“Life, like art, should be a celebration of a vision.” –Michael Larson
Every person with diabetes has a compelling reason to take good care of his health: It’s the best way to live a long, healthy life with diabetes and to minimize the risk of diabetes-related complications. Women with diabetes who are pregnant or who are even thinking about becoming pregnant have at least two compelling reasons to take the best care possible of their general health and their diabetes: their own well-being, as well as that of their planned child.
Having high blood glucose during the first 6–8 weeks of pregnancy raises the risk of birth defects, and the higher a woman’s HbA1c during that time, the higher the risk. (HbA1c is a measure of blood glucose control over a period of 2–3 months.) But many women don’t realize they are pregnant until several weeks after conception. That’s why it’s so important to plan a pregnancy, to use a reliable method of contraception until you’re ready to become pregnant, and to take any steps necessary to get your HbA1c level in goal range (as close to “normal” as possible) at least three months before you become pregnant.
The planning stages
Even if you’re not ready to have a baby, if you are a woman of childbearing age and think you might like to have a child at some point, it’s worth talking with your diabetes care team about preconception planning. Most likely, your discussions will focus on the benefits of tight blood glucose control before pregnancy. That’s because high blood glucose during pregnancy — even very early in a pregnancy — not only raises the risk of birth defects but also raises the risk of spontaneous abortion, or miscarriage. It can also cause a developing fetus to become too large (called macrosomia), making delivery difficult, and it often leads to hypoglycemia in the newborn.
The goals for blood glucose control listed in the American Diabetes Association’s clinical reference guide Medical Management of Pregnancy Complicated by Diabetes for women who are planning to become pregnant are “tighter,” or closer to normal, nondiabetic levels, than those for women who are not planning a pregnancy. (See “Pre-pregnancy Blood Glucose Targets”) If your blood glucose levels are not routinely at the recommended pre-pregnancy levels, talk to your diabetes care team about the changes you would need to make to get them there.
If you are ready to start actively planning a pregnancy, you need to line up appropriate medical and obstetrical care for both before and during pregnancy. The best approach for management of diabetes and pregnancy is to have a multidisciplinary team of health-care professionals that also includes you as an important member of the team. Teams may vary in their makeup, but they should generally include a physician that specializes in diabetes (such as a diabetologist, endocrinologist, or internal medicine specialist), a physician that specializes in pregnancy (an obstetrician, ideally one who is familiar with pregnancy and diabetes), a diabetes educator, a dietitian who specializes in diabetes management, a social worker, and any other specialists necessary for your care.
Your team members should work together to help you care for your diabetes and get your blood glucose levels as close to pre-pregnancy goals as possible. Your physician may also recommend that you start taking a prenatal vitamin containing at least 400 milligrams of folic acid, which is a B vitamin associated with a lower risk of a type of birth defects known as neural tube defects. Until you have achieved the best possible HbA1c level, it is recommended that you continue to use a reliable method of contraception.
In addition to focusing on blood glucose control, your team will want to evaluate you for any diabetes-related complications and treat any that are present before you become pregnant.
(Click here for some resources on pregnancy and diabetes.)
Certain medical conditions, particularly cardiovascular disease, can make pregnancy very risky. In addition, pregnancy can worsen some diabetes complications. For this reason, women with diabetes who are contemplating pregnancy should have a thorough medical evaluation before becoming pregnant and, if needed, receive treatment for any existing complications such as diabetic retinopathy (eye disease), nephropathy (kidney disease), neuropathy (nerve disease), and cardiovascular disease (heart disease).
Retinopathy. In some cases, diabetic retinopathy can worsen during pregnancy. The best way to prevent worsening is to gradually bring blood glucose levels into goal range prior to pregnancy. Ideally, all women with diabetes should have a dilated eye exam by a retinopathy specialist before becoming pregnant. At your exam, you will want to ask about the health of your eyes, any potential problems that could occur, as well as whether any further evaluation of your eyes might be needed during a pregnancy.
Nephropathy. It is important to have your kidney function evaluated before becoming pregnant. Your physician will likely order both blood tests and urine tests for a baseline assessment of your overall kidney health. If kidney disease is present, it can contribute to high blood pressure during pregnancy. You and your diabetes care team should discuss your kidney health as it relates to pregnancy.
Neuropathy. Diabetes management during pregnancy may be complicated by the presence of neuropathy. Any health problems or changes in bodily functioning caused by neuropathy should be treated before conception occurs. Some of the problems that can be caused by neuropathy include the following:
• Gastroparesis, or slowed stomach emptying
• Urinary retention
• Hypoglycemia unawareness, in which a person does not sense or does not experience the early signs of low blood glucose
• Orthostatic hypotension, or low blood pressure that occurs upon rising from a seated or lying-down position
• Carpal tunnel syndrome, or numbness, tingling, burning, pain, or a dull ache in the fingers, hands, or wrists, caused by pressure on the median nerve; worsening or onset of carpal tunnel syndrome is common during pregnancy.
