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Pregnancy and diabetes

Guidelines for women with diabetes (or previous gestational diabetes) planning a pregnancy.

With more and more people being diagnosed with diabetes (affecting an estimated 2 per cent of the UK population), the numbers of women with diabetes who also have to negotiate a pregnancy is also increasing.

With ongoing improvements in understanding the condition, medicines and accessories, the chances of having a safe and successful outcome for mother and child are greater to day than they ever have been.

As with any pregnancy, someone with diabetes should undertake the step after proper consideration and consultation. More than ever, close control of your blood sugars will be required, both for your own health and the health of your child while in the womb.

Blood testing
It will be important to undertake frequent blood testing, if you do not do so already, and you will be encouraged to tighten up on your targets.

Blood sugar values should be as close to normal as possible prior to conception to minimize risk to the developing baby. Fasting blood glucose (your morning blood test taken before you’ve eaten breakfast) should be around 6 mmol/L as often as possible. At King’s College London, a leading centre for diabetes, the guidelines are for 3.5 – 5.5 mmol/l) Aim for blood sugars below 8 mmol/L all the time. Again, King’s guidelines are for blood glucose levels to be between 4 – 7 mmol/l after meals. The aim is to average about 6 mmol/L. If you’re familiar with adjusting your insulin doses, based on frequent blood sugar levels, then do so to meet your new targets.

Being pregnant will mean that your energy requirements will alter. How your body processes the food you eat and the insulin you take means you will have to change from your normal, pre-pregnancy patterns, but it is likely that you will find control is actually easier to attain and maintain than when you’re not pregnant.

Insulin
Many people with diabetes now take two insulins — a long- acting (or ‘night-time’ insulin which lasts over 24 hours, as well as a short-acting one taken at meal times which lasts up to three hours. One or possibly both will have to be adjusted and probably re-adjusted throughout the duration of the pregnancy, with your body returning to pre-pregnancy requirements after the birth.

Any diabetic woman will be advised to do more blood tests, possibly as many as eight a day in order to achieve the tight blood sugar control that is desired.

In the main, you will probably stay on the same insulins that you were already taking, and most of the insulins available in the UK have some studies related to them on their affects during pregnancy. If you have major concerns, you can contact the insulin supplier for detailed information.

With your medical team:

  • Be sure that you are comfortable with the obstetrician who will be caring for you. Discuss each other’s expectations about diabetes care during pregnancy before you become pregnant.
  • Stay in touch with your medical team to discuss possible changes in insulins.
  • Your doctor may advise using an insulin pump, especially if you have elevated blood sugar levels despite your best efforts.
  • Glucogon Hypokits from Novo Nordisk are available on prescription in the UK.
  • If you are taking an ACE inhibitor because of renal disease (protein in your urine) or hypertension (high blood pressure), then this needs to be stopped and changed to a BP tablet that is fetus friendly prior to conception. (Statins – cholesterol lowering tablets, also need to be stopped). However, the protein in your urine may return during the pregnancy. If you do have kidney disease then you should consult with your medical team and possibly with a high-risk pregnancy specialist, as there are additional increased risks to a pregnancy. The decision for a pregnancy in this circumstance should be made very carefully.

    Hypos
    Plan to stay very active both before and during pregnancy, unless your obstetrician tells you to slow down. In fact, the more you exercise, the easier it should be to keep your blood sugar levels down. However, you should carry a store of quick-acting carbohydrate with you at all times in order to treat possible hypoglycaemia, which may occur with less notice than usual as your body has increased energy requirements during the pregnancy. In case of more extreme needs, be sure your partner and, if you are working, someone in the office knows how to give you a glucagen shot if you’re knocked out by low blood sugar. That will mean keeping a glucagen emergency kit handy (be sure those around you know where it is!).

    Kitbags can really help in this endeavour.

    Always wear some form of identification that indicates you have diabetes. With the very tight control that is recommended, you might have a severe insulin reaction that would need help from someone else.

