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Managing Diabetes

Managing Diabetes during Pregnancy

Introduction

This document discusses the care of pregnancy in people with pre-existing diabetes. Gestational diabetes is discussed on a separate web page. If you have Diabetes whether it be Type 1 or Type 2, your condition should be carefully managed, beginning well before you become pregnant.

See information on ‘planning a pregnancy’ for pre-pregnancy advice. These issues will usually be discussed with you at your ‘annual review’ for diabetes care.

I have just found out that I am pregnant – what should I do?

Contact your diabetes team as soon as possible.  All women who have diabetes should be followed up by a specialist clinic during pregnancy. This is to make sure your control is optimal and that you are monitored closely to minimise the risk of developing complications.

At the West Suffolk hospital you will be seen at the Medical Obstetric Clinic, which is held on a Wednesday afternoon in the Diabetes Centre. 

Who will I see in clinic ?

At the West Suffolk, you will see an obstetrician, a diabetes consultant, a midwife and a diabetes specialist nurse. In addition a dietician is available.

What will happen at my first appointment?

Ideally, you will have received pre-pregnancy counselling and much of the following will already have been done.

  1. Optimise diabetes control - transfer from oral hypoglycaemic tablets to insulin (if you have type 2 diabetes) as diabetes tablets are not recommended during pregnancy. You should commence regular blood glucose testing and see a dietician with a view to improving your diet
  2. If you have high blood pressure, we would optimise blood pressure control and change your medication if necessary. For example, ACE inhibitors, a type of blood pressure medication often prescribed for people with diabetes, are harmful to the baby. There are alternatives which can be given safely.
  3. Start on Folate supplements. High dose, 5mg, once daily for the first 3 months of your pregnancy. It is only available on prescription.

You will also be offered an ultrasound scan to try and ‘date’ the pregnancy.

Your HBA1C, long term glucose control indicator – will be taken.

Any problems I should look out for?

When you tighten up your control, you may experience more hypoglycaemia. If your hypo warnings are poor you should take extra care to avoid hypos. Regular blood sugar testing is essential.

Why is it important to attend a specialist clinic?

At the Specialist clinic you will have your pregnancy and blood sugar control closely monitored.

Pregnancy can increase the risk of developing diabetic complications, or worsen complications that already exist. Early signs of damage to blood vessels in the eye (retinopathy), high blood pressure and protein leakage from the kidneys (proteinuria) will be detected.

Attending a specialist clinic means you have a better chance of preventing these complications and early treatment should they occur.

Your baby’s size will also be monitored. You may have to undergo an ultrasound scan to measure the baby’s size and the amount of amniotic fluid which may sometimes be abnormally increased.

The Obstetrician will also decide on the timing of delivery. Women who have diabetes are not usually advised to continue pregnancy beyond forty weeks.

Plans will also be made for managing your baby after delivery as there is an increased risk of low blood sugar (hypoglycaemia) in the newborn infant, particularly if the mother’s diabetes control has been poor during pregnancy.

I take tablets – why can’t I continue on tablets during pregnancy?

There is no clear evidence that tablets are harmful during pregnancy. Indeed, research is being done as to whether tablet may be used during pregnancy.

Insulin is prescribed during pregnancy as we do not know as yet whether prescribing tablets may have any harmful effects on the baby.

Insulin is also  recommended during pregnancy as the best means of achieving optimal control of blood sugar.

Should I take Folic Acid?

Yes. You should take Folic Acid 5mg once daily during the first three months of your pregnancy.

What happens to my insulin dose during pregnancy?

During pregnancy insulin requirements tend to rise due to a variety of hormones produced by the placenta which oppose the action of insulin and push blood sugar levels higher. However in the early stages of pregnancy, particularly if troubled by morning sickness, a reduction in insulin dose is not uncommon.

What should my blood sugar levels be during pregnancy?

Your doctor or Diabetes Specialist Nurse will advise you on the target blood glucose levels during pregnancy. It is customary to aim for ‘tight’ control, i.e. HbA1c of 6.5% and blood glucose concentrations of between 4-5 mmol/l before meals and no higher than 7 mmol/l two hours after a meal.

What happens to my insulin dose after delivery?

After delivery most mothers will need a reduction of their dose of insulin often down to pre-pregnancy levels. Once the placenta is delivered, a rapid decline in insulin requirement is usual. If you are planning to breast feed you may need even less, and you will need to snack! Your diabetes team will discuss post delivery doses with you. It is often advisable to ‘run’ your sugars a little higher immediately post delivery until you have established a routine with your baby.

If you have type 2 diabetes and plan to breast feed, your doctor may decide to continue with insulin injections as some sugar lowering drugs may pass into the breast milk and cause the baby to have hypos.

Smoking

Smoking can harm your unborn child. If you are still smoking, it is most important for the sake of your baby that you should stop.

 

Dr Nishan Wijenaike MD, FRCP
Consultant Physician (Diabetes and Endocrinology)
West Suffolk Hospitals NHS Trust
Bury St Edmunds
June 2006