm pregnant?
• What should I expect during pregnancy?
• Will I have a normal delivery?
• Will the health of my baby be affected?
• Will my baby have diabetes?
• Is breastfeeding possible if I have diabetes?
• What can I expect after my baby is born?
• What if I take insulin?
• Carbohydrate snacks

What do I need to know before planning to get pregnant? 

• Over 95% of babies born to mothers with diabetes are born healthy and well.
• Good blood glucose control is especially important before and during pregnancy.
• To increase the chances of staying healthy throughout your pregnancy and having a healthy baby, you need to plan your pregnancy carefully. This means you (and your partner, if you have one) should discuss pregnancy management with specialised diabetes and obstetrics team. Your GP can give you a referral.
• For more information on planning your pregnancy if you have diabetes, see the resource here.

What happens at a pre-pregnancy assessment? 

• First, you will be given a series of blood tests which will check for anaemia, immunity to rubella (German measles), and thyroid and kidney function.
• You will also be given an HbA1c test, which measures your average blood glucose level over the previous 8–12 weeks. Your diabetes care team will be keen that you keep your HbA1c level as close to the non-diabetic range as possible. If your diabetes is controlled by tablets, they may recommend that you switch to insulin while you are pregnant.
• It is important to take regular folic acid supplements for at least three months before you become pregnant and for the first three months of your pregnancy. If you have diabetes it is recommended that you take 5 mg tablets rather than the usual 0.4 mg tablets. These tablets will need to be prescribed by your GP as the dose you need is much higher than what is available over the counter in a pharmacy.
• Certain medications need to be avoided in pregnancy. It may be advised that some tablets are discontinued and alternatives suggested.
• You will also be given the opportunity to raise any questions you have about your pregnancy and to get all the support and advice you will need to stay healthy throughout.

What about blood glucose control? 

• It is important to maintain blood glucose levels within the normal range (4–6 mmol/L before meals and no more than 8 mmol/L two hours after meals) for as much of the day as possible both before you become pregnant and throughout your pregnancy.
• This means you will have to test your blood glucose very regularly (at least before each meal and again before bed) and follow dietary recommendations very carefully.
• If your blood glucose levels are over 10 mmol/L it is important to test for ketones. These can increase quickly during pregnancy and risk harming your baby as well as making you ill. If you do develop ketones, you should contact your telephone helpline or GP immediately. 

What if I have a hypo when I'm pregnant? 

• Hypoglycaemia is common in pregnancy. You risk having more frequent hypoglycaemic episodes (‘hypos’) and they may be more severe when they occur.
• Get help from your diabetes care team if this is happening to you.  
• If you are injecting insulin with food you may need to reduce your insulin doses in early pregnancy or see the diabetes dietician for support and advice 
• You should make sure family, friends and colleagues are aware of the symptoms of hypos and know what to do to help you if you have one and are unable to treat it yourself. More information on this is available here.

What should I expect during pregnancy?

• In most hospitals, there is a dedicated multi-disciplinary team comprising obstetricians, other doctors, midwives, nurse specialists and dieticians involved in the care of women with diabetes who are pregnant.
• You will be encouraged to attend the clinic assessment as soon as your pregnancy is confirmed. Most women attend before they are 8 weeks pregnant and will continue to have more regular checks throughout their pregnancy than women who do not have diabetes.
• You will have several ultrasound scans to check foetal growth and development.
• As with almost all other pregnant women you are likely to be offered serum screening (a test to check for Down's syndrome and spina bifida) at 11 to 13 weeks.
• You will have more frequent checks of your eyes and kidney function during pregnancy. It is recommended that your eyes are checked 3 times during your pregnancy. This is because there can occasionally be changes to the eye during pregnancy, in which case you will be referred to a specialist opinion. Any eye changes generally revert back to normal after delivery.

Will I have a normal delivery?

