Family planning and diabetes

Planning a pregnancy when you have diabetes

If you have diabetes and are planning a pregnancy, it is important that you talk to your Diabetes Nurse or Hospital Doctor beforehand. This is because sugar control is very important at the time of conception, which will be before you know you are pregnant. Good sugar control will help reduce the risks of health problems to yourself and the baby. To achieve this, you may need some help to adjust your diet or diabetes treatment or in performing extra blood tests.

If your diabetes is treated with insulin, you may need to change your insulin doses or even change the number of injections you take, to improve your overall control.
If your diabetes is treated with tablets, then it is advisable that these are replaced with insulin injections before any pregnancy happens.
If you are on diet alone for your diabetes, then you may need to be started on insulin at some stage before or during pregnancy.

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

Make sure that your blood glucose is as near to normal as possible for at least 3 months before you try to become pregnant. This means 4-6 mmols before meals and no higher than 8 mmols 2 hours after a meal.
Your long-term control is usually assessed by the HbAIC test; ideally you should be aiming to have this below 7% before a pregnancy if possible.
It is important to take regular Folic Acid supplements for at least 3 months before and for the first 3 months of any pregnancy. Lack of Folic Acid could put your baby at a higher risk of developing Spina Bifida. For a mother with diabetes we usually advise 4-5mg tablets rather than the usual 0.4mg tablets advised for mothers without diabetes. 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 -ask your GP if you need help.
If you are on tablets for 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 your It is important that you continue with your usual contraception until you and your Diabetes Team are happy that it is safe for you to become pregnant and give you the ‘go-ahead’.

If you wish you can attend the pre-pregnancy clinic at Ninewells Ante-natal Clinic, a similar service is available in Perth and Angus - see your Diabetes Nurse Specialist for more information.

Once there is a gap of 5 weeks since the start of your last period, check a pregnancy test. As soon as you know that you are pregnant, tell your Diabetes Specialist Nurse, who will arrange for you to have an early visit to the hospital Ante-natal 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 of pregnancy.

High blood glucose before and in early pregnancy could prevent your baby from developing normally.
High glucose during a pregnancy causes the baby to grow quickly and become overweight, especially in the last 3 months. This can lead to problems for you during delivery (greater chance of Caesarian section or forceps delivery). It could also mean that your baby is more likely to be born prematurely or have problems controlling blood glucose (hypoglycaemia) immediately after birth.

Blood Tests and Insulin Doses

You will be asked to test your blood glucose at least 4 times daily (before each meal and before bedtime) but extra tests may be necessary. For good control the blood glucose should be kept between 4-6 mmols before meals.

To achieve this good control, you may need extra insulin injections and your overall insulin dose will increase. Often you will end up taking around 3-5 times your usual daily dose - this is normal. As soon as the baby is born, your dose will return to your pre-pregnancy level.

Hypos

In early pregnancy it is not uncommon to experience hypos more frequently. You may also find that the warning symptoms of hypoglycaemia are different from usual. It is important to be careful about driving, sleeping through snacks 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 around 16 weeks (or more) pregnant; your Diabetes 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 or family can be taught 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 the Diabetes and the Obstetric teams. These are based at either Ninewells Hospital or Perth Royal Infirmary. Initially you will be seen every 2-4 weeks but later in pregnancy you will be seen every week. At around 19 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 important to keep you glucose control as near normal as possible at this time to avoid the baby growing too large. From about 28 weeks you will have a scan every 2 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 a normal labour and delivery where possible. Sometimes if the baby has become overweight or your blood pressure goes 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 your insulin and calories will be given in a ‘drip’ containing glucose and insulin. The amount of insulin will be adjusted every hour depending on your blood tests. The drip will continue until after the baby is born.

After Delivery

You will go back to taking the dose of insulin you were on before your pregnancy as soon as the baby is born. Babies born to mothers who are treated with insulin always 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 ask the staff there any questions you might have.

Breastfeeding

Women with diabetes can breastfeed! You must remember to increase the amount of starchy foods you eat at each meal. This is because breast milk is high in carbohydrate. You may also require 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 to adjust your insulin and food intake by.

Going Home

You no longer need to be as strict about your glucose control as you were during pregnancy. Remember you will be dealing with a new baby and sleepless nights! Your Diabetes nurse will keep in contact with you and will arrange a date for you to be assessed by the Diabetes and Obstetric staff.