    Keeping your insulin injection device, blood testing kit as well as a source of sugar together in one, easy to access place can help both you and the people around you gain good control and will ensure that you can quickly test and take any action necessary on the result of the test.

    The birth
    Mothers with diabetes are often encouraged to either be induced at around 38 weeks, or to have a caesarean, due to the fact that their babies tend to be a little bit bigger than average, and that the placenta can ‘age’ a little faster, sometimes contributing to a complicated birth. At this stage sometimes a ‘sliding scale’ of insulin solution and sugar solution are giving to mothers via a drip, to allow the doctors monitor control. However, if the mother is capable of blood testing during the birth, then that may also be considered in consultation with the diabetes team and obstetrician.

    Breast-feeding
    Breast-feeding is encouraged with mothers with diabetes as with the rest of the population, the only issue for diabetic mothers being an impact on their own energy requirements. Continued close monitoring of blood sugars is advised, mainly as the mother will already be tired and having hypos won’t improve that situation at all. At this stage, the mother’s blood sugar levels will not be an issue for the baby or affect the breast milk in any way. Good control will simply be a benefit to a mother dealing with a newborn baby.

    General health advice to the mother:

  • Start folic acid supplements prior to conception if possible. Babies of mothers with diabetes are at increased risk of spina bifida. Folic acid has been shown to reduce this risk. Folic acid should be started at least one month prior to conception and continued for at least the first six weeks of pregnancy.
  • Talk to a dietician, especially if it’s been a while since you last spoke to one. There are lots of new ideas, such as carb counting or Dose Adjustment for Normal Eating (DAFNE) that you might not know about. Ideally, these need to have been considered prior to becoming pregnant rather than learned during the pregnancy.
  • Get your eyes examined. This is mainly just to be ‘on the safe side’, as pregnancy can affect the whole body, eyes included.

    Helen Brown’s story
    Helen Brown was working as a nurse when she started to feel ill five years ago. She had the classic symptoms of diabetes — thirstiness and tiredness and after a blood test she was diagnosed with type 1 (insulin dependent) diabetes.

    In 2005 she became pregnant having already discussed the implications for herself and her child with her diabetes consultant at James Cook University Hospital in Middlesborough, where she also worked.

    She says, “I did a lot of blood tests, usually about five a day, with insulin shots if required. I made sure I had all my blood testing kit and my insulin pen to hand, as well as access to some sugar if I needed it. That way I knew that I had what I needed to hand, which was a little less of a worry. In fact my control actually seemed easier when I was pregnant and I maintained consistently good blood test results.

    “Even labour was not too hard, although I was induced as there are increased risks for the baby of a diabetic mother later on in a pregnancy. I gave birth to Heidi, who was three weeks early and weighed 7lbs. She is fit and healthy, and so am I. After the birth I breast-fed her, and had to go through a certain process of my body getting used to not being pregnant but breast-feeding, so gaining control was something I had to face, but it got better over time as I adjusted to the new regime.

    “Everything about it has been worth it, and I hope to have more!”

    Printed information:
    Diabetes UK does a guide to pregnancy and diabetes, the latest edition has just been published. You can get a copy by calling Diabetes UK on 020-7424-1000.

    Online information:


    The UK’s leading charity for diabetes can supply booklets about how to achieve better control as well as information on products available for people with diabetes.


    This group focuses on the needs of people with diabetes who are treated with insulin, particularly those who use animal-derived insulins.


    Supplies kitbags that can contain all the equipment required to maintain good diabetes control.


    Suppliers of various diabetes-related products.


    An online magazine for people with diabetes from Abbott Diabetes Care.


    The site provides information and online buying of Owen Mumford’s range of Autolet insulin injection pens and lancets, among other products.

    Websites of the leading diabetes healthcare pharmaceutical companies:

    www.abbottdiabetescare.com
    For the precision and Freestyle blood test machines.


    Information on the Accu-chek Active, Compact and Advantage blood test machines from Roche Diagnositcs.


    The Acsencia blood test machine.


    For Lilly insulins and insulin delivery devices.


    For the Novo range of insulin and insulin delivery devices.

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