Pregnancy and Type 1 diabetes

Having a baby is a very important time in your life. It involves going through many changes as you and your body prepare for the coming baby. Managing your diabetes is very demanding during pregnancy while there is so much else going on. But it is very important for both you and your baby that you put extra effort into your diabetes at this time. Support for this intensive effort is available from your specialist diabetes service.

What is important before my pregnancy?

Planning your pregnancy

If your blood glucose levels are high at the time of conceiving your baby, and during the early weeks of pregnancy, your baby is at greater risk of developing abnormalities.

For this reason it is very important to plan your pregnancy where possible. If your pregnancy is planned you can work towards having as healthy-as-possible blood glucose levels during this time.

If you are not planning to become pregnant make doubly sure you are using a safe form of contraception. Many of the contraceptive pills are safe for women with diabetes. Intra Uterine Devices (IUDs) may carry an increased risk of infection for some women with diabetes. However, most doctors consider them to be safe. See your GP, family planning doctor or diabetes specialist to arrange contraception. If you know you have had unprotected sex at a time when you are not planning to become pregnant, it is best to visit your doctor as soon as possible afterwards for help and advice.

Once you have decided to become pregnant visit your nearest specialist diabetes service for pre pregnancy support and advice. It is best to plan this visit at least 4 months before you intend to start trying to conceive.

Laboratory tests before pregnancy

It is best to have the results of a recent blood glucose series and an HBA1c level available at this first visit. You and the diabetes service will get more from this first visit if you do some intensive home blood glucose testing for 2 weeks before the visit. Take along the recorded results. You should also have your kidney function and your thyroid function tested before becoming pregnant.

Insulin before pregnancy

It is important for you to get the healthiest blood glucose levels that you can achieve for three months before conceiving. And also for the duration of the pregnancy. For this reason the diabetes specialist may suggest that you change the insulin you are on, or the way in which you take your insulin.

If you are taking your insulin twice daily they may suggest you change to a more 'intensive' regime. This may mean taking three injections of short-acting insulin prior to your main meals and one or two injections of intermediate-acting insulin before breakfast and/or dinner or bed. Some people transfer onto an insulin pump to improve their blood glucose levels before and during pregnancy. Taking your insulin via a pump often makes it easier to achieve lower blood glucose levels. Discuss what you think will be best for you with your diabetes specialist.

Blood glucose levels

Before pregnancy it is best if you maintain your blood glucose levels as near to the normal range (that of people without diabetes) as possible. It’s best if your blood glucose levels are mostly between 4 - 8mml and your HBA1c less than or equal to 7%. You and your baby have the best chance of being healthy if you have these levels for three months before conception.

It will almost certainly make it easier for you to achieve these blood glucose levels if you work closely with both a dietician and a diabetes nurse educator during this time.

You should also be alert to the increased risk of having more frequent low blood glucose levels (hypoglycaemia or 'hypo'). The risk of 'hypos' inevitably increases when you are achieving lower blood glucose levels overall. It’s probably a very good idea for your partner or family to know how to inject glucagon if they have to.

Eye check

Before pregnancy you should have the retinas of your eyes checked, preferably by an ophthalmologist. Pregnancy can cause retinopathy (diabetes eye damage) to get worse. If you have retinopathy it is best if it is stabilised before you become pregnant.

Folic Acid

Folic acid is thought to reduce the risk of you having a child with spina bifida or other abnormalities. It is recommended that women take a 5mg folic acid supplement daily for four weeks before becoming pregnant and also for the first 12 weeks of pregnancy.

Alcohol

It is now considered that there is no safe level of alcohol during pregnancy. It is best to avoid alcohol altogether during any time when you may become pregnant. And also for the duration of your pregnancy. Drinking alcohol during pregnancy can cause your baby to have a condition called 'foetal alcohol syndrome'. This can result in the child having severe behavioural problems throughout life.

Smoking

If at all possible try to stop smoking before conceiving your child. All women who smoke are at more risk of developing problems during their pregnancy. Their babies are also at risk of being too small, premature or malnourished. If you have diabetes and smoke the risks to yourself and your baby are very much increased. The smoking and diabetes section of this website will tell you more about this, and suggest ways of overcoming smoking.

What is important when I’m pregnant

Risks to myself or the baby in pregnancy. Pregnancy can cause any 'small vessel disease' that you have to become worse. 'Small vessel disease' in diabetes is commonly damage to the blood vessels in your retinas (the backs of your eyes) and damage to the blood vessels in your kidneys (nephropathy). If you have either of these complications of diabetes you should talk things through with a diabetes specialist, before becoming pregnant.

