Pregestational Diabetes

(Sometimes medical terminology or jargon makes sense. Other times it doesn’t!!)

Pregestational Diabetes describes Diabetes in Pregnancy, where the diabetes was diagnosed prior to the pregnancy occurring.

Since we talk about pregnancy and type 1 diabetes elsewhere, this section will consider pregnancy in women with pre-existing type 2 diabetes.

Pregnancy in women with pre-existing Type 2 Diabetes

There is no reason why having diabetes should mean that you can’t or shouldn’t have children. Ideally, women with pre-existing diabetes would have comparable pregnancy outcomes to women without diabetes

That said though, there are some special considerations.

What happens in the body?

A woman’s Insulin requirements increase during pregnancy. This is due to increased food intake, maternal weight gain, and hormonal changes such as placental growth hormone, and placental lactogen, as well as increased prolactin and growth hormone production. As the pregnancy advances, the pancreatic β-cells are expected to keep up with the demand for increased insulin. Insulin resistance, the failure of the β-cell mass to expand, and a relative inadequate rise in insulin production all contribute to the development of diabetes.

Maternal glucose is transported across the placenta to the  growing foetus, and this delivery depends on the concentration gradient between the fetus and the maternal glucose levels. In the later part of pregnancy, the foetus diverts an increasing amount of maternal glucose towards itself, which leads to a decrease in maternal glucose levels. In order to maintain the concentration gradient of glucose across the placenta between the mother and the foetus, the maternal insulin resistance increases, as well as the hepatic glucose production. In turn, the β-cells increase insulin secretion to prevent excessive delivery of glucose to the foetus.

BEFORE the pregnancy

‘Preconception care’ is really important when you have diabetes. Studies have shown that for the best outcomes, blood glucose levels should be managed optimally before baby is even conceived.

Ideally all women with type 2 diabetes who are of childbearing age should be offered preconception counselling and advice as part of their routine diabetes health care.

Diabetes Management during Pregnancy

As with just about Everything Diabetes, the focus is aimed at keeping blood glucose levels in a safe and healthy range. A healthy lifestyle should underpin any pregnancy, but is especially important if you have diabetes in pregnancy.

Medication and Supplements

Metformin and insulin are the only two recommended therapies for GDM. Other medicines approved for treating type 2 diabetes – such as SGLT2 inhibitors or GLP1 receptor agonists – have not yet been approved for use during pregnancy.

In addition you should be advised to stop taking some other medications that may potentially harm the baby – e.g. statins and/or ACE inhibitors or angiotensin receptor blockers.

Daily folic acid (usually 5 mg) and iodine (usually mcg) should ideally have been started from conception unless contraindicated.

You may also be offered:

  • aspirin (usually 100 mg daily for prevention of preeclampsia if less than 20 weeks gestation
  • calcium supplementation for prevention of preeclampsia if low calcium diet
  • vitamin D supplementation if you have dark skin

Blood glucose management

Blood glucose levels (rather than HbA1c) are the best targets for glycaemic control in pregnancy as HbA1c often becomes unreliable due to increased red cell turnover.  Monitor blood glucose levels before meals and 1 or 2 hours post meals.

Aim for:

  • Pre-meal BGL 4 – 5 mmol/L (but be aware of hypoglycaemia)
  • 1 hour post-meal BGL < 7.4 mmol/L, or
  • 2 hour post-meal BGL < 6.7 mmol/L

In some cases you may be able to access continuous glucose monitoring (CGM) prior and/or during pregnancy. CGM can predict and detect asymptomatic hypoglycaemia and post-prandial peaks which may not be picked up using finger prick blood glucose monitoring.

>> More on Blood glucose monitoring

Potential problems during the pregnancy

Poorly managed diabetes during pregnancy can lead to serious health complications for both the mother and the baby. The risks are the same for women with pre-existing type 1 or type 2 diabetes and for those who develop gestational diabetes. Keeping blood glucose levels  in a healthy range before and during pregnancy can significantly lower these risks.

> More on Potential Complications of Pregnancy with Diabetes

The Birth Plan

Whilst the best Birth Plans can sometimes go ‘wrong’ on the day, it’s really important that both you and your healthcare team are comfortable with YOUR Birth Plan. Think of it as a list of your preferences

Some things to consider will include:

  • Any previous birthing experiences
  • Your preferred location/environment; clinical circumstances will obviously impact this at the time
  • Pain relief
  • A birthing partner
  • Immediately after the delivery – e.g. skin-to-skin contact
  • What would you like to happen to the placenta

Caesarian Section (C-section)

Women with Type 1 diabetes have a higher rate of C-sections compared to those without diabetes. Even if it’s not your preferred method of delivering your baby, it pays to be prepared for this eventuality.

Potential complications that can lead to either a planned or emergency C-section include: 

If your C-section is scheduled, you may have the opportunity to discuss how your diabetes is managed during the procedure. Alternatively you can include your preferences in the Birth Plan.

The surgery might take up to an hour, depending on how things go. Usually you would be given an epidural (spinal block) so that you are fully conscious but can’t feel anything below your waist. A screen is positioned such that you can’t see what’s going on below, but your birthing partner can usually observe if desired.

The Birth Plan

Whilst the best Birth Plans can sometimes go ‘wrong’ on the day, it’s really important that both you and your healthcare team are comfortable with YOUR Birth Plan. Think of it as a list of your preferences

Some things to consider will include:

  • Any previous birthing experiences
  • Your preferred location/environment; clinical circumstances will obviously impact this at the time
  • Pain relief
  • A birthing partner
  • Immediately after the delivery – e.g. skin-to-skin contact
  • What would you like to happen to the placenta

Caesarian Section (C-section)

Women with Type 1 diabetes have a higher rate of C-sections compared to those without diabetes. Even if it’s not your preferred method of delivering your baby, it pays to be prepared for this eventuality.

Potential complications that can lead to either a planned or emergency C-section include: 

If your C-section is scheduled, you may have the opportunity to discuss how your diabetes is managed during the procedure. Alternatively you can include your preferences in the Birth Plan.

The surgery might take up to an hour, depending on how things go. Usually you would be given an epidural (spinal block) so that you are fully conscious but can’t feel anything below your waist. A screen is positioned such that you can’t see what’s going on below, but your birthing partner can usually observe if desired.

Remember, as soon as baby is born any insulin requirements will drop back to levels close to those prior to pregnancy.

Breastfeeding

Ideally you will be considering breastfeeding for at least the first few months if possible, but it’s not “do-or-die”…

 

 

Breastfeeding

Ideally you will be considering breastfeeding for at least the first few months if possible, but it’s not “do-or-die”…

 

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