Diabetes in Pregnancy

How does diabetes affect pregnancy?

People with Type 1 or Type 2 diabetes have unique needs during pregnancy. While you may be very familiar with managing your blood sugar levels before pregnancy, being pregnant brings new and different challenges.

Having diabetes before pregnancy is sometimes called “pregestational diabetes” or “preexisting diabetes.” This is different from gestational diabetes, which is a type of diabetes you get during pregnancy (it usually goes away after childbirth).

Pregnancy can make it harder to keep your blood sugar in the recommended target range. This means your meals, physical activity levels and medications could change now that you’re pregnant. For most people, their diabetes management plan changes several times leading up to their due date. Keeping in close communication with your healthcare team throughout pregnancy is essential because it helps you and them identify when your treatment needs to change.

Know that it’s possible to have a healthy pregnancy and healthy baby if you have diabetes. It becomes more challenging to keep your blood sugar levels in your target range, but it doesn’t mean you can’t do it. Your healthcare team is there to help you and make sure diabetes doesn’t prevent you from having a healthy baby.

Is Type 1 diabetes a high-risk pregnancy?

Yes, both Type 1 and Type 2 diabetes are risk factors that increases your chances of pregnancy complications. Your pregnancy care provider will monitor you closely throughout your pregnancy to make sure the fetus is healthy and that you’re able to keep your blood sugar levels in a healthy range. Consistently high or low blood glucose levels can be harmful and lead to complications.

You’ll likely work with a doctor called a maternal-fetal medicine specialist (MFM), who specializes in high-risk pregnancies. Other than an obstetrician, your care team may also include:

• An endocrinologist. This is someone who specializes in hormone-related conditions.
• A registered dietitian. This is someone who offers guidance on what foods to eat to help manage diabetes and a healthy pregnancy.
• A diabetes educator. This is a specialist with extensive training and knowledge in managing diabetes.

How can I prepare for pregnancy if I have diabetes?

Talk to your healthcare provider if you have diabetes and wish to become pregnant. Ideally, this should happen about six months before you begin trying to conceive.

Having a good handle on your blood sugar levels before pregnancy is important because the goal is to have a tight glucose range during pregnancy. And it will become harder to maintain that range once you’re pregnant.

Most guidelines recommend having an A1C of 6.5% or lower before becoming pregnant to reduce the risk of complications. This is because consistently high blood sugar levels can affect fetal development in the first trimester when the organs and other essential tissues are forming.

Meeting with your healthcare team before trying for pregnancy is helpful because:

• Your providers can recommend ways to help you get your blood sugar levels in a healthier range.
• A dietitian can help you formulate eating plans that are healthy for both pregnancy and managing diabetes during pregnancy.
• You may need diabetes medication changes once you’re pregnant.
• You may want to get used to using new diabetes technology that can be especially helpful during pregnancy, like a continuous glucose monitor (CGM) or insulin pump.
• Your provider may recommend tests to check your health before pregnancy, like the health of your eyes, kidneys and heart. This is because pregnancy can make some existing diabetes complications (like retinopathy and nephropathy) worse or trigger them.

How will my diabetes management change during pregnancy?

The main factors that will affect how you manage diabetes during pregnancy include:

• Needing a tighter blood glucose range to decrease the risk of pregnancy complications.
• Adapting to changing insulin needs.
• Managing dietary needs for pregnancy while balancing blood sugar levels.

Blood sugar goals for diabetes pregnancies

Blood sugar goals for diabetes pregnancies are typically:

• Fasting: Below 95 mg/dL
• One hour after eating: Below 140 mg/dL
• Two hours after eating: Below 120 mg/dL

Another way to think of these numbers is with time in range (TIR). In general, TIR goals for adults with Type 1 diabetes in pregnancy are:

• At least 70% of time from 63 to 140 mg/dl (in-range)
• Less than 5% of time below 63 mg/dl
• Less than 25% of time above 140 mg/dl

Most guidelines recommend maintaining an A1C below 6% during pregnancy to decrease the risk of complications.

Due to these strict goals, your healthcare provider may recommend using a continuous glucose monitor (CGM) during pregnancy. It provides a better picture of how your glucose levels change over time than solely relying on manual finger sticks. This makes it easier to make precise changes to your diabetes management.

You’ll likely need to use several strategies to maintain such a tight blood sugar range, including:

• Carefully counting carbohydrates in your meals and snacks
• Giving insulin 10 to 15 minutes (or more) before you eat
• Using physical activity to help manage blood sugars

Your healthcare provider will go over these and other strategies with you.

Changing insulin needs during pregnancy

You can expect your insulin needs to change frequently during pregnancy. This is mainly due to an array of hormones. Diabetes affects everyone differently — and it’s the same during pregnancy. Because of this, it’s crucial to work closely with your healthcare team to make changes to your diabetes management plan. The changes will be unique to you and your needs.

