Pregnancy and Type 1 Diabetes
There is no reason why having type 1 diabetes should prevent you from having children.
Optimising blood glucose levels before and during pregnancy is really important for the health of both mother and developing baby. You should be closely monitored and supported by your health care team and midwife, and there are often special considerations for birthing.
These days everything has been made so much easier with the introduction of continuous glucose monitoring technology, and this is now funded for all people living with Type 1 diabetes in New Zealand.
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.
What this all boils down to is that if your blood glucose levels are higher than they should be your baby may grow too big, causing all sorts of problems for you (and especially when it comes to the birth!). And your baby’s insulin production may be higher than it should be at birth, resulting in significant hypoglycaemia when your maternal blood glucose supply is cut.
>> More on Potential Complications of Pregnancy when you have diabetes
Planning and preconception care
Planning is really important when it comes to having a baby if you have type 1 diabetes. In this context, ‘planning’ usually means the ‘stopping contraception’ part.
>> More on Diabetes and Contraception
Ideally you should receive preconception counselling and advice from your healthcare team as part of your routine diabetes care. Having an HbA1c of 48mmol/mol or less is ideal, before conception. If you are hoping to have a baby and your HbA1c is much higher than 50mmol/mol it is strongly recommended that you hold off trying until your HbA1c is lower. This is protect both you and the baby.
Unplanned pregnancies
To be fair, neither of my pregnancies were exactly “planned”! That said, I survived, as did my two beautiful children, without any significant complications. I found blood glucose management much easier during the pregnancies and of course both times I had the best motivation – the health of the baby that was growing inside me.
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.
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
If you’re using CGM
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Insulin needs over the course of your pregnancy
You can expect your insulin requirements to increase significantly during pregnancy, especially during the last few months of the pregnancy.
Supplements
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
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:
- Large baby
- The existence of diabetic eye or kidney disease
- Pre-eclampsia
- Previous c-section
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 your 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”…