Getting your blood glucose levels well down before your pregnancy, and keeping them in a healthy range during pregnancy may help to prevent these conditions from getting worse. If you have existing eye problems an eye specialist should monitor and treat your eyes before and throughout your pregnancy.

Your baby has a bigger chance of developing an abnormality than babies born to women without diabetes. Such abnormalities tend to be of their heart, spine and kidneys. The best way to bring down the risk of this happening is to have the healthiest possible HBA1c level that you can achieve, especially for the three months before and twelve weeks after conception. Your baby also has a higher risk of being still-born when you have diabetes.

Women with Type 1 diabetes, especially those who have had Type 1 for more than ten years, are more likely to develop serious heart or large blood vessel problems during pregnancy. Your doctor may well suggest that you have a scan of your heart before planning to become pregnant. Babies born to women with Type 1 diabetes also have an increased risk of being born smaller than usual.

Women with Type 1 diabetes also have a higher risk of developing HOP
(also called toxaemia, or pre eclampsia) during the pregnancy. HOP stands for hypertension (high blood pressure), oedema (swelling of the body), and proteinuria (loss of protein into the urine). If this condition develops it usually happens after the 30th week of pregnancy. If you notice your weight has suddenly increased, you have increased swelling, or you develop headaches, get help from your midwife quickly.

What happens during my pregnancy?

Diabetes puts you and your baby at higher risk of developing problems during the pregnancy. Because of this you will be in close contact with your health care team throughout your entire pregnancy. This team will include a diabetes specialist, an obstetrician, a midwife or specialist diabetes midwife, a dietitian and a diabetes nurse educator. It may also include an ophthalmologist.

You’ll be visiting your team fortnightly to weekly, depending how things are progressing.

Insulin during pregnancy

During pregnancy you release hormones called the 'placental hormones'. You also release higher levels of progesterone. These hormones are called 'diabetogenic' hormones. What this means is that they cause insulin resistance (which can cause diabetes in susceptible people). Insulin resistance is when your body cells find it harder to recognise or use insulin.

When you have insulin resistance you need a lot more insulin to do the same job. Therefore during pregnancy your insulin doses will increase, especially during the 2nd and 3rd trimester when these hormones are at their highest levels. Once your baby is born your insulin doses should rapidly drop back down again. You will have backup and advice for your insulin dose changes from your diabetes nurse educator (or your diabetes midwife) and your diabetes medical specialist.

Blood glucose testing during pregnancy

You will need to test your blood glucose levels very often during your pregnancy. Most people test between 4 - 8 times a day during pregnancy.

The target range set for your blood glucose levels during this time is likely to be lower than your targets before pregnancy. This is because women without diabetes tend to have slightly lower blood glucose levels during pregnancy than at other times. The aim of blood glucose management for those with diabetes during pregnancy is to get as close to this as possible.

Laboratory tests during pregnancy

It is good to get frequent laboratory blood glucose and HBA1c levels during pregnancy. These are to back up the results you are getting on your own blood glucose meter. Some diabetes services like you to have fructosamine tests as well. These look back over your average blood glucose levels for the past 2 - 3 weeks.

Scans during pregnancy

Scans are a good way of checking on the babies growth and development. They can also pick up on any problems developing. You are likely to have fairly frequent scans during your pregnancy.

What happens during my labour and delivery?

The aim with labour and delivery is to have a normal labour and vaginal delivery where possible – providing this doesn’t put you or your baby at risk. Because you have Type 1 diabetes it’s more likely that you will be recommended to avoid undergoing labour. This means it’s more likely you will need a caesarean section.

You will need to go onto an I.V. drip during either labour or caesarean section. The drip will have one bottle containing glucose and another bottle containing insulin. The rates of these drips will be changed according to your blood glucose levels. Your blood glucose levels will be checked at least every hour.

What happens when my baby is born?

Once your baby is born and you are eating well you will probably come off the I.V. drip quite quickly. Most people are able to eat soon after delivery. Your blood glucose levels will be checked often. You will probably restart insulin injections just before or just after your I.V. drip is stopped. Your insulin doses will be reduced right back to your pre-pregnancy doses.

Your baby’s blood glucose will be checked often in the first few days following birth. If your blood glucose levels were high during pregnancy your baby might have been making a lot of its own insulin in order to process the glucose it was getting from you. Once this supply of glucose is cut off (when the placenta separates) the baby is at risk of going low as it might temporarily have too much insulin. This is easily treated when it is picked up and is only temporary.

Once you go home it is important to stay in touch with the diabetes team until your blood glucose levels are settled and you are feeling confident with your insulin doses. You may find that your insulin doses will need adjustment if you are breast feeding. You should also have a post pregnancy eye and kidney function check.