If you have Type 1 diabetes, it’s common to need less insulin during the first trimester — but this isn’t true for everyone. Around the 16th week of pregnancy, insulin needs tend to ramp up. This is because the placenta makes hormones that increase insulin resistance. This happens in all pregnancies, not just in people with diabetes.

You’ll likely need more and more insulin until about the 36th or 37th week of pregnancy, when the insulin resistance typically levels off. Many people end up needing two to three times more insulin by this time compared to the amount of insulin they were taking pre-pregnancy.

You’ll work with your provider to make the necessary insulin changes during pregnancy. This could include changes to your:

• Basal or long-acting (background) insulin
• Insulin-to-carb ratio (ICR)
• Insulin sensitivity factor (ISF)

It’s important to note that your insulin needs will then drastically drop once you deliver the placenta after you deliver your baby. You’ll likely return to your pre-pregnancy insulin needs within about 30 minutes of delivering the placenta — or you may need even less insulin. Your healthcare provider will let you know how to adjust your insulin settings after delivery. Make sure you have a plan.

Diabetes and dietary needs during pregnancy

Proper nutrition is important for healthy pregnancies. Trying to balance nutritional needs for pregnancy and a tight blood sugar range can be difficult. And if you experience nausea and/or vomiting during pregnancy, it becomes even more complex.

A registered dietitian who specializes in diabetes pregnancies can help you formulate eating plans. They’ll provide guidance on how many macronutrients (carbohydrates, protein and dietary fat) you should aim to eat each day. Their recommendations will likely be different from general recommendations for pregnant women without diabetes. They’ll also recommend meals and snacks that balance macronutrients to help maintain steady blood sugar levels.

Type 1 diabetes management during pregnancy

Most people with Type 1 diabetes find that their insulin needs change frequently during pregnancy — usually weekly. Keeping a close watch on your glucose levels and noticing trends can significantly help you and your provider make precise changes to your treatment plan.

If you’re using multiple daily injections (MDI), your provider may recommend switching to an insulin pump so you have more flexibility in changing insulin settings. But you can still have a healthy pregnancy with MDI. If you were taking other medications before pregnancy, make sure to discuss if you can still use those medications during pregnancy.

As always, it’s important to quickly manage episodes of high and low blood sugar. Reach out to your provider if you’re experiencing frequent highs and/or lows.

Type 2 diabetes management during pregnancy

Most oral medications and non-insulin injectable medications for Type 2 diabetes aren’t safe for pregnancy. One exception is metformin. Because of this, you may need to use insulin for the first time to manage your blood sugar levels during pregnancy. And your insulin needs will likely increase as the pregnancy progresses.

Your healthcare team will work closely with you to fine tune a management plan. They’ll likely recommend using a CGM (continuous glucose monitor) if you don’t already do so.

What can I expect with a diabetes pregnancy?

You can expect significantly more prenatal appointments and tests than typical if you have diabetes. This is so your pregnancy care provider can monitor the fetus’s growth and your overall health closely. Aside from typical prenatal tests, like blood tests and an anatomy scan, you can also expect to have the following “extra” tests:

• Fetal echocardiogram. Your provider may recommend getting a fetal echocardiogram to check the structure of the fetus’s heart. This is because having preexisting diabetes can increase the risk of congenital heart conditions.
• Growth scans (ultrasounds). Your provider may recommend fetal growth scans every few weeks. This is especially important because the fetus is at increased risk for being larger than average. But it’s important to remember that these ultrasounds are just estimates. The fetus may be bigger or smaller than what the ultrasound shows.
• Nonstress tests (NSTs). In the third trimester, your provider may recommend weekly NSTs. This test checks the fetus’s heart rate and movements.
• Biophysical profiles (BPPs). Your provider may also recommend weekly BPPs. These are ultrasounds that check for fetal practice breathing, muscle tone and movement. It also measures the amount of amniotic fluid.

You’ll also have more frequent interactions with your endocrinologist or diabetes educator. They’ll suggest strategies and changes to keep your glucose levels as close to the target range as possible.

What are the possible risks and complications of having Type 1 or Type 2 diabetes in pregnancy?

It’s important to take steps to manage diabetes during pregnancy. Your risk for certain complications increases when your blood sugar is consistently too high. Frequent or severe low blood sugar episodes can also be dangerous.

