Planning a Pregnancy When You Have Diabetes

Contents

• Introduction
• Before pregnancy
• During pregnancy
• Labour and delivery
• After delivery
• Going home
• Breastfeeding

Introduction

Pre-conception care: If you are planning to become pregnant your diabetes care team may change some of your medications to alternatives that are safe to take in pregnancy.

It is especially important that your blood glucose is well controlled around the time that you conceive. Having good blood glucose control during pregnancy helps reduce the risk of complications that can affect you or your baby.

You will need help and support with adjusting your diet, diabetes medication and insulin and you will need regular blood tests throughout your pregnancy

• If you manage your diabetes with insulin, you may need to increase your insulin doses or the number of injections you take, in order to improve control of your blood glucose levels.
• If you manage your diabetes with tablets, some of these may need to be changed to other tablets that are safe in pregnancy.
• In some cases, tablets need to be replaced with insulin injections before you become pregnant.
• If you manage your diabetes through diet alone, you may need to begin taking tablets or insulin either before you become pregnant or during your pregnancy.

Before pregnancy

Before becoming pregnant, there are a number of important things for you to consider:

• Make sure that your blood glucose levels are as near to normal as possible for at least three months before you try to become pregnant. The target level is 4–6 mmol/L before meals and no more than 8 mmol/L two hours after meals.
• Your long-term blood glucose control is usually assessed by the HbA1c test. You should aim to have this below 48 mmol/mol (7%) before you become pregnant if at all possible.
• 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 any pregnancy. A lack of folic acid could put your baby at a higher risk of developing spina bifida. 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.
• Have your rubella (German measles) status checked by a blood test. If you are not immune to this, then you will need to be vaccinated.
• If you smoke, please stop. There is plenty of support available for this, so talk to your GP or diabetes care team and they will give you the help you need.
• If you are on medication for high blood pressure or to lower cholesterol, then these may need to be changed to alternative ones.
• It is important that you continue with your usual contraception until you and your diabetes care team are happy that it is safe for you to become pregnant and give you the go-ahead.
• You should attend the pre-pregnancy clinic – see your diabetes care team for more information about this.
• If there has been a gap of five weeks since the start of your last period, you should do a pregnancy test. As soon as you know that you are pregnant, tell your diabetes care team, who will arrange for you to have an early appointment at the hospital’s antenatal clinic.

During pregnancy

Now that you are pregnant, the hard work really starts! It is important that you keep your blood glucose as near to normal as possible for you for the whole duration of your pregnancy.

• High blood glucose levels during pregnancy cause the baby to grow quickly and become overweight, especially in the last three months. This could lead to problems for you during delivery, with a greater chance of needing a C-section or forceps delivery. It could also mean that your baby is more likely to be born prematurely or have problems with hypoglycaemia immediately after birth.

Blood tests

You will be asked to test your blood glucose at least four times daily (before each meal and before bedtime) but extra tests may be necessary. Remember that for good control, your blood glucose level should be kept between 4 and 6 mmol/L before meals

If you take insulin

To achieve and maintain good control of your blood glucose levels, you may need extra insulin injections and your overall insulin dose will increase. You could end up taking around three to five times your usual daily dose: this is perfectly normal. As soon as the baby is born, your dose can normally return to its pre-pregnancy level.

Hypos (low blood glucose)

In early pregnancy, it is not uncommon to experience hypoglycaemic episodes (‘hypos’) more frequently. You may also find that the warning symptoms of hypos are different from usual.

It is important to be careful about driving, sleeping through times when you would normally have a snack or spending long periods of time alone. If you are having frequent hypos, then it may be wise to stop driving altogether until you are at least 16 weeks pregnant. Your diabetes care team can advise you if you are worried about this.

Hypos may be more severe in pregnancy and you may need help from a friend or relative to treat them if you are unable to swallow sugary drinks. Friends and family can be taught how to treat hypos using glucagon injections, which can be prescribed by your GP.

Clinics

You will be asked to attend the hospital frequently for assessment by both diabetes and the obstetrics teams. Initially, you will be seen every two to four weeks but later in your pregnancy, you will be seen every week.

At around 20–22 weeks you will have a detailed ultrasound scan to check your baby's size and development.

From around 26 weeks, the baby will begin to put on weight. It is very important to keep your blood glucose levels as near to normal as possible during this time to prevent the baby from growing too big. From about 28 weeks you will have a scan every two weeks to check on your baby's growth.

When you reach 36 weeks, ask your diabetes nurse and midwife about how your labour will be managed and start to write your labour and delivery plan with your birth partner. You could teach your birth partner how to do blood testing. They also should know how to recognise your hypo symptoms.

Labour and delivery

The aim is to try for normal labour and delivery where possible. If your baby has become overweight or your blood pressure has gone up, the obstetrician may wish to induce labour early. Ask your obstetrician or midwife about how this will be done in your case.

During labour, you may be put on a glucose and insulin drip. The amount of insulin will be adjusted every hour depending on your blood tests. The drip may continue until after the baby is born.

After delivery

As soon as your baby is born, you should normally be able to go back to taking the dose of insulin you were on before your pregnancy. Babies born to mothers who are treated with insulin usually go to the Special Care Baby Unit (SCBU) for a short time for observation. You will be given the opportunity to visit the SCBU during your pregnancy and can ask the staff there any questions you might have.

If you are breastfeeding, however, you might need to reduce your insulin dose to 80% of what it was before pregnancy as your blood glucose will be lower. Your diabetes care team will give you slightly higher glucose readings to aim for in order to avoid having a hypo while you are caring for your baby.

Going home

Be kind to yourself and ask for help if you need it. You will be dealing with a new baby and sleepless nights which will affect your blood glucose levels! Your diabetes care team will keep in contact with you and will arrange a date for you to be assessed by diabetes and obstetrics staff.

Breastfeeding

Women with diabetes can breastfeed. You must remember, however, to eat a sufficient amount of starchy carbohydrate at each meal. This is because breast milk is high in carbohydrate. If you manage your diabetes with insulin, you may also need less insulin while breastfeeding, as the baby is taking carbohydrate away from you. Test before and after a few feeds so that you know how much you need to adjust your insulin and food intake.