Cardiovascular disease. Women with cardiovascular disease experience a high mortality rate during pregnancy, so if you have cardiovascular disease, you will want to discuss your level of risk with your diabetes care team. Because pregnancy creates increased demands on the heart, it is important that the heart be evaluated and that you have an exercise tolerance test to help determine if your heart can withstand the demands of pregnancy.
If you have severe complications of diabetes, you and your diabetes care team may decide that it is not safe for you to become pregnant. Discuss any risks you have with your team and work with them to determine a plan that is best for you.
Drugs and pregnancy
Some drugs that are commonly used in the treatment of diabetes may not be safe to take during pregnancy. Some examples include the cholesterol-lowering drugs known as statins, which are pregnancy category X, meaning there is positive evidence of risk to the fetus from the drugs, so they should not be used during pregnancy. Statins should be discontinued before conception, if possible. Blood-pressure-lowering drugs in the classes known as ACE inhibitors and ARBs are also not recommended during pregnancy and should also be discontinued before conception. If necessary, your physician may prescribe alternative drug therapies for controlling your cholesterol or blood pressure while you are planning for pregnancy.
The use of oral blood-glucose-lowering drugs for Type 2 diabetes management during pregnancy is controversial. Oral drugs are generally not recommended because there have been very few randomized controlled trials evaluating their safety during pregnancy. However, most retrospective studies and published clinical experience have not demonstrated an increased risk of birth defects in the infants of women treated with oral diabetes drugs during pregnancy. Therefore, if you currently take such drugs and are planning a pregnancy, it is best to discuss with your health-care provider what plan is best for you and your diabetes treatment.
The usual drug of choice for treatment of diabetes during pregnancy is insulin, and your physician may want to switch you to insulin before you become pregnant, both to get your blood glucose levels into goal range as well as to give you time to adjust to insulin therapy before having to also adjust to being pregnant.
Other injectable drugs for diabetes treatment, namely pramlinitide (brand name Symlin) and exenatide (Byetta), may not be recommended during pregnancy because, like oral diabetes drugs, neither has been studied in pregnant women.
Keep in mind that you should never discontinue any prescribed medicines without consulting your diabetes care team first. But if you suspect you’re pregnant, find out for sure as quickly as possible so your team can address how to take care of your health while also protecting that of your baby.
It is well known that smoking, drinking alcohol, and using illegal drugs can have negative effects on fetal health. If you use any of these substances, the best time to stop is before you become pregnant. If you have trouble stopping, ask your health-care team about safe options that might help.
The children of parents with diabetes have a somewhat higher risk of developing diabetes themselves. When a mother has Type 1 diabetes, her offspring have a 1% to 4% chance of developing diabetes during their lifetimes. The risk varies depending on the mother’s age when she gives birth: If a woman with Type 1 diabetes delivers a child before she reaches age 25, the baby’s chance of developing Type 1 diabetes is about 4%; if she has the baby after age 25, the risk goes down to approximately 1%. Having a father with Type 1 diabetes raises the risk of a child developing Type 1 diabetes to about 6%.
Having either a mother or a father with Type 2 diabetes may raise a child’s risk of developing Type 2 diabetes during his lifetime. When both parents have Type 2 diabetes, the child’s risk is higher than when just one parent has it. But while some cases of Type 2 diabetes have a strong genetic basis, others do not. Many cases of Type 2 diabetes can be delayed or even prevented by staying active and maintaining a healthy weight.
Whatever type of diabetes a parent has, it’s good to remember that having a higher risk of either type of diabetes does not guarantee that a person will get it. Research is ongoing to uncover the roots of diabetes, and prospective parents with Type 1 diabetes may want to consider helping with that research by participating in Type 1 Diabetes TrialNet as they consider expanding their family. Information about this collaborative effort to study, treat, and prevent Type 1 diabetes can be found online at www.diabetestrialnet.org/ or by calling (800) 425-8361.
Stacking the odds in your favor
Studies confirm that women with optimal diabetes care prior to pregnancy have a much lower incidence of having babies with birth defects than those who do not. However, almost two-thirds of pregnancies in women with diabetes are unplanned. In some cases, women whose blood glucose levels are not in optimal control have irregular menstrual cycles, which may lead them to believe they won’t get pregnant. However, this is an unreliable way to prevent pregnancy. If you are not ready to become pregnant, make sure you are using a reliable method of contraception. Having diabetes does not rule out any particular contraceptive methods, but it is nonetheless important that you talk to your physician about selecting a method that is safe and effective for you.
Bringing a child into the world is a big responsibility, so it’s important to consider whether you’re ready before you do. The time you take to get your diabetes into the best control possible is also a good time to consider whether you’re emotionally and financially — as well as physically — ready.
Don’t leave your health and your future up to chance. Take control, and visualize a plan that keeps everyone in your life (including any potential children) in the best possible health.