Having pregestational diabetes increases the risk of certain complications for:

• The fetus and pregnancy
• Your baby after birth
• You

Prenatal and postnatal complications

Having diabetes during pregnancy can increase the risk of the following complications for the fetus:

• Birth defects (congenital conditions). Birth defects occur in 6% to 12% of pregestational diabetes pregnancies. Congenital heart conditions are the most common, but this can include neutral tube defects and other abnormalities as well.
• Fetal macrosomia. This is when a newborn weighs more than 9 pounds, 15 ounces. Having a large baby increases their risk (and yours) for injury at delivery.
• Polyhydramnios. This means there’s an increased amount of amniotic fluid in the amniotic sac. It can lead to preterm labor and delivery.
• Preterm birth. Your risk for having a preterm birth is higher because if complications arise, your provider may decide delivery is the safest option (even if you haven’t reached full term).
• Stillbirth. Having pregestational diabetes may increase the risk of stillbirth.

After birth, your baby may be at increased risk for certain health conditions, too. While most people with diabetes give birth to healthy babies, there is a slightly higher risk of:

• Low blood sugar right after birth
• Breathing difficulties
• Jaundice

If your baby has any of these complications, they may need to receive care in the NICU (neonatal intensive care unit).

Babies born to people with diabetes may also be more likely to develop obesity later in life.

Complications that can affect you

Having diabetes during pregnancy can increase your risk of:

• Preeclampsia. Preeclampsia is high blood pressure and protein in your pee. Diabetes is a major risk factor for preeclampsia. Your provider will likely recommend taking low-dose aspirin after 12 weeks of gestation to minimize your risk of preeclampsia.
• Needing a C-section delivery. This is mostly because the fetus is at-risk for being large at birth.
• Low blood sugar. Due to trying to maintain a tight blood sugar range, you’re at increased risk of frequent and/or severe low blood sugar levels.
• Diabetes-related ketoacidosis (DKA). Due to increasing insulin resistance, you’re more at risk for DKA during pregnancy. Vomiting due to morning sickness can also contribute to DKA developing.
• Diabetes-related complications. Pregnancy can worsen existing diabetes complications, like retinopathy, nephropathy and neuropathy. It can also trigger them.

How will diabetes affect labor and delivery?

In most cases, healthcare providers recommend scheduled inductions for pregnant women with diabetes. When they recommend an induction varies based on several factors, but it’s usually at or before 39 weeks gestation. Each person and pregnancy is different. Together, you and your provider will decide what’s best for you.

Due to hormone fluctuations and the physical nature of labor, your blood sugar levels may rise or drop during labor — it’s difficult to predict. Depending on your provider and your hospital’s policies, you may be able to self-manage with an insulin pump or injections during labor and delivery. Or you may need an IV insulin drip.

Once you deliver the placenta, your insulin needs will drop significantly — typically, to pre-pregnancy levels or even lower. Work with your provider and make sure you have a plan in place to readjust your diabetes management plan after delivery.

How do I cope with having diabetes and being pregnant?

Having diabetes and being pregnant can present you with new challenges. Your pregnancy may be different from what you envisioned, and you may find yourself questioning your diabetes management plan. While everyone’s journey is different, anyone with diabetes who becomes pregnant can follow similar tips to make their experience as healthy as possible. This includes:

• Monitoring your blood sugar levels frequently (as directed by your provider).
• Keeping your blood sugar levels within your target range.
• Following your provider’s guidance on insulin, medications and other treatments.
• Attending your prenatal appointments and tests.
• Staying physically active. Talk to your provider about your activity level and if you should modify it.
• Eating healthy, well-balanced meals and snacks.
• Avoiding beverages containing alcohol and tobacco products.
• Taking care of your mental health.

When should I see my healthcare provider?

Contact your pregnancy care provider if you have diabetes and notice any of the following:

• You’re unable to keep your blood sugar in the target range despite your best efforts. (It’s either too low or too high.)
• Your blood sugar spikes or changes for reasons you don’t understand.
• The fetus is moving less.
• You leak fluid or blood from your vagina.
• You have blurred vision or increased thirst.
• You’re vomiting or unable to keep food and fluids down.

Remember, it’s always better to be overly cautious and ask questions. It can be stressful to worry about managing diabetes on top of worrying about pregnancy. Don’t make assumptions or shrug your feelings off — contact your provider for guidance.

What questions should I ask my healthcare provider?

If you have diabetes and become pregnant, you may want to ask your healthcare provider:

• How often should I check my blood sugar levels?
• What should my target range be?
• What are possible complications of not keeping my blood sugar at my target range?
• Will my insulin dosages need adjusted?
• Should I stop or start any other medications?
• Do you recommend any lifestyle changes?
• How frequently will I need to come for monitoring?
• Will I need to be induced early?

Do people with Type 1 diabetes have healthy babies?

Yes, most people with Type 1 diabetes (and Type 2 diabetes) have healthy babies. Managing your blood sugar levels and staying in close communication with your healthcare team is key to a healthy pregnancy.