• In the UK, around one-third of pregnant women who have diabetes have a vaginal delivery and two-thirds have a caesarean section. Whichever type of delivery you have, your blood glucose levels will be closely monitored and maintained throughout labour.
• All women with diabetes will be expected to have their babies in a hospital with access to a neonatal unit since the baby needs to have regular blood glucose measurements taken after birth to ensure they are not in the low range. You can talk to your midwife to arrange a tour of the labour suite and neonatal unit before you give birth.
• You will normally be expected to have your baby at no later than 40 weeks. Labour may be induced at this point if it shows no sign of beginning by itself.  

Will the health of my baby be affected?

• The vast majority of women with diabetes have perfectly healthy babies. Statistics show, however, that in comparison with the population as a whole, there is a slightly increased risk of neonatal death and problems with the development of some of the major organs. By maintaining excellent blood glucose control before and during your pregnancy, you can reduce these risks to levels approaching those of the non-diabetic population.
• Babies of mothers with diabetes tend to be bigger than other babies. The mother's blood glucose level is one of the key factors affecting the baby's growth so again it is crucial that you keep your blood glucose levels within the normal range as much as possible.

Will my baby have diabetes?

• Your baby will not be born with diabetes. In fact, babies of mothers with diabetes who take insulin tend to have low blood glucose levels. It is for this reason that your baby's blood glucose will be carefully monitored after birth.
• Compared to women who do not have diabetes, there is only a very slightly increased risk of your child developing type 1 diabetes in later life. For type 2 diabetes there is a stronger genetic link but the overall risk is still relatively low, particularly if your child maintains a healthy diet and lifestyle right into adulthood.

Is breastfeeding possible if I have diabetes?

• Yes, it is. The breast milk of mothers with diabetes is just the same as that of women without diabetes.
• In fact, just as for all other women, breastfeeding is generally recommended for women with diabetes. You should be aware, however, that it can reduce your blood glucose levels if you are taking insulin and that you may need to make some changes to your diet.

The table below shows the advantages of breastfeeding for both mother and baby.

Table 1: The Advantages of Breastfeeding

What can I expect after my baby is born?

• If you normally take insulin: your insulin requirements should return to pre-pregnancy levels or even less (you may have needed to take up to twice as much during your pregnancy).
• If you do not normally inject insulin: if you needed to do so during pregnancy you may be able to stop taking it after your baby is born, although you may need to take tablets. Your diabetes care team will discuss this with you.
• You will continue to need frequent blood tests.
• There may be a change in your blood glucose profile (i.e. your normal blood glucose levels).
• If you are breastfeeding you may need to increase the carbohydrate in your meals.

What if I take insulin when I am breastfeeding?

• The sound of a crying baby can increase or drop your blood glucose, the important thing is to know how it affects you.
• Do all you can to avoid low blood glucose now that you have a baby to look after. 
• Do relax your pregnancy blood glucose targets to 5–10mmol before meals, especially if breastfeeding.
• Be aware that being more active (day and night) can drop your blood glucose levels and cause hypos. 
• You should eat around 500 calories/50 g of carbohydrate extra daily, ideally as complex carbohydrates (see below for ideas).
• Continue your normal insulin injection technique.
• Drink plenty of water to remain well hydrated 
• Practise careful handwashing- use non-perfumed cream.
• Remember that breastfeeding is not a contraceptive!
• Try to eat before or during breastfeeding or expressing milk.
• Have easily available quick-acting carbohydrate or your usual hypo treatment nearby at all times.

Carbohydrate snacks

These all contain 500 calories or 50 g of carbohydrate. Choose wholegrain options where possible.

• Large sandwich + glass of milk (200 ml) + fresh fruit
• Cereal bar + yoghurt + fruit
• Standard size pitta bread + filling + 200 ml fresh fruit juice
• 4 oatcakes + cheese + crisps + fruit
• Large bowl cereal + 200 ml milk
• 2 slices toast + large banana + a latte + blueberry muffin
• Scone + butter/spread + jam + cappuccino 

Additional Resources

For further information, have a look at the NHS or Diabetes UK pages on pregnancy and diabetes.